Selection of initiatives to improve the management of patients with hereditary angioedema by the hospital pharmacy using the nominal group technique.

OBJECTIVE: To identify and promote hospital pharmacy initiatives to improve the management of patients with hereditary angioedema (HAE) within the Spanish healthcare system. METHOD: A panel of experts comprising hospital pharmacists, an allergist and a nurse/member of the Spanish Hereditary Angioedema Association (Asociación Española de Angioedema Familiar) highlighted initiatives to improve care for patients with HAE after identifying, evaluating and prioritising them. Prioritisation was assessed based on the impact on patient care and the feasibility of their implementation on a scale of 1-5. RESULTS: Seven key areas of activity for the role of hospital pharmacists in the management of patients with HAE were identified: evaluation and selection of medicines; hospital pharmacy dispensation and telepharmacy; pharmacotherapy follow-up and telemedicine; coordination with other healthcare teams involved in the care of patients with HAE; patient health education and training; research on HAE; and continuous education and training of hospital pharmacy service personnel. Ten initiatives with a mean impact score of 5 and a mean feasibility score of ≥4.1 were considered as high-priority initiatives. Half of the initiatives belong to the area concerning patient education and training (50%), followed by care coordination initiatives (30%) and continuous education and training (20%). CONCLUSIONS: Ten high-priority initiatives for the management of patients with HAE were identified by a panel of experts. The implementation of such initiatives by the hospital pharmacy service should enhance the management of patients with HAE in the Spanish healthcare system.

Out-of-pocket expenses and rationing of insulin and diabetes supplies: findings from the 2022 T1International cross-sectional web-based survey.

Introduction: Continue investigating Out-of-Pocket Expenses (OoPEs) and rationing of insulin and diabetes supplies, including impacts of the COVID-19 pandemic, for people with type 1 diabetes (T1D). Methods: A cross-sectional web-based survey was conducted in English and advertised by T1International's global network of patient advocates from May through September 2022. Participants provided monthly OoPEs and rationing frequency for insulin and supplies, impacts of the COVID-19 pandemic, and open-ended comments. Results: In the seven most represented countries, mean monthly OoPEs were highest in the United States, followed by Panama, Canada, and India, and were much lower in the United Kingdom, Germany, and Sweden. OoPEs were highest for participants with partial healthcare coverage, followed by those with no healthcare coverage. The COVID-19 pandemic negatively impacted access and/or affordability of insulin and/or supplies for over half of participants. Globally, 19.5% reported insulin rationing and 36.6% reported rationing glucose testing supplies. Qualitative analysis of open-ended responses identified themes such as 'mental health impacts' and 'limits to life choices.' Discussion: High OoPEs lead to rationing of insulin and supplies for many people with T1D globally. Healthcare systems improvements and price reductions of insulin and supplies are needed to ensure adequate, equitable access for all.

Moral distress among physicians in Norway: a longitudinal study.

OBJECTIVES: To explore and compare physicians' reported moral distress in 2004 and 2021 and identify factors that could be related to these responses. DESIGN: Longitudinal survey. SETTING: Data were gathered from the Norwegian Physician Panel Study, a representative sample of Norwegian physicians, conducted in 2004 and 2021. PARTICIPANTS: 1499 physicians in 2004 and 2316 physicians in 2021. MAIN OUTCOME MEASURES: The same survey instrument was used to measure change in moral distress from 2004 to 2021. Logistic regression analyses examined the role of gender, age and place of work. RESULTS: Response rates were 67% (1004/1499) in 2004 and 71% (1639/2316) in 2021. That patient care is deprived due to time constraints is the most severe dimension of moral distress among physicians, and it has increased as 68.3% reported this 'somewhat' or 'very morally distressing' in 2004 compared with 75.1% in 2021. Moral distress also increased concerning that patients who 'cry the loudest' get better and faster treatment than others. Moral distress was reduced on statements about long waiting times, treatment not provided due to economic limitations, deprioritisation of older patients and acting against one's conscience. Women reported higher moral distress than men at both time points, and there were significant gender differences for six statements in 2021 and one in 2004. Age and workplace influenced reported moral distress, though not consistently for all statements. CONCLUSION: In 2004 and 2021 physicians' moral distress related to scarcity of time or unfair distribution of resources was high. Moral distress associated with resource scarcity and acting against one's conscience decreased, which might indicate improvements in the healthcare system. On the other hand, it might suggest that physicians have reduced their ideals or expectations or are morally fatigued.

