Adapting portfolio theory for the evaluation of multiple investments in health with a multiplicative extension for treatment synergies

Portfolio theory is central to the analysis of risk in many areas of economics but is seldom used appropriately in health economics. This contribution examines the use of portfolio theory in the context of cost-effectiveness analysis (CEA). A number of modifications are needed to apply portfolio analysis to the economic evaluation of health care interventions. First, the method of reporting the results of a CEA, and consequently some of the underlying assumptions, needs to be modified. Second, portfolio theory needs to be expressed in terms of effects on individuals aggregated to a population. Finally, one needs to allow for the possibility of synergy between the various health interventions. This paper derives a general formula for a portfolio of health care interventions that allows for synergies between interventions where the population effects are aggregated from individual effects. A number of special cases are also derived to highlight the nature of the formulation of the modified portfolio theory. We conclude that, while modified portfolio theory adds a theoretical foundation to health care evaluations, it may not be operational until estimates of the correlation between interventions are available, and the question of uncertainty is resolved in health care evaluation. Also, while a synergy may be present at the individual level, when aggregated over a large population it may not be significant given the standard assumption of constant returns to scale.     

Trainee health care professionals'' knowledge of the health risks associated with obesity

BACKGROUND: Trainee nurses, doctors and dietitians will direct the future of obesity treatment and prevention. To do so effectively, they must have sufficient knowledge regarding the health risks associated with obesity and feel that part of their professional role is to counsel obese patients regarding these risks. METHODS: An online survey collected data on professional roles, training needs and the Obesity Risk Knowledge-10 (ORK-10) scale from 38 dietetic, 88 nursing (Diploma), 74 nursing (Masters) and 389 medical students. RESULTS: Final-year dietetic students demonstrated higher ORK-10 scale scores than final-year nursing (Dip), nursing (MSc) and medical students (P < 0.001). The majority of students agreed that part of their profession's role was to counsel obese patients about the health risks associated with obesity. Dietetic students were more satisfied with the teaching they had received than each of the other student groups (P < 0.05). CONCLUSION: Future health care professionals recognize their responsibility to communicate health risk information to obese patients. Dietetic students have a sound knowledge base to support them in this. Educators of trainee nurses and doctors may like to respond to their students' lower levels of knowledge and desire for more training.     

A framework for involving the public in health care coverage and resource allocation decisions

Coverage and resource allocation decisions are a very important area for public engagement because of their direct impact on the public's access to care and because the affected services are publicly funded. We present a framework that guides decision-makers through key questions they must address when deciding on, structuring, evaluating and disseminating the results of public engagement exercises, particularly as they relate to coverage and resource allocation decisions. The framework will enable decision-makers to better conduct viable and meaningful citizen engagement around these issues.     

Key principles for the improved conduct of health technology assessments for resource allocation decisions

Health technology assessment (HTA) is a dynamic, rapidly evolving process, embracing different types of assessments that inform real-world decisions about the value (i.e., benefits, risks, and costs) of new and existing technologies. Historically, most HTA agencies have focused on producing high quality assessment reports that can be used by a range of decision makers. However, increasingly organizations are undertaking or commissioning HTAs to inform a particular resource allocation decision, such as listing a drug on a national or local formulary, defining the range of coverage under insurance plans, or issuing mandatory guidance on the use of health technologies in a particular healthcare system. A set of fifteen principles that can be used in assessing existing or establishing new HTA activities is proposed, providing examples from existing HTA programs. The principal focus is on those HTA activities that are linked to, or include, a particular resource allocation decision. In these HTAs, the consideration of both costs and benefits, in an economic evaluation, is critical. It is also important to consider the link between the HTA and the decision that will follow. The principles are organized into four sections: (i) "Structure" of HTA programs; (ii) "Methods" of HTA; (iii) "Processes for Conduct" of HTA; and (iv) "Use of HTAs in Decision Making."     

Parental weighting of seizure risks vs. fever risks in vaccination tradeoff decisions

As part of a survey of about vaccination beliefs, a nationally representative sample of parents of young children answered a series of tradeoff questions that asked them to choose between two vaccination approaches that differed in terms of risks of vaccine complications, number of injections, and/or vaccine effectiveness. Most parents were willing to have their children endure more injections, and many were willing to forgo disease protection, in order to reduce the rare chance of febrile seizures. Yet, most parents were unwilling to trade disease protection to reduce the risk of fever alone, even though this is correlated with the risk of febrile seizures. Vaccine risk communications need to address the heightened emotional weight that parents give to febrile seizure risk, even when the rarity of such events is explicit.     

