1
|
van Alphen A, Lekkerkerker C, van Exel J, Baatenburg de Jong R, Ahaus K. Patients' perspectives on ethical principles to fairly allocate scarce surgical resources during the COVID-19 pandemic in the Netherlands: a Q-methodology study. BMJ Open 2024; 14:e086681. [PMID: 39313289 PMCID: PMC11429350 DOI: 10.1136/bmjopen-2024-086681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 09/04/2024] [Indexed: 09/25/2024] Open
Abstract
OBJECTIVES During the COVID-19 pandemic, healthcare professionals were faced with prioritisation dilemmas due to limited surgical capacity. While the views of healthcare professionals on fair allocation have been given considerable attention, the views of patients have been overlooked. To address this imbalance, our study aimed to identify which ethical principles are most supported by patients regarding the fair allocation of surgical resources. DESIGN A Q-methodology study was conducted. Participants ranked ordered 20 statements covering different viewpoints on fair allocation according to their point of view, followed by an interview. Principal component analysis followed by varimax rotation was used to identify subgroups who broadly agreed in terms of their rankings. SETTING The setting of this study was in the Netherlands. PARTICIPANTS 16 patient representatives were purposively sampled. RESULTS Two perspectives were identified, both of which supported utilitarianism. In perspective 1, labelled as 'clinical needs and outcomes', resource allocation should aim to maximise the health gains based on individual patient characteristics. In perspective 2, labelled as 'population outcomes and contribution to society', allocation should maximise health gains as with perspective 1, but this should also consider societal gains. CONCLUSIONS There was a broad agreement among patient representatives that utilitarianism should be the guiding ethical principle for fair allocation of scarce surgical resources. The insights gained from this study should be integrated into policymaking and prioritisation strategies in future healthcare crises.
Collapse
Affiliation(s)
- Anouk van Alphen
- Department of Otorhinolaryngology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Caroline Lekkerkerker
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Erasmus Centre for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Rob Baatenburg de Jong
- Department of Otorhinolaryngology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Kees Ahaus
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
2
|
Rendall J, McHugh N, Baker R, Mason H, Biosca O. From polarity to plurality: Perceptions of COVID-19 and policy measures in England and Scotland. Health Expect 2024; 27:e14069. [PMID: 38733243 PMCID: PMC11087883 DOI: 10.1111/hex.14069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 04/25/2024] [Accepted: 04/28/2024] [Indexed: 05/13/2024] Open
Abstract
AIM The aim of this study was to uncover perspectives on the COVID-19 pandemic and the responses implemented by the UK and Scottish Governments to help control the spread of infection. Such understanding could help to inform future responses to pandemics at individual, community and national levels. METHOD Q methodology was used to elicit perspectives from people in England and Scotland with different experiences of the pandemic including public health officials, key workers, those on furlough, those who were unvaccinated or vaccinated to different levels, those who were 'shielding' because they were at higher risk and people with different scientific expertise. Participants rank-ordered phrases about different aspects of COVID-19 according to their viewpoint. Factor analysis was then conducted in conjunction with interview material from the same respondents. RESULTS A four-factor solution was statistically supported and was interpretable alongside the qualitative accounts of participants loading on these factors. These four perspectives are titled Dangerous and Unaccountable Leadership, Fear and Anger at Policy and Public responses, Governing Through a Crisis and Injustices Exposed. CONCLUSION The four perspectives demonstrate plurality and nuance in views on COVID-19 and the associated policies and restrictions, going beyond a binary narrative that has been apparent in popular and social media. The four perspectives include some areas of common ground, as well as disagreement. We argue that understanding the detail of different perspectives might be used to build cohesion around policy initiatives in future. PATIENT OR PUBLIC CONTRIBUTION The development of the statement set, which is rank-ordered by participants in a Q study, and factor interpretations were informed by views of the general public. The statement set was initially developed using existing publicly available material based on members of the general public experiencing the pandemic first hand. It was then piloted with members of the public experiencing different challenges as a result of COVID-19 and the subsequent lockdown and updated based on feedback. Finally, interpretations of the identified factors were presented publicly and edited according to their feedback.
Collapse
Affiliation(s)
- Jack Rendall
- The Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Neil McHugh
- The Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Rachel Baker
- The Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Helen Mason
- The Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Olga Biosca
- The Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| |
Collapse
|
3
|
Gustavsson E, Lindblom L. Justification of principles for healthcare priority setting: the relevance and roles of empirical studies exploring public values. JOURNAL OF MEDICAL ETHICS 2024:jme-2022-108702. [PMID: 36813548 DOI: 10.1136/jme-2022-108702] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 02/16/2023] [Indexed: 06/18/2023]
Abstract
How should scarce healthcare resources be distributed? This is a contentious issue that became especially pressing during the pandemic. It is often emphasised that studies exploring public views about this question provide valuable input to the issue of healthcare priority setting. While there has been a vast number of such studies it is rarely articulated, more specifically, what the results from these studies would mean for the justification of principles for priority setting. On the one hand, it seems unreasonable that public values would straightforwardly decide the ethical question of how resources should be distributed. On the other hand, in a democratic society, it seems equally unreasonable that they would be considered irrelevant for this question. In this paper we draw on the notion of reflective equilibrium and discuss the relevance and roles that empirical studies may plausibly have for justification in priority setting ethics. We develop a framework for analysing how different kinds of empirical results may have different kinds of implications for justification.
Collapse
Affiliation(s)
- Erik Gustavsson
- Division of Philosophy and Applied Ethics, Department of Culture and Society, Linköping University, Linköping, Sweden
- The National Centre for Priorities in Health, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Lars Lindblom
- Division of Philosophy and Applied Ethics, Department of Culture and Society, Linköping University, Linköping, Sweden
| |
Collapse
|
4
|
Boxebeld S, Geijsen T, Tuit C, Exel JV, Makady A, Maes L, van Agthoven M, Mouter N. Public preferences for the allocation of societal resources over different healthcare purposes. Soc Sci Med 2024; 341:116536. [PMID: 38176245 DOI: 10.1016/j.socscimed.2023.116536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 11/27/2023] [Accepted: 12/19/2023] [Indexed: 01/06/2024]
Abstract
OBJECTIVE Increasing healthcare expenditures require governments to make difficult prioritization decisions. Considering public preferences can help raise citizens' support. Previous research has predominantly elicited preferences for the allocation of public resources towards specific treatments or patient groups and principles for resource allocation. This study contributes by examining public preferences for budget allocation over various healthcare purposes in the Netherlands. METHODS We conducted a Participatory Value Evaluation (PVE) choice experiment in which 1408 respondents were asked to allocate a hypothetical budget over eight healthcare purposes: general practice and other easily accessible healthcare, hospital care, elderly care, disability care, mental healthcare, preventive care by encouragement, preventive care by discouragement, and new and better medicines. A default expenditure was set for each healthcare purpose, based on current expenditures. Respondents could adjust these default expenditures using sliders and were presented with the implications of their adjustments on health and well-being outcomes, the economy, and the healthcare premium. As a constraint, the maximum increase in the mandatory healthcare premium for adult citizens was €600 per year. The data were analysed using descriptive statistics and a Latent Class Cluster Analysis (LCCA). RESULTS On average, respondents preferred to increase total expenditures on all healthcare purposes, but especially on elderly care, new and better medicines, and mental healthcare. Three preference clusters were identified. The largest cluster preferred modest increases in expenditures, the second a much higher increase of expenditures, and the smallest favouring a substantial reduction of the healthcare premium by decreasing the expenditure on all healthcare purposes. The analyses also demonstrated substantial preference heterogeneity between clusters for budget allocation over different healthcare purposes. CONCLUSIONS The results of this choice experiment show that most citizens in the Netherlands support increasing healthcare expenditures. However, substantial heterogeneity was identified in preferences for healthcare purposes to prioritize. Considering these preferences may increase public support for prioritization decisions.
Collapse
Affiliation(s)
- Sander Boxebeld
- Department of Health Economics, Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam, the Netherlands; Erasmus Choice Modelling Centre (ECMC), Erasmus University Rotterdam, the Netherlands; Erasmus Centre for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, the Netherlands.
| | | | | | - Job van Exel
- Department of Health Economics, Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam, the Netherlands; Erasmus Choice Modelling Centre (ECMC), Erasmus University Rotterdam, the Netherlands; Erasmus Centre for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, the Netherlands
| | - Amr Makady
- Janssen-Cilag B.V., Breda, the Netherlands
| | | | | | - Niek Mouter
- Populytics, Leiden, the Netherlands; Transport and Logistics Group, Faculty of Technology, Policy & Management (TPM), Delft University of Technology, the Netherlands
| |
Collapse
|
5
|
Scheefhals ZTM, de Vries EF, Struijs JN, Numans ME, van Exel J. Stakeholder perspectives on payment reform in maternity care in the Netherlands: A Q-methodology study. Soc Sci Med 2024; 340:116413. [PMID: 38000174 DOI: 10.1016/j.socscimed.2023.116413] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 06/29/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023]
Abstract
Based on theoretical notions, there is consensus that alternative payment models to the common fee-for-service model have the potential to improve healthcare quality through increased collaboration and reduced under- and overuse. This is particularly relevant for maternity care in the Netherlands because perinatal mortality rates are relatively high in comparison to other Western countries. Therefore, an experiment with bundled payments for maternity care was initiated in 2017. However, the uptake of this alternative payment model remains low, as also seen in other countries, and fee-for-service models prevail. A deeper understanding of stakeholders' perspectives on payment reform in maternity care is necessary to inform policy makers about the obstacles to implementing alternative payment models and potential ways forward. We conducted a Q-methodology study to explore perspectives of stakeholders (postpartum care managers, midwives, gynecologists, managers, health insurers) in maternity care in the Netherlands on payment reform. Participants were asked to rank a set of statements relevant to payment reform in maternity care and explain their ranking during an interview. Factor analysis was used to identify patterns in the rankings of statements. We identified three distinct perspectives on payment reform in maternity care. One general perspective, broadly supported within the sector, focusing mainly on outcomes, and two complementary perspectives, one focusing more on equality and one focusing more on collaboration. This study shows there is consensus among stakeholders in maternity care in the Netherlands that payment reform is required. However, stakeholders have different views on the purpose and desired design of the payment reform and set different conditions. Working towards payment reform in co-creation with all involved parties may improve the general attitude towards payment reform, may enhance the level of trust among stakeholders, and may contribute to a higher uptake in practice.
Collapse
Affiliation(s)
- Zoë T M Scheefhals
- Department of National Health and Healthcare, Center for Public Health, Healthcare and Society, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands; Department of Public Health and Primary Care, Health Campus The Hague, Leiden University Medical Center, The Hague, the Netherlands.
| | - Eline F de Vries
- Department of Health Economics and Healthcare, Center for Public Health, Healthcare and Society, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands.
| | - Jeroen N Struijs
- Department of National Health and Healthcare, Center for Public Health, Healthcare and Society, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands; Department of Public Health and Primary Care, Health Campus The Hague, Leiden University Medical Center, The Hague, the Netherlands.
| | - Mattijs E Numans
- Department of Public Health and Primary Care, Health Campus The Hague, Leiden University Medical Center, The Hague, the Netherlands.
| | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus Centre for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, Rotterdam, the Netherlands.
| |
Collapse
|
6
|
Ramlo SE. Using Q methodology in health sciences education to study subjectivity. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2023; 28:1711-1722. [PMID: 37071262 DOI: 10.1007/s10459-023-10214-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/04/2023] [Indexed: 06/19/2023]
Abstract
Q methodology is a unique, yet underutilized methodology designed specifically to scientifically study subjectivity. Q, as it is most often referred to, is an appropriate methodology whenever a researcher is interested in uncovering and describing the multiple divergent viewpoints on any topic. Such discovery of viewpoints provides insight into the subjectivities related to policies, values, priorities, judgements, opinions, and decisions. The disciplines where Q has been used for research are many, and include health sciences, education, and other social science / behavioral science fields. Because of its rather idiosyncratic place in research, however, many Q methodologists are self-taught or seek education through a few select universities that offer graduate level Q courses. The key to successfully approaching a Q study is to embrace its unique approach to studying subjectivity such that it is a powerful tool in health science education and other fields. It is common to find inconsistencies related to Q terminology, analyses, and decision making across studies. There is often an over reliance on concepts that come from purely quantitative methodologies such as R factor analysis rather than embracing the qualitative-quantitative hybridity of Q. This article is written as a primer with a focus on understanding Q at a deeper level rather than a step-by-step guide.
