Commentary: diversity and inclusion in the 21st century: bridging the moral and excellence imperatives

There is prolific evidence of a commitment to diversifying student and faculty populations in academic medicine, but far less evidence of its effectiveness. The social justice underpinning of this commitment is important and must continue to undergird diversity and inclusion efforts. In today's environment of pinched resources, however, moral arguments alone will not suffice. What the diversity and inclusion movement needs for the 21st century is to apply rigorous empirical methods to understanding the most effective and efficient interventions to contribute to institutional excellence.The collection of diversity and inclusion articles in this month's issue of Academic Medicine is quite comprehensive and speaks to a range of audiences, from those who consider themselves experts on diversity and inclusion to the casual and interested reader. This robust collection will afford diversity practitioners, institutional leaders, and policy influencers with greater insight into what defines an effective diversity strategy.The academic medicine community cannot derive top value from diversity efforts, however, until practitioners, deans, CEOs, and policy makers begin operating with a shared framework for success. The excellence imperative facing our medical schools and teaching hospitals calls for improved precision in decision making and resource deployment to drive sustainable outcomes, which in turn requires a strong degree of alignment among all involved parties.

Pharmacoeconomics and its implication on priority-setting for essential medicines in Tanzania: a systematic review

BACKGROUND

Due to escalating treatment costs, pharmacoeconomic analysis has been assigned a key role in the quest for increased efficiency in resource allocation for drug therapies in high-income countries. The extent to which pharmacoeconomic analysis is employed in the same role in low-income countries is less well established. This systematic review identifies and briefly describes pharmacoeconomic studies which have been conducted in Tanzania and further assesses their influence in the selection of essential medicines.

METHODS

Pubmed, Embase, Cinahl and Cochrane databases were searched using "economic evaluation", "cost-effectiveness analysis", "cost-benefit analysis" AND "Tanzania" as search terms. We also scanned reference lists and searched in Google to identify other relevant articles. Only articles reporting full economic evaluations about drug therapies and vaccines conducted in Tanzania were included. The national essential medicine list and other relevant policy documents related to the identified articles were screened for information regarding the use of economic evaluation as a criterion for medicine selection.

RESULTS

Twelve pharmacoeconomic studies which met our inclusion criteria were identified. Seven studies were on HIV/AIDS, malaria and diarrhoea, the three highest ranked diseases on the disease burden in Tanzania. Six studies were on preventive and treatment interventions targeting pregnant women and children under the age of five years. The national essential medicine list and the other identified policy documents do not state the use of economic evaluation as one of the criteria which has influenced the listing of the drugs.

CONCLUSION

Country specific pharmacoeconomic analyses are too scarce and inconsistently used to have had a significant influence on the selection of essential medicines in Tanzania. More studies are required to fill the existing gap and to explore whether decision-makers have the ability to interpret and utilise pharmacoeconomic evidence. Relevant health authorities in Tanzania should also consider how to apply pharmacoeconomic analyses more consistently in the future priority-setting decisions for selection of essential medicines.

Cognitive function in the community setting: the neighbourhood as a source of 'cognitive reserve'?

BACKGROUND

Existing research has found a positive association between cognitive function and residence in a socioeconomically advantaged neighbourhood. Yet, the mechanisms underlying this relationship have not been empirically investigated.

OBJECTIVE

To test the hypothesis that neighbourhood socioeconomic structure is related to cognitive function partly through the availability of neighbourhood physical and social resources (eg, recreational facilities, community centres and libraries), which promote cognitively beneficial activities such as exercise and social integration.

METHODS

Using data from a representative survey of community-dwelling adults in the city of Chicago (N=949 adults aged 50 and over), cognitive function was assessed with a modified version of the Telephone Interview for Cognitive Status instrument. Neighbourhood socioeconomic structure was derived from US census indicators. Systematic social observation was used to directly document the presence of neighbourhood resources on the blocks surrounding each respondent's residence.

RESULTS

Using multilevel linear regression, residence in an affluent neighbourhood had a net positive effect on cognitive function after adjusting for individual risk factors. For white respondents, the effects of neighbourhood affluence operated in part through a greater density of institutional resources (eg, community centres) that promote cognitively beneficial activities such as physical activity. Stable residence in an elderly neighbourhood was associated with higher cognitive function (potentially due to greater opportunities for social interaction with peers), but long term exposure to such neighbourhoods was negatively related to cognition.

CONCLUSIONS

Neighbourhood resources have the potential to promote 'cognitive reserve' for adults who are ageing in place in an urban setting.

