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Furthermore generic 5mg clarinex, the existence of a market is predicated on assumptions about the motives and activities of buyers and sellers in the market clarinex 5mg online. For example buy discount clarinex 5mg, the assumption that buyers are driven primarily purchase clarinex 5mg otc, if not exclusively, by economic motives does not fit well with what we know about the behavior of healthcare organizations. Another assumption from economic theory— that buyers seek to maximize their benefits from the exchange—is also an uncomfortable fit. Thus, a number of factors operate to prevent the buy- ers of health services from operating in the same manner as the buyers of lawn services or accounting services. The existence of a market also presumes that sellers compete for the consumer’s resources and that this competition determines the price of the goods and services offered. In healthcare, however, it is not unusual for healthcare providers to maintain a monopoly over a particular service within a particular market. It is even more common for oligopolies of healthcare organizations to dominate a particular market. Thus, the buyer of health services is frequently limited in her choice of medical personnel or facilities. As an industry, healthcare also differs from other sectors of society in terms of the diverse goals of its key organizations. The packaged goods industry, for example, has the unitary goal of producing, marketing, and The Challenge of Healthcare M arketing 25 distributing products directly to the consumer. The goals are straightfor- ward whether the product is detergent, cereal, or office supplies. The intent is to sell as many units as possible while extracting the maximum profit from the transaction. They provide employment and benefits for their employees and profits for their shareholders, and they usually contribute to the commu- nity in the form of donations, sponsorship of events, and so on, but these activities are secondary to their single-minded goal of selling consumer products. The diffuse goals of most healthcare organizations distinguish them from other firms. In other industries, potential buyers who do not have the ability to pay or who for some other reason are considered to be undesirable customers can be refused service. Most healthcare organizations, on the other hand, are obligated to accept clients even though the clients are unable to pay for the services and are deemed "undesirable. While providers may have some discretion in acceptance of patients with stable, routine conditions, emergency departments essentially cannot turn away any patient needing emergency care until the patient has at least been sta- bilized. While physician offices may require some payment on the front end for those patients without insurance, there are ethical considerations associated with turning a clearly symptomatic patient away. This situation means that healthcare organizations often provide services that are not profitable. Thus, the economic considerations that apply to other industries may be moderated by factors unique to healthcare. The healthcare industry also tends to be much less organized than other industries in the United States. Often referred to as a nonsystem, healthcare lacks the coordination and centralized (albeit often informal) systems of control found in other industries. Even industries characterized by cutthroat competition typically have a central clearinghouse of indus- try data and mechanisms for cooperating for the benefit of the industry overall. In contrast, the healthcare industry is characterized by fragmenta- tion, discontinuity, and a lack of coordination. It is also characterized by a dismaying lack of information on the industry itself and on its key play- ers. As a result, healthcare lacks the organization typically characteristic of an established market. Consumers in other industries typically pay directly for the goods and services they consume, either out of pocket or through some method of credit. In healthcare, while some small portion of the cost may be paid out of pocket by the consumer, the majority of the fees are likely to be paid by a third party.
An econom ic analysis can be defined as one that involves the use of analytical techniques to define choices in resource allocation purchase clarinex 5mg on-line. M ost of what I have to say on this subject com es from advice prepared by Professor M ichael D rum m ond’s team for authors and reviewers of econom ic analyses1 and three of the "U sers’ guides to the m edical literature" series order clarinex 5 mg overnight delivery,2 5 mg clarinex with amex, 3 discount 5mg clarinex with amex, 4 as well as the excellent pocket sized sum m ary by Jefferson and colleagues,5 all of which em phasise the im portance of setting the econom ic questions about a paper in the context of the overall quality and relevance of the study (see section 10. The first econom ic evaluation I ever rem em ber was a TV advertisem ent in which the pop singer Cliff Richard tried to persuade a housewife that the m ost expensive brand of washing up liquid on the m arket "actually works out cheaper". It was, apparently, stronger on stains, softer on the hands, and produced m ore bubbles per penny than "a typical cheap liquid". W hy should the effectiveness of a washing up liquid be m easured in term s of bubbles produced rather than plates cleaned? Forgive m e for sticking with this trivial exam ple but I’d like to use it to illustrate the four m ain types of econom ic evaluation which you will find in the literature (see Table 10. In term s of quality adjusted housewife hours (a com posite score reflecting tim e and effort needed to scrub plates clean and hand roughness caused by the liquid), Sudso provides 29 units per pound spent whereas Jiffo provides 23 units. The net overall cost (reflecting direct cost of the product, indirect cost of tim e spent washing up, and estim ated financial value of a clean plate relative to a slightly grubby one) of Sudso per day is 7. Cost utility analysis is unnecessary since, in this exam ple, we are interested in very little else apart from the num ber of plates cleaned per unit of washing up liquid; in other words, our outcom e has only one im portant dim ension. Cost benefit analysis is, in this exam ple, an absurdly com plicated way of telling you that Sudso cleans m ore plates per penny. There are, however, m any situations where health professionals, particularly those who purchase health care from real cash lim ited budgets, m ust choose between interventions for a host of different conditions whose outcom es (such as cases of m easles prevented, increased m obility after a hip replacem ent, reduced risk of death from heart attack or likelihood of giving birth to a live baby) cannot be directly com pared with one another. Controversy surrounds not just how these com parisons should be m ade (see section 10. These essential, fascinating, and frustrating questions are beyond the scope of this book but if you are interested I would recom m end you look up the references listed at the end of this chapter. From the hospital’s point of view, the cost of m y care included m y board and lodging for five days, a proportion of doctors’ and nurses’ tim e, drugs and dressings, and investigations (blood tests and a scan). I was off work for three weeks and m y dom estic duties were tem porarily divided between various friends, neighbours, and a nice young girl from a nanny agency. And, from m y point of view, there were several intangible costs, such as discom fort, loss of 153 H OW TO READ A PAPER independence, the allergic rash I developed on the m edication, and the cosm etically unsightly scar which I now carry on m y abdom en. On the benefit side, the operation greatly increased m y chances of staying alive. In addition, I had a nice rest from work and, to be honest, I rather enjoyed all the attention and sym pathy. I would be less likely to brag about m y experience if m y hospital adm ission had been precipitated by, say, an epileptic fit or a nervous breakdown, which have negative social stigm ata. Avoidance of hospital adm ission Investigations Return to paid work Staff salaries Indirect Clinical W ork days lost Postponem ent of death or disability Value of "unpaid" Relief of pain, nausea, breathlessness, etc. Intangible Quality of life Pain and suffering Increased m obility and independence Social stigm a Im proved wellbeing Release from sick role In the appendicitis exam ple, few patients (and even fewer purchasers) would perceive m uch freedom of choice in deciding to opt for the operation. But m ost health interventions do not concern definitive procedures for acutely life threatening diseases. M ost of us can count on developing at least one chronic, disabling, and progressive condition such as ischaem ic heart disease, high blood pressure, arthritis, chronic bronchitis, cancer, rheum atism , prostatic hypertrophy or diabetes. At som e stage, alm ost all of us will be forced to decide whether having a routine operation, taking a particular drug or m aking a com prom ise in our lifestyle (reducing our alcohol intake or sticking to a low-fat diet) is "worth it". But when the choices are about other people’s care, subjective judgem ents are the last thing that should enter the equation. M ost of us would want the planners and policym akers to use objective, explicit, and defensible criteria when m aking decisions such as "N o, M rs Brown m ay not have a kidney transplant". A num ber of questionnaires have been developed which attem pt to m easure overall health status, such as the N ottingham H ealth Profile, the SF-36 general health questionnaire (widely used in the U K) and the M cM aster H ealth U tilities Index Questionnaire (popular in N orth Am erica). For exam ple, answering "yes" to the question "D o you get very concerned about the food you are eating?
Both the generally fall into two categories discount 5 mg clarinex amex, which can broadly be neuroendocrine system and the immune system exhibit referred to "loose cannon" theories and "weak link" profound and speciﬁc functional impairments during theories cheap clarinex 5mg without prescription. Failure of the neuroendocrine system would be The "loose cannon" theories posit that some entropy- expected to produce profound impairments in homeo- producing agent is slowly wearing away at cellular macro- static systems buy clarinex 5 mg lowest price, including the loss of reproduction and molecular constituents discount clarinex 5 mg with amex. Considerable evidence suggests that oxidative damage increases with Similarly, failure of the immune system would be age. For example, it now appears in more, simultaneous overexpression of two different fact that, far from the expected relationship between enzymes that attenuate free radical damage, superoxide declining growth hormone and age-related mortality, dismutase and catalase, signiﬁcantly increases the life mice with growth hormone deﬁciency exhibit increased span of fruit ﬂies;20 no effect was seen when only one life span compared to wild-type mice, whereas mice with elevated growth hormone exhibit reduced life span. Similarly, exposure of nematodes to small molecules that mimic effects of superoxidase Similarly, although autoimmune processes cause type dismutase and catalse also increased life span. The major means by which glucose has been pro- roendocrine and immune systems do exhibit impairments posed to promote senescence is through nonenzymatic with age, little is known about the more primary mecha- attachment to proteins and nucleic acids through Schiff nisms that drive these changes. Therefore, in their current base formation, followed by an irreversible