Relationships between job satisfaction, occupational burnout and rationing of care among intensive care unit nurses.

Introduction: Rationing of nursing care is referred to as overlooking aspects of required patient care. Its result is incomplete or delayed services provided to the patient. Anesthesia nurses employed in an intensive care unit are exposed to a significant workload. Particularly heavy is the psychological burden leading in many cases to the onset of burnout syndrome and a decrease in job satisfaction. The aim of this paper: Was to determine the relationship between occupational burnout, job satisfaction and rationing of care among anesthesia nurses employed in intensive care units. Materials and methods: The study group consisted of 477 anesthesia nurses employed in intensive care units in Poland. The study was conducted between December 2022 and January 2023. The research tools were BERNCA-R questionnaire, Job Satisfaction Scale questionnaire and Maslach Burnout Inventory questionnaire, which were distributed to selected hospitals with a request to be forwarded to intensive care units and completed. In the statistical analysis, correlations were calculated using Spearman's rho coefficient, reporting the intensity of the relationship and its positive or negative direction. The analysis was performed using the IBM SPSS 26.0 package with the Exact Tests module. Results: The mean score of the BERNCA questionnaire was 1.65 ± 0.82. The mean score of occupational burnout was 60.82 ± 10.46. The level of emotional exhaustion, which significantly affects occupational burnout, was 26.39 ± 6.07, depersonalization was 14.14 ± 3.21 and lack of personal achievement was 20.29 ± 4.70. All the scores obtained exceeded the threshold of 50% of total points, which indicates the presence of occupational burnout at a significant level. The job satisfaction of the nurses surveyed was above mean at 23.00 ± 5.2 out of 35 total points. Conclusion: The results proved that there is a statistically significant, although with a weak strength of association, correlation between occupational burnout and rationing of care by anesthesia nurses. As the limitation of anesthesia nurses' ability to perform certain activities increases, their job satisfaction decreases. In a work environment that is conducive to nurses, there are fewer job responsibilities that are unfulfilled. Therefore, it is essential to create a friendly work environment for nursing staff that will promote the provision of services at the highest possible level.

COVID-19 critical care triage across Canada: a narrative synthesis and ethical analysis of early provincial triage protocols.

PURPOSE: The COVID-19 pandemic created conditions of scarcity that led many provinces within Canada to develop triage protocols for critical care resources. In this study, we sought to undertake a narrative synthesis and ethical analysis of early provincial pandemic triage protocols. METHODS: We collected provincial triage protocols through personal correspondence with academic and political stakeholders between June and August 2020. Protocol data were extracted independently by two researchers and compared for accuracy and agreement. We separated data into three categories for comparative content analysis: protocol development, ethical framework, and protocol content. Our ethical analysis was informed by a procedural justice framework. RESULTS: We obtained a total of eight provincial triage protocols. Protocols were similar in content, although age, physiologic scores, and functional status were variably incorporated. Most protocols were developed through a multidisciplinary, expert-driven, consensus process, and many were informed by influenza pandemic guidelines previously developed in Ontario. All protocols employed tiered morality-focused exclusion criteria to determine scarce resource allocation at the level of regional health care systems. None included a public engagement phase, although targeted consultation with public advocacy groups and relevant stakeholders was undertaken in select provinces. Most protocols were not publicly available in 2020. CONCLUSIONS: Early provincial COVID-19 triage protocols were developed by dedicated expert committees under challenging circumstances. Nonetheless, few were publicly available, and public consultation was limited. No protocols were ever implemented, including during periods of extreme critical care surge. A national approach to pandemic triage that incorporates additional aspects of procedural justice should be considered in preparation for future pandemics.