The challenges confronting clinicians in rural acute care settings: a participatory research project

INTRODUCTION

In Australia, as in many other developed countries, the current healthcare environment is characterised by increasing differentiation and patient acuity, aging of patients and workforce, staff shortages and a varied professional skills mix, and this is particularly so in rural areas. Rural healthcare clinicians are confronted with a broad range of challenges in their daily practice. Within this context, the challenges faced by rural acute care clinicians were explored and innovative strategies suggested. This article reports the findings of a study that explored these challenges across disciplines in acute healthcare facilities in rural New South Wales (NSW), Australia.

METHODS

A mixed method approach, involving a consultative, participatory 3 stage data collection process was employed to engage with a range of healthcare clinicians from rural acute care facilities in NSW. Participants were invited to complete a survey, followed by focus group discussions and finally facilitated workshops using nominal group technique.

RESULTS

The survey findings identified the respondents' top ranked challenges. These were organised into four categories: (1) workforce issues; (2) access, equity and opportunity; (3) resources; and (4) contextual issues. Participants in the focus groups were provided with a summary of the survey findings to prompt discussion about the challenges identified and impact of these on their professional and personal lives. The results of the final workshop stage of the study used nominal group process to focus the discussion on identifying strategies to address identified challenges.

CONCLUSIONS

This study builds on research conducted in a large metropolitan tertiary referral hospital. While it was found that rural clinicians share some of the challenges identified by their metropolitan counterparts, some identified challenges and solutions were unique to the rural context and require the innovative solutions suggested by the participants. This article provides insight into the working world of rural healthcare clinicians and offers practical solutions to some of the identified issues. The findings of this study may assist rurally based healthcare services to attract and retain clinical staff.

Can rural health insurance improve equity in health care utilization? A comparison between China and Vietnam

INTRODUCTION

Health care financing reforms in both China and Vietnam have resulted in greater financial difficulties in accessing health care, especially for the rural poor. Both countries have been developing rural health insurance for decades. This study aims to evaluate and compare equity in access to health care in rural health insurance system in the two countries.

METHODS

Household survey and qualitative study were conducted in 6 counties in China and 4 districts in Vietnam. Health insurance policy and its impact on utilization of outpatient and inpatient service were analyzed and compared to measure equity in access to health care.

RESULTS

In China, Health insurance membership had no significant impact on outpatient service utilization, while was associated with higher utilization of inpatient services, especially for the higher income group. Health insurance members in Vietnam had higher utilization rates of both outpatient and inpatient services than the non-members, with higher use among the lower than higher income groups. Qualitative results show that bureaucratic obstacles, low reimbursement rates, and poor service quality were the main barriers for members to use health insurance.

CONCLUSIONS

China has achieved high population coverage rate over a short time period, starting with a limited benefit package. However, poor people have less benefit from NCMS in terms of health service utilization. Compared to China, Vietnam health insurance system is doing better in equity in health service utilization within the health insurance members. However with low population coverage, a large proportion of population cannot enjoy the health insurance benefit. Mutual learning would help China and Vietnam address these challenges, and improve their policy design to promote equitable and sustainable health insurance.

Service guidelines based on Resource Utilization Groups Version III for Home Care provide decision-making support for case managers

Increasing costs and budget reductions combined with increasing demand from our growing, aging population support the need to ensure that the scarce resources allocated to home care clients match client needs. This article details how Integrated Home Care for the Calgary Zone of Alberta Health Services considered ethical and economic principles and used data from the Resident Assessment Instrument for Home Care (RAI-HC) and case mix indices from the Resource Utilization Groups Version III for Home Care (RUG-III/HC) to formulate service guidelines. These explicit service guidelines formalize and support individual resource allocation decisions made by case managers and provide a consistent and transparent method of allocating limited resources.

Efficiency of health care system in India: an inter-state analysis using DEA approach

Since independence a massive personnel and public health infrastructure has been created in India. However, there is no competition and hardly any choice to the poor patients resulting in poor quality services leading to allocative and technical inefficiencies. This study uses the data envelopment analysis model to assess and compare the efficiency of health system within various states of India. It shows the inadequacy of health infrastructure and manpower in the inefficient states where poor people are concentrated. Among the determinants of efficiency female literacy, poverty level, institutional delivery, and full immunization of children are proved to be important factors in explaining efficiency of health system in India.

