Estimating the out-of-pocket health expenditure in patients under 5 years with severe malnutrition in Afghanistan in 2023: Findings from a cross-sectional study.

Introduction: This study, of significant importance to healthcare professionals, policymakers, researchers, and organizations involved in child healthcare and malnutrition in Afghanistan, aimed to estimate the out-of-pocket expenditure (OOPE) in patients under 5 years old with severe malnutrition in a children's hospital in Herat Province, Afghanistan. Method: This study employed a meticulously designed cross-sectional descriptive-analytical approach with practical results. The research population consisted of families with malnourished children under 5 who were referred to Herat Children's Hospital. Data was collected using a comprehensive standard World Health Organization questionnaire to gather demographic information from children in Herat. A carefully selected convenience sampling method was used, with 300 referring patients participating in face-to-face interviews with the supervisors of these children. After obtaining personal consent and coordinating with health officials, interviews were conducted with the caregivers of children under 5 who suffered from severe malnutrition. The data was then analyzed using robust descriptive statistics, quantitative variables, mean and standard deviation, frequency, and relative frequency. Multiple regression analysis was used to determine the factors that most influenced direct payments from patients' pockets, ensuring the reliability and validity of the findings. Results: The results showed that OOPE in both households with seven and less than seven people and more than seven people was 68%. The findings indicated that among the residents of Herat referred to the studied hospital, these people spent 54% of the treatment costs directly out of pocket. In contrast, people in the rural areas of Herat pay 69% of the treatment costs to receive medical services straight out of pocket. The critical point is that 93% of the families have incurred catastrophic expenses to treat their children suffering from severe malnutrition. The research revealed that the patient's location and the education level of the head of the household were the most significant factors affecting out-of-pocket payments by patients. Conclusion: Increasing OOPE in rural Afghanistan poses a significant obstacle to equitable healthcare services and access to appropriate medicines. To support the goal of universal healthcare coverage, geographic imbalances, and broad health financing options must be addressed. Strengthening insurance coverage and more government assistance can significantly reduce these patients' out-of-pocket payments.

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.

When offering a patient beneficial treatment undermines public health.

Sometimes, offering someone beneficial care is likely to thwart the similar or more serious medical needs of more people. For example, when acute shortage is strongly predicted to persist, providing the long period on scarce intensive care that a certain COVID-19 patient needs is sometimes projected to block several future COVID-19 patients from receiving the shorter periods on intensive care that they will need. Expected utility is typically higher if the former is denied intensive care. A tempting initial account of such cases is that consequentialism supports denying care to that patient and nonconsequentialism supports providing that care. This paper argues that the consequentialist case is more complicated than it may initially seem and that nonconsequentialism sides more readily with denial of the beneficial treatment. It also shows that when denying it would directly enhance public health by a lot, either ethical approach would normally recommend denying it. Practical implications are discussed, including how to address conscientious objection to this shared recommendation.

Toward a Hybrid Theory of How to Allocate Health-related Resources.

How should scarce health-related resources be allocated? This paper argues that values that apply to these decisions fail to always fully determine what we should do. Health maximization and allocation-according-to-need are suggested as two values that should be part of a general theory of how to allocate health-related resources. The "small improvement argument" is used to argue that it is implausible that one alternative is always better, worse, or equal to another alternative with respect to these values. Approaches that rely on these values are thus incomplete. To deal with this, it is suggested that we ought to use incomplete theories in a two-step process. Such a process first discards ineligible alternatives, and, second, uses reasons grounded in collective commitments to identify a unique, best alternative in the remaining set.

Practices and challenges for hemophilia management under resource constraints in Thailand.

Hemophilia is an inherited bleeding disorder caused by deficiency of a specific coagulation factor. Factor VIII deficiency is responsible for hemophilia A while factor IX deficiency is responsible for hemophilia B. As per the 2020 annual global survey by the World Federation of Hemophilia, only 1828 Thai hemophiliacs have been registered to the national healthcare system. The reason for the low number is the underdiagnosis which is a major concern in the real-world practice among Asian countries. In Thailand, most hemophiliacs are diagnosed by general practitioners, pediatricians or internists at rural hospitals and are referred to hemophilia specialists at the Hemophilia Treatment Centers (HTCs). Despite the challenges pertaining to infrastructure and cost of treatment, Thailand has progressed substantially in providing the required hemophilia care, as evidenced by an evolution in acquiring and sharing knowledge as well as collaborative efforts among multiple stakeholders over the past three decades. In this letter-to-the-editor, the authors have summarized the practices for and challenges faced with hemophilia management in Thailand.

Cost-Effectiveness, Incompleteness, and Discrimination.