RéSUMé: OBJECTIF: La pandémie de COVID-19 a créé des conditions de pénurie qui ont amené de nombreuses provinces canadiennes à élaborer des protocoles de triage pour l'allocation des ressources en soins intensifs. Dans le cadre de cette étude, nous avons cherché à réaliser une synthèse narrative et une analyse éthique des premiers protocoles provinciaux de triage lors de la pandémie. MéTHODE: Nous avons recueilli les protocoles de triage provinciaux en correspondant de façon personnelle avec des intervenant·es universitaires et politiques entre juin et août 2020. Les données des protocoles ont été extraites indépendamment par deux personnes de l'équipe de recherche et comparées pour en vérifier l'exactitude et la concordance. Nous avons séparé les données en trois catégories pour l'analyse comparative du contenu : l'élaboration d'un protocole, le cadre éthique et le contenu du protocole. Notre analyse éthique s'est appuyée sur un cadre de justice procédurale. RéSULTATS: Nous avons obtenu un total de huit protocoles de triage provinciaux. Les protocoles étaient similaires dans leur contenu, bien que l'âge, les scores physiologiques et l'état fonctionnel aient été incorporés de manière variable. La plupart des protocoles ont été élaborés dans le cadre d'un processus consensuel multidisciplinaire dirigé par des expert·es, et bon nombre d'entre eux ont été élaborés en fonction des lignes directrices sur la pandémie de grippe élaborées antérieurement en Ontario. Tous les protocoles utilisaient des critères d'exclusion à plusieurs niveaux axés sur la moralité pour déterminer l'affectation de ressources limitées au niveau des systèmes de soins de santé régionaux. Aucun ne comportait de phase de mobilisation du public, bien que des consultations ciblées aient été menées auprès des groupes de défense des droits du public et des instances concernées dans certaines provinces. La plupart des protocoles n'étaient pas accessibles au public en 2020. CONCLUSION: Les premiers protocoles provinciaux de triage pour la COVID-19 ont été élaborés par des comités spécialisés d'expert·es dans des circonstances difficiles. Néanmoins, peu d'entre eux étaient accessibles au public et la consultation publique était limitée. Aucun protocole n'a été mis en œuvre, même pendant les périodes de pointe extrême en soins intensifs. Une approche nationale du triage en cas de pandémie qui intègre d'autres aspects de justice procédurale devrait être envisagée en prévision de futures pandémies.

Multicomponent processes to identify and prioritise low-value care in hospital settings: a scoping review.

OBJECTIVES: This scoping review mapped and synthesised original research that identified low-value care in hospital settings as part of multicomponent processes. DESIGN: Scoping review. DATA SOURCES: Electronic databases (EMBASE, PubMed, CINAHL, PsycINFO and Cochrane CENTRAL) and grey literature were last searched 11 July and 3 June 2022, respectively, with no language or date restrictions. ELIGIBILITY CRITERIA: We included original research targeting the identification and prioritisation of low-value care as part of a multicomponent process in hospital settings. DATA EXTRACTION AND SYNTHESIS: Screening was conducted in duplicate. Data were extracted by one of six authors and checked by another author. A framework synthesis was conducted using seven areas of focus for the review and an overuse framework. RESULTS: Twenty-seven records were included (21 original studies, 4 abstracts and 2 reviews), originating from high-income countries. Benefit or value (11 records), risk or harm (10 records) were common concepts referred to in records that explicitly defined low-value care (25 records). Evidence of contextualisation including barriers and enablers of low-value care identification processes were identified (25 records). Common components of these processes included initial consensus, consultation, ranking exercise or list development (16 records), and reviews of evidence (16 records). Two records involved engagement of patients and three evaluated the outcomes of multicomponent processes. Five records referenced a theory, model or framework. CONCLUSIONS: Gaps identified included applying systematic efforts to contextualise the identification of low-value care, involving people with lived experience of hospital care and initiatives in resource poor contexts. Insights were obtained regarding the theories, models and frameworks used to guide initiatives and ways in which the concept 'low-value care' had been used and reported. A priority for further research is evaluating the effect of initiatives that identify low-value care using contextualisation as part of multicomponent processes.

