Ethical analysis of scarce resources in pediatric home care

Developments in medical care and technology over the last two decades have raised new problems and demands for both health care providers and consumers. Families face years of financial and emotional stress from caring for chronically ill children. These interrelationships and the ethical issues involved are addressed in this paper.     

Equity in the allocation of health care resources

This paper examines some of the issues that arise when seeking to tackle health inequalities in a context of limited health care resources. Increasingly, central agencies are using devolved budgets for health care providers as a central instrument of expenditure control. Equity objectives play an important role in the resource allocation methods used to determine such budgets. Yet, unless integrated into a proper system of risk management, the use of budgets can lead to serious inequity. The paper discusses the potential contributions of different disciplines to promoting equity within a health care budgetary regime.     

The public health issues in nursing home care

Characteristics of patients in nursing homes and the nursing homes in the United States are reviewed. Issues concerning the selection of right nursing home for the right patient are discussed in the context of measuring the needs of the patient, describing the environment of the home, and involving the patient and family in the selection process so that the best patient-environment mix can be obtained. The major issues after nursing home placement relate to quality and cost of care. The problems in measuring quality of care in the nursing home are addressed, and a goal-attainment model is proposed for both quality assessment and cost containment. Examining alternatives to nursing home care and encouraging research into diseases that lead to placement in nursing homes are seen as high priority goals in the field.     

National security and the health of people: human needs and the allocation of scarce resources

Gellhorn, a professor at the Harvard School of Public Health, delivered this paper as the opening address to the Eighth International Conference on the Social Sciences and Medicine, held in Scotland in August 1983. He discusses the impact of the international arms race on public health and economic development, particularly in Third World nations. His paper is followed by commentaries by Christine K. Cassel of the University of Oregon Department of Medicine; Margot Jefferys, emeritus professor of medical sociology at the University of London; F.M. Mburu of the University of Nairobi Department of Community Health; Peter J.M. McEwan, a professor of social sciences in Scotland; Vicente Navarro of the Johns Hopkins University School of Hygiene and Public Health; Harmon L. Smith of the Duke University Divinity School; and Philip Wood, of the University of Manchester ARC Epidemiology Research Unit.     

Urgency coding as a dynamic tool in management of waiting lists for psychogeriatric nursing home care in The Netherlands

Criteria are used to prioritise patients on waiting lists for health care services. This is also true for waiting lists for admission to psychogeriatric nursing homes. A patient's position on these latter waiting lists is determined by (changes in) urgency and waiting time. The present article focuses on the process and outcome of an urgency coding system in a fair selection of patients. It discusses the use of urgency codes in the daily practice of waiting list management and the related waiting times. Patients and their informal caregivers were followed from entry on the waiting list to admission to a nursing home. Caregivers were interviewed during the waiting period and after their relative's admission to a nursing home, and the formal urgency codes on the waiting list were monitored. Seventy-eight of the initial 93 patients were admitted to a nursing home. High urgency codes were commonly assigned and the waiting times were shorter for patients with higher urgency codes. Negative consequences of an urgency coding system, e.g. patients with less urgency not being admitted at all and patients not being admitted to the nursing home of their choice, could not be demonstrated. Patients without higher urgency codes were admitted after a mean waiting time of 28 weeks. It may be questioned whether this long waiting time is problematic, because satisfaction of the caregivers with regard to waiting times was not influenced by the actual waiting times. An urgency coding system enables health care professionals to react to changes in the situation of both patients and caregivers by adjusting urgency codes to influence the length of time until nursing home admission.     

Mathematical programming for the efficient allocation of health care resources

Previous discussions of methods for the efficient allocation of health care resources subject to a budget constraint have relied on unnecessarily restrictive assumptions. This paper makes use of established optimization techniques to demonstrate that a general mathematical programming framework can accommodate much more complex information regarding returns to scale, partial and complete indivisibility and program interdependence. Methods are also presented for incorporating ethical constraints into the resource allocation process, including explicit identification of the cost of equity.     

Consumer views of health care: a comparison of hospital and home care

A small interview study (n = 40) is described. Families were generally satisfied with their health care experience although they expressed a clear preference for home care as compared with hospitalization. A significant group of parents identified lack of information as a shortcoming of hospital care.     

Cost-effectiveness implications based on a comparison of nursing home and home health case mix.

Case-mix differences between 653 home health care patients and 650 nursing home patients, and between 455 Medicare home health patients and 447 Medicare nursing home patients were assessed using random samples selected from 20 home health agencies and 46 nursing homes in 12 states in 1982 and 1983. Home health patients were younger, had shorter lengths of stay, and were less functionally disabled than nursing home patients. Traditional long-term care problems requiring personal care were more common among nursing home patients, whereas problems requiring skilled nursing services were more prevalent among home health patients. Considering Medicare patients only, nursing home patients were much more likely to be dependent in activities of daily living (ADLs) than home health patients. Medicare nursing home and home health patients were relatively similar in terms of long-term care problems, and differences in medical problems were less pronounced than between all nursing home and all home health patients. From the standpoint of cost-effectiveness, it would appear that home health care might provide a substitute for acute care hospital use at the end of a hospital stay, and appears to be a more viable option in the care of patients who are not severely disabled and do not have profound functional problems. The Medicare skilled nursing facility, however, is likely to continue to have a crucial role in posthospital care as the treatment modality of choice for individuals who require both highly skilled care and functional assistance.     

Strategic costs and preferences revelation in the allocation of resources for health care

This article examines the resources allocation process in the internal market for health care in an environment characterised by asymmetry of information. We analyse the strategic behaviour of the provider and show how, by misreporting its cost function and reservation utility, it might shift the allocation of resources away from the purchaser’s objectives. Although the fundamental importance of equity, efficiency and risk aversion considerations which have been the traditional focus of the literature on allocation of resources should not be denied, this paper shows that contracts and internal markets are not neutral instruments and more research should be devoted to studying their effects.     

Human resources management practices and patient satisfaction in home health care

Patient satisfaction is an important issue for home health providers. This study tested the influence of organizational factors, particularly human resource management practices, on quality of care, as measured by patient satisfaction. Six hundred ninety-six patients of thirteen home health agencies were surveyed to test the influence of organizational factors on five dimensions of patient satisfaction. Organizational variables included size of the agency, staffing characteristics, educational preparation of RNs, continuing education, and compensation. We found that full-time staffing, the number of BSN-prepared RNs, and percent of budget allocated to benefits all predicted high patient satisfaction scores.