This paper argues that cost-effectiveness analysis in the healthcare sector introduces a discrimination risk that has thus far been underappreciated and outlines some approaches one can take toward this. It is argued that appropriate standards used in cost-effectiveness analysis in the healthcare sector fail to always fully determine an optimal option, which entails that cost-effectiveness analysis often leaves decision makers with large sets of permissible options. Larger sets of permissible options increase the role of decision makers' biases, whims, and prejudices, which means that the discrimination risk increases. Two ways of mitigating this are identified: tinkering with standards used in the cost-effectiveness analysis and outlining anti-discrimination guidelines for decision makers.

Cost-Effectiveness and the Avoidance of Discrimination in Healthcare: Can We Have Both?

Many ethical theorists believe that a given distribution of healthcare is morally justified only if (1) it is cost-effective and (2) it does not discriminate against older adults and disabled people. However, if (3) cost-effectiveness involves maximizing the number of quality-adjusted life-years (QALYs) added by a given unit of healthcare resource, or cost, it seems the pursuit of cost-effectiveness will inevitably discriminate against older adults and disabled patients. I show why this trilemma is harder to escape than some theorists think. We cannot avoid it by using age- or disability-weighted QALY scores, for example. I then explain why there is no sense of "discrimination" on which discrimination is both unjust, and thus something healthcare rationing must avoid, and something cost-effective healthcare rationing inevitably involves. I go on to argue that many of the reasons we have for not favoring rationing that maximizes QALYs outside the healthcare context apply in healthcare as well. Thus, claim (1) above is dubious.

Global Association of COVID-19 Pandemic Measures with Cancer Treatment: A Systematic Review and Meta-Analysis.

IMPORTANCE: The COVID-19 pandemic has put a serious strain on health services, including cancer treatment. OBJECTIVE: This study aimed to investigate the changes in cancer treatment worldwide during the first phase of the SARS-CoV-2 outbreak. DATA SOURCES: Pubmed, Proquest, and Scopus databases were searched comprehensively for articles published between 1 January 2020 and 12 December 2021, in order to perform a systematic review and meta-analysis conducted following the PRISMA statement. STUDY SELECTION: Studies and articles that reported data on the number of or variation in cancer treatments between the pandemic and pre-pandemic periods, comprising oncological surgery, radiotherapy, and systemic therapies, were included. DATA EXTRACTION AND SYNTHESIS: Data were extracted from two pairs of independent reviewers. The weighted average of the percentage variation was calculated between the two periods to assess the change in the number of cancer treatments performed during the pandemic. Stratified analyses were performed by type of treatment, geographic area, time period, study setting, and type of cancer. RESULTS: Among the 47 articles retained, we found an overall reduction of -18.7% (95% CI, -24.1 to -13.3) in the total number of cancer treatments administered during the COVID-19 pandemic compared to the previous periods. Surgical treatment had a larger decrease compared to medical treatment (-33.9% versus -12.6%). For all three types of treatments, we identified a U-shaped temporal trend during the entire period January-October 2020. Significant decreases were also identified for different types of cancer, in particular for skin cancer (-34.7% [95% CI, -46.8 to -22.5]) and for all geographic areas, in particular, Asia (-42.1% [95% CI, -49.6 to -34.7]). CONCLUSIONS AND RELEVANCE: The interruption, delay, and modifications to cancer treatment due to the COVID-19 pandemic are expected to alter the quality of care and patient outcomes.

The impact of a national formulary expansion on diabetics.

This paper estimates the causal effect of the expansion of Colombia's national prescription drug formulary to include five new types of insulin on the healthcare utilization and costs of type I diabetics and explores the mechanisms through which outpatient cost reductions are realized. We find that expanded coverage generates an increase in the cost of insulin for type I diabetics equal to 17% of their baseline healthcare costs. At the same time, their annual outpatient care utilization falls by 1.9 claims. We devise tests to explore the relative importance of two mechanisms by which the expansion may have lowered type I diabetics' non-drug healthcare utilization: spillovers from drug to non-drug spending and rationing of care. We find no evidence that the formulary expansion reduces the rate of complications from diabetes and find substantial declines in non-drug costs even among the subset of diabetics with no scope for spillovers. We find large reductions in the utilization of discretionary care including diagnostic tests, but no such declines for the use of essential drugs, suggesting that rationing of care is the primary driver of observed cost savings.