Collapse
Affiliation(s)
- Susan E Ramlo
- University of Akron & SueZ Q, LLC, 3189 Middleton Rd, 44236, Hudson, OH, USA.
| |
Collapse
|
7
|
Huang SF, Liao JY. Home Care Aides' Perspectives of Occupational Tobacco Smoke Exposure: A Q Methodology Study. Nicotine Tob Res 2023; 25:1641-1647. [PMID: 37279967 DOI: 10.1093/ntr/ntad087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 05/06/2023] [Accepted: 06/06/2023] [Indexed: 06/08/2023]
Abstract
INTRODUCTION The increased growth of older adults has generated demand for home care aides (HCAs). Occupational tobacco smoke exposure (OTSE) may risk their health which should be paid attention to. AIMS AND METHODS This study explored the HCAs' perspectives of OTSE to inform health promotion programs catering to individual needs. A two-stage Q methodology was employed for data collection and analysis. Thirty-nine Q statements were extracted in the first stage and then 51 HCAs with OTSE were recruited to complete Q sorting in the second stage. PQ Method software was used for data analysis. Principal component analysis was performed to determine the most appropriate number of factors. RESULTS The five factors identified from HCAs' perspective of OTSE explained 51% of the variance. The HCAs agreed that OTSE could increase cancer risk. The HCAs with factor I did not care about OTSE, tending to complete their work. The HCAs with factor II agreed with the health hazards of OTSE, but did not know how to help their clients stop smoking. The HCAs with factor III cared about OTSE but were afraid of disrupting the client-provider relationship. The HCAs with factor IV regarded OTSE as a priority for occupational interventions whereas the HCAs with factor V did not think OTSE was an issue and believed that they could balance work and OTSE health hazards. CONCLUSIONS Our findings will inform the design of home care pre-service and on-the-job training courses. Long-term care policies should be developed to promote smoke-free workplaces. IMPLICATIONS There are five types of HCAs' perspectives on OTSE. The tailor interventions can be developed to help them avoid the OTSE (eg, opening windows for ventilation or using air purification equipment) and have an OTSE-free space.
Collapse
Affiliation(s)
- Su-Fei Huang
- Department of Intelligent Technology and Long-Term Care, MacKay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
| | - Jung-Yu Liao
- Department of Health Promotion and Health Education, National Taiwan Normal University, Taipei, Taiwan
| |
Collapse
|
8
|
Stenmarck MS, Jølstad B, Baker R, Whitehurst DG, Barra M. A severely fragmented concept: Uncovering citizens' subjective accounts of severity of illness. Soc Sci Med 2023; 330:116046. [PMID: 37392648 DOI: 10.1016/j.socscimed.2023.116046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 06/09/2023] [Accepted: 06/21/2023] [Indexed: 07/03/2023]
Abstract
Universal healthcare is constrained by national governments' finite health resources. This gives rise to complex priority-setting dilemmas. In several universal healthcare systems, the notion of severity (Norwegian: 'alvorlighet') is a key consideration in priority setting, such that treatments for 'severe' illness may be prioritised even when evidence suggests it would not be as cost-effective as treatment options for other conditions. However, severity is a poorly-defined concept, and there is no consensus on what severity means in the context of healthcare provision - whether viewed from public, academic, or professional perspectives. Though several public preference-elicitation studies demonstrate that severity is considered relevant in healthcare resource distribution, there is a paucity of research on public perceptions on the actual meaning of severity. We conducted a Q-methodology study between February 2021 and March 2022 to investigate views on severity amongst general public participants in Norway. Group interviews (n = 59) were conducted to gather statements for the Q-sort ranking exercises (n = 34). Data were analysed using by-person factor analysis to identify patterns in the statement rankings. We present a rich picture of perspectives on the term 'severity', and identify four different, partly conflicting, views on severity in the Norwegian population, with few areas of consensus. We argue that policymakers ought to be made aware of these differing perspectives on severity, and that there is need for further research on the prevalence of these views and on how they are distributed within populations.
Collapse
Affiliation(s)
- Mille Sofie Stenmarck
- The Health Services Research Unit - HØKH, Akershus University Hospital HF, Lørenskog, Norway; Faculty of Medicine, University of Oslo, Norway.
| | - Borgar Jølstad
- The Health Services Research Unit - HØKH, Akershus University Hospital HF, Lørenskog, Norway
| | - Rachel Baker
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Scotland, UK
| | | | - Mathias Barra
- The Health Services Research Unit - HØKH, Akershus University Hospital HF, Lørenskog, Norway
| |
Collapse
|
9
|
Cadham CJ, Prosser LA. Eliciting Trade-Offs Between Equity and Efficiency: A Methodological Scoping Review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:943-952. [PMID: 36805575 DOI: 10.1016/j.jval.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/09/2023] [Accepted: 02/12/2023] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To identify differences in the approaches and results of studies that elicit equity-efficiency trade-offs that can inform equity-informative cost-effectiveness analysis for healthcare resource allocation. METHODS We searched Ovid (Medline), EconLit, and Scopus prior to June 25, 2021. Inclusion criteria were: (1) peer-reviewed or (2) gray literature; (3) published in English; (4) survey-based; (5) parameterized a social welfare function to quantify inequality aversion or (6) elicited a trade-off in equity and efficiency characteristics of health interventions. Exclusion criteria were: (1) studies that did not conduct a trade-off or (2) theoretical studies. We abstracted details on study methods, results, and limitations. Studies were grouped by following approach: (1) social welfare function or (2) preference ranking and distributional weighting. We described findings separately for each approach category. RESULTS Seventy-seven papers were included, 28 parameterized social welfare functions and 49 were classified as preference ranking and distributional weighting. Study methods were heterogeneous. Studies were conducted across 29 countries. Sample sizes and composition, survey methods and question framing varied. Preferences for equity were mixed. Across both approach categories: 39 studies were classified as clear evidence of inequality aversion; 33 found mixed evidence; and 4 had no evidence of aversion. Evidence of between and within-study heterogeneity was found. Preferences for equity may differ by gender, profession, political ideology, income, and education. CONCLUSIONS Substantial variability in study methods limit the direct comparability of findings and their use in equity-informed cost-effectiveness analysis. Future researches using representative samples that explore within and between country heterogeneity is needed.
Collapse
Affiliation(s)
- Christopher J Cadham
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA.
| | - Lisa A Prosser
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, MI, USA; Susan B. Meister Child Health Evaluation and Research Center, Department of Pediatrics, Medical School, University of Michigan, Ann Arbor, MI, USA
| |
Collapse
|
10
|
van Hulsen MAJ, Rohde KIM, van Exel J. Preferences for investment in and allocation of additional healthcare capacity. Soc Sci Med 2023; 320:115717. [PMID: 36716698 DOI: 10.1016/j.socscimed.2023.115717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 01/17/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023]
Abstract
Policy makers need to make decisions regarding the allocation of scarce healthcare resources. We study preferences for investment in additional healthcare capacity and allocation between two regions, focusing on reducing waiting time for elective surgery for a physical health problem. We elicit preferences from a societal and an individual perspective, with unequal initial waiting times between the two regions. In an online survey, 1039 respondents were randomly assigned to one of three versions of the experiment: (1) a social planner perspective, placing respondents in the role of a policy maker; (2) an individual perspective where the respondent's own region was better off regarding initial waiting times; (3) an individual perspective where the individual's own region was worse off regarding initial waiting times. Respondents were asked to rank the status quo and five scenarios where the investment in additional capacity led to different distributions of shorter waiting times between regions. For all allocations we presented both the reduction in waiting time and the resulting final waiting time for both regions. We find that in version 1 of the experiment, preferences were in line with inequality aversion and Rawlsian preferences regarding final waiting time. In version 3, similar preferences were found, although here they also align with individualistic preferences. In version 2, preferences were more heterogeneous, with both individualistic and egalitarian preferences present. Concluding, individualistic and egalitarian preferences mostly concerned final waiting time. We therefore recommend policy makers to focus on the effect on final waiting time instead of the reduction of waiting time.
Collapse
Affiliation(s)
- Merel A J van Hulsen
- Erasmus School of Economics (ESE), Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus Research Institute of Management (ERIM), Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Kirsten I M Rohde
- Erasmus School of Economics (ESE), Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus Research Institute of Management (ERIM), Erasmus University Rotterdam, Rotterdam, the Netherlands; Tinbergen Institute, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - Job van Exel
- Tinbergen Institute, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus School of Health Policy & Management (ESHPM), Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus Centre for Health Economics Rotterdam (EsCHER), Rotterdam, the Netherlands.
| |
Collapse
|
11
|
An identifiable model of lung mechanics to diagnose and monitor COPD. Comput Biol Med 2023; 152:106430. [PMID: 36543001 DOI: 10.1016/j.compbiomed.2022.106430] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 11/23/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Current methods to diagnose and monitor COPD employ spirometry as the gold standard to identify lung function reduction with reduced forced expiratory volume (FEV1)/vital capacity (VC) ratio. Current methods utilise linear assumptions regarding airway resistance, where nonlinear resistance modelling may provide rapid insight into patient specific condition and disease progression. This study examines model-based expiratory resistance in healthy lungs and those with progressively more severe COPD. METHODS Healthy and COPD pressure (P)[cmH2O] and flow (Q)[L/s] data is obtained from the literature, and 5 intermediate levels of COPD and responses are created to simulate COPD progression and assess model-based metric resolution. Linear and nonlinear single compartment models are used to identify changes in inspiratory (R1,insp) and linear (R1,exp)/nonlinear (R2Φ) expiratory resistance with disease severity and over the course of expiration. RESULTS R1,insp increases from 2.1 to 7.3 cmH2O/L/s, R1,exp increases from 2.4 to 10.0 cmH2O/L/s with COPD severity. Nonlinear R2Φ increases (mean R2Φ: 2.5 cmH2O/L/s (healthy) to 24.4 cmH2O/L/s (COPD)), with increasing end-expiratory nonlinearity as COPD severity increases. CONCLUSION Expiratory resistance is increasingly highly nonlinear with COPD severity. These results show a simple, nonlinear model can capture fundamental COPD dynamics and progression from regular breathing data, and such an approach may be useful for patient-specific diagnosis and monitoring.
Collapse
|
12
|
The prominence effect in health-care priority setting. JUDGMENT AND DECISION MAKING 2022. [DOI: 10.1017/s1930297500009463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Abstract
People often choose the option that is better on the most subjectively
prominent attribute — the prominence effect. We studied the effect of
prominence in health care priority setting and hypothesized that values
related to health would trump values related to costs in treatment choices,
even when individuals themselves evaluated different treatment options as
equally good. We conducted pre-registered experiments with a diverse Swedish
sample and a sample of international experts on priority setting in health
care (n = 1348). Participants, acting in the role of policy makers, revealed
their valuation for different medical treatments in hypothetical scenarios.
Participants were systematically inconsistent between preferences expressed
through evaluation in a matching task and preferences expressed through
choice. In line with our hypothesis, a large proportion of participants
(General population: 92%, Experts 84% of all choices) chose treatment
options that were better on the health dimension (lower health risk) despite
having previously expressed indifference between those options and others
that were better on the cost dimension. Thus, we find strong evidence of a
prominence effect in health-care priority setting. Our findings provide a
psychological explanation for why opportunity costs (i.e., the value of
choices not exercised) are neglected in health care priority
setting.
