Priority access to health care: Evidence from an exogenous policy shock

Access to care is an important issue in public health care systems. Unlike private systems, in which price equilibrates supply and demand, public systems often ration medical services through wait times. Access that is given on a first come, first served basis might not yield an allocation of resources that maximizes the health of a population, potentially creating suboptimal heterogeneity in wait times. In this study, we examine an access disparity between two groups of patients—established patients and new patients. We exploit an exogenous policy change—implemented by the U.S. Veterans Health Administration—that removed the disparity and homogenized the wait time. We find strong evidence that without such a policy, established patients have priority access over new patients. We discuss whether this is a suboptimal allocation of resources. We additionally find that established patient priority access is an important determinant of access for new patients; accounting for it increased the explanatory power of our statistical model of new patient wait times by a factor of five. The findings imply that policy and management decisions may be more effective in achieving the optimal distribution of access if access heterogeneity is recognized and accounted for explicitly.     

Prioritization for bariatric surgery: capturing Canadian patient preference weights using a discrete choice experiment

BackgroundBariatric surgery is an effective treatment for adults affected by obesity. Demand is greater than supply and a prioritization system for patients is needed.ObjectiveClinical practice guidelines recommends bariatric surgery as a management strategy for adults with severe obesity (body mass index ≥40 or 35–40 kg/m² with co-morbidities). Eligible patient’s access surgery on a first-come-first-serve basis and wait times can be several years. This study quantifies patient preferences toward attributes that could be evaluated when prioritizing patients for surgery.SettingA Canada-wide study of adults living with obesity.MethodsA discrete choice experiment was conducted via email with a sample of Canadian adults with obesity. Six relevant attributes were identified through focus groups. Respondents completed 12 choice tasks and demographic and weight loss–related questions. A multinomial logit model was used to estimate preference weights of each attribute.ResultsA total of 515 individuals completed the survey. Fifty-nine percent were female, 97% made previous weight loss attempts, and 5% had bariatric surgery. On average patients prioritized individuals with significant problems with daily activities versus none (odds ratio [OR] 4.41; 95% confidence interval [CI] 4.31–4.52); 3 existing cardiovascular co-morbidities versus 0 (OR 4.24; 95%CI 4.12–4.36); extreme impact on mental health versus no impact (OR 3.73; 95%CI 3.64–3.84); 6 other co-morbidities versus 0 (OR 3.43; 95%CI 3.31–3.55); waiting 5 versus 1 year (OR 1.59; 95%CI 1.46–1.68); and a body mass index of 60 versus 40 (OR 1.52; 95%CI 1.43–.62).ConclusionAll 6 attributes were important to patients in the prioritization for bariatric surgery. However, the number of cardiovascular co-morbidities and the impact on daily activities were considered most important.     

Wird die Bereitstellung stationärer allergologischer Leistungen an deutschen Universitätshautkliniken durch die DRG‐Systematik beeinflusst?

Background: Diagnostic provocation tests (ICD Z01.5) have a low cost weight in the German DRG system. We aimed at investigating a possible economic impact on the number of provocation tests in German university medical centers (UMC) for dermatology. Methods: We review quality records of 35 German UMC for 2008 and 2010 (ICD Z01.5, total number of patients as well as priority ranking). Results: 33/35 hospitals gave full data for both years including the ten most frequent diagnoses. Between 2008 and 2010, total number of patients treated increased in 23/33 (70 %) UMC, those with ICD Z01.5 only in 11/24 (46 %) UMC with full data. In 2008, the ICD Z01.5 was in the top ten list of main diagnoses in 29/33 (88 %) hospitals, in 2010 in 25/33 (76 %); also, priority ranking tended to decrease. In contrast, total number of ICD Z01.5 in Germany tended to increase slightly. Conclusions: We noticed a tendency for decreasing numbers of provocation tests being performed in dermatological UMC in Germany. As there is no evidence for a decreasing number of patients suffering from allergies, one may speculate about a shift to non‐university departments due to an economic impact.     

