Patient Engagement: The Key to Redesign the Exchange Between the Demand and Supply for Healthcare in the Era of Active Ageing

The last decades' changes in the epidemiological trends of chronic disease - also due to the ageing population - and the increased length and quality of life among the majority of Western population have introduced important changes in the organization and management of the healthcare systems. Consequently, health systems throughout the world are searching for new and effective ways to make their services more responsive to new patients and the public's health needs and demands. The idea of patient engagement - borrowed from the marketing conceptualization of consumer engagement - moves from the assumption that making patients/clients co-producers of their health can enhance their satisfaction with the healthcare system as well as their responsibility in both care and prevention by improving clinical outcomes and reducing health delivery costs. To make people aware of their health services options by supporting them in the decision-making process and to engage them in enacting preventive and healthy behaviors is vital for achieving successful health outcomes and preventing waste of resources. In this chapter, we outline a model (PHE model) that explains the patients' subjective experience with their health management process and the levers that may enact the passage from one phase of the process to the other. Based on this conceptual model of patient engagement will be proposed a tool kit of priority actions that may sustain the patient in its process of engagement.

[Experience and problems of the primary health care centers' specialists in the implementation of the integrated health system based on family medicine in Ukraine]

The experience of the primary health care' centers in Lviv, Mykolaiv, Kherson regions on the basis of family medicine, integrated medical space, modern governance mechanisms, market technology, promotion trasmural' approach, intersectoral coordination and collaboration and preventative health care population allows to get the maximum effectiveness of the provision of public health in relation to a particular administrative area with limited resources.

Identifying prioritization criteria to supplement critical care triage protocols for the allocation of ventilators during a pandemic influenza

The purpose of this study was to identify supplementary criteria to provide direction when the Ontario Health Plan for an Influenza Pandemic (OHPIP) critical care triage protocol is rendered insufficient by its inability to discriminate among patients assessed as urgent, and there are insufficient critical care resources available to treat those in that category. To accomplish this task, a Supplementary Criteria Task Force for Critical Care Triage was struck at the University of Toronto Joint Centre for Bioethics. The task force reviewed publically available protocols and policies on pandemic flu planning, identified 13 potential triage criteria and determined a set of eight key ethical, legal and practical considerations against which it assessed each criterion. An online questionnaire was distributed to clinical, policy and community stakeholders across Canada to obtain feedback on the 13 potential triage criteria toward selecting those that best met the eight considerations. The task force concluded that the balance of arguments favoured only two of the 13 criteria it had identified for consideration: first come, first served and random selection. The two criteria were chosen in part based on a need to balance the clearly utilitarian approach employed in the OHPIP with equity considerations. These criteria serve as a defensible "fail safe" mechanism for any triage protocol.

[A new mode of primary health care--pilot regions experience]

It has been analyzed the new model of primary health care (PHC), implemented in the pilot regions, which is based on international approaches with proven efficacy. It has been evaluated the organization of primary health care in the pilot regions from the point of performance by the health care system of its main goals and objectives--improvement of health of the population, optimization of financial resources allocation (distribution), ensuring sensitivity, accessibility and structural efficiency of health care. It is proved that the modernization model of health care in Ukraine is fully consistent with the principles, requirements and criteria produced for the effective operation of the primary health care assistance in the world. Using actual data and taking into account the context, a complex of measures to implement the PHC model of modernization in Ukraine has been determined.

The transformation of disabilities organizations

This article summarizes the five major characteristics of the transformation era and describes how intellectual and closely related developmental disabilities organizations can apply specific transformation strategies associated with each characteristic. Collectively, the characteristics and strategies provide a framework for transformation thinking, learning, and acting. Specific application examples are given.

Allocating limited resources in a time of fiscal constraints: a priority setting case study from Dalhousie University Faculty of Medicine

Facing a projected $1.4M deficit on a $35M operating budget for fiscal year 2011/2012, members of the Dalhousie University Faculty of Medicine developed and implemented an explicit, transparent, criteria-based priority setting process for resource reallocation. A task group that included representatives from across the Faculty of Medicine used a program budgeting and marginal analysis (PBMA) framework, which provided an alternative to the typical public-sector approaches to addressing a budget deficit of across-the-board spending cuts and political negotiation. Key steps to the PBMA process included training staff members and department heads on priority setting and resource reallocation, establishing process guidelines to meet immediate and longer-term fiscal needs, developing a reporting structure and forming key working groups, creating assessment criteria to guide resource reallocation decisions, assessing disinvestment proposals from all departments, and providing proposal implementation recommendations to the dean. All departments were required to submit proposals for consideration. The task group approved 27 service reduction proposals and 28 efficiency gains proposals, totaling approximately $2.7M in savings across two years. During this process, the task group faced a number of challenges, including a tight timeline for development and implementation (January to April 2011), a culture that historically supported decentralized planning, at times competing interests (e.g., research versus teaching objectives), and reductions in overall health care and postsecondary education government funding. Overall, faculty and staff preferred the PBMA approach to previous practices. Other institutions should use this example to set priorities in times of fiscal constraints.