Collapse
|
13
|
Samenjo KT, Bengtson M, Onasanya A, Zambrano JCI, Oladunni O, Oladepo O, van Engelen J, Diehl JC. Stakeholders’ Perspectives on the Application of New Diagnostic Devices for Urinary Schistosomiasis in Oyo State, Nigeria: A Q-Methodology Approach. GLOBAL HEALTH: SCIENCE AND PRACTICE 2022; 10:GHSP-D-21-00780. [PMID: 36041843 PMCID: PMC9426976 DOI: 10.9745/ghsp-d-21-00780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 05/31/2022] [Indexed: 11/16/2022]
Abstract
New diagnostic devices for schistosomiasis should be designed to function best within the local endemic health care context and support stakeholders at various levels of the health care system in performing the tasks to help control and eventually eliminate schistosomiasis. Urinary schistosomiasis is a waterborne parasitic infection caused by Schistosoma haematobium that affects approximately 30 million people annually in Nigeria. Treatment and eradication of this infection require effective diagnostics. However, current diagnostic tests have critical shortcomings and consequently are of limited value to stakeholders throughout the health care system who are involved in targeting the diagnosis and subsequent control of schistosomiasis. New diagnostic devices that fit the local health care infrastructure and support the different stakeholder diagnostic strategies remain a critical need. This study focuses on understanding, by means of Q-methodology, the context of use and application of a new diagnostic device that is needed to effectively diagnose urinary schistosomiasis in Oyo State, Nigeria. Q-methodology is a technique that investigates subjectivity by exploring how stakeholders rank-order opinion statements about a phenomenon. In this study, 40 statements were administered to evaluate stakeholder perspectives on the context of use and application of potential new diagnostic devices and how these perspectives or viewpoints are shared with other stakeholders. Potential new diagnostic devices will need to be deployable to remote or distant communities, be affordable, identify and confirm infection status before treatment in patients whose diagnosis of urinary schistosomiasis is based on self-reporting, and equip health care facilities with diagnostic devices optimized for the local setting while requiring local minimal infrastructural settings. Similarly, the context of use and application of a potential new diagnostic device for urinary schistosomiasis is primarily associated with the tasks stakeholders throughout the health care system perform or procedures employed. These findings will guide the development of new diagnostic devices for schistosomiasis that match the contextual landscape and diagnostic strategies in Oyo.
Collapse
Affiliation(s)
- Karlheinz Tondo Samenjo
- Department of Sustainable Design Engineering, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, Netherlands.
| | - Michel Bengtson
- Department of Parasitology, Leiden University Medical Center, Leiden, Netherlands
| | - Adeola Onasanya
- Department of Sustainable Design Engineering, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, Netherlands
| | - Juan Carlo Intriago Zambrano
- Department of Water Management, Faculty of Civil Engineering and Geosciences, Delft University of Technology, Delft, Netherlands
| | - Opeyemi Oladunni
- Department of Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Oladimeji Oladepo
- Department of Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria
| | - Jo van Engelen
- Department of Sustainable Design Engineering, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, Netherlands
| | - Jan-Carel Diehl
- Department of Sustainable Design Engineering, Faculty of Industrial Design Engineering, Delft University of Technology, Delft, Netherlands
| |
Collapse
|
14
|
Dieteren CM, van Hulsen MAJ, Rohde KIM, van Exel J. How should ICU beds be allocated during a crisis? Evidence from the COVID-19 pandemic. PLoS One 2022; 17:e0270996. [PMID: 35947541 PMCID: PMC9365136 DOI: 10.1371/journal.pone.0270996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 06/21/2022] [Indexed: 11/19/2022] Open
Abstract
Background The first wave of the COVID-19 pandemic overwhelmed healthcare systems in many countries, and the rapid spread of the virus and the acute course of the disease resulted in a shortage of intensive care unit (ICU) beds. We studied preferences of the public in the Netherlands regarding the allocation of ICU beds during a health crisis. Methods We distributed a cross-sectional online survey at the end of March 2020 to a representative sample of the adult population in the Netherlands. We collected preferences regarding the allocation of ICU beds, both in terms of who should be involved in the decision-making and which rationing criteria should be considered. We conducted Probit regression analyses to investigate associations between these preferences and several characteristics and opinions of the respondents. Results A total of 1,019 respondents returned a completed survey. The majority favored having physicians (55%) and/or expert committees (51%) play a role in the allocation of ICU beds and approximately one-fifth did not favor any of the proposed decision-makers. Respondents preferred to assign higher priority to vulnerable patients and patients who have the best prospect of full recovery. They also preferred that personal characteristics, including age, play no role. Conclusion “Our findings show that current guidelines for allocating ICU beds that include age as an independent criterion may not be consistent with societal preferences. Age may only play a role indirectly, in relation to the vulnerability of patients and their prospect of full recovery. Allocation of ICU beds during a health crisis requires a multivalue ethical framework.”
Collapse
Affiliation(s)
- Charlotte M. Dieteren
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Erasmus Centre for Health Economics Rotterdam (EsCHER), Rotterdam, The Netherlands
- * E-mail:
| | - Merel A. J. van Hulsen
- Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Erasmus Research Institute of Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Kirsten I. M. Rohde
- Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Erasmus Research Institute of Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Tinbergen Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Erasmus Centre for Health Economics Rotterdam (EsCHER), Rotterdam, The Netherlands
- Tinbergen Institute, Erasmus University Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
15
|
Perception of Medical Students on the Need for End-of-Life Care: A Q-Methodology Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19137901. [PMID: 35805560 PMCID: PMC9265334 DOI: 10.3390/ijerph19137901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/24/2022] [Accepted: 06/25/2022] [Indexed: 12/04/2022]
Abstract
End-of-life care and the limitation of therapeutic effort are among the most controversial aspects of medical practice. Many subjective factors can influence decision-making regarding these issues. The Q methodology provides a scientific basis for the systematic study of subjectivity by identifying different thought patterns. This methodology was performed to find student profiles in 143 students at Cantabria University (Spain), who will soon deal with difficult situations related to this topic. A chi-square test was used to compare proportions. We obtained three profiles: the first seeks to ensure quality of life and attaches great importance to the patient’s wishes; the second prioritizes life extension above anything else; the third incorporates the economic perspective into medical decision-making. Those who had religious beliefs were mostly included in profile 2 (48.8% vs. 7.3% in profile 1 and 43.9% in profile 3), and those who considered that their beliefs did not influence their ethical principles, were mainly included in profile 3 (48.5% vs. 24.7% in profile 1 and 26.8% in profile 2). The different profiles on end-of-life care amongst medical students are influenced by personal factors. Increasing the clinical experience of students with terminally ill patients would contribute to the development of knowledge-based opinion profiles and would avoid reliance on personal experiences.
Collapse
|
16
|
Kim IJ. Exploring societal perspectives on priorities at the end of life in South Korea using Q-methodology. Jpn J Nurs Sci 2022; 19:e12495. [PMID: 35678103 DOI: 10.1111/jjns.12495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/10/2022] [Accepted: 05/02/2022] [Indexed: 11/29/2022]
Abstract
AIM To explore societal perspectives on priorities at the end of life in South Korea, an Asian country with high characteristics of Confucian culture. Based on this understanding, this study proposes strategies for establishing well-dying Confucian heritage cultures. METHODS Q-methodology, suitable for analyzing human subjectivity, was used in this study. Thirty-four Q-statements were extracted from the 170 Q population, which were gathered from literature reviews and online resources. Participants were 33 people expected to present diverse views of priorities at the end of their lives. The data were analyzed with principal component analysis and varimax rotations using the PQMethod software. RESULTS Four distinct perspectives on priorities at the end of life in South Korea were identified: "Emphasizing the right to self-determination," "Avoiding burdening the family," "Putting life first," and "Connotations with a complex perspective." CONCLUSIONS This study provides strategies for preparing various nursing interventions or policies for the establishment of a well-dying culture based on the four identified perspectives on priorities at the end of life, especially in countries with Confucian heritage cultures.
Collapse
Affiliation(s)
- Ick-Jee Kim
- Department of Nursing, Youngsan University, Yangsan, Gyeongsangnam-do, Republic of Korea
| |
Collapse
|
17
|
Szabo SM, Audhya IF, Feeny D, Neumann P, Malone DC, Gooch KL. Societal perspectives on disease and treatment attributes characterizing rare diseases: a qualitative study from the United States. J Patient Rep Outcomes 2022; 6:9. [PMID: 35072826 PMCID: PMC8785152 DOI: 10.1186/s41687-022-00413-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 01/06/2022] [Indexed: 12/01/2022] Open
Abstract
PURPOSE Under a societal perspective, disease and treatment attributes that the general public deem important should be considered within value frameworks. The objective was to investigate how members of the general public value attributes beyond health gains and healthcare system expenditures; and better understand their perspectives regarding the importance of attributes typically characterizing rare genetic diseases like Duchenne muscular dystrophy (DMD). METHODS Qualitative interviews were conducted to elicit feedback on the importance of disease and treatment attributes from general public participants from three US cities. Participants ranked attributes (scale, 1-10) in terms of importance for future research, reported their rationale for ranking, and provided feedback specific to rare diseases. Interview transcripts were coded using NVivo for thematic analysis. RESULTS The 33 participants (median age, 51 years; 48.5% male) ranked disease severity (mean [median] ranking, 8.7 [9.0]), treatment availability (8.7 [9.0]), and impact on life expectancy (8.4 [9.0]), as most important. The impact on the family, need for equity, and intrinsic value of life were frequently provided rationales. While rare disease as an attribute received a relatively low ranking (6.1 [7.0]), 88% of participants prioritized disease profiles including attributes of severity, health related quality of life (HRQoL) impact, limited lifespan and young age at onset. CONCLUSION Attributes including disease severity, impact on life expectancy and HRQoL, and treatment availability were all highly important to members of the general public. These findings support the growing evidence regarding the importance of expanding value assessments to include attributes considered important from a societal perspective.
Collapse
|
18
|
Ha EH. Home-dwelling older adults' attitudes and perceptions of dementia: A Q-methodological study in South Korea. Jpn J Nurs Sci 2022; 19:e12467. [PMID: 34981635 DOI: 10.1111/jjns.12467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/15/2021] [Accepted: 11/26/2021] [Indexed: 11/30/2022]
Abstract
AIM Older adult attitudes and perceptions of dementia can have a major impact on early diagnosis, efforts to prevent and appropriately treat it, as well as being a family burden. The aim of this study is to explore attitudes and perceptions of dementia of home-dwelling older adults using Q-methodology. METHOD A total of 42 adults, age 65 or over, who live in South Korea ranked 37 Q statements about their attitudes and perceptions of dementia into A Q sort table grid. RESULTS The following three distinct viewpoints were extracted: (1) it is my responsibility to prevent and to care about dementia (family-centered view); (2) there are no ways to treat dementia (despairing views); and (3) dementia is a national responsibility (nation-centered view). CONCLUSION Based on these results, central and local government and communities should work together with older adults to manage dementia and reflect these three viewpoints when developing systematic dementia management programs.
Collapse
Affiliation(s)
- Eun-Ho Ha
- Department of Nursing, Jungwon University, Goesan-gun, South Korea
| |
Collapse
|
19
|
Tinghög G, Strand L. Public Attitudes Toward Priority Setting Principles in Health Care During COVID-19. FRONTIERS IN HEALTH SERVICES 2022; 2:886508. [PMID: 36925871 PMCID: PMC10012618 DOI: 10.3389/frhs.2022.886508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022]
Abstract
What role should cost-effectiveness play in health care priority setting? We assess the level of acceptance toward different priority setting principles in health care during COVID-19 and in general, thereby exploring public support for principles presented at different levels of abstraction. An online survey was distributed to a diverse sample of the Swedish population (n = 1 553). The results show that respondents were generally more supportive of priority setting principles when expressed in general abstract terms than when expressed in more case specific concrete terms. However, prioritization based on cost-effectiveness was deemed as more acceptable when expressed in concrete terms related to health maximization rather than as an abstract principle. Respondents had a general inclination in support of physicians and other health care professionals the primary responsibility for the allocation of scarce resources in the healthcare during COVID-19, while being less supportive of health economists and politicians being involved in these decisions.