Is there an ethical obligation to split every donor liver? Scarce resources,medical factors,and ethical reasoning

SLT has the potential to counter the worldwide shortage of donor organs. Although the preferred recipients of SLT are usually pediatric patients, a more stringent ethical argument than the fundamental prioritization of children is to demonstrate that SLT of deceased donor organs could increase access to this potentially lifesaving resource for all patients, including children. Several empirical studies show that SLT also makes it possible to achieve similar outcomes to WLT in adults if several factors are observed. In general, it can be regarded as ethically permissible to insist on splitting a donor liver if, in an individual case, SLT is expected to have a similar outcome to that of WLT. The question is therefore no longer whether, but under what conditions SLT is able to achieve similar results to WLT. One of the main challenges of the current debate is the restricted comparability of the available data. We therefore have an ethical obligation to improve the available empirical data by implementing prospective clinical studies, SLT programs, and national registries. The introduction of 2 modes of allocation—one for patients willing to accept both SLT and WLT, and a second for patients only willing to accept WLT—would help to resolve the issue of patient autonomy in the case of mandatory splitting policy.     

Prioritizing research needs based on a systematic evidence review: a pilot process for engaging stakeholders

Background/context Systematic evidence reviews (SERs) identify knowledge gaps in the literature, a logical starting place for prioritizing future research. Varied methods have been used to elicit diverse stakeholders’ input in such prioritization. Objective To pilot a simple, easily replicable process for simultaneously soliciting consumer, clinician and researcher input in the identification of research priorities, based on the results of the 2009 SER on screening adults for depression in primary care. Methods We recruited 20 clinicians, clinic staff, researchers and patient advocates to participate in a half‐day event in October 2009. We presented SER research methods and the results of the 2009 SER. Participants took part in focus groups, organized by profession; broad themes from these groups were then prioritized in a formal exercise. The focus group content was also subsequently analysed for specific themes. Results Focus group themes generally reacted to the evidence presented; few were articulated as research questions. Themes included the need for resources to respond to positive depression screens, the impact of depression screening on delivery systems, concerns that screening tools do not address comorbid or situational causes of depression and a perceived ‘disconnect’ between screening and treatment. The two highest‐priority themes were the system effects of screening for depression and whether depression screening effectively leads to improved treatment. Conclusion We successfully piloted a simple, half‐day, easily replicable multi‐stakeholder engagement process based on the results of a recent SER. We recommend a number of potential improvements in future endeavours to replicate this process.     

Development of a consumer product ingredient database for chemical exposure screening and prioritization

Consumer products are a primary source of chemical exposures, yet little structured information is available on the chemical ingredients of these products and the concentrations at which ingredients are present. To address this data gap, we created a database of chemicals in consumer products using product Material Safety Data Sheets (MSDSs) publicly provided by a large retailer. The resulting database represents 1797 unique chemicals mapped to 8921 consumer products and a hierarchy of 353 consumer product “use categories” within a total of 15 top-level categories. We examine the utility of this database and discuss ways in which it will support (i) exposure screening and prioritization, (ii) generic or framework formulations for several indoor/consumer product exposure modeling initiatives, (iii) candidate chemical selection for monitoring near field exposure from proximal sources, and (iv) as activity tracers or ubiquitous exposure sources using “chemical space” map analyses. Chemicals present at high concentrations and across multiple consumer products and use categories that hold high exposure potential are identified. Our database is publicly available to serve regulators, retailers, manufacturers, and the public for predictive screening of chemicals in new and existing consumer products on the basis of exposure and risk.     

The need and total cost of Finnish eyecare services: a simulation model for 2005–2040

Purpose: The aims of this study were: (i) to create a structural simulation model capable of predicting the future need and cost of eyecare services in Finland; and (ii) to test and rank different policy alternatives for access to care and the required physician workforce. Methods: Using the system dynamics approach, the number and cost of patients with cataract, glaucoma, diabetic retinopathy and age‐related macular degeneration (AMD) were described with causal‐loop diagrams and were then translated into a set of mathematical equations to build a computer simulation model. Mathematically, the problem was formulated as a set of differential equations that were solved numerically with specialized software. The validity of the model was tested against prevalence and administrative historical data. The costs covered by the public sector in Finland were obtained from 2003 from the Finnish Hospital Discharge Register (including outpatient care), the Finnish Social Insurance Institution and a survey of hospital price lists. Different levels of access to public care were then simulated in four eye diseases, for which the model estimated the need for services and resources and their costs in the years 2005–2040. Results: The model forecasted that the adoption of the 2005 national ‘access to care’ criteria for cataract surgery would shorten waiting lists. If the workload of Finnish ophthalmologists were kept at the 2003 level, the graduation rate of new ophthalmologists would have to increase by 75% from the current level. If all glaucoma patients were followed in the public sector in future, even this increase in training would not meet the demand for physician workforce. The current model indicated that the screening frequency of diabetes can be increased without large sacrifices in terms of costs. AMD therapy has a significant role in the allocation of future resources in eyecare. The modelling study predicted that ageing alone will increase the costs of eyecare during the next four decades in Finland by about 1% per year in real terms (undiscounted and without inflation of unit costs). The increases in total yearly costs were on average 8.6% between 2001 and 2003. Conclusions: The results of this modelling study indicate that policy initiatives, such as defining criteria for access to care, can have substantial implications on the demand for care and waiting times whereas the effect of ageing alone was relatively small. Measures to control several other factors – such as the adoption and price level of new technologies, treatments and practice patterns – will be at least equally important in order to restrain healthcare costs effectively.     

