The limits to demand for health care

Leveraging Responsible, Explainable, and Local Artificial Intelligence Solutions for Clinical Public Health in the Global South

In the present paper, we will explore how artificial intelligence (AI) and big data analytics (BDA) can help address clinical public and global health needs in the Global South, leveraging and capitalizing on our experience with the "Africa-Canada Artificial Intelligence and Data Innovation Consortium" (ACADIC) Project in the Global South, and focusing on the ethical and regulatory challenges we had to face. "Clinical public health" can be defined as an interdisciplinary field, at the intersection of clinical medicine and public health, whilst "clinical global health" is the practice of clinical public health with a special focus on health issue management in resource-limited settings and contexts, including the Global South. As such, clinical public and global health represent vital approaches, instrumental in (i) applying a community/population perspective to clinical practice as well as a clinical lens to community/population health, (ii) identifying health needs both at the individual and community/population levels, (iii) systematically addressing the determinants of health, including the social and structural ones, (iv) reaching the goals of population's health and well-being, especially of socially vulnerable, underserved communities, (v) better coordinating and integrating the delivery of healthcare provisions, (vi) strengthening health promotion, health protection, and health equity, and (vii) closing gender inequality and other (ethnic and socio-economic) disparities and gaps. Clinical public and global health are called to respond to the more pressing healthcare needs and challenges of our contemporary society, for which AI and BDA can help unlock new options and perspectives. In the aftermath of the still ongoing COVID-19 pandemic, the future trend of AI and BDA in the healthcare field will be devoted to building a more healthy, resilient society, able to face several challenges arising from globally networked hyper-risks, including ageing, multimorbidity, chronic disease accumulation, and climate change.

Early-switch versus late-switch in patients with diabetic macular edema: a cost-effectiveness study

Background

To evaluate the cost-effectiveness of early- versus late-switch to the intravitreal-dexamethasone implant (DEX-i) in patients with diabetic macular edema (DME) who did not adequately respond to vascular endothelial growth factor inhibitors (anti-VEGF).

Methods

Retrospective analysis of a multicenter Clinical Data Registry. The registry included DME eyes who received 3 intravitreal anti-VEGF injections (early-switch) or > 3 intravitreal anti-VEGF injections (late-switch) before switching to DEX-i injections. The primary outcome was to estimate the incremental cost needed to obtain a best-corrected visual acuity (BCVA) improvement ≥ 0.1 or a central-retinal thickness CRT ≤ 250 μm.

Results

The analysis included 108 eyes, 32 (29.6%) and 76 (70.4%) in the early- and late-switch groups, respectively. Early-switch strategy was associated with a cost saving of €3,057.8; 95% CI: €2,406.4–3,928.4, p < 0.0001). Regarding incremental-cost-effectiveness ratio, late-switch group was associated with an incremental cost of €25,735.2 and €13,533.2 for achieving a BCVA improvement ≥ 0.1 at month 12 and at any of the time-point measured, respectively. At month 12, 38 (35.2%) eyes achieved a BCVA improvement ≥ 0.1. At month 12, 52 (48.1) eyes had achieved a CRT ≤ 250 micron. As compared to baseline, the mean (95% CI) CRT reduction was − 163.1 (− 212.5 to − 113.7) µm and − 161.6 (− 183.8 to − 139.3) µm in the early-switch and late-switch groups, respectively, p = 0.9463.

Conclusions

In DME eyes, who did not adequately respond to anti-VEGF, switching to DEX-i at early stages (after the first 3-monthly injections) was found to be more cost-effective than extending the treatment to 6-monthly injections of anti-VEGF.

Variation in surgical demand and time to hip fracture repair: a Canadian database study

Background

Competing demands for operative resources may affect time to hip fracture surgery. We sought to determine the time to hip fracture surgery by variation in demand in Canadian hospitals.

Methods

We obtained discharge abstracts of 151,952 patients aged 65 years or older who underwent surgery for a hip fracture between January, 2004 and December, 2012 in nine Canadian provinces. We compared median time to surgery (in days) when demand could be met within a two-day benchmark and when demand required more days, i.e. clearance time, to provide surgery, overall and stratified by presence of medical reasons for delay.