Collapse
Affiliation(s)
- Gustav Tinghög
- Swedish National Centre for Priority Setting in Health Care, Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Management and Engineering, Linköping University, Linköping, Sweden
| | - Liam Strand
- Swedish National Centre for Priority Setting in Health Care, Department of Health, Medicine, and Caring Sciences, Linköping University, Linköping, Sweden
| |
Collapse
|
20
|
Rotteveel AH, Lambooij MS, van Exel J, de Wit GA. To what extent do citizens support the disinvestment of healthcare interventions? An exploration of the support for four viewpoints on active disinvestment in the Netherlands. Soc Sci Med 2021; 293:114662. [PMID: 34953417 DOI: 10.1016/j.socscimed.2021.114662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 11/19/2021] [Accepted: 12/15/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Active disinvestment of healthcare interventions (i.e. discontinuing reimbursement by means of a policy decision) has received limited public support in the past. Previous research has identified four viewpoints on active disinvestment among citizens in the Netherlands. However, it remained unclear how strong these viewpoints are supported by society, and by whom. Therefore, the current study aimed to 1) measure the support for these four viewpoints and 2) assess whether support is associated with background characteristics of citizens. METHOD In an online survey, a representative sample of adult citizens in the Netherlands (n = 1794) was asked to rate their agreement with short narratives of the four viewpoints on a 7-point Likert scale. The survey also included questions on sociodemographic characteristics, health status, healthcare utilization, and opinions about responsibility and costs in the healthcare context. Logistic regression models were estimated for each viewpoint to assess the association between viewpoint support and these characteristics. RESULTS The support for the different viewpoints varied between 46.8% and 57.7% of the sample. Viewpoint support was associated with participants' age, gender, educational level, financial situation, healthcare utilization, opinion on the responsibility of the government for the health of citizens, and opinion on whether the increase in healthcare expenditure and health insurance premiums is considered a problem. CONCLUSION Resistance to active disinvestment may partially be explained by the consequences of disinvestment citizens anticipate experiencing themselves. Citizens considering the increase in healthcare expenditure a larger problem were more supportive of disinvestment than those considering it less of a problem.
Collapse
Affiliation(s)
- Adriënne H Rotteveel
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands; Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Mattijs S Lambooij
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - G Ardine de Wit
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| |
Collapse
|
21
|
Morrell L, Buchanan J, Rees S, Barker RW, Wordsworth S. What Aspects of Illness Influence Public Preferences for Healthcare Priority Setting? A Discrete Choice Experiment in the UK. PHARMACOECONOMICS 2021; 39:1443-1454. [PMID: 34409564 PMCID: PMC8599241 DOI: 10.1007/s40273-021-01067-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 05/03/2023]
Abstract
BACKGROUND Decisions on funding new healthcare technologies assume that all health improvements are valued equally. However, public reaction to health technology assessment (HTA) decisions suggests there are health attributes that matter deeply to them but are not currently accounted for in the assessment process. We aimed to determine the relative importance of attributes of illness that influence the value placed on alleviating that illness. METHOD We conducted a discrete choice experiment survey that presented general public respondents with 15 funding decisions between hypothetical health conditions. The conditions were defined by five attributes that characterise serious illnesses, plus the health gain from treatment. Respondent preferences were modelled using conditional logistic regression and latent class analysis. RESULTS 905 members of the UK public completed the survey in November 2017. Respondents generally preferred to provide treatments for conditions with 'better' characteristics. The exception was treatment availability, where respondents preferred to provide treatments for conditions where there is no current treatment, and were prepared to accept lower overall health gain to do so. A subgroup of respondents preferred to prioritise 'worse' health states. CONCLUSION This study suggests a preference among the UK public for treating an unmet need; however, it does not suggest a preference for prioritising other distressing aspects of health conditions, such as limited life expectancy, or where patients are reliant on care. Our results are not consistent with the features currently prioritised in UK HTA processes, and the preference heterogeneity we identify presents a major challenge for developing broadly acceptable policy.
Collapse
Affiliation(s)
- Liz Morrell
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, UK.
- Oxford-UCL Centre for the Advancement of Sustainable Medical Innovation, Radcliffe Department of Medicine, University of Oxford, Oxford, UK.
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Sian Rees
- Oxford Academic Health Science Network, Oxford, UK
| | - Richard W Barker
- Oxford-UCL Centre for the Advancement of Sustainable Medical Innovation, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Old Road Campus, Roosevelt Drive, Oxford, OX3 7LF, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| |
Collapse
|
22
|
Dieteren CM, Reckers-Droog VT, Schrama S, de Boer D, van Exel J. Viewpoints among experts and the public in the Netherlands on including a lifestyle criterion in the healthcare priority setting. Health Expect 2021; 25:333-344. [PMID: 34845790 PMCID: PMC8849370 DOI: 10.1111/hex.13385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 09/10/2021] [Accepted: 10/01/2021] [Indexed: 11/28/2022] Open
Abstract
Context It remains unclear whether there would be societal support for a lifestyle criterion for the healthcare priority setting. This study examines the viewpoints of experts in healthcare and the public regarding support for a lifestyle‐related decision criterion, relative to support for the currently applied criteria, in the healthcare priority setting in the Netherlands. Methods We conducted a Q methodology study in samples of experts in healthcare (n = 37) and the public (n = 44). Participants (total sample N = 81) ranked 34 statements that reflected currently applied decision criteria as well as a lifestyle criterion for setting priorities in healthcare. The ranking data were subjected to principal component analysis, followed by oblimin rotation, to identify clusters of participants with similar viewpoints. Findings We identified four viewpoints. Participants with Viewpoint 1 believe that treatments that have been proven to be effective should be reimbursed. Those with Viewpoint 2 believe that life is precious and every effort should be made to save a life, even when treatment still results in a very poor state of health. Those with Viewpoint 3 accept government intervention in unhealthy lifestyles and believe that individual responsibility should be taken into account in reimbursement decisions. Participants with Viewpoint 4 attribute importance to the cost‐effectiveness of treatments; however, when priorities have to be set, treatment effects are considered most important. All viewpoints were supported by a mix of public and experts, but Viewpoint 1 was mostly supported by experts and the other viewpoints were mostly supported by members of the public. Conclusions This study identified four distinct viewpoints on the healthcare priority setting in the Netherlands, each supported by a mix of experts and members of the public. There seems to be some, but limited, support for a lifestyle criterion—in particular, among members of the public. Experts seem to favour the decision criteria that are currently applied. The diversity in views deserves attention when policymakers want to adhere to societal preferences and increase policy acceptance.
Collapse
Affiliation(s)
- Charlotte M Dieteren
- Department of Health Economics, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.,Erasmus Centre for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Vivian T Reckers-Droog
- Department of Health Economics, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.,Erasmus Centre for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Sara Schrama
- Department of Health Economics, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Dynothra de Boer
- Department of Health Economics, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Job van Exel
- Department of Health Economics, Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.,Erasmus Centre for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, Rotterdam, The Netherlands
| |
Collapse
|
23
|
Vandavasi RKK, McConville D, Uen JF, Wu KW. Do employee perceptions of needs–supply fit impact job satisfaction and job search behavior? JOURNAL OF GENERAL MANAGEMENT 2021. [DOI: 10.1177/03063070211013343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In this study, a job characteristics profile is developed to calculate indirect measures of needs–supply (N-S) fit. Two surveys were conducted with employees in Taiwan, to test N-S fit, employee job satisfaction, intention to leave, and job search behavior. The findings show that employee perceptions of indirect N-S fit are significantly related to job satisfaction and negatively related to intention to leave and job search behavior. We find that an individual’s desires, needs, and subjective “fit” perceptions can impact considerably on how the individual thinks and feels about their job and their inclinations to leave. In addition to contributing empirical evidence of how employee perceptions of N-S fit can affect employee intentions to leave, we conclude that it is of practical importance for practitioners to assess the congruence between an employee’s perceptions of what he or she needs in a job and their subjective perceptions of what is supplied.
Collapse
Affiliation(s)
| | | | | | - Ko-Wei Wu
- National Sun Yat-sen University, Kaohsiung
| |
Collapse
|
24
|
Q Methodology in the COVID-19 Era. Healthcare (Basel) 2021; 9:healthcare9111491. [PMID: 34828537 PMCID: PMC8620337 DOI: 10.3390/healthcare9111491] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/29/2021] [Accepted: 10/31/2021] [Indexed: 11/16/2022] Open
Abstract
All face-to-face studies were affected by the COVID-19 pandemic, as they could not be run in person due to rules and guidance linked to social distancing which were in force during the outbreak. Finding and testing an available COVID-secure approach for both participants and researchers was important as was the need to continue conducting such studies during this critical time. At present, the extant literature indicates a clear gap in research that elucidates how to carry out a Q methodology study online, step by step. This paper describes an option for online Q methodology using an approach that simulates all of the steps performed in a face-to-face setting using an open-source software known as Easy-HtmlQ. Using a case study in telemedicine adoption as illustration, this paper also considers the perspective of both research participants and Q methodology researchers via semi-structured interviews. Using Easy-HtmlQ V1.1 in online Q methodology studies appears to be an affordable, practical and user-friendly solution. Some of the benefits associated with running Q methodology studies online were the decreased costs, enabling the recruitment of wider number of participants, providing a COVID-19-secure environment and offering convenience to both participants and researchers during the research process. The findings of this study may contribute to increasing the number of online Q methodology studies in the future, as it has succeeded in offering a feasible approach for Q methodology researchers.
Collapse
|
25
|
Ghanbari V, Ardalan A, Zareiyan A, Nejati A, Hanfling D, Bagheri A, Rostamnia L. Perceptions on principle of priority setting in disaster triage: A Q-method study. Int Emerg Nurs 2021; 59:101064. [PMID: 34563940 DOI: 10.1016/j.ienj.2021.101064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 07/23/2021] [Accepted: 07/29/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION An ethical plan is required to make decisions regarding setting the priority for assisting injured patients through triage. The aim of this study was to explore the measures used to sort patients for ethical decision-making in disaster triage. METHOD The participants were 54 clinicians and non-clinicians among the Iranian experts. Q-statements were selected from a literature review and face-to-face interviews. Data were analyzed by principal components factor analysis (PCA), Varimax, and hand-rotation techniques. RESULTS Distinct perspectives included: Saving patients with greater medical needs, survivability of patients and the community, providing effective treatment based on available capacity, maximizing health gain, supporting the human generation and productive and independent lives. Approximately 61% of the variance in decision is explained by these factors. CONCLUSION A combination of saving more people and more positive outcomes has been accepted to make an ethical decision in triage. Public engagement needs to reach a more acceptable view of patients' prioritizing factors in a scarce-resource situation.
Collapse
Affiliation(s)
- Vahid Ghanbari
- Emergency Nursing Department, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Ali Ardalan
- Health in Disaster and Emergencies Department, School of Public Health, Tehran University of Medical Sciences, Avecina Ave, Keshavarz Boulevard, Tehran, Iran.
| | - Armin Zareiyan
- Health in Disaster and Emergencies Department, School of Nursing, AJA University of Medical Sciences, Tehran, Iran
| | - Amir Nejati
- Department of Emergency Medicine, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Dan Hanfling
- MD; Clinical Professor of Emergency Medicine, George Washington University, Washington, DC, United States
| | - Alireza Bagheri
- Center for Medical Ethics and History of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Leili Rostamnia
- Nursing Department, School of Nursing and Midwifery, Kermanshah University of Medical Sciences, Kermanshah, Iran
| |
Collapse
|
26
|
Crowe S, Barker E, Roberts M, Lloyd L, de Barros CM, Rebelo-Harris B, Meads C, Saunders CL. Are we asking the right questions? Working with the LGBTQ+ community to prioritise healthcare research themes. RESEARCH INVOLVEMENT AND ENGAGEMENT 2021; 7:64. [PMID: 34556178 PMCID: PMC8460395 DOI: 10.1186/s40900-021-00298-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/14/2021] [Indexed: 06/13/2023]
Abstract
BACKGROUND Conversations about research priorities with members of the public are rarely designed specifically to include people who identify as Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ+) and are not researchers. METHODS Generally, to address this gap, and specifically, to inform future research for CLS, we carried out a rapid review of published research priority sets covering LGBTQ+ topics, and an online workshop to prioritise identified themes. RESULTS Rapid review: results. The rapid review identified 18 LGBTQ+ research priority sets. Some focussed on specific populations such as women or men, younger or older people or people living within families. Five addressed transgender and gender non- conforming populations. All of the research priority sets originated from English-speaking, high and middle-income countries (UK, US, Canada, and Australia), and date from 2016 onwards. Prioritization approaches were wide-ranging from personal commentary to expert workshops and surveys. Participants involved in setting priorities mostly included research academics, health practitioners and advocacy organisations, two studies involved LGBTQ+ public in their process. Research priorities identified in this review were then grouped into themes which were prioritised during the workshop. Workshop: results. For the workshop, participants were recruited using local (Cambridge, UK) LGBTQ+ networks and a national advert to a public involvement in research matching website to take part in an online discussion workshop. Those that took part were offered payment for their time in preparing for the workshop and taking part. Participants personal priorities and experiences contributed to a consensus development process and a final ranked list of seven research themes and participants' experiences of healthcare, mental health advocacy, care homes, caring responsibilities, schools and family units added additional context. CONCLUSIONS From the workshop the three research themes prioritised were: healthcare services delivery, prevention, and particular challenges / intersectionality of multiple challenges for people identifying as LGBTQ+. Research themes interconnected in many ways and this was demonstrated by the comments from workshop participants. This paper offers insights into why these priorities were important from participants' perspectives and detail about how to run an inclusive and respectful public involvement research exercise. On a practical level these themes will directly inform future research direction for CLS.