Ética do uso de escores prognósticos em unidade de terapia intensiva: revisão integrativa / Ethics in the use of prognostic scores in intensive care units: an integrative review / Ética del uso de puntajes pronósticos en una unidad de cuidados intensivos: una revisión integradora

Resumo O enfrentamento da covid-19 suscitou uma série de problemas na área da saúde, em razão do aumento da demanda de cuidados intensivos. Para solucionar a crise causada pela escassez de recursos de alta complexidade, a tomada de decisão tem se norteado por escores prognósticos, porém esse processo inclui uma dimensão moral, ainda que esta seja menos evidente. Mediante revisão integrativa, este artigo buscou refletir sobre a razoabilidade da utilização de indicadores de gravidade para definir a alocação de recursos escassos na saúde. Observou-se que o trabalho realizado em situações de escassez de recursos provoca sobrecarga moral, convergindo para busca por soluções padronizadas e objetivas, como a utilização de escores prognósticos. Conclui-se que seu uso isolado e indiscriminado não é eticamente aceitável e merece avaliação cautelosa, mesmo em situações emergenciais, como a da covid-19.

Abstract Facing COVID-19 caused many problems in the healthcare field, due to the rise in the intensive care demand. To solve this crisis, caused by the scarcity of resources of high complexity, decision-making has been guided by prognostic scores; however, this process includes a moral dimension, although less evident. With na integrative review, this article sought to reflect on the reasonability of using severity indicators to define the allocation of the scarce resources in healthcare. We observed that the work carried out on resource scarcity situations causes moral overload, converging to the search for standard and objective solutions, such as the use of prognostic scores. We conclude that their isolated and indiscriminate use is not ethically acceptable and deserves cautious evaluation, even in emergency situations, such as COVID-19.

Resumen La lucha contra el Covid-19 implicó una serie de problemas en el área de la salud, debido al aumento de la demanda de cuidados intensivos. Para solucionar la crisis provocada por la escasez de recursos de alta complejidad, la toma de decisiones estuvo orientada por puntuaciones pronósticas, pero este proceso incluye una dimensión moral aún menos evidente. A partir de una revisión integradora, este artículo buscó reflexionar sobre la razonabilidad de utilizar indicadores de gravedad para definir la asignación de recursos escasos en salud. El trabajo realizado en situaciones de escasez de recursos genera sobrecarga moral, llevando a la búsqueda de soluciones estandarizadas y objetivas, como el uso de puntuaciones de pronóstico. Se concluye que su uso aislado e indiscriminado no es éticamente aceptable y merece una cuidadosa evaluación, incluso en situaciones de emergencia, como la del Covid-19.

Coronavirus Disease 2019 (COVID-19) Vaccine Prioritization in Low- and Middle-Income Countries May Justifiably Depart From High-Income Countries' Age Priorities.

In high-income countries that were first to roll out coronavirus disease 2019 (COVID-19) vaccines, older adults have thus far usually been prioritized for these vaccines over younger adults. Age-based priority primarily resulted from interpreting evidence available at the time, which indicated that vaccinating the elderly first would minimize COVID-19 deaths and hospitalizations. The World Health Organization counsels a similar approach for all countries. This paper argues that some low- and middle-income countries that are short of COVID-19 vaccine doses might be justified in revising this approach and instead prioritizing certain younger persons when allocating current vaccines or future variant-specific vaccines.

What influences the implementation and sustainability of antibiotic stewardship programmes in hospitals? A qualitative study of antibiotic pharmacists' perspectives across South West England.

OBJECTIVES: Antibiotic stewardship programmes (ASPs) are needed at every hospital as they can improve antibiotic use and address antibiotic resistance. Pharmacists are key agents and specialists in these programmes. This study explored antibiotic pharmacists' perceptions of factors that influence the implementation and sustainability of hospital-based ASPs. METHODS: Semistructured interviews were conducted with hospital antibiotic pharmacists face-to-face or by telephone. NVivo V.12 software was used to collate and organise the data grouped within codes. Thematic analysis was undertaken using inductive and deductive approaches to produce overarching themes. RESULTS: Thirteen pharmacists from 13 hospitals were interviewed. Four main themes were identified: (1) 'organisational culture' which highlighted the importance of strong local clinical leadership to help achieve organisational buy-in and address resistance among physicians or clinical hierarchies; (2) 'national influences' including networks, guidance and incentive schemes which were considered to be a driver to bring about changes across organisation; (3) 'continuous monitoring with feedback ASP data, preferably through direct communication' to demonstrate the impact of the programmes which then facilitated ongoing support from local leadership and improved engagement across organisation; and (4) 'resources' which indicated the need of information technology and dedicated personnel with protected time to support ASP activities. CONCLUSIONS: Interventions and strategies should operate at different levels-individual, team, organisational and national-to help implement and sustain ASPs in hospital. This is also the first study to identify and highlight the importance of national initiatives in contributing to the implementation and sustainability of hospital-based ASPs.

