Public and Private Health Care Financing with Alternate Public Rationing

We develop a model to analyze health care nancing arrangements and under alternative public sector rationing rules. Health care is demanded by individuals varying in income and severity of illness. There is a limited supply of health care resources used to treat individuals, causing some individuals to go untreated. We examine outcomes under full public finance, full private finance, and mixed, parallel public and private finance under two rationing rules for the public sector: needs-based rationing and random rationing. Insurers (both public and private) must bid to obtain the necessary health care resources to treat their beneficiaries. While the public insurer's ability-to-pay is limited by its (fixed) budget, the private insurer's willingness-to-pay re ects the individuals' willingness-to-pay for care. When permitted, the private sector supplies supplementary health care to those willing and able to pay. The introduction of private insurance diverts treatment from relatively poor to relatively rich individuals. Moreover, if the public insurer allocates care according to need, the average severity of the untreated is higher in a mixed system than in a pure public system. While we can unambiguously sign most comparative static effects for a general set of distribution functions for income and severity, a complete analysis of the relationship between public sector rationing and the scope for a private health insurance market requires distributional assumptions. For a bivariate uniform distribution function we nd that the private health insurance market is smaller when the public sector rations according to need as compared to random allocation of health care.health care financing, rationing rules

Recurrent symptomatic aortic sac seroma after open abdominal aortic aneurysm repair

The expansion of an abdominal aortic aneurysm sac after conventional repair has been rarely described. All cases in the literature have been associated with polytetrafluoroethylene grafts and perigraft seromas. We present a patient with a recurrent, symptomatic periaortic graft seroma after conventional repair. The etiology of this problem along with its potential increasing significance in the endovascular era is reviewed

The medical science DMZ: a network design pattern for data-intensive medical science

Abstract: Objective We describe a detailed solution for maintaining high-capacity, data-intensive network flows (eg, 10, 40, 100 Gbps+) in a scientific, medical context while still adhering to security and privacy laws and regulations. Materials and Methods High-end networking, packet-filter firewalls, network intrusion-detection systems. Results We describe a “Medical Science DMZ” concept as an option for secure, high-volume transport of large, sensitive datasets between research institutions over national research networks, and give 3 detailed descriptions of implemented Medical Science DMZs. Discussion The exponentially increasing amounts of “omics” data, high-quality imaging, and other rapidly growing clinical datasets have resulted in the rise of biomedical research “Big Data.” The storage, analysis, and network resources required to process these data and integrate them into patient diagnoses and treatments have grown to scales that strain the capabilities of academic health centers. Some data are not generated locally and cannot be sustained locally, and shared data repositories such as those provided by the National Library of Medicine, the National Cancer Institute, and international partners such as the European Bioinformatics Institute are rapidly growing. The ability to store and compute using these data must therefore be addressed by a combination of local, national, and industry resources that exchange large datasets. Maintaining data-intensive flows that comply with the Health Insurance Portability and Accountability Act (HIPAA) and other regulations presents a new challenge for biomedical research. We describe a strategy that marries performance and security by borrowing from and redefining the concept of a Science DMZ, a framework that is used in physical sciences and engineering research to manage high-capacity data flows. Conclusion By implementing a Medical Science DMZ architecture, biomedical researchers can leverage the scale provided by high-performance computer and cloud storage facilities and national high-speed research networks while preserving privacy and meeting regulatory requirements

Guidelines for the use of diagnostic imaging in musculoskeletal pain conditions affecting the lower back, knee and shoulder: A scoping review

Background Musculoskeletal (MSK) pain is one of the most common reasons for primary care consultation, particularly pain in the lower back (LBP), knee and shoulder. The use of diagnostic imaging for MSK pain is increasing, but it is unclear whether this increase is justified on the basis of clinical practice guideline (CPG) recommendations. Aim To identify and map the content of CPGs that informs the use of diagnostic imaging in those with nontraumatic LBP, knee and shoulder pain in primary and intermediate care in the UK. Design and Setting A scoping review of CPGs. Methods This scoping review was conducted and is reported in accordance with PRISMA guidance. A broad search strategy included electronic searches of MEDLINE, CINAHL, PsychINFO and SPORTDiscus from 2009 to 17 April 2019. This was conducted alongside a search of guideline repositories and was combined with a snowball search of Google, relevant professional bodies and use of social media. Results 31 relevant CPGs were included. Routine use of diagnostic imaging for those with nontraumatic LBP, knee or shoulder pain is generally discouraged in primary care or intermediate care. Diagnostic imaging should be reserved for when specific or serious pathology is suspected or where the person is not responding to initial nonsurgical management and the imaging result is expected to change clinical management decisions. Conclusion Diagnostic imaging should not be routinely requested in primary or intermediate care for nontraumatic LBP, knee or shoulder pain. CPGs do not justify the increasing imaging rates in the UK for MSK pain

Willingness-to-Pay for Parallel Private Health Insurance: Evidence from a Laboratory Experiment