Collapse
Affiliation(s)
| | | | | | - Lucy Lloyd
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, East Forvie Building, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK
| | | | | | - Catherine Meads
- Faculty of Health, Education, Medicine and Social Care, Anglia Ruskin University, Cambridge, UK
| | - Catherine L Saunders
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, East Forvie Building, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK.
| |
Collapse
|
27
|
Afsharmanesh G, Rahimi F, Zarei L, Peiravian F, Mehralian G. Public and decision-maker stated preferences for pharmaceutical subsidy decisions in Iran: an application of the discrete choice experiment. J Pharm Policy Pract 2021; 14:74. [PMID: 34488901 PMCID: PMC8422609 DOI: 10.1186/s40545-021-00365-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/29/2021] [Indexed: 11/29/2022] Open
Abstract
Background The argument about funding criteria poses challenges for health decision-makers in all countries. This study aimed to investigate the public and decision-maker preferences for pharmaceutical subsidy decisions in Iran. Methods A discrete choice experiment (DCE) was used for eliciting the preferences of the public and decision-makers. Four attributes including health gain after treatment, the severity of the disease, prevalence of the disease, and monthly out of pocket and relevant levels were designed in the form of hypothetical scenarios. The analysis was done by using conditional logit analysis. Results The results show all of four attributes are important for pharmaceutical subsidy decisions. But a medicine that improves health gain after treatment is more likely to be a choice in subsidy decisions (by relative importance of 28% for public and 42% for decision-makers). Out of pocket, severity, and prevalence of disease subsequently influence the preferences of the public and decision-makers, respectively. The greatest difference is observed in changing the health gain after treatment and out of pocket levels, between public and decision-makers. Conclusion This research reveals that the public is willing and able to provide preferences to inform policymakers for pharmaceutical decision-making; it also sets grounds for further studies. Supplementary Information The online version contains supplementary material available at 10.1186/s40545-021-00365-0.
Collapse
Affiliation(s)
- Gita Afsharmanesh
- Department of Pharmacoeconomics and Pharma Management, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Vali-e-asr, Niayesh Junction, Tehran, Iran
| | - Farimah Rahimi
- Health Management and Economics Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Leila Zarei
- Health Policy Research Center, Institute of Health, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Farzad Peiravian
- Department of Pharmacoeconomics and Pharma Management, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Vali-e-asr, Niayesh Junction, Tehran, Iran
| | - Gholamhossein Mehralian
- Department of Pharmacoeconomics and Pharma Management, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Vali-e-asr, Niayesh Junction, Tehran, Iran.
| |
Collapse
|
28
|
A decision support system to solve the problem of health care priority-setting. JOURNAL OF SCIENCE AND TECHNOLOGY POLICY MANAGEMENT 2021. [DOI: 10.1108/jstpm-01-2021-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
The purpose of this study is to provide a decision support tool to deal with the problem of seting priorites among patients competing for limited health care resources. Limited resources and unlimited demands prevent health-care services to be provided to all those in need. This became publicity evident with the current Covid-19 pandemic. Although controversial, health care rationing has always existed and is now inevitable. Setting priorities becomes then inevitable. How to define those priorities is a complex and yet irresolvable issue mainly because it involves several and conflicting criteria, translated into efficiency and equity considerations. This is why multi-criteria decision analysis (MCDA) was introduced to health care as an appropriate decision-support framework for solving complex problems.
Design/methodology/approach
This paper proposes the application of two combined approaches – analytic hierarchy process (AHP)-Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) and AHP-VlseKriterijumska Optimizacija I Kompromisno Resenje (VIKOR), as decision support tools to rank patients with competing needs in a more effective and equitable way. A rationing scenario involving four patients, differentiated by personal characteristics and health conditions, is used to illustrate, test and compare the applicability of both approaches. After extraction of the relative weights of the prioritization criteria involved in the hypothetical scenario from paired wise comparison methods, TOPSIS and VIKOR priority setting methods were designed.
Findings
Results suggest that patients ranking from both combination approaches are similar and in accordance with the order made directly by health-care professionals. Therefore, the relative weights computed by AHP in combination with TOPSIS and/or VIKOR methods could be used with suitable applicability by health-care decision-makers.
Originality/value
This study is the first attempt to apply a combination of MCDA methods to patients’ prioritization context and the first to cross previous studies to deepen and consolidate the research.
Collapse
|
29
|
Reckers-Droog V, van Exel J, Brouwer W. Willingness to Pay for Health-Related Quality of Life Gains in Relation to Disease Severity and the Age of Patients. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1182-1192. [PMID: 34372984 DOI: 10.1016/j.jval.2021.01.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 01/18/2021] [Accepted: 01/24/2021] [Indexed: 05/19/2023]
Abstract
OBJECTIVES Decision-making frameworks that draw on economic evaluations increasingly use equity weights to facilitate a more equitable and fair allocation of healthcare resources. These weights can be attached to health gains or reflected in the monetary threshold against which the incremental cost-effectiveness ratios of (new) health technologies are evaluated. Currently applied weights are based on different definitions of disease severity and do not account for age-related preferences in society. However, age has been shown to be an important equity-relevant characteristic. This study examines the willingness to pay (WTP) for health-related quality of life (QOL) gains in relation to the disease severity and age of patients, and the outcome of the disease. METHODS We obtained WTP estimates by applying contingent-valuation tasks in a representative sample of the public in The Netherlands (n = 2023). We applied random-effects generalized least squares regression models to estimate the effect of patients' disease severity and age, size of QOL gains, disease outcome (full recovery/death 1 year after falling ill), and respondent characteristics on the WTP. RESULTS Respondents' WTP was higher for more severely ill and younger patients and for larger-sized QOL gains, but lower for patients who died. However, the relations were nonlinear and context dependent. Respondents with a lower age, who were male, had a higher household income, and a higher QOL stated a higher WTP for QOL gains. CONCLUSIONS Our results suggest that-if the aim is to align resource-allocation decisions in healthcare with societal preferences-currently applied equity weights do not suffice.
Collapse
Affiliation(s)
- Vivian Reckers-Droog
- Erasmus Centre for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, The Netherlands; Erasmus School of Health Policy & Management, Erasmus University Rotterdam, The Netherlands.
| | - Job van Exel
- Erasmus Centre for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, The Netherlands; Erasmus School of Health Policy & Management, Erasmus University Rotterdam, The Netherlands; Erasmus School of Economics, Erasmus University Rotterdam, The Netherlands
| | - Werner Brouwer
- Erasmus Centre for Health Economics Rotterdam (EsCHER), Erasmus University Rotterdam, The Netherlands; Erasmus School of Health Policy & Management, Erasmus University Rotterdam, The Netherlands; Erasmus School of Economics, Erasmus University Rotterdam, The Netherlands
| |
Collapse
|
30
|
Churruca K, Ludlow K, Wu W, Gibbons K, Nguyen HM, Ellis LA, Braithwaite J. A scoping review of Q-methodology in healthcare research. BMC Med Res Methodol 2021; 21:125. [PMID: 34154566 PMCID: PMC8215808 DOI: 10.1186/s12874-021-01309-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 04/30/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Q-methodology is an approach to studying complex issues of human 'subjectivity'. Although this approach was developed in the early twentieth century, the value of Q-methodology in healthcare was not recognised until relatively recently. The aim of this review was to scope the empirical healthcare literature to examine the extent to which Q-methodology has been utilised in healthcare over time, including how it has been used and for what purposes. METHODS A search of three electronic databases (Scopus, EBSCO-CINAHL Complete, Medline) was conducted. No date restriction was applied. A title and abstract review, followed by a full-text review, was conducted by a team of five reviewers. Included articles were English-language, peer-reviewed journal articles that used Q-methodology (both Q-sorting and inverted factor analysis) in healthcare settings. The following data items were extracted into a purpose-designed Excel spreadsheet: study details (e.g., setting, country, year), reasons for using Q-methodology, healthcare topic area, participants (type and number), materials (e.g., ranking anchors and Q-set), methods (e.g., development of the Q-set, analysis), study results, and study implications. Data synthesis was descriptive in nature and involved frequency counting, open coding and the organisation by data items. RESULTS Of the 2,302 articles identified by the search, 289 studies were included in this review. We found evidence of increased use of Q-methodology in healthcare, particularly over the last 5 years. However, this research remains diffuse, spread across a large number of journals and topic areas. In a number of studies, we identified limitations in the reporting of methods, such as insufficient information on how authors derived their Q-set, what types of analyses they performed, and the amount of variance explained. CONCLUSIONS Although Q-methodology is increasingly being adopted in healthcare research, it still appears to be relatively novel. This review highlight commonalities in how the method has been used, areas of application, and the potential value of the approach. To facilitate reporting of Q-methodological studies, we present a checklist of details that should be included for publication.
Collapse
Affiliation(s)
- Kate Churruca
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd, Sydney, NSW, 2109, Australia.
| | - Kristiana Ludlow
- School of Psychology, University of Queensland, Brisbane, QLD, 4072, Australia
- Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, 2109, Australia
| | - Wendy Wu
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd, Sydney, NSW, 2109, Australia
| | - Kate Gibbons
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd, Sydney, NSW, 2109, Australia
| | - Hoa Mi Nguyen
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd, Sydney, NSW, 2109, Australia
| | - Louise A Ellis
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd, Sydney, NSW, 2109, Australia
| | - Jeffrey Braithwaite
- Centre for Healthcare Resilience and Implementation Science, Australian Institute of Health Innovation, Macquarie University, Level 6, 75 Talavera Rd, Sydney, NSW, 2109, Australia
| |
Collapse
|
31
|
Pinho M. Public preferences for allocating absolute scarce critical healthcare resources during the COVID-19 pandemic. J Health Organ Manag 2021; ahead-of-print. [PMID: 34018706 DOI: 10.1108/jhom-12-2020-0494] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE This paper aims to investigate the Portuguese general public views regarding the criteria that should guide critical COVID-19 patients to receive medical devices (ventilators and IUC beds) during the current pandemic context. Based on rationing principles and protocols proposed in ethical and medical literature the authors explore how Portuguese general public evaluates the fairness of five allocation principles: "prognosis", "severity of health condition", "patients age", "instrumental value" (frontline healthcare professionals should be prioritized during the pandemic) and "lottery". DESIGN/METHODOLOGY/APPROACH An online questionnaire was used to collect data from a sample of 586 Portuguese citizens. Descriptive statistics and non-parametric tests were used to define a hierarchy of prioritization criteria and to test for the association between respondents support to them and their socio-demographic and health characteristics. FINDINGS Respondents gave top priority to prognosis when faced with absolute scarcity, followed closely by the severity of health condition, patient's age with instrumental value receiving lowest support, on average. However, when the age of the patients was confronted with survival, younger-first principle prevailed over recovery. In a pandemic context, lottery was considered the least fair allocation method. The findings suggest that respondents' opinions are aligned with those of ethicists but are partially in disagreement with the protocol suggested for Portugal. ORIGINALITY/VALUE This study represents the first attempt to elicit public attitudes towards distributive criteria during a pandemic and, therefore, in a real context where the perception is that life and death decisions have to be made.