Professional burnout of nurses and the level of rationing of nursing care: an observational preliminary study.

BACKGROUND: Nurses are one of the professional groups most exposed to experiencing professional burnout. Professional burnout has a negative impact on the quality of nursing care, including causing care rationing. Therefore, it is very important to understand the determinants of both professional burnout and care rationing, as well as their mutual relationships. The aim of the study was to understand the impact of professional burnout among nurses on the level of rationing of nursing care. METHODS: The study was conducted among 100 nurses at the Glogów County Hospital (Poland) from November 14, 2011, to November 18, 2022. The following Polish version of the standardized research tools were utilized: the Basel Extent of Rationing of Nursing Care- Revised (BERNCA-R) questionnaire and the Oldenburg Burnout Inventory (OLBI). Additionally, a survey designed by the authors was employed. RESULTS: The BERNCA-R significantly correlates (p < 0.05) and positively (r > 0) with OLBI (disengagement), resulting in a higher degree of care rationing. The average overall BERNCA-R score was 1.56 points (SD = 0.62), indicating that the frequency of care rationing among respondents ranged from "never" to "rarely." Among participants in the OLBI questionnaire, 63% of respondents had a moderate level of work exhaustion, 36% had a high level of work exhaustion, and 1% had a low level of work exhaustion. In turn, 58% of respondents had a moderate level of disengagement, 38% had a high level of disengagement, and 4% had a low level of disengagement. Moreover, a statistically significant association with the BERNCA-R score concerning the workplace (ward) and participation in training on preventing professional burnout was shown. CONCLUSIONS: The rationing of nursing care was found to be at a low level. The higher the level of disengagement, the greater the level of care rationing was observed. In conservative units, nurses demonstrated a higher level of care rationing. Nurses' expectations regarding the reduction of professional burnout include, among other things, higher remuneration, an increase in the number of staff, and an improvement in the work atmosphere.

Learning motivation and self-assessment in health economics: a survey on overconfidence in healthcare providers.

INTRODUCTION: Lifelong learning is the foundation for professionals to maintain competence and proficiency in several aspects of economy and medicine. Until now, there is no evidence of overconfidence (the belief to be better than others or tested) and clinical tribalism (the belief that one's own group outperforms others) in the specialty of health economics. We investigated the hypothesis of overconfidence effects and their relation to learning motivation and motivational patterns in healthcare providers regarding healthcare economics. METHODS: We conducted a national convenience online survey of 116 healthcare workers recruited from social and personal networks to detect overconfidence effects and clinical tribalism and to assess learning motivation. Instruments included self-assessments for five learning dimensions (factual knowledge, skills, attitude, problem-solving and behaviour) and a four-item situational motivation scale. The analysis comprised paired t-tests, correlation analyses and two-step cluster analyses. RESULTS: We detected overplacement, overestimation and signs of clinical tribalism. Responders in the physician subgroup rated themselves superior to colleagues and that their professional group was superior to other professions. Participants being educators in other competencies showed high overconfidence in health economics. We detected two groups of learners: overconfident but motivated persons and overconfident and unmotivated learners. Learning motivation did not correlate with overconfidence effects. DISCUSSION: We could show the presence of overconfidence in health economics, which is consistent with studies in healthcare and the economy. The subjective perception of some medical educators, being role models to students and having a superior 'attitude' (eg, morality) concerning the economy may foster prejudice against economists as students might believe them. It also may aggravate moral distress and disrupts interactions between healthcare providers managers and leaders. Considering the study's limitations, lifelong interprofessional and reflective training and train-the-trainer programmes may be mandatory to address the effects.

Results of EAHP's 2023 shortages survey.