How to fairly allocate scarce medical resources? Controversial preferences of healthcare professionals with different personal characteristics.

The scarcity of medical resources is widely recognized, and therefore priority setting is inevitable. This study examines whether Portuguese healthcare professionals (physicians vs nurses): (i) share the moral guidance proposed by ethicists and (ii) attitudes toward prioritization criteria vary among individual and professional characteristics. A sample of 254 healthcare professionals were confronted with hypothetical prioritization scenarios involving two patients distinguished by personal or health characteristics. Descriptive statistics and parametric analyses were performed to evaluate and compare the adherence of both groups of healthcare professionals regarding 10 rationing criteria: waiting time, treatment prognosis measured in life expectancy and quality of life, severity of health conditions measured in pain and immediate risk of dying, age discrimination measured in favoring the young over older and favoring the youngest over the young, merit evaluated positively or negatively, and parenthood. The findings show a slight adherence to the criteria. Waiting time and patient pain were the conditions considered fairer by respondents in contrast with the ethicists normative. Preferences for distributive justice vary by professional group and among participants with different political orientations, rationing experience, years of experience, and level of satisfaction with the NHS. Decision-makers should consider the opinion of ethicists, but also those of healthcare professionals to legitimize explicit guidelines.

An empirical bioethical examination of Norwegian and British doctors' views of responsibility and (de)prioritization in healthcare.

In a world with limited resources, allocation of resources to certain individuals and conditions inevitably means fewer resources allocated to other individuals and conditions. Should a patient's personal responsibility be relevant to decisions regarding allocation? In this project we combine the normative and the descriptive, conducting an empirical bioethical examination of how both Norwegian and British doctors think about principles of responsibility in allocating scarce healthcare resources. A large proportion of doctors in both countries supported including responsibility for illness in prioritization decisions. This finding was more prominent in zero-sum scenarios where allocation to one patient means that another patient is denied treatment. There was most support for incorporating prospective responsibility (through patient contracts), and low support for integrating responsibility into co-payments (i.e. through requiring responsible patients to pay part of the costs of treatment). Finally, some behaviours were considered more appropriate grounds for deprioritization (smoking, alcohol, drug use)-potentially because of the certainty of impact and direct link to ill health. In zero-sum situations, prognosis also influenced prioritization (but did not outweigh responsibility). Ethical implications are discussed. We argue that the role that responsibility constructs appear to play in doctors' decisions indicates a needs for more nuanced-and clear-policy. Such policy should account for the distinctions we draw between responsibility-sensitive and prognostic justifications for deprioritization.

A catalogue of tools and variables from crisis and routine care to support decision-making about allocation of intensive care beds and ventilator treatment during pandemics: Scoping review.

PURPOSE: This scoping review sought to identify objective factors to assist clinicians and policy-makers in making consistent, objective and ethically sound decisions about resource allocation when healthcare rationing is inevitable. MATERIALS AND METHODS: Review of guidelines and tools used in ICUs, hospital wards and emergency departments on how to best allocate intensive care beds and ventilators either during routine care or developed during previous epidemics, and association with patient outcomes during and after hospitalisation. RESULTS: Eighty publications from 20 countries reporting accuracy or validity of prognostic tools/algorithms, or significant correlation between prognostic variables and clinical outcomes met our eligibility criteria: twelve pandemic guidelines/triage protocols/consensus statements, twenty-two pandemic algorithms, and 46 prognostic tools/variables from non-crisis situations. Prognostic indicators presented here can be combined to create locally-relevant triage algorithms for clinicians and policy makers deciding about allocation of ICU beds and ventilators during a pandemic. No consensus was found on the ethical issues to incorporate in the decision to admit or triage out of intensive care. CONCLUSIONS: This review provides a unique reference intended as a discussion starter for clinicians and policy makers to consider formalising an objective a locally-relevant triage consensus document that enhances confidence in decision-making during healthcare rationing of critical care and ventilator resources.

Scarce Resource Allocation in a Pandemic: A Protocol to Promote Equity, Timeliness, and Transparency.

Shortages of equipment, medication, and staff under coronavirus disease 2019 may force hospitals to make wrenching decisions. Although bioethical guidance is available, published procedures for decision-making processes to resolve the time-sensitive conflicts are rare. Failure to establish decision-making procedures before scarcities arise exposes clinicians to moral distress and potential legal liability, entrenches existing systemic biases, and leaves hospitals without processes to guarantee transparency and consistency in the application of ethical guidelines. Formal institutional processes can reduce the panic, inequity, and irresolution that arise from confronting ethical conflicts under duress. Drawing on expertise in critical care medicine, bioethics, and political science, we propose a decision-making protocol to ensure fairness in the resolution of conflict, timely decision-making, and accountability to improve system response.