Collapse
Affiliation(s)
- Micaela Pinho
- Research on Economics, Management and Information Technologies (REMIT), Portucalense University, Porto, Portugal.,Portucalense Institute for Legal Reseach (IJP), Porto, Portugal.,Research Unit in Governance, Competitiveness and Public Policies (GOVCOPP), University of Aveiro, Aveiro, Portugal
| |
Collapse
|
32
|
Macaulay B, McHugh N, Steiner A. Public perspectives on health improvement within a remote-rural island community. Health Expect 2021; 24:1286-1299. [PMID: 33955117 PMCID: PMC8369116 DOI: 10.1111/hex.13260] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 03/01/2021] [Accepted: 04/03/2021] [Indexed: 01/28/2023] Open
Abstract
Background Rural health outcomes are often worse than their urban counterparts. While rural health theory recognizes the importance of the social determinants of health, there is a lack of insight into public perspectives for improving rural health beyond the provision of health‐care services. Gaining insight into perceived solutions, that include and go beyond health‐ care, can help to inform resource allocation decisions to improve rural health. Objective To identify and describe shared perspectives within a remote‐rural community on how to improve rural health. Method Using Q methodology, a set of 40 statements were developed representing different perceptions of how to improve rural health. Residents of one remote‐rural island community ranked this statement set according to their level of agreement. Card‐sorts were analysed using factor analysis to identify shared points of view and interpreted alongside post‐sort qualitative interviews. Results Sixty‐two respondents participated in the study. Four shared perspectives were identified, labelled: Local economic activity; Protect and care for the community; Redistribution of resources; and Investing in people. Factors converged on the need to relieve poverty and ensure access to amenities and services. Discussion and conclusions Factors represent different elements of a multifaceted theory of rural health, indicating that ‘lay’ respondents are capable of comprehending various approaches to health improvement and perspectives are not homogenous within rural communities. Respondents diverged on the role of individuals, the public sector and ‘empowered’ community‐based organizations in delivering these solutions, with implications for policy and practice. Public Contribution Members of the public were involved in the development and piloting of the statement set.
Collapse
Affiliation(s)
- Bobby Macaulay
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Neil McHugh
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Artur Steiner
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| |
Collapse
|
33
|
Lee HY, Bae EY, Lee K, Kang M, Oh J. Public Preferences in Resource Allocation for Insurance Coverage of Dental Implant Service in South Korea: Citizens' Jury. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18084135. [PMID: 33919799 PMCID: PMC8070823 DOI: 10.3390/ijerph18084135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/01/2021] [Accepted: 04/09/2021] [Indexed: 11/16/2022]
Abstract
The Korean government sought to include dental implant services for the elderly in the benefits package of the national health insurance. In 2014, the Citizens' Jury was held to discuss the topic, during which thirty jurors, randomly selected from the 2665 applicants, participated in a day-long deliberation process after having an information session on the topic by a team of experts. There was a substantial shift in opinion during the deliberation session toward a more cost-conscious view. Most jurors supported limiting the coverage of dental implant to only one tooth per individual given the extent of the financial burden that will be imposed on the population. They opposed covering implant services for the front teeth, given that the implant of front teeth generally serves aesthetic purposes rather than restoring mastication function. The government's final decision in 2014 was to offer coverage up to two teeth, regardless of tooth location. This scheme based on the jury's recommendations in 2014 has been implemented without policy failure to date, which shows that the lay public can meaningfully contribute to a decision-making process regarding controversial agendas such as benefits packages for expensive health services.
Collapse
Affiliation(s)
- Hwa-Young Lee
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115, USA;
- Institute of Convergence Science (ICONS), Convergence Science Academy, Yonsei University, Seoul 03722, Korea
| | - Eun-Young Bae
- College of Pharmacy, Gyeongsang National University, Jinju-si 52828, Korea;
| | - Kyungdo Lee
- Department of Health Behavior, Society and Policy, Rutgers School of Public Health, Piscataway, NJ 08854, USA;
| | - Minah Kang
- Department of Public Administration, Ewha Womans University, Seodaemun-gu, Seoul 120-750, Korea;
| | - Juhwan Oh
- Department of Medicine, Seoul National University College of Medicine, Seoul 03080, Korea
- Correspondence:
| |
Collapse
|
34
|
Campagne DM. Accountability for an unhealthy lifestyle. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2021; 22:351-355. [PMID: 32361840 DOI: 10.1007/s10198-020-01192-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Daniel M Campagne
- Faculty of Psychology, Department of Personality, Evaluation and Psychological Treatments, Universidad Nacional de Educación a Distancia (UNED), 10 Calle Juan del Rosal, 28040, Madrid, Spain.
| |
Collapse
|
35
|
de Ruijter UW, Lingsma HF, Bax WA, Legemaate J. Hidden bedside rationing in the Netherlands: a cross-sectional survey among physicians in internal medicine. BMC Health Serv Res 2021; 21:233. [PMID: 33726737 PMCID: PMC7967991 DOI: 10.1186/s12913-021-06229-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 03/02/2021] [Indexed: 11/28/2022] Open
Abstract
Background Healthcare rationing can be defined as withholding beneficial care for cost reasons. One form in particular, hidden bedside rationing, is problematic because it may result in conflicting loyalties for physicians, unfair inequality among patients and illegitimate distribution of resources. Our aim is to establish whether bedside rationing occurs in the Netherlands, whether it qualifies as hidden and what physician characteristics are associated with its practice. Methods Cross-sectional online questionnaire on knowledge of -, experience with -, and opinion on rationing among physicians in internal medicine within the Dutch healthcare system. Multivariable ordinal logistic regression was used to explore relations between hidden bedside rationing and physician characteristics. Results The survey was distributed among 1139 physicians across 11 hospitals with a response rate of 18% (n = 203). Most participants (n = 129; 64%) had experience prescribing a cheaper course of treatment while a more effective but more expensive alternative was available, suggesting bedside rationing. Subsequently, 32 (24%) participants never disclosed this decision to their patient, qualifying it as hidden. The majority of participants (n = 153; 75%) rarely discussed treatment cost. Employment at an academic hospital was independently associated with more bedside rationing (OR = 17 95%CI 6.1–48). Furthermore, residents were more likely to disclose rationing to their patients than internists (OR = 3.2, 95%CI 2.1–4.7), while salaried physicians were less likely to do so than physicians in private practice (OR = 0.5, 95%CI 0.4–0.8). Conclusion Hidden bedside rationing occurs in the Netherlands: patient choice is on occasion limited with costs as rationale and this is not always disclosed. To what extent distribution of healthcare should include bedside rationing in the Netherlands, or any other country, remains up for debate. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06229-2.
Collapse
Affiliation(s)
- Ursula W de Ruijter
- Medical Decision Making Section, Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands. .,Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands.
| | - Hester F Lingsma
- Medical Decision Making Section, Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Willem A Bax
- Department of Internal Medicine, Northwest Clinics, Alkmaar, The Netherlands
| | - Johan Legemaate
- Health Law Section, Department of Ethics, Law and Humanities, Amsterdam University Medical Centers, location AMC, Amsterdam, The Netherlands
| |
Collapse
|
36
|
Rotteveel AH, Reckers-Droog VT, Lambooij MS, de Wit GA, van Exel NJA. Societal views in the Netherlands on active disinvestment of publicly funded healthcare interventions. Soc Sci Med 2021; 272:113708. [PMID: 33516087 DOI: 10.1016/j.socscimed.2021.113708] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 12/18/2020] [Accepted: 01/14/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To obtain public support for the active disinvestment (i.e. policy decision to stop reimbursement) of healthcare interventions, it is important to have insight in what the public thinks about disinvestment and which considerations they find relevant in this context. Currently, evidence on relevant considerations in the disinvestment context is limited. Therefore, this study aimed to explore the societal views in the Netherlands on the active disinvestment of healthcare interventions and obtain insight into the considerations that are relevant for those holding the different views. METHODS A Q-methodology study was conducted among a purposively selected sample of citizens (n = 43). Data were collected in June and July 2019. Participants individually ranked a set of 43 statements broadly covering the issues that participants could consider relevant in the disinvestment context, from 'least agree' to 'most agree'. Qualitative feedback on the statement ranking was collected from each participant using a questionnaire. Principal component analysis followed by oblimin rotation was used to identify clusters of participants with similar statement rankings. These clusters/factors were interpreted as distinct viewpoints using the factor arrays and qualitative questionnaire responses of participants. RESULTS Four viewpoints were identified. People holding viewpoint I believe that reimbursement of necessary healthcare should be maintained, irrespective of its costs. People holding viewpoint II agree with viewpoint I, although they believe that necessity should be objectively determined. People holding viewpoint III think that unnecessary, ineffective and inefficient healthcare should be disinvested. People holding viewpoint IV, consider it most important that disinvestment decision-making processes are transparent and consistent. CONCLUSION Insight in the distinct viewpoints identified in this study contributes to a better understanding of why it has been considered difficult to obtain public support for disinvestment of healthcare interventions, and can help policymakers to change their approach to disinvestment to increase public support.
Collapse
Affiliation(s)
- A H Rotteveel
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands; Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - V T Reckers-Droog
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - M S Lambooij
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - G A de Wit
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - N J A van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, the Netherlands; Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, the Netherlands
| |
Collapse
|
37
|
Afsharmanesh G, Mehralian G, Peiravian F. Attributes Development for Pharmaceutical Subsidization: A Qualitative Study. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH : IJPR 2020; 19:203-217. [PMID: 32922481 PMCID: PMC7462491 DOI: 10.22037/ijpr.2019.15507.13136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Discrete choice experiments (DCES) as a stated preference method have used increasingly to determine preferences attached to some attributes associated to health. Although, the validity of this type of studies comprehensively depends on the appropriate determination of attributes and attribute-levels for DCES, there is little rigorous evidence regarding which factors or attributes and attribute- levels should be counted for eliciting public preferences in health resource allocation. This paper responds to such question by carefully doing a qualitative study. A qualitative study used semi-structured interviews, which were audio recorded, transcribed and subject to thematic analysis. Sixteen participants had been key informants and decision makers of pharmaceutical and health system. Initially, by conducting a meticulous literature review, an inclusive list of attributes associated with intended policy was identified. Qualitative data for the development of attributes and their levels were collected using 16 key informant interviews and were analyzed by software MAXQDA followed by a focus group discussion (FGD) with 7 people, well-familiar with the notion pharmaceutical policy and Pharmacoeconomics. The 311 codes in four main dimensions were initially identified by conducting interviews. However, for being manageable within a DCE, they were classified and limited to four attributes, including severity of disease without treatment, health gain after treatment, frequency of patients, and cost of treatment per patient. This qualitative study provides enough evidence for designing and doing a precise discrete choice experiment answering the question about public preferences in pharmaceutical subsidization and contributes empirical evidence to the limited methodological literature on attributes development for DCE, specifically within low and middle-income countries.
Collapse
Affiliation(s)
- Gita Afsharmanesh
- Department of Pharmacoeconomics and Pharma Management, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Gholamhossein Mehralian
- Department of Pharmacoeconomics and Pharma Management, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzad Peiravian
- Department of Pharmacoeconomics and Pharma Management, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| |
Collapse
|
38
|
Clark M, Adams D. Listening to parents to understand their priorities for autism research. PLoS One 2020; 15:e0237376. [PMID: 32790720 PMCID: PMC7425861 DOI: 10.1371/journal.pone.0237376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 07/24/2020] [Indexed: 12/28/2022] Open
Abstract
Involving the autism community in research increases the real-world translation and impact of findings. The current study explored the research priorities of parents of school-aged children on the autism spectrum across the home, school, and community settings. A combination of content analysis of an online questionnaire (n = 134) and Q-sort methodology (n = 9) was used. The most commonly identified research priorities in the online questionnaire were child health and well-being (home setting), socialisation and social support (school), and community awareness and understanding of autism (community). The Q-sort method highlighted different top priorities, with understanding the parent, sibling, child and family impact and stress the highest ranked priority for home, teacher/staff education and support for the school, and recognizing and supporting anxiety for the community. The implications of the findings are discussed in relation to shifting the framework of autism research to align research agendas with parental priorities.