AIMS AND OBJECTIVE: The aim of the European Association of Hospital Pharmacists (EAHP)'s 2023 shortages survey was to collect data on causes and mitigation strategies of shortages of medicines and medical devices and their impact on patient care. The survey targeted hospital pharmacists (HPs), physicians (PHYs), nurses (NRS) and other healthcare professionals (OHCPs). A separate set of questions addressed patients (PTNs). METHODS: A 49-question survey was carried out by a team at EAHP, collecting information from European HPs, PTNs, NRS, PHYs and OTHCs on shortages of medicines and medical devices in their respective countries. The survey ran from 27 February to 19 May 2023. The results were analysed by EAHP. RESULTS: There were 1497 HP responses to the 2023 survey. While 95% (n=1429) of HPs and 86% (n=127) of OHCPs consider medicine shortages an ongoing problem, 84% (n=48) of PHYs and 68% (n=15) of NRS also agreed. Shortages of active pharmaceutical ingredients (77%, n=1148), manufacturing (67%, n=1007) and supply chain problems (50%, n=752) are major causes of shortages according to HPs as well as NRS and OHCPs; PHYs (49%, n=18) consider pricing to be the driver. More than 60% (n=765) of HPs, 55% (n=11) of NRS, 57% (n=30) of PHYs and 46% (n=56) of OHCPs experienced shortages of medical devices in 2022. Antimicrobials were most affected, according to all respondent groups, followed by analgesics, anaesthetics, cardiovascular and paediatric medicines. HPs (59%, n=269), NRS (57%, n=4), OHCPs (56%, n=37) and PHYs (54%, n=14) consider delays in care as the main consequence of medication shortages. CONCLUSIONS: Shortages of medicines and medical devices affect healthcare services and patient care. Increased transparency and access to information regarding ongoing and emerging shortages as well as better preparedness of healthcare professionals is crucial to their effective management.

Associations between nursing home care environment and unfinished nursing care explored. Secondary analysis of cross-sectional data.

Understanding unfinished nursing care and its relationship with modifiable care environment factors is crucial for the service delivery to long-term frail patients. This secondary analysis aimed to explore the associations between characteristics of the care environment and unfinished nursing care, as reported by nursing care workers in Norwegian nursing homes. Of 931 respondents (37% response rate) from 66 nursing homes, six care environment characteristics correlated with at least two types of unfinished nursing care. Resources and Multidisciplinary collaboration showed a positive association with all four unfinished care categories. Input and acknowledgement, Professional, or Interpersonal leadership were not associated to unfinished care. In summary, our findings suggest that nursing care workers reporting positive care environment descriptions also reported lower frequencies of unfinished nursing care. This study offers insights crucial for human resource management which ultimately can be used to improve patient outcomes in nursing homes.

Trends in inequalities in avoidable hospitalisations across the COVID-19 pandemic: a cohort study of 23.5 million people in England.

OBJECTIVE: To determine whether periods of disruption were associated with increased 'avoidable' hospital admissions and wider social inequalities in England. DESIGN: Observational repeated cross-sectional study. SETTING: England (January 2019 to March 2022). PARTICIPANTS: With the approval of NHS England we used individual-level electronic health records from OpenSAFELY, which covered ~40% of general practices in England (mean monthly population size 23.5 million people). PRIMARY AND SECONDARY OUTCOME MEASURES: We estimated crude and directly age-standardised rates for potentially preventable unplanned hospital admissions: ambulatory care sensitive conditions and urgent emergency sensitive conditions. We considered how trends in these outcomes varied by three measures of social and spatial inequality: neighbourhood socioeconomic deprivation, ethnicity and geographical region. RESULTS: There were large declines in avoidable hospitalisations during the first national lockdown (March to May 2020). Trends increased post-lockdown but never reached 2019 levels. The exception to these trends was for vaccine-preventable ambulatory care sensitive admissions which remained low throughout 2020-2021. While trends were consistent by each measure of inequality, absolute levels of inequalities narrowed across levels of neighbourhood socioeconomic deprivation, Asian ethnicity (compared with white ethnicity) and geographical region (especially in northern regions). CONCLUSIONS: We found no evidence that periods of healthcare disruption from the COVID-19 pandemic resulted in more avoidable hospitalisations. Falling avoidable hospital admissions has coincided with declining inequalities most strongly by level of deprivation, but also for Asian ethnic groups and northern regions of England.

