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

Suppressing a Blocked Balance Recovery Step: A Novel Method to Assess an Inhibitory Postural Response

Stepping to recover balance is an important way we avoid falling. However, when faced with obstacles in the step path, we must adapt such reactions. Physical obstructions are typically detected through vision, which then cues step modification. The present study describes a novel method to assess visually prompted step inhibition in a reactive balance context. In our task, participants recovered balance by quickly stepping after being released from a supported forward lean. On rare trials, however, an obstacle blocked the stepping path. The timing of vision relative to postural perturbation was controlled using occlusion goggles to regulate task difficulty. Furthermore, we explored step suppression in our balance task related to inhibitory capacity measured at the hand using a clinically feasible handheld device (ReacStick). Our results showed that ReacStick and step outcomes were significantly correlated in terms of successful inhibition (r = 0.57) and overall reaction accuracy (r = 0.76). This study presents a novel method for assessing rapid inhibition in a dynamic postural context, a capacity that appears to be a necessary prerequisite to a subsequent adaptive strategy. Moreover, this capacity is significantly related to ReacStick performance, suggesting a potential clinical translation

Reduction of Sunburn Damage to Skin by Topical Application of Vitamin E Acetate Following Exposure to Ultraviolet B Radiation: Effect of Delaying Application or of Reducing Concentration of Vitamin E Acetate Applied

The skin of the skh-1 mouse after ultraviolet B (280-320 nm, UVB) irradiation shows the pathological changes typical of sunburn damage: spongiosis (edematous spaces) around some cells, necrosis of keratinocytes, giving rise to sunburn cells, inflammatory infiltration ofpolymorphonuclear leucocytes, etc. In our previous study, these were accompanied by erythema, increased skin sensitivity, and edematous swelling. The topical application of tocopherol acetate (TA) immediately after the UVB exposure decreased these changes. In this paper, multiple measurements of the skin thickness were made at different locations along the magnetic resonance imaging (MRI) cross-sectional image of the skin. This permits effects to be quantified with (if desired) the contralateral half of the back serving as an internal control, either exposed (positive control) or unexposed (negative control). Topical application of TA resulted in an increase in the concentration of free tocopherol in the skin. No qualitative differences in ultrastructural appearance of the DVB-irradiated, TA-treated skin could be discerned by careful examination. In vivo high resolution video microscopy of blood flow in venules of the irradiated mouse ear revealed a large (tenfold) but not statistically significant decrease in stationary lymphocytes adhering to the venule walls. The delaying of the application of TA up to 8 hours after the termination of UVB irradiation still offered statistically significant protection as did immediate application of 5% TA in diluent Myritol 318 (Delios S, Henkel)

Complex population dynamics as a competition between multiple time-scale phenomena

The role of the selection pressure and mutation amplitude on the behavior of a single-species population evolving on a two-dimensional lattice, in a periodically changing environment, is studied both analytically and numerically. The mean-field level of description allows to highlight the delicate interplay between the different time-scale processes in the resulting complex dynamics of the system. We clarify the influence of the amplitude and period of the environmental changes on the critical value of the selection pressure corresponding to a phase-transition "extinct-alive" of the population. However, the intrinsic stochasticity and the dynamically-built in correlations among the individuals, as well as the role of the mutation-induced variety in population's evolution are not appropriately accounted for. A more refined level of description, which is an individual-based one, has to be considered. The inherent fluctuations do not destroy the phase transition "extinct-alive", and the mutation amplitude is strongly influencing the value of the critical selection pressure. The phase diagram in the plane of the population's parameters -- selection and mutation is discussed as a function of the environmental variation characteristics. The differences between a smooth variation of the environment and an abrupt, catastrophic change are also addressesd.Comment: 15 pages, 12 figures. Accepted for publication in Phys. Rev.

Energy-aware Georouting with Guaranteed Delivery in Wireless Sensor Networks with Obstacles

International audienceWe propose, EtE, a novel end-to-end localized routing protocol for wireless sensor networks that is energy-efficient and guarantees delivery. To forward a packet, a node s in graph G computes the cost of the energy weighted shortest path between s and each of its neighbors in the forward direction towards the destination which minimizes the ratio of the cost of the shortest path to the progress (reduction in distance towards the destination). It then sends the message to the first node on the shortest path from s to x: say node x′. Node x′ restarts the same greedy rout- ing process until the destination is reached or an obstacle is encountered and the routing fails. To recover from the latter scenario, local minima trap, our algorithm invokes an energy-aware Face routing that guarantees delivery. Our work is the first to optimize energy consumption of Face routing. It works as follows. First, it builds a connected dominating set from graph G, second it computes its Gabriel graph to obtain the planar graph G′. Face routing is invoked and applied to G′ only to determine which edges to follow in the recovery process. On each edge, greedy rout- ing is applied. This two-phase (greedy-Face) End-to-End routing process (EtE) reiterates until the final destination is reached. Simulation results show that EtE outperforms several existing geographical routing on en- ergy consumption metric and delivery rate. Moreover, we prove that the computed path length and the total energy of the path are constant factors of the optimal for dense networks

