Managing healthcare budgets in times of austerity: the role of program budgeting and marginal analysis

Given limited resources, priority setting or choice making will remain a reality at all levels of publicly funded healthcare across countries for many years to come. The pressures may well be even more acute as the impact of the economic crisis of 2008 continues to play out but, even as economies begin to turn around, resources within healthcare will be limited, thus some form of rationing will be required. Over the last few decades, research on healthcare priority setting has focused on methods of implementation as well as on the development of approaches related to fairness and legitimacy and on more technical aspects of decision making including the use of multi-criteria decision analysis. Recently, research has led to better understanding of evaluating priority setting activity including defining ‘success’ and articulating key elements for high performance. This body of research, however, often goes untapped by those charged with making challenging decisions and as such, in line with prevailing public sector incentives, decisions are often reliant on historical allocation patterns and/or political negotiation. These archaic and ineffective approaches not only lead to poor decisions in terms of value for money but further do not reflect basic ethical conditions that can lead to fairness in the decision-making process. The purpose of this paper is to outline a comprehensive approach to priority setting and resource allocation that has been used in different contexts across countries. This will provide decision makers with a single point of access for a basic understanding of relevant tools when faced with having to make difficult decisions about what healthcare services to fund and what not to fund. The paper also addresses several key issues related to priority setting including how health technology assessments can be used, how performance can be improved at a practical level, and what ongoing resource management practice should look like. In terms of future research, one of the most important areas of priority setting that needs further attention is how best to engage public members

Consistency of metabolic responses and appetite sensations under postabsorptive and postprandial conditions

The present study aimed to investigate the reliability of metabolic and subjective appetite responses under fasted conditions and following consumption of a cereal-based breakfast. Twelve healthy, physically active males completed two postabsorption (PA) and two postprandial (PP) trials in a randomised order. In PP trials a cereal based breakfast providing 1859 kJ of energy was consumed. Expired gas samples were used to estimate energy expenditure and fat oxidation and 100 mm visual analogue scales were used to determine appetite sensations at baseline and every 30 min for 120 min. Reliability was assessed using limits of agreement, coefficient of variation (CV), intraclass coefficient of correlation and 95% confidence limits of typical error. The limits of agreement and typical error were 292.0 and 105.5 kJ for total energy expenditure, 9.3 and 3.4 g for total fat oxidation and 22.9 and 8.3 mm for time-averaged AUC for hunger sensations, respectively over the 120 min period in the PP trial. The reliability of energy expenditure and appetite in the 2 h response to a cereal-based breakfast would suggest that an intervention requires a 211 kJ and 16.6 mm difference in total postprandial energy expenditure and time-averaged hunger AUC to be meaningful, fat oxidation would require a 6.7 g difference which may not be sensitive to most meal manipulations

Population genetics of trypanosoma brucei rhodesiense: clonality and diversity within and between foci

African trypanosomes are unusual among pathogenic protozoa in that they can undergo their complete morphological life cycle in the tsetse fly vector with mating as a non-obligatory part of this development. Trypanosoma brucei rhodesiense, which infects humans and livestock in East and Southern Africa, has classically been described as a host-range variant of the non-human infective Trypanosoma brucei that occurs as stable clonal lineages. We have examined T. b. rhodesiense populations from East (Uganda) and Southern (Malawi) Africa using a panel of microsatellite markers, incorporating both spatial and temporal analyses. Our data demonstrate that Ugandan T. b. rhodesiense existed as clonal populations, with a small number of highly related genotypes and substantial linkage disequilibrium between pairs of loci. However, these populations were not stable as the dominant genotypes changed and the genetic diversity also reduced over time. Thus these populations do not conform to one of the criteria for strict clonality, namely stability of predominant genotypes over time, and our results show that, in a period in the mid 1990s, the previously predominant genotypes were not detected but were replaced by a novel clonal population with limited genetic relationship to the original population present between 1970 and 1990. In contrast, the Malawi T. b. rhodesiense population demonstrated significantly greater diversity and evidence for frequent genetic exchange. Therefore, the population genetics of T. b. rhodesiense is more complex than previously described. This has important implications for the spread of the single copy T. b. rhodesiense gene that allows human infectivity, and therefore the epidemiology of the human disease, as well as suggesting that these parasites represent an important organism to study the influence of optional recombination upon population genetic dynamics

The experience of long-term opiate maintenance treatment and reported barriers to recovery: A qualitative systematic review