Ethical dilemmas in prioritizing patients for scarce radiotherapy resources.

BACKGROUND: Radiotherapy is an essential component of cancer treatment, yet many countries do not have adequate capacity to serve all patients who would benefit from it. Allocation systems are needed to guide patient prioritization for radiotherapy in resource-limited contexts. These systems should be informed by allocation principles deemed relevant to stakeholders. This study explores the ethical dilemmas and views of decision-makers engaged in real-world prioritization of scarce radiotherapy resources at a cancer center in Rwanda in order to identify relevant principles. METHODS: Semi-structured interviews were conducted with a purposive sample of 22 oncology clinicians, program leaders, and clinical advisors. Interviews explored the factors considered by decision-makers when prioritizing patients for radiotherapy. The framework method of thematic analysis was used to characterize these factors. Bioethical analysis was then applied to determine their underlying normative principles. RESULTS: Participants considered both clinical and non-clinical factors relevant to patient prioritization for radiotherapy. They widely agreed that disease curability should be the primary overarching driver of prioritization, with the goal of saving the most lives. However, they described tension between curability and competing factors including age, palliative benefit, and waiting time. They were divided about the role that non-clinical factors such as social value should play, and agreed that poverty should not be a barrier. CONCLUSIONS: Multiple competing principles create tension with the agreed upon overarching goal of maximizing lives saved, including another utilitarian approach of maximizing life-years saved as well as non-utilitarian principles, such as egalitarianism, prioritarianism, and deontology. Clinical guidelines for patient prioritization for radiotherapy can combine multiple principles into a single allocation system to a significant extent. However, conflicting views about the role that social factors should play, and the dynamic nature of resource availability, highlight the need for ongoing work to evaluate and refine priority setting systems based on stakeholder views.

Dynamic IL-6R/STAT3 signaling leads to heterogeneity of metabolic phenotype in pancreatic ductal adenocarcinoma cells.

Malignancy is enabled by pro-growth mutations and adequate energy provision. However, global metabolic activation would be self-terminating if it depleted tumor resources. Cancer cells could avoid this by rationing resources, e.g., dynamically switching between "baseline" and "activated" metabolic states. Using single-cell metabolic phenotyping of pancreatic ductal adenocarcinoma cells, we identify MIA-PaCa-2 as having broad heterogeneity of fermentative metabolism. Sorting by a readout of lactic acid permeability separates cells by fermentative and respiratory rates. Contrasting phenotypes persist for 4 days and are unrelated to cell cycling or glycolytic/respiratory gene expression; however, transcriptomics links metabolically active cells with interleukin-6 receptor (IL-6R)-STAT3 signaling. We verify this by IL-6R/STAT3 knockdowns and sorting by IL-6R status. IL-6R/STAT3 activates fermentation and transcription of its inhibitor, SOCS3, resulting in delayed negative feedback that underpins transitions between metabolic states. Among cells manifesting wide metabolic heterogeneity, dynamic IL-6R/STAT3 signaling may allow cell cohorts to take turns in progressing energy-intense processes without depleting shared resources.

Impact of Surge Strain and Pandemic Progression on Prognostication by an Established COVID-19-Specific Severity Score.