Collapse
Affiliation(s)
- Megan Clark
- Autism Centre of Excellence, School of Education and Professional Studies, Griffith University, Brisbane, Australia
- Griffith Institute for Educational Research, Griffith University, Brisbane, Australia
| | - Dawn Adams
- Autism Centre of Excellence, School of Education and Professional Studies, Griffith University, Brisbane, Australia
- Griffith Institute for Educational Research, Griffith University, Brisbane, Australia
| |
Collapse
|
39
|
Nicolet A, van Asselt ADI, Vermeulen KM, Krabbe PFM. Value judgment of new medical treatments: Societal and patient perspectives to inform priority setting in The Netherlands. PLoS One 2020; 15:e0235666. [PMID: 32645035 PMCID: PMC7347112 DOI: 10.1371/journal.pone.0235666] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 06/21/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND In many countries, medical interventions are reimbursed on the basis of recommendations made by advisory boards and committees that apply multiple criteria in their assessment procedures. Given the diversity of these criteria, it is difficult to find common ground to determine what information is required for setting priorities. OBJECTIVE To investigate whether society and patients share the same interests and views concerning healthcare priorities. METHODS We applied a framework of discrete choice models in which respondents were presented with judgmental tasks to elicit their preferences. They were asked to choose between two hypothetical scenarios of patients receiving a new treatment. The scenarios graphically presented treatment outcomes and patient characteristics. Responses were collected through an online survey administered among respondents from the general population (N = 1,253) and patients (N = 1,389) and were analyzed using conditional logit and mixed logit models. RESULTS The respondents' preferences regarding new medical treatments revealed that they attached the most relative importance to additional survival years, age at treatment, initial health condition, and the cause of disease. Minor differences in the relative importance assigned to three criteria: age at treatment, initial health, and cause of disease were found between the general population and patient samples. Health scenarios in which patients had higher initial health-related quality of life (i.e., a lower burden of disease) were favored over those in which patients' initial health-related quality of life was lower. CONCLUSIONS Overall, respondents within the general population expressed preferences that were similar to those of the patients. Therefore, priority-setting studies that are based on the perspectives of the general population may be useful for informing decisions on reimbursement and other types of priority-setting processes in health care. Incorporating the preferences of the general population may simultaneously increase public acceptance of these decisions.
Collapse
Affiliation(s)
- Anna Nicolet
- Department of Epidemiology and Health Systems, Institute of Social and Preventive Medicine (Unisanté), Lausanne, Switzerland
- * E-mail:
| | - Antoinette D. I. van Asselt
- Department of Epidemiology and Health Systems, Institute of Social and Preventive Medicine (Unisanté), Lausanne, Switzerland
| | - Karin M. Vermeulen
- Department of Epidemiology and Health Systems, Institute of Social and Preventive Medicine (Unisanté), Lausanne, Switzerland
| | - Paul F. M. Krabbe
- Department of Epidemiology and Health Systems, Institute of Social and Preventive Medicine (Unisanté), Lausanne, Switzerland
| |
Collapse
|
40
|
Bijlmakers L, Jansen M, Boer B, van Dijk W, Groenewoud S, Zwaap J, Helderman JK, van Exel J, Baltussen R. Increasing the Legitimacy of Tough Choices in Healthcare Reimbursement: Approach and Results of a Citizen Forum in The Netherlands. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:32-38. [PMID: 31952671 DOI: 10.1016/j.jval.2019.07.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 04/25/2019] [Accepted: 07/08/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Some studies in the Netherlands have gauged public views on principles for healthcare priority setting, but they fall short of comprehensively explaining the public disapproval of several recent reimbursement decisions. OBJECTIVE To obtain insight into citizens' preferences and identify the criteria they would propose for decisions pertaining to the benefits package of basic health insurance. METHODS Twenty-four Dutch citizens were selected for participation in a Citizen Forum, which involved 3 weekends. Deliberations took place in small groups and in plenary, guided by 2 moderators, on the basis of 8 preselected case studies, which participants later compared and prioritized under the premise that not all treatments can or need to be reimbursed. Participants received opportunities to inform themselves through written brochures and live interactions with 3 experts. RESULTS The Citizen Forum identified 16 criteria for inclusion or exclusion of treatments in the benefits package; they relate to the condition (2 criteria), treatment (11 criteria), and individual characteristics of those affected by the condition (3 criteria). In most case studies, it was a combination of criteria that determined whether or not participants favored inclusion of the treatment under consideration in the benefits package. Participants differed in their opinion about the relative importance of criteria, and they had difficulty in operationalizing and trading off criteria to provide a recommendation. CONCLUSIONS Informed citizens are prepared to make and, to a certain extent, capable of making reasoned choices about the reimbursement of health services. They realize that choices are both necessary and possible. Broad public support and understanding for making tough choices regarding the benefits package of basic health insurance is not automatic: it requires an investment.
Collapse
Affiliation(s)
- Leon Bijlmakers
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands.
| | - Maarten Jansen
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bert Boer
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Wieteke van Dijk
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Stef Groenewoud
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Jan-Kees Helderman
- Institute for Management Research, Radboud University, Nijmegen, The Netherlands
| | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands; Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Rob Baltussen
- Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| |
Collapse
|
41
|
Cram P, Girotra S, Matelski J, Koh M, Landon B, Han L, Lee DS, Ko DT. Utilization of Advanced Cardiovascular Therapies in the United States and Canada: An Observational Study of New York and Ontario Administrative Data. Circ Cardiovasc Qual Outcomes 2020; 13:e006037. [PMID: 31957474 PMCID: PMC7006709 DOI: 10.1161/circoutcomes.119.006037] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 12/03/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Endovascular aortic aneurysm repair (EVAR), left ventricular assist device (LVAD), and transcatheter aortic valve replacement (TAVR) are expensive cardiovascular technologies with potential to benefit large numbers of patients. There are few population-based studies comparing utilization between countries. Our objective was to compare patient characteristics and utilization patterns of EVAR, LVAD, and TAVR in Ontario, Canada, and New York State, United States. METHODS AND RESULTS We performed a retrospective cohort study using administrative data to identify all adults who received EVAR, LVAD, or TAVR in Ontario and New York between 2012 and 2015. We compared socio-demographics of EVAR, LVAD, and TAVR recipients in Ontario and New York. We compared standardized utilization rates between jurisdictions for each procedure. We identified 3295 EVAR recipients from Ontario and 6236 from New York (mean age 74.6 versus 74.5 years; P=0.61): 136 LVAD recipients from Ontario and 686 from New York (age, 57.4 versus 57.7 years; P=0.80): 1708 TAVR recipients from Ontario and 4838 from New York (age, 83.1 versus 83.1; P=1.0). A significantly smaller percentage of EVAR and TAVR recipients in Ontario were female compared to New York (EVAR, 15.8% versus 22.1% female; P<0.001; TAVR, 45.9% versus 51.8%; P<0.001), but for LVAD the percentage female was similar (21.3% versus 20.8%; P=0.99). Utilization was significantly higher in New York for all procedures: EVAR (12.8 procedures per-100 000 adults per-year in Ontario, 20.2 in New York; P<0.001); LVAD (0.3 in Ontario versus 1.3 in New York; P<0.001); and TAVR (6.6 in Ontario, 14.3 in New York; P<0.001). Higher utilization of EVAR and TAVR in New York relative to Ontario increased substantially with increasing age. CONCLUSIONS We observed significantly higher utilization of EVAR, LVAD, and TAVR in New York compared to Ontario. Our results highlight important differences in how 2 different countries are using advanced cardiovascular therapies.
Collapse
Affiliation(s)
- Peter Cram
- Department of Medicine, University of Toronto, Toronto, ON
- Division of General Internal Medicine and Geriatrics, Sinai Health System and University Health Network, Toronto, ON
- ICES, Toronto, ON
- North American Observatory on Health Systems and Policies, University of Toronto, Toronto, ON
| | - Saket Girotra
- Department of Medicine, University of Iowa, Iowa City, IA
- Comprehensive Access Delivery Research and Evaluation, Iowa City Veterans Affairs Medical Center, Iowa City, IA
| | - John Matelski
- Division of General Internal Medicine and Geriatrics, Sinai Health System and University Health Network, Toronto, ON
| | | | - Bruce Landon
- Department of Health Care Policy, Harvard Medical School and Division of General Medicine, Beth Israel Deaconess Medical Center
| | | | - Douglas S. Lee
- Department of Medicine, University of Toronto, Toronto, ON
- ICES, Toronto, ON
- Peter Munk Cardiac Centre and Joint Department of Medical Imaging, University Health Network, Toronto, ON
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
| | - Dennis T. Ko
- Department of Medicine, University of Toronto, Toronto, ON
- ICES, Toronto, ON
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, ON
| |
Collapse
|
42
|
Reckers-Droog V, Jansen M, Bijlmakers L, Baltussen R, Brouwer W, van Exel J. How does participating in a deliberative citizens panel on healthcare priority setting influence the views of participants? Health Policy 2019; 124:143-151. [PMID: 31839335 DOI: 10.1016/j.healthpol.2019.11.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 10/14/2019] [Accepted: 11/28/2019] [Indexed: 11/25/2022]
Abstract
A deliberative citizens panel was held to obtain insight into criteria considered relevant for healthcare priority setting in the Netherlands. Our aim was to examine whether and how panel participation influenced participants' views on this topic. Participants (n = 24) deliberated on eight reimbursement cases in September and October, 2017. Using Q methodology, we identified three distinct viewpoints before (T0) and after (T1) panel participation. At T0, viewpoint 1 emphasised that access to healthcare is a right and that prioritisation should be based solely on patients' needs. Viewpoint 2 acknowledged scarcity of resources and emphasised the importance of treatment-related health gains. Viewpoint 3 focused on helping those in need, favouring younger patients, patients with a family, and treating diseases that heavily burden the families of patients. At T1, viewpoint 1 had become less opposed to prioritisation and more considerate of costs. Viewpoint 2 supported out-of-pocket payments more strongly. A new viewpoint 3 emerged that emphasised the importance of cost-effectiveness and that prioritisation should consider patient characteristics, such as their age. Participants' views partly remained stable, specifically regarding equal access and prioritisation based on need and health gains. Notable changes concerned increased support for prioritisation, consideration of costs, and cost-effectiveness. Further research into the effects of deliberative methods is required to better understand how they may contribute to the legitimacy of and public support for allocation decisions in healthcare.
Collapse
Affiliation(s)
- Vivian Reckers-Droog
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, the Netherlands.
| | - Maarten Jansen
- Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Leon Bijlmakers
- Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Rob Baltussen
- Radboud Institute for Health Sciences, Radboudumc, Nijmegen, the Netherlands
| | - Werner Brouwer
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, the Netherlands; Erasmus School of Economics, Erasmus University Rotterdam, the Netherlands
| | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, the Netherlands; Erasmus School of Economics, Erasmus University Rotterdam, the Netherlands
| |
Collapse
|
43
|
Hofmann B. Biases distorting priority setting. Health Policy 2019; 124:52-60. [PMID: 31822370 DOI: 10.1016/j.healthpol.2019.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 09/24/2019] [Accepted: 11/24/2019] [Indexed: 02/08/2023]
Abstract
Modern health care faces an ever widening gap between technological possibilities and available resources. To handle this challenge we have constructed elaborate systems for health policy making and priority setting. Despite such systems many health care systems provide a wide range of documented low-value care while being unable to afford emerging high-value care. Accordingly, this article sets out asking why priority setting in health care has so poor outcomes while relevant systems are well developed and readily available. It starts to identify some rational and structural explanations for the discrepancy between theoretical efforts and practical outcomes in priority setting. However, even if these issues are addressed, practical priority setting may still not obtain its goals. This is because a wide range of irrational effects is hampering priority setting: biases. By using examples from the literature the article identifies and analyses a wide range of biases indicating how they can distort priority setting processes. Overuse, underuse, and overinvestment, as well as hampered disinvestment and undermined priority setting principles are but some of the identified implications. Moreover, while some biases are operating mainly on one level, many are active on the micro, meso and on the macro level. Identifying and analyzing biases affecting priority setting is the first, but crucial, step towards improving health policy making and priority setting in health care.
Collapse
Affiliation(s)
- Bjørn Hofmann
- Institute for the Health Sciences at the Norwegian University of Science and Technology, Gjøvik, Norway; The Centre of Medical Ethics at the University of Oslo, Norway.
| |
Collapse
|
44
|
Hackert MQN, Brouwer WBF, Hoefman RJ, van Exel J. Views of older people in the Netherlands on wellbeing: A Q-methodology study. Soc Sci Med 2019; 240:112535. [PMID: 31557554 DOI: 10.1016/j.socscimed.2019.112535] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 08/31/2019] [Accepted: 09/05/2019] [Indexed: 12/12/2022]
Abstract
Population ageing and restricted budgets result in the need for an efficient allocation of scarce resources in care services for older people. As these services tend to address more than only health, diverse wellbeing measures have been developed to assess their benefits in economic evaluations. These measures are grounded in research on wellbeing of older people and its determinants. Little is known about possible heterogeneity in this context and the extent to which wellbeing measures cover the aspects of wellbeing that are most important to older people with different views on wellbeing. We conducted a Q-methodology study between December 2016 and October 2017 to investigate the variety in views among people aged 65 and older in the Netherlands on what is important to their wellbeing. A purposive sample of 53 respondents ranked 34 opinion statements according to importance to their wellbeing and explained their ranking during a follow-up interview. Data were analysed using by-person factor analysis to identify common patterns in the rankings of the statements. Five distinct views were extracted in which different aspects were considered important: (I) health, financial security and a life partner; (II) family, support and physical functioning (III); autonomy, mental health and helping others; (IV) social contacts, support, mental health and religion; and (V) a life partner, social contacts, living environment and adaptation. This heterogeneity in views of older people on what constitutes wellbeing supports the use of person-centered approaches in care services for older people. Arguably, (evaluations of) policies and services for older people should take this plurality into consideration.