Improving resource allocation decisions for health and HIV programmes in South Africa: Bioethical,cost-effectiveness and health diplomacy considerations

The escalating expenditure on patients with HIV/AIDS within an inadequately funded public health system is tending towards crowding out care for patients with non-HIV illnesses. Priority-setting decisions are thus required and should increasingly be based on an explicit, transparent and accountable process to facilitate sustainability. South Africa's public health system is eroding, even though the government has received extensive donor financing for specific conditions, such as HIV/AIDS. The South African government's 2007 HIV plan anticipated costs exceeding 20% of the annual health budget with a strong focus on treatment interventions, while the recently announced 2012–2016 National Strategic HIV plan could cost up to US$16 billion. Conversely, the total non-HIV health budget has remained static in recent years, effectively reducing the supply of health care for other diseases. While the South African government cannot meet all demands for health care simultaneously, health funders should attempt to allocate health resources in a fair, efficient, transparent and accountable manner, in order to ensure that publicly funded health care is delivered in a reasonable and non-discriminatory fashion. We recommend a process for resource allocation that includes ethical, economic, legal and policy considerations. This process, adapted for use by South Africa's policy-makers, could bring health, political, economic and ethical gains, whilst allaying a social crisis as mounting treatment commitments generated by HIV have the potential to overwhelm the health system.     

浙江省卫生资源配置的公平性分析

目的了解浙江省卫生资源配置的公平现状,发现其优势和不足,提出针对性的建议。方法对浙江省的医疗卫生机构数、医疗卫生机构床位数、卫生总人员数、卫生技术人员数、执业医师数和注册护士数等相关数据进行统计描述,用Gini系数和Lorenz曲线测量卫生资源配置的公平程度及其变化。结果 2011年,浙江省卫生资源Gini系数按人口分布在0.10~0.17之间,按地域面积分布在0.12~0.24之间;2006-2011年,浙江省医疗卫生机构的基尼系数最低,处于最佳公平状态,注册护士公平性分布的Gini系数有所上升。结论浙江省卫生资源配置公平性总体较好,卫生资源按人口配置的公平性优于按地域配置,其中,医疗卫生机构配置的公平性最好,注册护士配置的公平性有待优化。     

2000-2006年江苏省卫生资源配置的公平性分析

目的：评价江苏省卫生资源配置的公平性。方法：对2000-2006年江苏省相关数据进行统计描述，用Lorenz曲线和Gini系数测量卫生资源配置的公平程度及其变化。结果：卫生资源Gini系数按人口分布在0．16～0.22之间，按土地面积分布在0．24-0．32之间，床位轻微下降，注册护士等人力资源有所上升。结论：江苏省卫生资源配置的公平性较好，卫生资源人口配置公平性优于地理配置，床位配置的公平性趋优，注册护士等人力资源配置的公平性变差。     

Risk perception and communication in vaccination decisions: a fuzzy-trace theory approach

The tenets of fuzzy-trace theory, along with prior research on risk perception and risk communication, are used to develop a process model of vaccination decisions in the era of Web 2.0. The theory characterizes these decisions in terms of background knowledge, dual mental representations (verbatim and gist), retrieval of values, and application of values to representations in context. Lack of knowledge interferes with the ability to extract the essential meaning, or gist, of vaccination messages. Prevention decisions have, by definition, a status quo option of "feeling okay." Psychological evidence from other prevention decisions, such as cancer screening, indicates that many people initially mentally represent their decision options in terms of simple, categorical gist: a choice between (a) a feeling-okay option (e.g., the unvaccinated status quo) versus (b) taking up preventive behavior that can have two potential categorical outcomes: feeling okay or not feeling okay. Hence, applying the same theoretical rules as used to explain framing effects and the Allais paradox, the decision to get a flu shot, for example, boils down to feeling okay (not sick) versus feeling okay (not sick) or not feeling okay (sick, side effects, or death). Because feeling okay is superior to not feeling okay (a retrieved value), this impoverished gist supports choosing not to have the flu vaccine. Anti-vaccination sources provide more coherent accounts of the gist of vaccination than official sources, filling a need to understand rare adverse outcomes.     

How state-funded home care programs respond to changes in Medicare home health care: resource allocation decisions on the front line

OBJECTIVE: To examine how case managers in a state-funded home care program allocate home care services in response to information about a client's Medicare home health care status, with particular attention to the influence of work environment. DATA SOURCES/STUDY SETTING: Primary data collected on 355 case managers and 26 agency directors employed in June 1999 by 26 of the 27 regional agencies administering the Massachusetts Home Care Program for low-income elders. STUDY DESIGN: Data were collected in a cross-sectional survey study design. A case manager survey included measures of work environment, demographics, and factorial survey vignette clients (N = 2,054), for which case managers assessed service eligibility levels. An agency director survey included measures of management practices. DATA COLLECTION/EXTRACTION METHODS: Hierarchical linear models estimated the effects of work environment on the relationship between client receipt of Medicare home health care and care plan levels while controlling for case-mix differences in agencies' clients. PRINCIPAL FINDINGS: Case managers did not supplement extant Medicare home health services, but did allocate more generous service plans to clients who have had Medicare home health care services recently terminated. This finding persisted when controlling for case mix and did not vary by work environment. Work environment affected overall care plan levels. CONCLUSIONS: Study findings indicate systematic patterns of frontline resource allocation shaping the relationships among community-based long-term care payment sources. Further, results illustrate how nonuniform implementation of upper-level initiatives may be partially attributed to work environment characteristics.     