Results

For persons admitted when demand corresponded to a 2-day clearance time, 68% of patients underwent surgery within the 2-day benchmark. When demand corresponded to a clearance time of one week, 51% of patients underwent surgery within 2 days. Compared to demand that could be served within the two-day benchmark, adjusted median time to surgery was 5.1% (95% confidence interval [CI] 4.1–6.1), 12.2% (95% CI 10.3–14.2), and 22.0% (95% CI 17.7–26.2) longer, when demand required 4, 6, and 7 or more days to clear the backlog, respectively. After adjustment, delays in median time to surgery were similar for those with and without medical reasons for delay.

Conclusion

Increases in demand for operative resources were associated with dose-response increases in the time needed for half of hip fracture patients to undergo surgery. Such delays may be mitigated through better anticipation of day-to-day supply and demand and increased response capability.

The modelled impact of increases in physical activity: the effect of both increased survival and reduced incidence of disease

Physical activity can affect ‘need’ for healthcare both by reducing the incidence rate of some diseases and by increasing longevity (increasing the time lived at older ages when disease incidence is higher). However, it is common to consider only the first effect, which may overestimate any reduction in need for healthcare. We developed a hybrid micro-simulation lifetable model, which made allowance for both changes in longevity and risk of disease incidence, to estimate the effects of increases in physical activity (all adults meeting guidelines) on measures of healthcare need for diseases for which physical activity is protective. These were compared with estimates made using comparative risk assessment (CRA) methods, which assumed that longevity was fixed. Using the lifetable model, life expectancy increased by 95 days (95% uncertainty intervals: 68–126 days). Estimates of the healthcare need tended to decrease, but the magnitude of the decreases were noticeably smaller than those estimated using CRA methods (e.g. dementia: change in person-years, −0.6%, 95% uncertainty interval −3.7% to +1.6%; change in incident cases, −0.4%, −3.6% to +1.9%; change in person-years (CRA methods), −4.0%, −7.4% to −1.6%). The pattern of results persisted under different scenarios and sensitivity analyses. For most diseases for which physical activity is protective, increases in physical activity are associated with decreases in indices of healthcare need. However, disease onset may be delayed or time lived with disease may increase, such that the decreases in need may be relatively small and less than is sometimes expected.

Affordability as a discursive accomplishment in a changing National Health Service

Health systems worldwide face the challenges of rationing. The English National Health Service (NHS) was founded on three core principles: universality, comprehensiveness, and free at the point of delivery. Yet patients are increasingly hearing that some treatments are unaffordable on the NHS. We considered affordability as a social accomplishment and sought to explore how those charged with allocating NHS resources achieved this in practice. We undertook a linguistic ethnography to examine the work practices of resource allocation committees in three Primary Care Trusts (PCTs) in England between 2005 and 2012, specifically deliberations over 'individual funding requests' (IFRs)--requests by patients and their doctors for the PCT to support a treatment not routinely funded. We collected and analysed a diverse dataset comprising policy documents, legal judgements, audio recordings, ethnographic field notes and emails from PCT committee meetings, interviews and a focus group with committee members. We found that the fundamental values of universality and comprehensiveness strongly influenced the culture of these NHS organisations, and that in this context, accomplishing affordability was not easy. Four discursive practices served to confer legitimacy on affordability as a guiding value of NHS health care: (1) categorising certain treatments as only eligible for NHS funding if patients could prove 'exceptional' circumstances; (2) representing resource allocation decisions as being not (primarily) about money; (3) indexical labelling of affordability as an ethical principle, and (4) recontextualising legal judgements supporting refusal of NHS treatment on affordability grounds as 'rational'. The overall effect of these discursive practices was that denying treatment to patients became reasonable and rational for an organisation even while it continued to espouse traditional NHS values. We conclude that deliberations about the funding of treatments at the margins of NHS care have powerful consequences both for patients and for redrawing the ideological landscape of NHS care.