Collapse
Affiliation(s)
- Mariska Q N Hackert
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, P.O. Box 1738, 3000 DR, Rotterdam, the Netherlands.
| | - Werner B F Brouwer
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, P.O. Box 1738, 3000 DR, Rotterdam, the Netherlands.
| | - Renske J Hoefman
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, P.O. Box 1738, 3000 DR, Rotterdam, the Netherlands.
| | - Job van Exel
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, P.O. Box 1738, 3000 DR, Rotterdam, the Netherlands; Erasmus School of Economics, Erasmus University Rotterdam, Rotterdam, the Netherlands.
| |
Collapse
|
45
|
A Scoring Index of Prioritization Factors Between Patients: An Iberian Comparison. Health Care Manag (Frederick) 2019; 38:267-275. [PMID: 31261196 DOI: 10.1097/hcm.0000000000000274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study intends to develop a Prioritization Scoring Index of Iberian Peninsula comprising Portuguese and Spanish citizens, to weigh the importance assigned to rationing criteria used to prioritize patients. Data were collected through an online survey from 2 samples of 355 Portuguese and 564 Spanish members of the general public. Respondents faced 12 hypothetical rationing scenarios and should reveal their level of agreement with each one according to a Likert scale. The statements comprise 3 allocative considerations: egalitarianism, efficiency, and equity. Findings suggest that Portuguese and Spanish respondents gave greater importance to the treatments outcomes, to the severity of the illness, and to younger patients. Furthermore, Iberian respondents assigned 57% of the weighting to equity considerations, 40% to efficiency considerations, and approximately only 3% to egalitarianism. Spaniards weighted more than Portuguese both equity and efficiency considerations while weighted less the egalitarian principle. Iberian Peninsula respondents require resource allocation decisions in health to be informed by considerations of equity as well as efficiency. As the first was most valued, it seems plausible that Portuguese and Spanish respondents are willing to sacrifice some efficiency to achieve a more equitable distribution of health.
Collapse
|
46
|
Traina G, Martinussen PE, Feiring E. Being Healthy, Being Sick, Being Responsible: Attitudes towards Responsibility for Health in a Public Healthcare System. Public Health Ethics 2019; 12:145-157. [PMID: 31384303 PMCID: PMC6655377 DOI: 10.1093/phe/phz009] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Lifestyle-induced diseases are becoming a burden on healthcare, actualizing the discussion on health responsibilities. Using data from the National Association for Heart and Lung Diseases (LHL)’s 2015 Health Survey (N = 2689), this study examined the public’s attitudes towards personal and social health responsibility in a Norwegian population. The questionnaires covered self-reported health and lifestyle, attitudes towards personal responsibility and the authorities’ responsibility for promoting health, resource-prioritisation and socio-demographic characteristics. Block-wise multiple linear regression assessed the association between attitudes towards health responsibilities and individual lifestyle, political orientation and health condition. We found a moderate support for social responsibility across political views. Respondents reporting unhealthier eating habits, smokers and physically inactive were less supportive of health promotion policies (including information, health incentives, prevention and regulations). The idea that individuals are responsible for taking care of their health was widely accepted as an abstract ideal. Yet, only a third of the respondents agreed with introducing higher co-payments for treatment of ‘self-inflicted’ conditions and levels of support were patterned by health-related behaviour and left-right political orientation. Our study suggests that a significant support for social responsibility does not exclude a strong support for personal health responsibility. However, conditional access to healthcare based on personal lifestyle is still controversial.
Collapse
Affiliation(s)
- Gloria Traina
- Department of Health Management and Health Economics, University of Oslo
| | - Pål E Martinussen
- Department of Sociology and Political Science, Norwegian University of Science and Technology (NTNU)
| | - Eli Feiring
- Department of Health Management and Health Economics, University of Oslo
| |
Collapse
|
47
|
Chamberlain C, Owen-Smith A, MacKichan F, Donovan JL, Hollingworth W. "What's fair to an individual is not always fair to a population": A qualitative study of patients and their health professionals using the Cancer Drugs Fund. Health Policy 2019; 123:706-712. [PMID: 31279588 DOI: 10.1016/j.healthpol.2019.05.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 05/28/2019] [Accepted: 05/31/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To understand the values attached to cancer treatment at the end of life (EoL) to inform policy decisions around the Cancer Drugs Fund (CDF) and the National Institute for Health and Care Excellence (NICE) EoL criterion. DESIGN Semi-structured interviews with patients and health professionals. Purposive recruitment was performed iteratively alongside analysis of interview transcripts using constant comparison. PARTICIPANTS Patients with incurable prostate and colorectal cancer (n = 22) who received drugs funded through the CDF and oncologists and palliative care professionals (n = 16) treating patients on CDF drugs. RESULTS While the majority of patient and oncologist participants expressed gratitude for access to the CDF, some patient participants reported experiencing a sense of guilt, and many oncologists admitted to concern about the justice of a ring-fenced fund solely for anti-cancer drugs. For patient and professional participants, cancer drugs were not necessarily seen as a funding priority over other calls on the NHS purse. Overall, patients and health professionals emphasised prioritising quality over quantity at the end of life, with only a minority describing improved quality of life at the end of life which added value. CONCLUSION While patients and oncologists appreciated the drugs available through the CDF, most expressed concern about its fairness. Competing participant views about the added value of the end of life is challenging for resource allocation.
Collapse
Affiliation(s)
- Charlotte Chamberlain
- Bristol Medical School, Population Health Sciences, 39 Whatley Rd, Bristol, BS8 2PS, UK.
| | - Amanda Owen-Smith
- Bristol Medical School, Population Health Sciences, 39 Whatley Rd, Bristol, BS8 2PS, UK.
| | - Fiona MacKichan
- Bristol Medical School, Population Health Sciences, 39 Whatley Rd, Bristol, BS8 2PS, UK.
| | - Jenny L Donovan
- Bristol Medical School, Population Health Sciences, 39 Whatley Rd, Bristol, BS8 2PS, UK.
| | - William Hollingworth
- Bristol Medical School, Population Health Sciences, 39 Whatley Rd, Bristol, BS8 2PS, UK.
| |
Collapse
|
48
|
Pinho M, Pinto Borges A. The Views of Health Care Professionals and Laypersons Concerning the Relevance of Health-Related Behaviors in Prioritizing Patients. HEALTH EDUCATION & BEHAVIOR 2019; 46:728-736. [DOI: 10.1177/1090198119853604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article aims to investigate to what extent health care professionals in Portugal find health-related behaviors relevant as a criterion to priority setting, to study what type of risk behavior they consider relevant in such decisions and to compare their views with those of laypersons. An online questionnaire was used to collect data from a sample of 178 health care professionals and 295 laypersons. The statistical analysis was performed through the application of generalized linear models and logistic regressions. Health professionals consider more than laypersons that information about health-related behaviors is relevant in prioritization between individuals. Both groups regard information about illegal drug abuse, excessive alcohol consumption, and smoking more important to priority setting decisions than information about overweight or lack of physical exercise. The findings are important for the definition of rationing policies as the professionals’ decisions are those that, ultimately, influence health expenditure.
Collapse
Affiliation(s)
- Micaela Pinho
- Universidade Portucalense, Porto, Portugal
- University of Aveiro, Aveiro, Portugal
| | | |
Collapse
|
49
|
Truijens D, van Exel J. Views on deceased organ donation in the Netherlands: A q-methodology study. PLoS One 2019; 14:e0216479. [PMID: 31125339 PMCID: PMC6534345 DOI: 10.1371/journal.pone.0216479] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 04/22/2019] [Indexed: 11/19/2022] Open
Abstract
In many countries, such as the US, Germany, France, and the Netherlands, governments are dealing with a great shortage of organ donors. Even though people generally show positive attitudes towards organ donation, they often do not actually register as organ donors themselves. This study's objective was to explore prevailing viewpoints among the Dutch population on deceased organ donation and the relation between aspects of the viewpoints potentially influencing the decision to register as an organ donor. Although substantive research about attitudes on organ donation has been conducted, this is the first study investigating people's viewpoints focusing on the relation between beliefs, tastes, preferences, motives, goals and other constituents underlying people's viewpoints on organ donation, such as the role of the media and public policies. This Q-methodology study revealed four viewpoints: "not donating your organs is a waste", "it does not go with my religion", "my family should decide"; and "it's a good deed, but I'm doubtful". These viewpoints convey information on potential reasons for the gap between people's favourable attitudes towards organ donation and the low number of actual registrations, and opportunities for policy makers to address certain target groups more adequately.
Collapse
Affiliation(s)
- Daphne Truijens
- Erasmus University Rotterdam, Institute for Philosophy & Economics (EIPE), Rotterdam, the Netherlands
- Erasmus University Rotterdam, Erasmus School of Economics, Rotterdam, the Netherlands
| | - Job van Exel
- Erasmus University Rotterdam, Erasmus School of Economics, Rotterdam, the Netherlands
- Erasmus University Rotterdam, Erasmus School of Health Policy & Management, Rotterdam, the Netherlands
| |
Collapse
|
50
|
Kirschbaum M, Barnett T, Cross M. Q sample construction: a novel approach incorporating a Delphi technique to explore opinions about codeine dependence. BMC Med Res Methodol 2019; 19:101. [PMID: 31088351 PMCID: PMC6518693 DOI: 10.1186/s12874-019-0741-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 04/26/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Q methodology is an evidenced approach to researching subjectivity, involving a combination of qualitative and quantitative techniques. The methodology has been used successfully in healthcare research to explore the opinions of patients and healthcare providers about topics such as the illness experience, healthcare services, clinical practice and professional training. Q methodology studies require the generation of a Q sample, a set of opinion statements representing the phenomenon of interest. This paper describes a novel and rigorous approach to develop a Q sample for a study exploring misusers' opinions about over-the-counter (OTC) codeine dependence and critically examines the associated methodological issues. METHODS Development of the Q sample in this study involved three steps; (1) identification of opinion statements via a comprehensive literature search, (2) application of a theoretical framework, the Capability, Opportunity, Motivation - Behaviour (COM-B) model of behaviour, to group and then reduce the number of statements and (3) use of a Delphi technique to achieve expert consensus on the final selection of statements. The Delphi component involved a multidisciplinary panel of 15 addiction experts comprised of doctors, nurses, pharmacists, psychologists and researchers, who were recruited purposively. Experts rated each statement using a 5-point scale of perceived importance. Two Delphi rounds were undertaken and consensus for inclusion of a statement was set at a median score of ≥4 and an interquartile range of ≤1. RESULTS A total of 842 statements representing codeine misusers' opinions about OTC codeine dependence were identified from the literature. Statements were grouped thematically using the COM-B framework and representative statements were selected, reducing the number to 111. After two Delphi rounds, addiction experts achieved consensus on 46 statements which formed the final Q sample. CONCLUSIONS This paper describes a new and systematic approach to Q sample construction and explores associated methodological issues that could be useful for those considering Q methodology and for furthering the rigour of this research technique.
Collapse
Affiliation(s)
- Melissa Kirschbaum
- University of Tasmania Centre for Rural Health, Locked Bag 1372, Launceston, Tasmania 7250 Australia
| | - Tony Barnett
- University of Tasmania Centre for Rural Health, Locked Bag 1372, Launceston, Tasmania 7250 Australia
| | - Merylin Cross
- University of Tasmania Centre for Rural Health, Locked Bag 1372, Launceston, Tasmania 7250 Australia
| |
Collapse
|