农户疾病风险处理策略研究述评

疾病影响农户生计。本文从疾病风险测度、疾病对农户生计影响、农户疾病风险处理策略等方面对现有研究进行述评。疾病对农户生计短期影响表现为减少劳动时间和降低正常消费水平等;大病可能导致10年或更长的严重负面影响,特别是影响农户人力资本发展。面对疾病风险,农户采取诸如计划免疫、安全饮水及参加医保项目等"事前"预防措施;他们还积极采取收入和消费平滑的"事后"风险处理策略来度过难关,例如减少家庭消费、借贷、变卖消费性和生产性资产、向外地移居等策略。不同经济状况的农户会采取适合于自身经济能力的疾病风险处理策略。未来的研究需要在疾病对农户收入的持续影响以及对贫困农户生计的影响,不同特征农户疾病风险处理策略比较等方面进行深入分析。     

Maximising health versus sharing: Measuring preferences for the allocation of the health budget

Empirical evidence indicates that people consider sharing health resources to be important even in the absence of the attributes usually associated with equity (age, social class, ethnicity, disease severity or geographic location). If government is to take account of these preferences then survey methods are needed which allow their measurement. The present paper presents a new technique for measuring these preferences and reports the results of a representative survey of 626 Australians which employed the technique. The online and postal survey did not include any of the attributes usually associated with equity but was designed to quantify the respective importance of sharing life years (outcome egalitarianism), resource sharing per se and the changing importance of total health as other attributes varied. Results indicate respondents were primarily concerned with outcome egalitarianism, and that cost per life year had a relatively small effect upon their allocative decisions.     

Health risks in the global shipping industry: An overview

The shipping industry has always been one in which workers' relative risks of ill health, injury and death have been considerable. However, the industry has been utterly transformed since the mid 1970s by the shift to flags of convenience, the sub-contracting of operations by owners to international ship management companies and crewing companies, the explosive growth of mixed nationality crews, and technological and economic changes which have reduced crewing levels and extended working hours. The shipping industry has become arguably the first truly global industry, inadequately controlled by flag-state and port-state regulatory regimes. The evidence of the impact of globalisation on seafarers' health and safety is reviewed and found to be fragmentary but indicative of potentially serious deleterious effects. Closer monitoring of seafarers' health and safety is required as is an enhanced international regulatory regime to narrow the very wide gap between best and worst industry practice.     

Decentralizing resource allocation: early experiences with district health boards in New Zealand

OBJECTIVES: In New Zealand in 2001, a system of purchasing health services by a centralized purchasing agency was replaced by 21 district health boards (DHBs) which are responsible for both providing health services directly and for purchasing services from non-government providers. This paper describes the processes associated with the allocation of health resources in the decentralized system and considers the extent to which four of the government's stated objectives are likely to be achieved. METHODS: Two rounds of interviews with national stakeholders and senior DHB personnel plus case studies in five districts which included key informant interviews, observation at board meetings and document analysis. RESULTS: The re-structuring of the health sector in New Zealand appears to have simultaneously enhanced and inhibited the achievement of government objectives. Local decision-making has encouraged greater local responsiveness and new funding arrangements have allayed concerns about inter-regional equity. The system is less commercially oriented than it was during the 1990s and collaboration between DHBs is improving. However, the combination of increased integration of purchasing and provision within DHBs and the focus on financial deficits in the early years appears to have inhibited the development of partnership relationships between DHBs and non-government providers, and of longer-term funding arrangements for high quality providers. Non-government providers perceive that DHBs have a tendency to favour their own providers when allocating contracts. CONCLUSIONS: Decentralized decision-making is starting to make some inroads towards achieving some of the government's objectives with respect to resource allocation and purchasing.     

深圳市卫生资源配置公平性研究

[目的]评价和分析深圳市卫生资源配置的公平性和合理性,为政府制定卫生政策提供参考和科学依据。[方法]结合引力模型与基尼系数、集中指数和集中曲线的统计学描述方法综合评价深圳市2016年卫生资源的配置情况。[结果]深圳市卫生资源分布不均衡;医疗可达性差距较大,基本呈现由中心城区向外逐渐递减的趋势;床位数和卫生技术人员数按人口分布的基尼系数分别为0.62%0.75,按地理分布的基尼系数分别为0.81和0.77,处于不公平状态,且两者的集中指数分别为0.16和0.17,倾向于经济发展水平高的地区。[结论]深圳市卫生资源的可达性和公平性有待提升,要以需求为导向,结合人口、地域、经济发展等多种因素考虑卫生资源的配置,保障医疗服务覆盖薄弱区域居民的就医公平性。     

我国卫生资源配置中存在的主要问题

该文从我国卫生资源利用实际出发,主要分析卫生资源配置中存在的不公平性、低效性和不 合理性,并提出了简要的政策建议。