Acute rheumatic fever: the danger for our children

THE NEW Zealand Government's allocation of $21 million in the 2013 Budget for treatment and prevention of acute rheumatic fever (ARF) highlights the impact this disease has on the long-term health of New Zealand's marginalised communities. ARF is a disease confined largely to developing nations and is regarded in the developed world as a disease of deprivation and poverty, yet New Zealand has a high incidence, Largely within Maori and Pacific populations. ARF arises from an often mild throat infection caused by streptococcal bacteria. The mechanisms by which this microorganism triggers rheumatic fever and its cardiac sequelae are complex. Awareness of these mechanisms can help health professionals understand prevention and treatment strategies designed to reduce the burden of ARF in vulnerable communities.

Value-based resource management: a model for best value nursing care

With the health care environment shifting to a value-based payment system, Catholic Health Initiatives nursing leadership spearheaded an initiative with 14 hospitals to establish best nursing care at a lower cost. The implementation of technology-enabled business processes at point of care led to a new model for best value nursing care: Value-Based Resource Management. The new model integrates clinical patient data from the electronic medical record and embeds the new information in care team workflows for actionable real-time decision support and predictive forecasting. The participating hospitals reported increased patient satisfaction and cost savings in the reduction of overtime and improvement in length of stay management. New data generated by the initiative on nursing hours and cost by patient and by population (Medicare severity diagnosis-related groups), and patient health status outcomes across the acute care continuum expanded business intelligence for a value-based population health system.

Objectivity of reimbursement decisions - does it always has to pay off?

Rising health care needs impose increased pressure on limited budgets of health care systems around the world. Not only life expectancy is improved, but also increases awareness of patients on modern treatments. It, as a result, leads to the constant search for ways to rationalize health services better attuned to the ability to pay.

THE PURPOSE OF THE STUDY

Analysis of the pricing and reimbersement criteria included in the Polish law.

MATERIALS AND METHODS

Based on a literature review to specify criteria for the allocation of resources in the health sector and to compare them to those included in the "Act on reimbursement of medicines, foodstuffs intended for particular nutritional and medical devices".

RESULTS

Economic criteria dominate the rules governing the reimbursement process of pharmacotherapy in Poland. Referring to the principle of equity they focus on the ability to improve health. Two aspects are repeated frequently: cost-effectiveness and impact on payer's budget.

CONCLUSION

Selection of the allocation criteria was carried out in the Polish law to a limited extend, which may give rise to difficulties in making objective reimbursement decisions.

Commentary: Sense and sensibility: the role of specialists in health care reform

How to redesign the incentives structure in the United States to reward effective coordinated care rather than production volume is a staggering public health policy challenge. In the mind of the public, there is a fine distinction between health care rationing and rational health care. Specialists have a vital but underappreciated role in reining in health care costs, but specific incentives to elicit behavior change with positive social outcomes remain ambiguous. It is imperative, therefore, that redesigning the incentives structure is thoughtfully considered, modeled, and tested prior to implementation, lest an inferior-quality model is inadvertently adopted and costs are only marginally contained. Quality metrics need to be universal and reflect real patient outcomes instead of the degree of investment by the institution in the reporting tools. Still, specialists should take immediate action to implement safe and efficient procedures and to assess their long-term impact on patients' quality of life. Scientific evaluations should guide both the assessment of the appropriateness and the safe delivery of care. Investment in high-quality data architecture and the science of health delivery implementation is an imperative if health care reform is to achieve its goals. Coordination and collaboration between specialists and primary care physicians is essential to this enterprise. Specialists can champion these efforts as they pertain to their areas of expertise by considering their care episodes in the context of the patient as a whole, working closely with generalists, and returning to the mindset of the specialist as a family doctor.