Professional Claims, Uncertainty and the Politics of Care: Impact on Referral and Equitable Care in Traumatic Brain Injury

Rising healthcare expenditure and more explicit rationing of healthcare resources is a central feature of healthcare systems globally. In Australia, reform efforts have targeted the high cost areas such as the public hospital system. This has increased the demands on professionals to reduce length of stay and complicated post-hospital referral of people with complex and severe injury. In the area of traumatic brain injury (TBI), pressures on existing rehabilitation resources and a changing healthcare environment, with greater emphasis on efficiency and evidence-based practice, confront professionals' efforts to provide equitable care. In this paper, some of the key issues important in understanding patterns of referral in TBI are presented. It is argued that referral decisions exemplify a negotiation of professional claims and value judgements that not only conceal the uncertainty in decision-making, but also more notably, reflect the lack of attention to equity in the broader politics of care. Case studies are used to illustrate these issues and to discuss the implications for equitable care in the contemporary healthcare environment in Australia. The paper concludes by outlining the challenges and opportunities in applying evidence-based decision-making in TBI and some future directions for attaining more equitable patterns of referral.

Socioeconomic patterns in the use of public and private health services and equity in health care

Background

Several studies in wealthy countries suggest that utilization of GP and hospital services, after adjusting for health care need, is equitable or pro-poor, whereas specialist care tends to favour the better off. Horizontal equity in these studies has not been evaluated appropriately, since the use of healthcare services is analysed without distinguishing between public and private services. The purpose of this study is to estimate the relation between socioeconomic position and health services use to determine whether the findings are compatible with the attainment of horizontal equity: equal use of public healthcare services for equal need.

Methods

Data from a sample of 18,837 Spanish subjects were analysed to calculate the percentage of use of public and private general practitioner (GP), specialist and hospital care according to three indicators of socioeconomic position: educational level, social class and income. The percentage ratio was used to estimate the magnitude of the relation between each measure of socioeconomic position and the use of each health service.

Results

After adjusting for age, sex and number of chronic diseases, a gradient was observed in the magnitude of the percentage ratio for public GP visits and hospitalisation: persons in the lowest socioeconomic position were 61–88% more likely to visit public GPs and 39–57% more likely to use public hospitalisation than those in the highest socioeconomic position. In general, the percentage ratio did not show significant socioeconomic differences in the use of public sector specialists. The magnitude of the percentage ratio in the use of the three private services also showed a socioeconomic gradient, but in exactly the opposite direction of the gradient observed in the public services.

Conclusion

These findings show inequity in GP visits and hospitalisations, favouring the lower socioeconomic groups, and equity in the use of the specialist physician. These inequities could represent an overuse of public healthcare services or could be due to the fact that persons in high socioeconomic positions choose to use private health services.

Am I my brother's gatekeeper? Professional ethics and the prioritisation of healthcare

At the 5th International Conference on Priorities in Health Care in Wellington, New Zealand, 2004, one resonating theme was that for priority setting to be effective, it has to include clinicians in both decision making and the enforcement of those decisions. There was, however, a disturbing undertone to this theme, namely that doctors, in particular, were unjustifiably thwarting good systems of prioritising scarce healthcare resources. This undertone seems unfair precisely because doctors may, and in some cases do, feel obligated by their professional ethics to remain uninvolved either in deciding priorities and in some cases in enforcing them. I will argue that the professional role of a doctor ought not be considered inconsistent with the role of a priority setter or enforcer, as long as one crucial element is in place, a rationally coherent and broadly justifiable regime for prioritising healthcare. Given this I conclude both that prioritisation and doctoring are not incompatible under certain conditions, and that the education of healthcare professionals ought to include material on distributive justice in healthcare.

[Association of income with use of and access to health services in Spain at the beginning of the XXI century]

OBJECTIVE

To estimate the association of household income and provincial income with visits to general practitioners and specialists and with hospitalization and to determine whether waiting times to access these services vary with both economic variables.

METHOD

Data from the 2001 National Health Survey were used. The association was estimated by sex- and age-adjusted odds ratios; in the case of per capita income, odds ratios were also adjusted for household income. Percentiles and the geometric mean of waiting times in each health service were estimated and the statistical significance of their association with both economic variables was evaluated.

