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Author(s): Daniela Choukair [sup.1] [sup.2] , Susanne Rieger [sup.1] , Dirk Bethe [sup.1] , Dorothea Treiber [sup.1] , Georg F. Hoffmann [sup.1] [sup.2] , Corinna Grasemann [sup.3] , Peter Burgard [...], Background The structured transition of adolescents and young adults with chronic kidney disease (CKD) from pediatric to adult care is important, but data on the time and resources required for the necessary components of the transition process and the associated costs are lacking. Methods In a prospective single-center cohort study of 52 patients with pre-transplant CKD (CKD stage 1, n = 10; stage 2, n = 6; stage 3, n = 5; stage 4 and 5, 1 patient each) or kidney transplant recipients (KTR), resource use and costs were evaluated for the key elements of a structured transition pathway, including (i) assessment of patients&apos; disease-related knowledge and needs, (ii) required education and counseling sessions, and (iii) compiling an epicrisis and a transfer appointment of the patient with the current pediatric and the future adult nephrologist. Results Forty-four of 52 enrolled patients (84.6%) completed the transition pathway and were transferred to adult care. The mean time from the decision to start the transition process until the final transfer consultation was 514 ± 204 days. The process was significantly longer for KTR (624 ± 150 [range, 307-819] days) than for patients with pre-transplant CKD (365 ± 172 [range, 1-693] days; P < 0.0001). The cumulative costs of all counseling and education sessions performed including the transfer appointment were 763 ± 473 Euro; it was significantly higher in KTR (966 ± 457 Euro) than in patients with pre-transplant CKD (470 ± 320 Euro; P < 0.0001). Conclusions A structured transition pathway for patients with CKD is resource and time-consuming due to the complexity of the disease and should be sufficiently funded. Graphical Abstract

1 | INTRODUCTION If decisions on the allocation of health resources were guided by the principals of health economics alone, funds would be allocated in ways intended to lead to [...], Introduction: With limited funds available, meeting global health targets requires countries to both mobilize and prioritize their health spending. Within this context, countries have recognized the importance of allocating funds for HIV as efficiently as possible to maximize impact. Over the past six years, the governments of 23 countries in Africa, Asia, Eastern Europe and Latin America have used the Optima HIV tool to estimate the optimal allocation of HIV resources. Methods: Each study commenced with a request by the national government for technical assistance in conducting an HIV allocative efficiency study using Optima HIV. Each study team validated the required data, calibrated the Optima HIV epidemic model to produce HIV epidemic projections, agreed on cost functions for interventions, and used the model to calculate the optimal allocation of available funds to best address national strategic plan targets. From a review and analysis of these 23 country studies, we extract common themes around the optimal allocation of HIV funding in different epidemiological contexts. Results and discussion: The optimal distribution of HIV resources depends on the amount of funding available and the characteristics of each country&apos;s epidemic, response and targets. Universally, the modelling results indicated that scaling up treatment coverage is an efficient use of resources. There is scope for efficiency gains by targeting the HIV response towards the populations and geographical regions where HIV incidence is highest. Across a range of countries, the model results indicate that a more efficient allocation of HIV resources could reduce cumulative new HIV infections by an average of 18% over the years to 2020 and 25% over the years to 2030, along with an approximately 25% reduction in deaths for both timelines. However, in most countries this would still not be sufficient to meet the targets of the national strategic plan, with modelling results indicating that budget increases of up to 185% would be required. Conclusions: Greater epidemiological impact would be possible through better targeting of existing resources, but additional resources would still be required to meet targets. Allocative efficiency models have proven valuable in improving the HIV planning and budgeting process. Keywords: HIV modeling; allocative efficiency; cost-effectiveness; optimal HIV investment; resource allocation; resource needs

Background: The Inter-professional Spine Assessment and Education Clinics (ISAEC) were developed to improve primary care assessment, education and management of patients with persistent or recurrent low back pain-related symptoms. This [...]

Abstract This paper attempts to address some of the issues surrounding rationing of healthcare services, with application to Greece's delivery of cardiac services. To this end, first, we provide highlights [...]

THE PRIORITIZATION OF HEALTH CARE RESOURCES AND RATIONING IS A paradigm example of difficult choices, and yet one might well wonder why. Individuals are continually forced every day to prioritize [...]

Purpose. The diagnosis of tuberculosis remains controversial between clinicians and public health officers. Public health officials fear to treat too many patients; clinicians fear that truly diseased will be denied [...]

Healthcare rationing is here to stay. No one likes it and we would prefer to give everyone all the care they need and deserve. We know that there simply are not enough resources to do this, however. So resources will be rationed. In some cases, rationed resources will go to the young, not the aged. When this happens, there is a very good chance (indeed Miller claims it is fact) that there will not only be age bias, but sex bias in the rationing. Miller confronts us with the issue, and challenges us with the defense of such practices, and offers an alternative framework for dealing with the problem.

Author Affiliations: COVID vaccine allocation and a dramatic telescope collapse At 8 a.m. on 1 December, the Arecibo telescope's instrument platform crashed into the dish below, tearing more gashes into [...], The latest science news, in brief. The latest science news, in brief.