A fair share for the orphans: ethical guidelines for a fair distribution of resources within the bounds of the 10-year-old European Orphan Drug Regulation

For a significant number of patients, there exists no, or only little, interest in developing a treatment for their disease or condition. Especially with regard to rare diseases, the lack of commercial interest in drug development is a burning issue. Several interventions have been made in the regulatory field in order to address the commercial disinterest in these conditions. However, existing regulations mainly focus on the provision of incentives to the sponsors of clinical trials of orphan drugs, and leave unanswered the overarching question about the rightful place of orphan drugs in resource allocation systems. In this article, we analyse the ethical aspects of funding research and development in the field of rare diseases. We then propose an ethical framework that can help health policy makers move forward in the difficult matter of fairly allocating resources for the prevention, diagnosis and treatment of rare diseases.

EQ-5D for the assessment of health-related quality of life and resource allocation in children: a systematic methodological review

OBJECTIVES

EQ-5D is widely used in studies with adults as a source of generic health-related quality of life information and utility weights to inform resource allocation decisions. This methodological systematic review describes the extent to which EQ-5D has been used in the evaluation of children's health care, assesses psychometric properties, and makes recommendations for future good practice.

METHODS

Systematic searches of databases and the Internet to identify studies published during 2000-2010 that either used EQ-5D with children younger than age 19 years as an outcome measure or reported psychometric data. Study characteristics, including measures and psychometric data, were extracted into tables for analysis.

RESULTS

We identified 29 studies that used four versions of the EQ-5D: adult EQ-5D, EQ-5D-Y, Dutch EQ-5D child, and extended with cognitive dimension, EQ-5D+C. Twelve of 29 studies did not specify the EQ-5D version used. Existing literature lacks detail on the specific use of EQ-5D and its potential effects on findings. Version use and psychometric properties were inadequately reported. There are large gaps in current knowledge of psychometric properties across all versions when used with children.

CONCLUSIONS

For reasons of comparability with resource use across adult and children's services, there are arguments for continued use of EQ-5D in studies with children. We recommend use of EQ-5D alongside children-specific quality of life measures and disease-specific measures. Researchers are encouraged to undertake methodological and philosophical analyses to better understand and improve evidence as to how adults who make decisions about resource allocation can best take account of children in decision making.

Optimizing medical resources for spaceflight using the integrated medical model

INTRODUCTION

Efficient allocation of medical resources for spaceflight is important for crew health. The Integrated Medical Model (IMM) was developed to estimate medical event occurrences, mitigation, and resource requirements. An optimization module was created for IMM that uses a systematic process of elimination and preservation to maximize crew health outcomes subject to resource constraints.

METHODS

A maximum medical kit is identified and resources are eliminated according to their relative impact on outcomes of interest. Additional steps allow opportunities for resources to be added back into the medical kit if possible. The effectiveness of the module is demonstrated under six alternative mission profiles by optimizing the medical kit to maximize the expected Crew Health Index (CHI), and comparisons are made with minimum and maximum kits.

RESULTS

The optimum and maximum kits had similar expected CHI, but CHI was more variable for the optimum kit. The maximum kit resulted in the best outcomes, but required at least 13.7 times the mass of the optimum kit and 26.6 times the volume. The largest difference in mean CHI between the optimum and maximum kits occurred for four crewmembers on a 180-d mission (91.1% vs. 95.4%).

CONCLUSIONS

The optimization module may be used as an objective tool to assist with the efficient allocation of medical resources for spaceflight. The module provides a flexible algorithm that may be used in conjunction with the IMM model to assist in medical kit requirements and design.

Allocating scarce resources in disasters: emergency department principles

Decisions about medical resource triage during disasters require a planned structured approach, with foundational elements of goals, ethical principles, concepts of operations for reactive and proactive triage, and decision tools understood by the physicians and staff before an incident. Though emergency physicians are often on the front lines of disaster situations, too often they have not considered how they should modify their decisionmaking or use of resources to allow the "greatest good for the greatest number" to be accomplished. This article reviews key concepts from the disaster literature, providing the emergency physician with a framework of ethical and operational principles on which medical interventions provided may be adjusted according to demand and the resources available. Incidents may require a range of responses from an institution and providers, from conventional (maximal use of usual space, staff, and supplies) to contingency (use of other patient care areas and resources to provide functionally equivalent care) and crisis (adjusting care provided to the resources available when usual care cannot be provided). This continuum is defined and may be helpful when determining the scope of response and assistance necessary in an incident. A range of strategies is reviewed that can be implemented when there is a resource shortfall. The resource and staff requirements of specific incident types (trauma, burn incidents) are briefly considered, providing additional preparedness and decisionmaking tactics to the emergency provider. It is difficult to think about delivering medical care under austere conditions. Preparation and understanding of the decisions required and the objectives, strategies, and tactics available can result in better-informed decisions during an event. In turn, adherence to such a response framework can yield thoughtful stewardship of resources and improved outcomes for a larger number of patients.