Equity weights in the allocation of health care: the rank-dependent QALY model

This paper introduces the rank-dependent quality-adjusted life-years (QALY) model, a new method to aggregate QALYs in economic evaluations of health care. The rank-dependent QALY model permits the formalization of influential concepts of equity in the allocation of health care, such as the fair innings approach, and it includes as special cases many of the social welfare functions that have been proposed in the literature. An important advantage of the rank-dependent QALY model is that it offers a straightforward procedure to estimate equity weights for QALYs. We characterize the rank-dependent QALY model and argue that its central condition has normative appeal.     

A Meta-Analytic Inquiry into the Relationship Between Selected Risk Factors and Problem Behavior

Identifying the predictors of problem behavior is essential both for understanding the causes of such behavior and for preventing it. Although a great deal of research has sought to identify the factors predictive of problem behavior, much of the research to date has been correlational and tells us little about causality. This study attempts to improve on the correlational research by applying meta-analytic techniques to existing experimental and quasi-experimental studies of school-based prevention. The following 3 risk factors were examined: academic performance, bonding to school, and social competency skills. The most convincing evidence of a relationship between risk and problem behavior was found for bonding to school. Positive changes in attachment and commitment to school resulting from the preventive interventions were consistently accompanied by positive changes in problem behavior. Preventive interventions that produced improvements in academic performance produced moderate improvements in problem behavior. With regard to social competence, the association depended in large part on the type of measure used to assess social competency skills. Changes in self-report measures of social competency were unrelated to changes in problem behavior, whereas a strong positive correlation was observed between changes in ratings and observations of social competency by others and improvements in problem behavior.     

Assumptions of the QALY procedure

The Quality Adjusted Life Year (QALY) has been proposed as a useful index for those managing the provision of health care because it enables the decision-maker to compare the 'value' of different health care programmes and in a way which, potentially at least, reflects social preferences about the appropriate pattern of provision. The index depends on a combination of a measure of morbidity and the risk of mortality. Methodological debate has tended to concentrate on the technicalities of producing a scale of health; and philosophical argument has concentrated on the ethics of interpersonal comparison. There is little recognition of the fragility of the theoretical assumptions underpinning the proposed combination of morbidity and risk of mortality. The context in which the proposed indices are being developed is examined in Section 2. Whilst most working in the field of health measurement eschew over-simplification, it is clear that the application of micro-economics to management is greatly facilitated if a single index can be agreed. The various approaches to combining morbidity and mortality are described in Section 3. The crucial assumptions concern the measurement and valuation of morbidity; the procedures used for scaling morbidity with mortality; and the role of risk. The nature of the valuations involved are examined in Section 4. It seems unlikely that they could ever be widely acceptable; the combination with death and perfect health poses particular problems; and aggregation across individuals compounds the problem. There are also several technical difficulties of scaling and of allowing for risk which have been discussed elsewhere and so are only considered briefly in Section 5 of this paper.(ABSTRACT TRUNCATED AT 250 WORDS)     

Palliative Care and the QALY Problem

Practitioners of palliative care often argue for more resources to be provided by the state in order to lessen its reliance on charitable funding and to enable the services currently provided to some of those with terminal illnesses to be provided to all who would benefit from it. However, this is hard to justify on grounds of cost-effectiveness, since it is in the nature of palliative care that the benefits it brings to its patients are of short duration. In particular, palliative care fares badly under a policy of QALY-maximisation, since procedures which prevent premature death (provided the life is of reasonable quality) or improve quality of life for those with longer life expectancy will produce more QALYs. This paper examines various responses to this problem and argues that in order to justify increased resources for palliative care its advocates must reject the ‘atomistic’ view of the value of life implicit in the QALY approach in favour of a `holistic' or `narrative' account. This, however, has implications which advocates of palliative care may be reluctant to embrace.     