formation incarnations, none of the entropic theories of aging are of Amadori products, the same process that produces complete, and it cannot be said that considerable evi- glycated hemoglobin. Mobbs Physiology of Aging Although this derivation is far from accomplished, simply being able to formulate such a precisely quantitative As organisms age, they accrue functional impairments in question is evidence of the state of gerontology as a sci- virtually every physiologic system. Analysis suggests that at least the form Shock and his coworkers developed a general rule of of the Gompertz curve may arise from evolutionary thumb that many physiologic systems accrue impair- effects, involving a decline in the force of natural selec- 28 ments at a rate of about 5% to 10% per decade after the tion acting on age-speciﬁc mortality. In the top panel that a heart rate more than 80% of maximum attainable (A), the survival curve (fraction of initial population left during a stress test is dangerous, and that the maximum alive as age increases) of a typical ("normal") population heart rate attainable during a stress test reliably is compared with the survival curve of a genetically decreases by about 1 beat per minute each year during similar population placed into an optimum environment aging. The rate of this decline is reduced by about half ("enhanced environment") or a population modiﬁed in highly trained athletes, but even in such athletes, genetically or subject to dietary restriction. Note that an maximum heart rate and maximum oxygen consumption enhanced environment can increase average life span rate nevertheless decline with age. In contrast, genetic variance and dietary restriction can increase not only average life span but maximum life span as well. When these same data are plotted in terms The Gompertz Curve of rate of mortality (the number of individuals that have The essential feature of senescence, at least when applied died over an arbitrarily small unit of time), the mortality to mortality, is that the rate at which death occurs rate of all groups increases exponentially with age and increases with time. If the rate at which death occurred reaches the same high rate toward the end of life; the were constant (e. In most species, nential increase (although then the rate increases even senescence, manifest as an increase in the rate of mortal- faster toward the end of life), whereas genotype and ity with age, can be described by a remarkably simple dietary restriction can actually change the rate at which mathematical function. Because mortality rate increases species that have been studied, including ﬂies, nematodes, exponentially with age, these effects are more easily and rodents, increases exponentially with time, ﬁrst understood by subjecting the rate data to a logarithmic observed in humans by Benjamin Gompertz after observ- transform. After such a transform, log (mortality rate) ing actuarial statistics and reported in 1825. Normal and enhanced envi- pertz equation can be stated succinctly as Rm(t) =-(1/n) ronment groups have similar slopes. If anything, the dn/dt = R e(at), where Rm(t) is the mortality rate at time enhanced environment group may exhibit a slightly * 0 or age t, n = the number of survivors at time t, R0 is the higher slope because the intercept is lower, whereas mortality rate at time t = 0, interpreted as a vulnerability genotype and dietary restriction can actually decrease the factor depending on the hostility of the environment, slope of this transform. This When the rate of mortality becomes high enough, an equation can be linearized by log transform into arbitrarily small number of individuals will be left alive lnRm(t) = ln(R0) + at. In practice, maximum The intercept of this line is generally dependent on the life span is determined empirically, and in humans is gen- hostility of the environment, whereas the slope is depend- erally assumed to be around 125 years (for women; some- ent on the genetic background of the population, for what lower for men). Normal, standard population dynamics; enhanced environment, dynamic pattern as might be observed by idealized optimization of environ- ment, leading to "rectangularization" of the survival curve; enhanced genotype or dietary restriction, dynamic pattern observed by single gene mutations that extend maximum life span (such as AGE-1) or by dietary restriction regimens that extend maximum life span. Depicted in this way, rate of mortal- ity increases exponentially with age (Gompertz function). Note that rectangularization of the mor- tality curve may decrease initial rate of mortality but does not necessarily increase maximum life span and may indeed lead to increased mortality rate during the late period of life, whereas genetic or dietary enhancement of maximal life span is expected to entail decreased rate of mortality but not necessarily a decreased initial mortality rate. In humans, the generally population of heterologous individuals in this phenome- accepted range of applicability is between ages 20 and 80 non has yet to be determined. A particularly interesting recent development is evidence in both humans and other species29,30 that the Pathology Versus Senescence slope of the linearized Gompertz equation (that is, the increase in the rate of mortality, or the second derivative The Gompertz equation applies not only to mortality but of survival) begins to decrease at very old ages, and also to diseases and may be used to resolve a major and possibly the rate of mortality becomes constant (e. These remarkable results have profound ogy, or disease, and what is commonly (although, as we implications for our view of the process of senescence, have seen, unrigorously) called normal aging? This dis- because senescence necessarily entails an increased rate tinction is not merely semantic but addresses fundamen- of mortality with age.