RESULTS

Subjects with the lowest household income showed the highest frequency of visits to general practitioners and hospitalization, although they waited longer for hospital admission. Subjects with the lowest household income also showed the lowest frequency of specialist visits: the odds ratio in the lowest income quartile with respect to the highest income quartile was 0.73 (95% CI: 0.62-0.87). However, when only visits to specialists working in the public system were analyzed, the lowest frequency of visits was observed in subjects with the highest household income. No differences were found in health services utilization or in waiting times according to provincial income.

CONCLUSIONS

The frequency of specialist visits according to household income shows a different pattern from that observed for visits to general practitioners and hospitalizations. The longest waiting times for admission to hospital were observed in subjects with the lowest household income.

Fair Rationing is Essentially Local: An Argument for Postcode Prescribing

In this paper I argue that resource allocation in publicly funded medical systems cannot be done using a purely substantive theory of justice, but must also involve procedural justice. I argue further that procedural justice requires institutions and that these must be "local" in a specific sense which I define. The argument rests on the informational constraints on any non-market method for allocating scarce resources among competing claims of need. However, I resist the identification of this normative account of local justice with the actual approach to local decision-making taken within the UK National Health Service. I illustrate my argument with reference to the case of provision of In Vitro Fertilisation within the UK NHS.

"Saying no is no easy matter" a qualitative study of competing concerns in rationing decisions in general practice

Background

The general practitioner in Norway is expected to ensure equity and effectiveness through fair rationing. At the same time, due to recent reforms of the Norwegian health care sector, both the role of economic incentives and patient autonomy have been strengthened. Studies indicate that modern general practitioners, both in Norway and in other countries are uncomfortable with the gatekeeper role, but there is little knowledge about how general practitioners experience rationing in practice.

Methods

Through focus group interviews with Norwegian general practitioners, we explore physicians' attitudes toward factors of influence on medical decision making and how rationing dilemmas are experienced in everyday practice.

Results

Four major concerns appeared in the group discussions: The obligation to ration health care, professional autonomy, patient autonomy, and competition. A central finding was that the physicians find rationing difficult because saying no in face to face relations often is felt uncomfortable and in conflict with other important objectives for the general practitioner.

Conclusion

It is important to understand the association between using economic incentives in the management of health care, increasing patient autonomy, and the willingness among physicians to contribute to efficient, fair and legitimate resource allocation.

Projected incidence of mechanical ventilation in Ontario to 2026: Preparing for the aging baby boomers*

OBJECTIVE

The aging baby boomers are expected to have a significant impact on the healthcare system. Mechanical ventilation is an age-dependent, costly, and relatively nondiscretionary medical service that may be particularly affected by the aging population. We forecast the future incidence of mechanical ventilation to the year 2026 to understand the impact of aging baby boomers on critical care resources.

DESIGN

Population-based, sex-specific, and age-specific mechanical ventilation incidences for adults for the year 2000 were directly standardized to population projections to estimate the incidence of mechanical ventilation, in 5-yr intervals, from 2006 to 2026. Sensitivity analyses were performed by varying population projections and mechanical ventilation incidence for the elderly.

SETTING

Province of Ontario, Canada.

PATIENTS

Noncardiac surgery, mechanically ventilated adults.

INTERVENTIONS

None.

MAIN RESULTS

The projected number of ventilated patients in 2026 was 34,478, representing an 80% increase from 2000. The crude incidence increased 31%, from 222 to 291 per 100,000 adults. The annually compounded projected growth rate during this 26-yr period was 2.3%, similar to the actual growth rate experienced in the 1990s. The projected incidence was relatively insensitive to changes in assumptions, with estimates for 2026 ranging from 31,473 to 36,313 ventilated adults.

CONCLUSIONS

The incidence of mechanical ventilation projected to the year 2026 will steadily increase and outpace population growth as occurred in the 1990s. In the current environment in which intensive care unit resources are limited and ventilated patients already use a significant proportion of acute care resources, planning for this continued growth is necessary. Existing evidence-based strategies that improve both the efficiency and efficacy of critical care services should be carefully evaluated for widespread implementation.

Ageing and healthcare costs in Australia: a case of policy‐based evidence?