Avenues of Influence: the Relationship between Health Impact Assessment and Determinants of Health and Health Equity

This study aims to identify perceived impacts of Health Impact Assessment (HIA) on decision-making, determinants of health, and determinants of health equity and outline the mechanisms through which these impacts can occur. The research team conducted a mixed-methods study of HIAs in the USA. First, investigators collected data regarding perceived HIA impacts through an online questionnaire, which was completed by 149 stakeholders representing 126 unique HIAs. To explore in greater depth the themes that arose from the online survey, investigators conducted semi-structured interviews with 46 stakeholders involved with 27 HIAs related to the built environment. This preliminary study suggests that HIAs can strengthen relationships and build trust between community and government institutions. In addition, this study suggests that HIA recommendations can inform policy and decision-making systems that determine the distribution of health-promoting resources and health risks. HIA outcomes may in turn lead to more equitable access to health resources and reduce exposure to environmental harms among at-risk populations. Future research should further explore associations between HIAs and changes in determinants of health and health equity by corroborating findings with other data sources and documenting potential impacts and outcomes of HIAs in other sectors.     

论卫生服务公平性与特需医疗服务之关系

公立医院要不忘自身的职责，承担起卫生服务公平性的重任，又要根据自身发展的需要，适度地开展特需医疗服务，要普通医疗服务与特需医疗服务公抓并举，使医院在激烈的医疗市场竞争中抢占制高点，不断地发展壮大。     

Value of a QALY for France: A New Approach to Propose Acceptable Reference Values

ObjectiveFrance has included health economic assessment (HEA) as an official criterion for innovative drug pricing since 2013. Until now, no cost-effectiveness threshold (CET) has been officially proposed to qualify incremental cost-effectiveness ratios (ICERs). Although the French health authorities have publicly expressed the need for such reference values, previous initiatives to determine these have failed. The study aims to propose a locally adapted method for estimating a preference-based value for a quality-adjusted life-year (QALY) based on a rational approach to public policy choices in France.MethodsWe used the official French value of statistical life (VSL) of €3 million (USD 3.25 million), proposed in 2013 by the French General Commission on Strategy and Prediction. We first estimated the value of life-year (VoLY) by age category according to life expectancy and official discounts recommended for HEA in France. We then estimated a value of statistical QALY (VSQ) by weighting VoLYs with demographic data and French EQ-5D-3L tariffs.ResultsThe estimated average VoLYs and VSQs were €120 185 (USD 130 000) and €147 093 (USD 159 022), respectively, assuming a discount rate of 2.5% and €166 205 (USD 179 681) and €201 398 (USD 217 728), respectively, assuming a discount rate of 4.5%.ConclusionAssuming that, as in other public domains, equity in access to healthcare across all disease areas and between all users is desirable, we propose an estimate of VSQ that is consistent with this goal. Our estimates of €147 093 (USD 179,681) to €201 398 (USD 217 728) should be perceived as breakeven costs for a QALY rather than a market access threshold. Such VSQs could be used as reference values for ICERs in HEA in France.     

探讨医院档案信息化建设

目的探讨医院的档案信息化建设.方法对当前医院档案存在的问题和医院档案信息化的优点等有关问题进行对比分析,并对医院档案信息化建设中要注意的问题进行了探讨.结果通过对比分析,阐明了医院档案信息化建设的重要性和必要性.结论只要我们用科学的发展观来分析问题,解决问题,医院档案信息化就一定能够实现.     

应付策略与职业紧张关系的探讨

目的探讨应付策略与职业紧张的关系。方法采用横断面研究方法对515名油田工人进行调查,用职业紧张测量工具测试油田工人的应付策略、职业紧张因素、个性特征及职业紧张反应。结果36.9%油田工人采取了充分的应付策略。应付策略评分与文化程度、人际关系、对人的责任、对事的责任、提升机会、参与机会、任务一致性、工作自主性、工作挑战性、工作满意感、心理卫生、情绪平衡、正性情绪、A型行为及自尊感评分呈正相关,与组内冲突、负性情绪、抑郁症状、每日紧张感、工作心理控制源及社会支持评分呈负相关。应付策略充分者的工作人际关系、对人的责任、参与机会、工作自主性、工作挑战性、工作满意感、情绪平衡、正性情绪和忍耐性评分明显高于应付策略的中等或不足水平者(P<0.05或P<0.01),而每日紧张感、外控性和社会支持评分则明显低于应付策略的中等水平、不足水平者(P<0.05或P<0.01)。逐步回归分析结果表明,应付策略与正性情绪关系密切。结论应付策略对职业紧张有较大的影响;有效的应付策略有助于缓解精神紧张状态,提高社会适应能力。然而,油田工人总体的有效应付策略尚不够充分,可能与个性特征等有关。     