IMPORTANCE: Many U.S. State crisis standards of care (CSC) guidelines incorporated Sequential Organ Failure Assessment (SOFA), a sepsis-related severity score, in pandemic triage algorithms. However, SOFA performed poorly in COVID-19. Although disease-specific scores may perform better, their prognostic utility over time and in overcrowded care settings remains unclear. OBJECTIVES: We evaluated prognostication by the modified 4C (m4C) score, a COVID-19-specific prognosticator that demonstrated good predictive capacity early in the pandemic, as a potential tool to standardize triage across time and hospital-surge environments. DESIGN: Retrospective observational cohort study. SETTING: Two hundred eighty-one U.S. hospitals in an administrative healthcare dataset. PARTICIPANTS: A total of 298,379 hospitalized adults with COVID-19 were identified from March 1, 2020, to January 31, 2022. m4C scores were calculated from admission diagnosis codes, vital signs, and laboratory values. MAIN OUTCOMES AND MEASURES: Hospital-surge index, a severity-weighted measure of COVID-19 caseload, was calculated for each hospital-month. Discrimination of in-hospital mortality by m4C and surge index-adjusted models was measured by area under the receiver operating characteristic curves (AUC). Calibration was assessed by training models on early pandemic waves and measuring fit (deviation from bisector) in subsequent waves. RESULTS: From March 2020 to January 2022, 298,379 adults with COVID-19 were admitted across 281 U.S. hospitals. m4C adequately discriminated mortality in wave 1 (AUC 0.779 [95% CI, 0.769-0.789]); discrimination was lower in subsequent waves (wave 2: 0.772 [95% CI, 0.765-0.779]; wave 3: 0.746 [95% CI, 0.743-0.750]; delta: 0.707 [95% CI, 0.702-0.712]; omicron: 0.729 [95% CI, 0.721-0.738]). m4C demonstrated reduced calibration in contemporaneous waves that persisted despite periodic recalibration. Performance characteristics were similar with and without adjustment for surge. CONCLUSIONS AND RELEVANCE: Mortality prediction by the m4C score remained robust to surge strain, making it attractive for when triage is most needed. However, score performance has deteriorated in recent waves. CSC guidelines relying on defined prognosticators, especially for dynamic disease processes like COVID-19, warrant frequent reappraisal to ensure appropriate resource allocation.

Rationing of nursing care in Internal Medicine Departments-a cross-sectional study.

BACKGROUND: Implicit rationing of nursing care refers to a situation in which necessary nursing care is not performed to meet all of the patients' needs. PURPOSE: To examine the factors influencing the rationing of nursing care, nurses' assessment of the quality of patient care, and their job satisfaction in Internal Medicine Departments. METHODS: A cross-sectional descriptive study was undertaken. The study included 1164 nurses working in the Internal Medicine Departments in 8 hospitals (Lower Silesia, Poland). The Perceived Implicit Rationing of Nursing Care instrument was used. RESULTS: Respondents rarely ration nursing care, with a mean score of 1.12 (SD = 0.68). The mean score for quality of patient care was 6.99 (SD = 1.92). In contrast, the mean job satisfaction score was 6.07 points (SD = 2.22). The most important predictors of high rates of rationing of nursing care were work experience of 16-20 years (regression parameter: 0.387) and a Bachelor's degree in nursing (regression parameter: 0.139). Nurses' assessment of the quality of patient care ratings were increased by having a Master's degree in nursing (regression parameter: 0.41), and significantly decreased by work experience of 16-20 years (regression parameter: -1.332). Independent predictors of job satisfaction ratings in both univariate and multivariate analysis were Master's degree and long-shift working patterns. CONCLUSION: The factors that influence an increased level of nursing care rationing on medical wards are nurse seniority, exceeding 16 years and female gender. Obtaining a Master's degree in nursing indicates improved nurses' assessment of the quality of patient care.

Racionamiento, inflación e inequidad sanitaria en Venezuela: caso de las enfermedades cardiovasculares / Rationing, inflation and health inequity in Venezuela: case of cardiovascular diseases

los modelos público-sanitarios de caráctermonopólico como el venezolano, suelen asociarse a tendencias al racionamiento de los bienes y servicios que proveen a sus usuarios, así como a la merma de la calidad de estos. Por otro lado, la provisión de dichos bienes y servicios por la vía de mecanismos de mercado, tiene ante sí, el inconveniente que supone el ambiente inflacionario de su economía, cuyo impacto en los precios limita el acceso del paciente a su consumo. El caso de la enfermedad cardiovascular ofrece algunas claves para la comprensión de este fenómeno en el medio venezolano.