There have been dire predictions that population ageing will result in skyrocketing health costs. However, numerous studies have shown that the effect of population ageing on health expenditure is likely to be small and manageable. Pessimism about population ageing is popular in policy debates because it fits with ideological positions that favour growth in the private sector and seek to contain health expenditure in the public sector. It might also distract attention from the need to evaluate the appropriateness and effectiveness of current patterns of care. Pessimistic scenarios have stifled debate and limited the number of policy options considered. Policy making in Australia would be improved if we took a more realistic view of the effect of population ageing on health expenditure.

The cancer technology appraisal programme of the UK's National Institute for Clinical Excellence

The National Institute for Clinical Excellence (NICE) was established to ensure faster and more equitable uptake of new technologies by the NHS, through the provision of guidance on clinical and cost-effectiveness. The treatment of cancer is one of the UK government's priority areas and a range of guidance products have been developed by NICE to support implementation of national plans for managing patients with cancer in England and Wales. In its first 3 years, NICE's main activity was the "Technology Appraisals Programme" and it has created considerable interest and some controversy. 15 (out of a total of 56) technology appraisals related to oncology have been completed and another four are in preparation. The open, transparent, and inclusive approach NICE has adopted in reaching its decisions highlights the difficult ethical issues that need to be addressed in seeking to balance individual desires with public-health requirements. In this review we describe the process of appraising technologies, and address the recent criticism of the appraisal programme with regard to treatment of patients with cancer.

NHS waiting lists and evidence of national or local failure: analysis of health service data

OBJECTIVES

To investigate the national distribution of prolonged waiting for elective day case and inpatient surgery, and to examine associations of prolonged waiting with markers of NHS capacity, activity in the independent sector, and need.

SETTING

NHS hospital trusts in England.

POPULATION

People waiting for elective treatment in the specialties of general surgery; ear, nose and throat surgery; ophthalmic surgery; and trauma and orthopaedic surgery.

MAIN OUTCOME MEASURE

Numbers of people waiting six months or longer (prolonged waiting). Characteristics of trusts with large numbers waiting six months or longer were examined by using logistic regression.

RESULTS

The distribution of numbers of people waiting for day case or elective surgery in all the specialties examined was highly positively skewed. Between 52% and 83% of patients waiting longer than six months in the specialties studied were found in one quarter of trusts, which in turn contributed 23-45% of the national throughput specific to the specialty. In general, there was little evidence to show that capacity (measured by numbers of operating theatres, dedicated day case theatres, available beds, and bed occupancy rate) or independent sector activity were associated with prolonged waiting, although exceptions were noted for individual specialties. There was consistent evidence showing an increase in prolonged waiting, with increased numbers of anaesthetists across all specialties and with increased bed occupancy rates for ear, nose and throat surgery. Markers of greater need for health care, such as deprivation score and rate of limiting long term illness, were inversely associated with prolonged waiting.

CONCLUSION

In most instances, substantial numbers of patients waiting unacceptably long periods for elective surgery were limited to a small number of hospitals. Little and inconsistent support was found for associations of prolonged waiting with markers of capacity, independent sector activity, or need in the surgical specialties examined.

Data information and knowledge: the health informatics model and its role in evidence-based medicine

The health informatics model consists of three essential parts: data, information and knowledge. These elements are arranged in a hierarchy, with data at the base of the model providing the basis for establishing information and leading in turn to the potential generation of knowledge. The informatics model converges closely with the principles, aims and tasks of evidence-based medicine (EBM), particularly as they relate to searching, appraising, reviewing and utilizing information and research. The development of health informatics today has its origins in the growth of statistics in the 18th and 19th centuries. As a new and growing discipline, statistics burgeoned amidst the challenge of measuring, monitoring and ultimately governing societies in the throes of massive change and expansion. The governance role embraced by statistics in the past resembles many aspects of the role ascribed to audit, quality assurance and EBM today. There are some deep-seated paradoxes within the field of health informatics. The informatics model posits an oversimplified and linear progression of data to information and knowledge. Health informatics may involve the spreading and dissemination of information but this should be seen as only a part, not the equivalent, of the complex process of generating knowledge.