Test-retest reliability of health state valuation techniques: the time trade off and person trade off

Economic analysis is increasingly being employed in formal resource allocation decision-making processes in health care. As a consequence, the methods employed by economic analysts are increasingly subject to close scrutiny. One such area of methodology concerns the instruments used to elicit preferences for various health states for use in the construction of quality-adjusted life years. There are a number of techniques which may be used to elicit preferences and different techniques produce different results. The objective of this study was to explore the test-retest reliability of two techniques: Time Trade Off (TTO) and Person Trade Off (PTO) valuations were collected by a general population postal survey. A total of 798 respondents returned questionnaires. The intra class correlation coefficients ranged from 0.40 to 0.88 for TTO and, -0.17 to 0.82 for PTO, with the majority of coefficients being >0.50. The reliability coefficients varied between techniques and health states, with the TTO technique tending to produce higher coefficients. While the reliability results for TTO were generally positive, the reliability results for PTO are less clear.

Allocating scarce resources in disasters: emergency department principles

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

Analysis of the environmental impact of insulin infusion sets based on loss of resources with waste

Insulin pump therapy [continuous subcutaneous insulin infusion (CSII)] requires regular change of infusion sets every 2-3 days in order to minimize the risk of skin irritations or other adverse events. This has been discussed to be a potential burden to the environment. The purpose of this analysis was to perform an environmental assessment of insulin pump infusion sets based on loss of resources occurring during incineration of the discarded products and by means of a lifecycle concept used to weight a material in relation to its rareness on earth and its consumption. In addition to five infusion sets (Inset30, InsetII, Comfort, Quick-set, and Cleo), a patch pump (Omnipod) was also included in this analysis. The annual loss in waste of the so called "person reserve" of 3 days of catheter use was compared with daily consumption of a cup of coffee in a disposable paper cup and to a soft drink in an aluminum can. The weight-based loss in resources through waste for the infusion sets (except for Cleo) corresponded to 70-200% of the loss of resources for a coffee cup (Cleo, 320%; Omnipod, 1,821,600%) and to 1-3% of the loss from an aluminum soft drink can (Cleo, 5%; Omnipod, 31,200%). The loss or resources by use of infusion sets used in insulin pump therapy appears to be low and is similar to the burden induced by the uptake of one cup of coffee per day. The loss or resources with regular CSII is considerably lower than the loss or resources induced by patch pumps.

Health aid and governance in developing countries

Despite anecdotal evidence that the quality of governance in recipient countries affects the allocation of international health aid, there is no quantitative evidence on the magnitude of this effect, or on which dimensions of governance influence donor decisions. We measure health-aid flows over 1995-2006 for 109 aid recipients, matching aid data with measures of different dimensions of governance and a range of country-specific economic and health characteristics. Everything else being equal, countries with more political rights receive significantly more aid, but so do countries with higher corruption levels. The dependence of aid on political rights, even when we control for other governance indicators, suggests that health aid is sometimes used as an incentive to reward political reforms.

Health dynamics: implications for efficiency and equity in priority setting

Health dynamics are intertemporal fluctuations in health status of an individual or a group of individuals. It has been found in empirical studies of health inequalities that health dynamics can differ systematically across subgroups, even if prevalence measured at one point in time is the same. We explore the relevance of the concept of health dynamics in the context of cost-effectiveness analysis. Although economic evaluation takes health dynamics into account where they matter in terms of efficiency, we find that it fails to take into account the equity dimensions of health dynamics. In addition, the political implications of health dynamics may influence resource allocation decisions, possibly in opposing directions.

Why mental health services in low- and middle-income countries are under-resourced, underperforming: an indian perspective

The inadequacies of mental health services in low- and middleincome countries are often attributed to inadequate allocation of resources. This may not be entirely true. The experience in India suggests that a top-down approach to planning, divorced from the ground realities, poor governance, managerial incompetence and unrealistic expectations from low-paid/poorly motivated primary healthcare personnel play an important role and may result in the failure of even adequately funded programmes. The ambitious National Mental Health Programme (NMHP), launched in 1983 and aimed at providing basic mental health services through the existing primary healthcare system, using the Bellary model, failed to achieve any of its targets over the subsequent decades. In early 2001, the NMHP was radically revamped. It was re-launched as part of the Tenth Five-Year Plan (2002-07) and the budgetary allocation was increased more than 7-fold. However, the programme faltered due to techno-managerial underperformance and the initial momentum was lost. The reasons for this failure are analysed and possible remedial strategies suggested. While the experience documented in the paper is country-specific and relates to India, it may hold useful lessons for other low- and middle-income countries.