Public-health models of a monopolistic nature, suchas the Venezuelan, bring with them trends in the rationing ofthe goods and services they provide to their users, as well as inthe reduction of their quality. On the other hand, the provisionof these goods and services by means of market mechanisms hasbefore it, in our environment, the enormous impediment posedby the inflationary environment of its economy, whose impacton prices limits the patient's access to consumption. The case of cardiovascular disease offers some keys to understanding thisphenomenon in the Venezuelan environment.

Ration health resources to save more statistical lives from cervical cancer death in Africa: Why are we allowing them to die?

Public health interventions, particularly in low- and middle-income countries (LMICs), are implemented with the never-ending challenge of limited resources and the ever-present challenge of choosing between interventions. While necessary, the application of ethical analysis is absent in most of such decision-making, resulting in fewer favourable consequences. In applying ethical principles to the saving of women from the burden of cervical cancer, I argue in favour of saving statistical lives (investing in prevention) in LMICs, by mapping the principles of justice in resource allocation to the prevailing circumstance. The key facts in this circumstance are that providing treatment (which is saving identified lives), involves mostly providing palliative treatment, which is associated with a high likelihood of death among the identified lives while undergoing treatment or shortly thereafter. I focus on the dilemma of having a national cancer prevention program versus the expansion of cancer treatment facilities.

Public preferences in healthcare resource allocation: A discrete choice experiment in South Korea.

OBJECTIVES: This study aimed to explore the public view on priority-setting criteria for healthcare resource allocation. Specifically, it investigates how the value of a quality-adjusted life year (QALY) varies depending on patient characteristics. METHODS: A discrete choice experiment was conducted using an online sample of the general South Korean population. Respondents were presented with two competing treatment scenarios. The attributes of the scenarios were age at disease onset, life expectancy without treatment, life-years gain with treatment, health-related quality of life (HRQoL) without treatment, and HRQoL gains with treatment. Two hundred choice sets were generated and randomly allocated into 20 blocks. A conditional logit model was used to estimate the factors affecting the respondents' choices. RESULTS: A total of 3,482 respondents completed the survey. The larger the QALY gain, the more likely it was that the scenario would be chosen but with a diminishing marginal value. Respondents prioritized 40-year-old patients over 5-year-olds and 5-year-olds over 70-year-olds and prioritized baseline HRQoL of 40% and 60% over 20%. Patients at the end of life were not preferred to those with a longer life expectancy. CONCLUSION: Overall, respondents preferred health-maximizing options without explicit consideration for end-of-life patients or those with poor health. In addition, they revealed a kinked preference for patient age, prioritizing middle-aged patients over children and older people.

Is It Possible to Allocate Life? Triage, Ageism, and Narrative Identity.

Triage protocols can exclude older patients for the sake of effectiveness and this may be defended as the older have already had their fair share of life, which can mean fair amounts or complete lives. Nevertheless, if life is considered as a narrative, mentioning amounts might be nonsensical. Narratives have a quality of unity; so, life events are fragments whose meanings are dependent on the meaning of the whole. Thus, time units do not represent a reliable measure of the content of life. In addition, people's experience is different from the external flow of time, making its significance relative. Moreover, to compare the completeness of lives qualitatively, it is necessary to have a common cultural understanding, which is improbable to agree on in a modern society. Therefore, basic assumptions of the accounts that refer to fair shares of lives are mistaken, and these accounts do not support age-based rationing.

Consequences of a shortage and rationing: Evidence from a pediatric vaccine.

Shortages and rationing are common in health care, yet we know little about the consequences. We examine an 18-month shortage of the pediatric Haemophilus Influenzae Type B (Hib) vaccine. Using insurance claims data and variation in shortage exposure across birth cohorts, we find that the shortage reduced uptake of high-value primary doses by 4 percentage points and low-value booster doses by 26 percentage points. This suggests providers largely complied with rationing recommendations. In the long-run, catch-up vaccination occurred but was incomplete: shortage-exposed cohorts were 4 percentage points less likely to have received the ir booster dose years later. We also find that the shortage and rationing caused provider switches, extra provider visits, and negative spillovers to other care.