Byline: Y. Michael Barilan (1) Keywords: allocation of scarce resources in healthcare; medicine; motivation; utilitarianism; well being Abstract: Utilitarianism focuses on the optimization of personal well being in ways that seems to make the practice of medicine irrelevant to the well being of the practitioners, unless given external incentives such as money or honor. Care based on indirect incentives is considered inferior to care motivated internally. This leads to the paradox of utilitarian care. Following Nozick's conceptual Pleasure Machine it is argued that in addition to the promotion of personal well being, people care about fulfilling their well being in a world which is real, just, good, and beautiful. Complete mechanization of social and personal life in accordance with a strict utilitarian regime is also incompatible with the kind of world people desire, even if it promises more fulfillments in terms of personal well being. This explains the so-called Taurek-Parfit paradox, according to which sometimes ethics seems 'to count the numbers' and sometimes not. The very pursuit of utilitarianism does not contribute to any personal life plan. The helping professions make the world a better place for us to live in, even though they do not necessarily bear directly on the well being of any individual other than the recipients of care. This resolves the paradox of utilitarian care. Author Affiliation: (1) Department of Internal Medicine B, Meir Hospital, Kfar Saba and Department of Behavioral Sciences, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Article History: Registration Date: 18/10/2004

Byline: Rui Nunes (1) Keywords: Evidence-Based Medicine; priorities in healthcare Abstract: Evidence-Based Medicine (EBM) is defined as the conscious, and judicious use of current best evidence in making decisions about the care of individual patients. The greater the level of evidence the greater the grade of recommendation. This pioneering explicit concept of EBM is embedded in a particular view of medical practice namely the singular nature of the patient-physician relation and the commitment of the latter towards a specific goal: the treatment and the well being of his or her client. Nevertheless, in many European countries as well as the United States, this 'integration of the best evidence from systematic research with clinical expertise and patient values'appears to be re-interpreted in light of the scarcity of healthcare resources. The purpose of this paper is double. First, to claim that from an ethical perspective EBM should be a guideline to clinical practice and second, that in specific circumstances EBM might be a useful tool in macro-allocation of healthcare resources. Methodologically the author follows Norman Daniels' theory of 'democratic accountability'to justify this assumption. That is, choices in healthcare must be accountable by democratic procedures. This perspective of distributive justice is responsible for the scope and limits of healthcare services. It follows that particular entitlements to healthcare -- namely expensive innovative treatments and medicines --may be fairly restricted as long as this decision is socially and democratically accountable and imposed by financial restrictions of the system. In conclusion, the implementation of EBM, as long as it limits the access to drugs and treatments of unproven scientific results is in accordance with this perspective. The use of EBM is regarded as an instrument to facilitate the access of all citizens to a reasonable level of healthcare and to promote the efficiency of the system. Author Affiliation: (1) Department of Bioethics and Medical Ethics, School of Medicine, Oporto University, Portugal, Estrada da Circunvalacao, 9925, Porto, 4250-150, Portugal Article History: Registration Date: 07/10/2004 Article note: This revised version was published online in October 2005 with corrections to the Cover Date.

The integration of claims framework provides a viable framework for health-care rationing and recognizes 3 main sources of claims: consequences, deontology and procedures. The concluding social choice rules, which are generalizations of health-maximizations, are found through non-linear programming.

Byline: Christoph Benn (1), Adnan A. Hyder (2) Keywords: christianity; distribution of health care resources; equity; interreligious dialogue; Islam Abstract: Inequities in health and health care are one of the greatest challenges facing the international community today. This problem raises serious questions for health care planners, politicians and ethicists alike. The major world religions can play an important role in this discussion. Therefore, interreligious dialogue on this topic between ethicists and health care professionals is of increasing relevance and urgency. This article gives an overview on the positions of Islam and Christianity on equity and the distribution of resources in health care. It has been written in close collaboration and constant dialogue between the two authors coming from the two religions. Although there is no specific concept for the modern term equity in either of the two religions, several areas of agreement have been identified: All human beings share the same values and status, which constitutes the basis for an equitable distribution of rights and benefits. Special provisions need to be made for the most needy and disadvantaged. The obligation to provide equitable health services extends beyond national and religious boundaries. Several areas require intensified research and further dialogue: the relationship between the individual and the community in terms of rights and responsibilities, how to operationalize the moral duty to decrease global inequalities in health, and the understanding and interpretation of human rights in regard to social services. Author Affiliation: (1) German Institute for Medical Mission, Paul-Lechler-Str.24, 72076, Tubingen, Germany (2) Johns Hopkins Bioethics Institute Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Suite E-8132, Baltimore, MD, 21205, USA Article History: Registration Date: 09/10/2004 Article note: This revised version was published online in October 2005 with corrections to the Cover Date.

This article examines how medical corporations review candidates for surgery. The authors discuss the criteria involved when determining which cases are appropriate for surgery, maintaining the decisions are largely based upon previous surgeries for the same condition and whether treatment is economical.