Background/Aim: To inform understanding of the experience of long-term opiate maintenance and identify barriers to recovery. Methods: A qualitative systematic review. Results: 14 studies in 17 papers, mainly from the USA (65%), met inclusion criteria, involving 1,088 participants. Studies focused on methadone prescribing. Participants reported stability; however, many disliked methadone. Barriers to full recovery were primarily ‘inward focused'. Conclusion: This is the first review of qualitative literature on long-term maintenance, finding that universal service improvements could be made to address reported barriers to recovery, including involving ex-users as positive role models, and increasing access to psychological support. Treatment policies combining harm minimisation and abstinence-orientated approaches may best support individualised recovery

Engaging Students With Course Content Using Scheduled and Unscheduled Emails and Text Messages

This study addressed college students’ acceptance of push communication (i.e., email and SMS messaging) as a means of receiving course-related content, and modified the Unified Theory of Acceptance and Use of Technology by including Scheduled Message as an independent variable. Surveys of 301 students’ perceptions of instructor-sent email and SMS texts directing them to materials in six instructors’ 10 courses were analyzed by PLS-PM for their impact on the students’ intention to use these push communication technologies. In contrast to previous studies on technology acceptance, we evaluated actual usage patterns for both the scheduled and unscheduled push communication. Scheduled emails did not yield higher average duration times or unique visitors than unscheduled ones, yet click-through rates and return visits were higher. Scheduled SMS messages did yield higher average duration times, unique visitors, and click-through rates than unscheduled SMS messages, yet unscheduled SMS messages yielded more return visits. We argue that the differences in the results for email vs. SMS may have been due to email’s slower delivery time. We also consider implications for faculty wishing to facilitate distributed learning among students via push communication

Evaluation of changes in sleep breathing patterns after primary palatoplasty in cleft children

Introduction: There is a need to more clearly understand the characteristics of breathing patterns in children with cleft palate in the first year of life, as there is little data available to guide current practice. Pierre Robin patients are known to have a higher incidence, however we hypothesised sleep breathing disturbance is not confined to this sub-group of cleft patient. Methods: We conducted a prospective observational study of sleep disordered breathing patterns in a cohort of infants with oro-nasal clefts (cleft palate with or without cleft lip) to describe the spectrum of sleep breathing patterns both pre and post palate repair. Sleep breathing studies were performed pre- and post-operatively in sequential infants referred to a regional cleft lip and palate unit. Results of sleep breathing studies were analysed according to American Academy of Sleep Medicine scoring guidelines and correlated with clinical history and details of peri-operative respiratory compromise. The degree of sleep disordered breathing was characterised using desaturation indices (number of desaturations from baseline SpO2 of >=4%, per hour). Results: Thirty-nine infants were included in this study, twenty-five female and fourteen male. Twelve had isolated Cleft Palate as part of an associated syndrome. Patients were categorised into Isolated Cleft Palate, Isolated Cleft Palate in the context of Pierre Robin Sequence, and those with Cleft Lip and Palate. All groups demonstrated some degree of sleep breathing abnormality. Not unsurprisingly the eight infants with Pierre Robin Sequence had a significantly higher desaturation index before surgical intervention (p=0.043), and were more likely to require a pre-operative airway intervention (p=0.009). Palate repair in this group did not alter the relative distribution of patients in each severity category of sleep disorder breathing. Surgical repair of the secondary palate in the remaining children was associated with some improvement but by no means complete resolution of their sleep disordered breathing patterns. Conclusions: We conclude that sleep breathing disturbance is not confined to Pierre Robin patients alone and all cleft palate patients should undergo pre-operative and post-operative sleep breathing analysis

Evaluation of an open-field autorefractor's ability to measure refraction and hence potential to assess objective accommodation in pseudophakes

Background: To evaluate the accuracy of an open-field autorefractor compared with subjective refraction in pseudophakes and hence its ability to assess objective eye focus with intraocular lenses (IOLs). Methods: Objective refraction was measured at 6 m using the Shin-Nippon NVision-K 5001/Grand Seiko WR-5100K open-field autorefractor (five repeats) and by subjective refraction on 141 eyes implanted with a spherical (Softec1 n=53), aspherical (SoftecHD n=37) or accommodating (1CU n=22; Tetraflex n=29) IOL. Autorefraction was repeated 2 months later. Results: The autorefractor prescription was similar (average difference: 0.09±0.53 D; p=0.19) to that found by subjective refraction, with ~71% within ±0.50 D. The horizontal cylindrical components were similar (difference: 0.00±0.39 D; p=0.96), although the oblique (J45) autorefractor cylindrical vector was slightly more negative (by -0.06±0.25 D; p=0.06) than the subjective refraction. The results were similar for each of the IOL designs except for the spherical IOL, where the mean spherical equivalent difference between autorefraction and subjective was more hypermetropic than the Tetraflex accommodating IOL (F=2.77, p=0.04). The intrasession repeatability wa