Pharmaceuticals and Personal Care Products in the Environment: What Are the Big Questions?

Background: Over the past 10–15 years, a substantial amount of work has been done by the scientific, regulatory, and business communities to elucidate the effects and risks of pharmaceuticals and personal care products (PPCPs) in the environment.Objective: This review was undertaken to identify key outstanding issues regarding the effects of PPCPs on human and ecological health in order to ensure that future resources will be focused on the most important areas.Data sources: To better understand and manage the risks of PPCPs in the environment, we used the “key question” approach to identify the principle issues that need to be addressed. Initially, questions were solicited from academic, government, and business communities around the world. A list of 101 questions was then discussed at an international expert workshop, and a top-20 list was developed. Following the workshop, workshop attendees ranked the 20 questions by importance.Data synthesis: The top 20 priority questions fell into seven categories: a) prioritization of substances for assessment, b) pathways of exposure, c) bioavailability and uptake, d) effects characterization, e) risk and relative risk, f ) antibiotic resistance, and g) risk management.Conclusions: A large body of information is now available on PPCPs in the environment. This exercise prioritized the most critical questions to aid in development of future research programs on the topic.     

Network‐Informed Gene Ranking Tackles Genetic Heterogeneity in Exome‐Sequencing Studies of Monogenic Disease

Genetic heterogeneity presents a significant challenge for the identification of monogenic disease genes. Whole‐exome sequencing generates a large number of candidate disease‐causing variants and typical analyses rely on deleterious variants being observed in the same gene across several unrelated affected individuals. This is less likely to occur for genetically heterogeneous diseases, making more advanced analysis methods necessary. To address this need, we present HetRank, a flexible gene‐ranking method that incorporates interaction network data. We first show that different genes underlying the same monogenic disease are frequently connected in protein interaction networks. This motivates the central premise of HetRank: those genes carrying potentially pathogenic variants and whose network neighbors do so in other affected individuals are strong candidates for follow‐up study. By simulating 1,000 exome sequencing studies (20,000 exomes in total), we model varying degrees of genetic heterogeneity and show that HetRank consistently prioritizes more disease‐causing genes than existing analysis methods. We also demonstrate a proof‐of‐principle application of the method to prioritize genes causing Adams‐Oliver syndrome, a genetically heterogeneous rare disease. An implementation of HetRank in R is available via the Website http://sourceforge.net/p/hetrank/ .     

A guide on gene prioritization in studies of psychiatric disorders

There has been an increasing interest in the identification of genetic variants causing individual differences in human behavior. Psychiatrists have contributed to the genetics field by defining the most important behavioral characteristics and by studying the association between genetic variants and behavioral differences within phenotypically well‐characterized samples in which detailed assessments have been collected (e.g. neuroimaging). These samples are typically limited in size and are therefore not suitable for a genome‐wide association analysis. Instead, gene association studies conducted in such samples typically focus on a few genes of interest, allowing smaller sample sizes. However, the selection of high‐priority genes is not always straightforward and psychiatrists will usually have a limited background in genetics. We aim to fill this gap by (i) providing a basic introduction to genetics; (ii) showing how the selection of genes of interest can be optimized by the use of two web tools: Polysearch and Gene Prospector; (iii) illustrating how statistical power analyses can be performed and discussing the importance of sufficiently powered studies. This guide can help psychiatrists with limited experience in genetics in designing genetic studies that allow identification of specific behavioral, cognitive, or neural correlates of genetic risk variants, while avoiding common pitfalls. Copyright © 2015 John Wiley & Sons, Ltd.