Debate over the effects of public versus private health care financing has been, and continues to be, active in both academic outlets and policy circles. Theoretical literature on parallel health care financing is often built on untested behavioural assumptions and the empirical evidence generally depends upon the institutional details of the specific health care systems under analysis. This paper contributes to the literature on parallel health care finance by developing and executing a revealed preference laboratory experiment based on the theoretical model of parallel health care finance in Cuff et al. (2008). The theoretical model involves individuals with varying severities of illness who demand health care from a limited supply of health care resources. Health care resources are purchased by the public sector and rationed free of charge to individuals, or purchased by individuals through a private insurance market. The general theoretical model is converted into a discrete experimental representation of a large-scale economy where individuals are price takers, the probability of receiving public health care is exogenous and the willingness-to-pay (WTP) for private health insurance is elicited from subjects. The experimental design includes two within-subject factors based on the theoretical model: the public sector rationing rule (rationing based on need or severity versus rationing based on a random allocation) and the probability of being publicly treated (high versus low). The experimental design also includes two between-subjects treatments based on the frame of the experiment (neutral frame versus health frame) and on the distribution of private health insurance prices (high prices versus low prices). The results show the public system's allocation rule and the probability of receiving health care from the public system both significantly affect an individual's WTP for private health insurance in the predicted direction, although the WTP values tend to be above the actual theoretical predictions. When the public system allocates health care based on need, the average WTP is lower than under random allocation. A higher probability of receiving health care from the public system elicits a lower WTP regardless of how the public system allocates health care. It is also found that when the public system allocates health care based on need, the WTPs are significantly higher under a neutral frame than a health frame

Endovascular repair of bilateral common iliac artery aneurysms following open abdominal aortic aneurysm repair with preservation of both hypogastric arteries using commercially available stent grafts

Endovascular treatment of aneurysmal disease has become the predominant form of repair for all aneurysms. Some areas continue to pose specific challenges to stay within the general tenets of successful repair, mainly achieving adequate seal without sacrificing other arterial pathways. Following aortic aneurysm repair, the common iliac arteries can continue to have aneurysmal degeneration. We present a case of bilateral common iliac artery aneurysms that presented 9 years after open repair of an infrarenal abdominal aortic aneurysm in conjunction with an extensive aortic dissection. These were repaired using endovascular techniques with preservation of both hypogastric arteries

New functional families (FunFams) in CATH to improve the mapping of conserved functional sites to 3D structures.

CATH version 3.5 (Class, Architecture, Topology, Homology, available at http://www.cathdb.info/) contains 173 536 domains, 2626 homologous superfamilies and 1313 fold groups. When focusing on structural genomics (SG) structures, we observe that the number of new folds for CATH v3.5 is slightly less than for previous releases, and this observation suggests that we may now know the majority of folds that are easily accessible to structure determination. We have improved the accuracy of our functional family (FunFams) sub-classification method and the CATH sequence domain search facility has been extended to provide FunFam annotations for each domain. The CATH website has been redesigned. We have improved the display of functional data and of conserved sequence features associated with FunFams within each CATH superfamily

A proposed standard for quantifying 3-D hindlimb joint poses in living and extinct archosaurs

The last common ancestor of birds and crocodylians plus all of its descendants (clade Archosauria) dominated terrestrial Mesozoic ecosystems, giving rise to disparate body plans, sizes, and modes of locomotion. As in the fields of vertebrate morphology and paleontology more generally, studies of archosaur skeletal structure have come to depend on tools for acquiring, measuring, and exploring three-dimensional (3-D) digital models. Such models, in turn, form the basis for many analyses of musculoskeletal function. A set of shared conventions for describing 3-D pose (joint or limb configuration) and 3-D kinematics (change in pose through time) is essential for fostering comparison of posture/movement among such varied species, as well as for maximizing communication among scientists. Following researchers in human biomechanics, we propose a standard methodological approach for measuring the relative position and orientation of the major segments of the archosaur pelvis and hindlimb in 3-D. We describe the construction of anatomical and joint coordinate systems using the extant guineafowl and alligator as examples. Our new standards are then applied to three extinct taxa sampled from the wider range of morphological, postural, and kinematic variation that has arisen across >250 million years of archosaur evolution. These proposed conventions, and the founding principles upon which they are based, can also serve as starting points for measuring poses between elements within a hindlimb segment, for establishing coordinate systems in the forelimb and axial skeleton, or for applying our archosaurian system more broadly to different vertebrate clades

GeMMA: functional subfamily classification within superfamilies of predicted protein structural domains

GeMMA (Genome Modelling and Model Annotation) is a new approach to automatic functional subfamily classification within families and superfamilies of protein sequences. A major advantage of GeMMA is its ability to subclassify very large and diverse superfamilies with tens of thousands of members, without the need for an initial multiple sequence alignment. Its performance is shown to be comparable to the established high-performance method SCI-PHY. GeMMA follows an agglomerative clustering protocol that uses existing software for sensitive and accurate multiple sequence alignment and profile–profile comparison. The produced subfamilies are shown to be equivalent in quality whether whole protein sequences are used or just the sequences of component predicted structural domains. A faster, heuristic version of GeMMA that also uses distributed computing is shown to maintain the performance levels of the original implementation. The use of GeMMA to increase the functional annotation coverage of functionally diverse Pfam families is demonstrated. It is further shown how GeMMA clusters can help to predict the impact of experimentally determining a protein domain structure on comparative protein modelling coverage, in the context of structural genomics