The Swedish National Survey of the Quality and Organization of Diabetes Care in Primary Healthcare--Swed-QOP

AIM

To describe the quality and organization of diabetes care in primary healthcare in Sweden regarding resources and ways of working.

METHOD

A questionnaire was used to collect data from all 921 primary healthcare centres (PHCCs) in Sweden. Of these, 74.3% (n=684) responded to the questionnaire covering list size of the PHCCs, number of diabetic patients, personnel resources and ways of working.

RESULTS

The median list size reported from the PHCCs was 9,000 patients, 294 of whom were diabetic patients. The majority (72%) of PHCCs had diabetes-responsible general practitioners (GPs) and almost all (97%) had diabetes specialist nurses (DSNs) with some degree of postgraduate education in diabetes. The PHCCs reported that they used regional/local diabetes guidelines (93%), were engaged in call-recall diabetic reviews by GP(s) (66%) and DSN(s) (89%), checked that patients had participated in the reviews by GP(s) (69%) and DSN(s) (78%), arranged group education programmes (23%) and reported data to a National Diabetes Register (82%).

CONCLUSIONS

The presence of diabetes-responsible GP(s) and DSN(s) who use guidelines may contribute to good and equal quality of care. It is, however, necessary to improve the call-recall system and there is an urgent need for all diabetic patients to receive patient education.

Allocating scarce medical resources to the overweight

BACKGROUND

A programmatic research effort investigated how lay people weigh information on hypothetical patients when making decisions regarding the allocation of scarce medical resources. This study is partly replicative and partly innovative, and looks particularly at whether overweight patients would be discriminated against in allocating resources.

AIMS

This study aims to determine the importance given to specific patient characteristics when lay participants are asked to allocate scarce medical resources.

SAMPLE

In all, 156 British adults (82 males, 73 females), aged 19 to 84 years, took part. There were few students.

METHOD

Participants completed a questionnaire requiring them to rank 16 hypothetical patients for access to a kidney dialysis machine.The demographic information presented regarding each hypothetical patient differed on four dimensions: gender, weight, mental health, and religiousness.

RESULTS

There were significant main effects for gender, weight, and mental health; females, patients of normal weight, and the mentally well were ranked the highest priority for access to a kidney dialysis machine. Participants discriminated most regarding the weight of hypothetical patients.

CONCLUSION

Different patient characteristics, unrelated to medical prognoses, particularly being overweight, may have an impact on decisions regarding the use of scarce medical resources.

Benchmarking by the RAFAELA Patient Classification system - a descriptive study of optimal nursing intensity levels

The overall aim of the RAFAELA system is that the personnel resources should be in balance with the patients' caring needs, i.e. when the nursing intensity per nurse is on the optimal level of the unit. The RAFAELA system consists of three parts: the OPCq (Oulu Patient Classification Qualisan) instrument for measuring the nursing intensity, registration of the daily nursing resources and the PAONCIL (Professional Assessment of Optimal Nursing Care Intensity Level) method. The aim of this paper is (1) to describe the structure of benchmarking with the RAFAELA system and (2) to present comparisons of optimal nursing intensity levels in Finnish hospitals by using data from RAFAELA benchmarking reports in 2001. Totally 86 wards from 14 different hospitals in Finland took part in the study, the optimal nursing intensity had been decided for 53 wards. Data was analyzed using descriptive statistics. The average workload was on adult wards 25.2 NCI points per nurse. The optimal NCI was exceeded during 48% of the days and under during 22% of the days. An imbalance between nursing intensity and personnel resources clearly affects the care quality and the results. Benchmarking with the RAFAELA system provides nurse managers with many opportunities in their decision processes in human resource management.

[Constitutional requirements of rationing]

Rationing is an emotive issue in the field of public health. This complicates the rational discourse, which is indispensable for analyzing the rationing conditions as set out by constitutional law and which requires manifold differentiation and consideration that shall briefly be outlined in the following short contribution. Of central significance is the distinction between indirect and direct rationing as well as the reference to the essential responsibility of legislators for rationing decisions.

Evidence-based guidelines--an introduction

Recommendations in the form of clinical practice guidelines are increasingly common. Clinical guidelines are systematically developed statements designed to help administrators, practitioners and patients make decisions about appropriate health care for specific circumstances. In North America, guidelines developed by professional societies, government panels and cooperative groups are frequently used to measure quality, to allocate resources and to determine how health care dollars are spent. For clinicians, guidelines provide a summary of the relevant medical literature and offer assistance in deciding which diagnostic tests to order, which treatments to use for specific conditions, when to discharge patients from the hospital, and many other aspects of clinical practice.