This article examines the decision-making process of community mental health teams (CMHTs) in determining whether or not patients should be assigned to caseloads. The author discusses how CMHTs process referrals form psychiatrists and psychologists, maintaining they may decide on less intensive treatment options, delay acceptance by requesting more information, or reject candidates by claiming they are inappropriate.

This article compares managed care organizations in the United States and British Columbia. The authors, analyzing data from group interviews conducted with nurses in British Columbia and California, argue managed care in both countries does not live up to its promises of more efficient and cheaper health care, and maintain medical care is rationed by early discharge policies and staff reduction.

This article discusses the categorization of patients by medical staff in a French emergency department. The author examines the decision-making process of the medical personnel regarding who is eligible for care and concludes the emergency department staff takes into consideration clinical, organizational, moral, and social factors, leading to micro-rationing of health care.

This article discusses health care rationing practices. The authors, exploring power relations, economics, and social practices within the health care system, argue the allocation of limited health care resources can be used to support certain interests against others and maintain rationing is a socially constructed reality.

Hong Kong is undergoing a public debate on the need to reform and future directions of reforming its health care system. This paper highlights the debates and considerations brought up by the Hospital Authority, the largest provider of public health care in Hong Kong, on the ethical principles and societal values underlying the upcoming reform. It is recognized that the exact meanings behind each ethical principle and value must be debated and clarified during the reform process. In a modern day society like Hong Kong, societal values are likely to be diversified. A health care system also has to fulfil different and often conflicting objectives of equity, efficiency, quality and choice. It would be difficult for a health care system to satisfy these different values and objectives based on a single value parameter. The Hong Kong experience shows that a society may prefer a combination of strategies in addressing different societal values. The re-structuring of the health care system in Hong Kong should therefore be based on a balanced and optimum combination of various financing and delivery strategies. Key words: Hong Kong health care reform, societal values

Seven reports of cost-effectiveness analysis (CEA) in nursing literature have been studied. The studies are from the period 1992-1996. The goal was review of recommendations of the U.S. Panel of Cost-Effectiveness in Health and Medicine of the Public Health Service. Nursing CEA studies considered were found to be neither more nor less defective than such studies performed in the health care or medical care fields. An array of diverse effects were studied, and costs and effects were related. Techniques of economic evaluation and decision analysis should be included in graduate nursing curricula.

An alternative approach to the person trade-off technique is formulated to address the issue concerning the effectiveness of cost per quality-adjusted life-years (QALYs). The approach is seen to maximize QALY's use in giving relevant information regarding allocation of scarce health care resources through consideration of individual utility and health-related social welfare function. It also entails questioning in relation to health gain.

Many physicians engage in rationing health care resources even though they might not use the term to describe their actions. This often occurs in the context of reducing health care costs. One way this is done is to use the accepted standard of care even though there may be more effective but expensive alternates. Managed care plans force patients to see certain specialists even though another physician may be more suitable. Some physicians will try the best treatment only after other cheaper treatments have failed. All of these scenarios are used to control costs.

Dr. Bruce Vladeck states three prerequisites to the Health Care Financing Administration's (HCFAs) projection of Medicare and managed care:expanded choice, responsiveness, and beneficiary empowerment. Vladeck excludes the need for cost control. A long-term multiple, capitated, and managed care system will rationalize the health care delivery system and enhance the quality of care. Bureaucratic hurdles, rationing care, and ratcheting down of fees need to be avoided. The implications of a capitated system and the role of HCFA in meeting the new challenge of cost control are discussed.

Centralized, democratic rules are often asserted as a superior basis for rationing than individualized physician discretion. This article counters this prevailing wisdom by exploring the deficiencies of rule-based rationing. Rules are too imprecise to accurately reflect all the nuances of physical and mental impairment and the complexity of medical science, particularly considering the widely varying personal values that different patients attach to medical risk and benefit. Rule-based rationing also suffers from the biasing effects of interest group pressure on political processes and the tendency to absolve physicians from any moral responsibility for the rationing decisions they implement. Internalizing cost constraints is a more socially and professionally acceptable means of rationing and, in any event, it is inevitable since even a preponderance of rule-based rationing will leave considerable areas of discretion for physician judgment in the implementation and interpretation of the rules. As a consequence, despite the flaws of bedside rationing, it is foolhardy to dispense with it entirely in favor of an exclusively rule-based system. Key Words: Bedside rationing, cost-constraints, rule-based rationing.

The prevailing legal and ethical opinion that rationing decisions must always be disclosed to patients is countered. Although conventional informed consent law could theoretically extend to decisions to decline treatment because of costs, it has not yet done so. Moreover, abandonment law does not prohibit declining treatment for economic reasons. A new theory of economic informed consent would stipulate that when patients make informed decisions to purchase less expensive health insurance, they are consenting in advance either to limiting marginally beneficial treatment or to waiving their right to be informed of particular decisions not to treat. Whether this will prove workable or will be accepted by the courts depends on the specifics of the enrollment disclosures, the range of choices given to subscribers, and their capacity to understand them.