Equity Weights for Socioeconomic Position: Two Methods—Survey of Stated Preferences and Epidemiological Data

Background

There is an implicit equity approach in cost-effectiveness analysis that values health gains of socioeconomic position groups equally. An alternative approach is to integrate equity by weighting quality-adjusted life-years according to the socioeconomic position group.

妊娠高血压患者妊中期MSAFP值与胎盘早剥的关系

目的 探讨妊娠高血压患者监测妊娠中期无畸形单胎孕妇血清甲胎蛋白（maternal serumalpha—fetoprotein，MSAFP）值在预测并发胎盘早剥的临床意义。方法 对100名妊娠24～26周孕妇的MSAFP值、妊娠结局进行回顾性分析。结果 妊娠高血压疾病并发胎盘早剥与非胎盘早剥组母血AFP的平均值分别为：（251．4±64．3）μg／L，（152．4±49．4）μg／L，两者差异有统计学意义（P〈0．05）。以250峭／L为临界值，≥250μg／L者妊娠高血压疾病并发胎盘早剥发生率均较低于此值的孕妇增高（P〈0．01）。结论 监测妊娠中期MSAFP值可以作为预测妊娠高血压疾病并发胎盘早剥的一项有效指标，在产前检查中应用有一定的临床意义。     

临床路径管理与公立医院成长的关系探讨

本文通过分析临床路径管理与公立医院成长间的关系,探讨了临床路径管理对公立医院成长的影响及其因素。旨在证实临床路径管理对公立医院成长具有促进作用的同时,为推动临床路径深入可持续地发展提供进一步的理论支持。     

放射卫生监督管理工作某些问题的探讨

目的 探讨放射防护卫生监督管理工作中的有关实际问题。方法 根据《放射性同位素与射线装置放射防护条例》。结果 提出了解决有关问题的方法措施。结论 应尽快制定与《条例》相配套的实施细则。     

合则增益分则偏颇--试论公平与效率的关系及在医院管理中的作用

正确处理公平与效率的关系．发挥两者的作用是医院管理的实质性内涵和全部工作。医院改革也好．改制也好,改进也好．都离不开公平与效率的关系。在处理公平与效率关系方面．可调是诸子百家,仁者见仁,智者见智。笔者认为公平与效率应该是优化组合的关系．公平是前提．效率是基础;公平是目的．效率是手段．是一个有机的整体．互为支撑．相辅相成。就医院而言．“追求社会公平．注重服务效率．兼顾经济效益。就较好地体现了辨证法中“两点论“和“重点论”的观点．也较好地体现了医疗卫生行业的公益性和与时俱进的时代性。在医疗服务过程中．政府和市场在处理公平与效率关系问题上．各有千秋．政府主导公平．市场引导效率．医院作为载体．尽力靠近公平．努力提高效率．应该也是可能做到的。最后,笔者认为．政府、市场、医院三考的完美融合是实现公平与效率优化组合的保证,这是本文的主旨。     

社会资本与健康公平关系的实证研究

目的：探讨社会资本对我国城市居民健康公平的影响。方法：分析方法包括单因素和logistic回归分析。主要测量指标包括自评健康指标和因子分析得到的5个社会资本因子。结果：邻里关系、互惠与社会支持高分组的人群自评健康差的概率只有低分组的1．37倍和1.32倍。但是引入社会资本变量后，贫困对自评健康的影响并没有很明显的减少。结论：在消除贫困所带来的影响的前提下，推动贫困人口社会资本的发展，对健康公平的改善会更有意义。