Managing resources in NHS dentistry: using health economics to inform commissioning decisions

Background: The aim of this study is to develop, apply and evaluate an economics-based framework to assist commissioners in their management of finite resources for local dental services. In April 2006, Primary Care Trusts in England were charged with managing finite dental budgets for the first time, yet several independent reports have since criticised the variability in commissioning skills within these organisations. The study will explore the views of stakeholders (dentists, patients and commissioners) regarding priority setting and the criteria used for decision-making and resource allocation. Two inter-related case studies will explore the dental commissioning and resource allocation processes through the application of a pragmatic economics-based framework known as Programme Budgeting and Marginal Analysis. Methods/Design: The study will adopt an action research approach. Qualitative methods including semi-structured interviews, focus groups, field notes and document analysis will record the views of participants and their involvement in the research process. The first case study will be based within a Primary Care Trust where mixed methods will record the views of dentists, patients and dental commissioners on issues, priorities and processes associated with managing local dental services. A Programme Budgeting and Marginal Analysis framework will be applied to determine the potential value of economic principles to the decision-making process. A further case study will be conducted in a secondary care dental teaching hospital using the same approach. Qualitative data will be analysed using thematic analysis and managed using a framework approach. Discussion: The recent announcement by government regarding the proposed abolition of Primary Care Trusts may pose challenges for the research team regarding their engagement with the research study. However, whichever commissioning organisations are responsible for resource allocation for dental services in the future; resource scarcity is highly likely to remain an issue. Wider understanding of the complexities of priority setting and resource allocation at local levels are important considerations in the development of dental commissioning processes, national oral health policy and the future new dental contract which is expected to be implemented in April 2014

‘Real-world’ health care priority setting using explicit decision criteria: a systematic review of the literature

BACKGROUND: Health care decision making requires making resource allocation decisions among programs, services, and technologies that all compete for a finite resource pool. Methods of priority setting that use explicitly defined criteria can aid health care decision makers in arriving at funding decisions in a transparent and systematic way. The purpose of this paper is to review the published literature and examine the use of criteria-based methods in ‘real-world’ health care allocation decisions. METHODS: A systematic review of the published literature was conducted to find examples of ‘real-world’ priority setting exercises that used explicit criteria to guide decision-making. RESULTS: We found thirty-three examples in the peer-reviewed and grey literature, using a variety of methods and criteria. Program effectiveness, equity, affordability, cost-effectiveness, and the number of beneficiaries emerged as the most frequently-used decision criteria. The relative importance of criteria in the ‘real-world’ trials differed from the frequency in preference elicitation exercises. Neither the decision-making method used, nor the relative economic strength of the country in which the exercise took place, appeared to have a strong effect on the type of criteria chosen. CONCLUSIONS: Health care decisions are made based on criteria related both to the health need of the population and the organizational context of the decision. Following issues related to effectiveness and affordability, ethical issues such as equity and accessibility are commonly identified as important criteria in health care resource allocation decisions. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1186/s12913-015-0814-3) contains supplementary material, which is available to authorized users

An exploratory cluster randomised controlled trial of knowledge translation strategies to support evidence-informed decision-making in local governments (The KT4LG study)

Background: Childhood overweight and obesity is the most prevalent and, arguably, politically complex child health problem internationally. Governments, communities and industry have important roles to play, and are increasingly expected to deliver an evidence-informed system-wide prevention program. However, efforts are impeded by a lack of organisational access to and use of research evidence. This study aims to identify feasible, acceptable and ideally, effective knowledge translation (KT) strategies to increase evidence-informed decision making in local governments, within the context of childhood obesity prevention as a national policy priority.Methods/Design: This paper describes the methods for KT4LG, a cluster randomised controlled trial which is exploratory in nature, given the limited evidence base and methodological advances. KT4LG aims to examine a program of KT strategies to increase the use of research evidence in informing public health decisions in local governments. KT4LG will also assess the feasibility and acceptability of the intervention. The intervention program comprises a facilitated program of evidence awareness, access to tailored research evidence, critical appraisal skills development, networking and evidence summaries and will be compared to provision of evidence summaries alone in the control program. 28 local governments were randomised to intervention or control, using computer generated numbers, stratified by budget tertile (high, medium or low). Questionnaires will be used to measure impact, costs, and outcomes, and key informant interviews will be used to examine processes, feasibility, and experiences. Policy tracer studies will be included to examine impact of intervention on policies within relevant government policy documents.Discussion: Knowledge translation intervention studies with a focus on public health and prevention are very few in number. Thus, this study will provide essential data on the experience of program implementation and evaluation of a system-integrated intervention program employed within the local government public health context. Standardised programs of system, organisational and individual KT strategies have not been described or rigorously evaluated. As such, the findings will make a significant contribution to understanding whether a facilitated program of KT strategies hold promise for facilitating evidence-informed public health decision making within complex multisectoral government organisations.<br /