Operationalizing Ethical Guidance for Ventilator Allocation in Minnesota: Saving the Most Lives or Exacerbating Health Disparities?

A statewide working group in Minnesota created a ventilator allocation scoring system in anticipation of functioning under a Crisis Standards of Care declaration. The scoring system was intended for patients with and without coronavirus disease 2019. There was disagreement about whether the scoring system might exacerbate health disparities and about whether the score should include age. We measured the relationship of ventilator scores to in-hospital and 3-month mortality. We analyzed our findings in the context of ethical and legal guidance for the triage of scarce resources. DESIGN: Retrospective cohort study. SETTING: Multihospital within a single healthcare system. PATIENTS: Five-hundred four patients emergently intubated and admitted to the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The Ventilator Allocation Score was positively associated with higher mortality (p < 0.0001). The 3-month mortality rate for patients with a score of 6 or higher was 96% (42/44 patients). Age was positively associated with mortality. The 3-month mortality rate for patients 80 and older with scores of 4 or greater was 93% (40/43 patients). Of patients assigned a score of 5, those with end stage renal disease had lower mortality than patients without end stage renal disease although the difference did not achieve statistical significance (n = 27; 25% vs 58%; p = 0.2). CONCLUSIONS: The Ventilator Allocation Score can accurately identify patients with high rates of short-term mortality. However, these high mortality patients only represent 27% of all the patients who died, limiting the utility of the score for allocation of scarce resources. The score may unfairly prioritize older patients and inadvertently exacerbate racial health disparities through the inclusion of specific comorbidities such as end stage renal disease. Triage frameworks that include age should be considered. Purposeful efforts must be taken to ensure that triage protocols do not perpetuate or exacerbate prevailing inequities. Further work on the allocation of scarce resources in critical care settings would benefit from consensus on the primary ethical objective.

Hidden bedside rationing in the Netherlands: a cross-sectional survey among physicians in internal medicine.

BACKGROUND: Healthcare rationing can be defined as withholding beneficial care for cost reasons. One form in particular, hidden bedside rationing, is problematic because it may result in conflicting loyalties for physicians, unfair inequality among patients and illegitimate distribution of resources. Our aim is to establish whether bedside rationing occurs in the Netherlands, whether it qualifies as hidden and what physician characteristics are associated with its practice. METHODS: Cross-sectional online questionnaire on knowledge of -, experience with -, and opinion on rationing among physicians in internal medicine within the Dutch healthcare system. Multivariable ordinal logistic regression was used to explore relations between hidden bedside rationing and physician characteristics. RESULTS: The survey was distributed among 1139 physicians across 11 hospitals with a response rate of 18% (n = 203). Most participants (n = 129; 64%) had experience prescribing a cheaper course of treatment while a more effective but more expensive alternative was available, suggesting bedside rationing. Subsequently, 32 (24%) participants never disclosed this decision to their patient, qualifying it as hidden. The majority of participants (n = 153; 75%) rarely discussed treatment cost. Employment at an academic hospital was independently associated with more bedside rationing (OR = 17 95%CI 6.1-48). Furthermore, residents were more likely to disclose rationing to their patients than internists (OR = 3.2, 95%CI 2.1-4.7), while salaried physicians were less likely to do so than physicians in private practice (OR = 0.5, 95%CI 0.4-0.8). CONCLUSION: Hidden bedside rationing occurs in the Netherlands: patient choice is on occasion limited with costs as rationale and this is not always disclosed. To what extent distribution of healthcare should include bedside rationing in the Netherlands, or any other country, remains up for debate.

Ethical rationing of healthcare resources during COVID-19 outbreak: Review.

While rationing of healthcare resources is inevitable even in the most developed economies, particularly on the wake of a pandemic, ethical basis of its implementation needs to be reviewed. With sudden and huge demand for drugs and medical supplies and equipments, the need for rationing arises and thus the concept becomes unavoidable. Thus, we aimed to review and analyse on the key ethical issues in the concept of healthcare rationing. Our search in various PubMed databases resulted articles explaining on the concept of strategizing the priorities based on universal ethical principles of justice, benevolence and ensuring equality rather than wealth, power, geographical location or other personal biases. Concrete and pragmatic regulations and guidelines for systematic rationing have to be framed and followed. In addition, physicians being sensitive and empowered on deciding bedside rationing in coordination with the recommendations of ethicists and healthcare officials, will ensure fair practice.