1.         “These terms used as synonyms by some authors. The reduction of health inequalities is a focus of many national and international health organisations. The need for pragmatic evidence based approaches has led to the development of a number of evidence based equity initiatives. This paper describes a new program that focuses on upon evidence based tools, which are useful for policy initiatives that reduce inequities’.”

Source:  Tugwell, P. et al  (2006).  Reduction of inequalities in health ; assessing evidence based tools.  Int J Equity in Health 5: 1  doi 10.1186/1474-9276-5-11.

2.         “It is important to distinguish between two similar-sounding, but quite different, concepts:  “equality” and “equity”.   The former implies equal shares of something;  the latter, a “fair” or “just” distribution, which may or may not result in equal shares.”

Source:  Rice, T.   (1998)   The Economics of Health Reconsidered.   Health Administration Press, Chicago  (P.152).

“our findings have  shown that editor and authors – at least in these five high impact journalks at least- continue to fail to serve the needs ofthose who wish to use the results of randomised trials to make decisions about health services”
Clarke m, hopewell s and chalmers i(2010)
clinical trials should begin and end with systematic reviews of relevant evidence ; 12 years and still waiting
lancet 376;20

‘ to understand the difference between the present environment for biomedical innovations and a value-conscious one requires thinking of three effects of every innovation: its effect of the quality of care ( including reductions in mortality and morbidity rates ,relief of pain and improvements of other types of care that patients desire), its effects on the cost of care 9 the resources used to develop and provide to patients, relative to those used for current practice) and its effects on the value of care ( changes in quality relative to changes in cost). Until now most biomedical innovations have been evaluated ( if at all) only in terms of the ir effect on the quality of care. Cost is usually ignored, which means that value is ignored as well’
fuchs v r (2010)
new priorities for future biomedical innovations
NEJM 363;704-707

“Avedis Donabedian was an Armenian, and his nationality was in many ways as important to him as were Cochrane’s roots in Scotland.   In 2003, Oxford University Press published a book whose copyright rested with the American University of Armenia entitled An Introduction to Quality Assurance in Health Care (8).  In his preface, Donabedian states that:  ‘It was with great reluctance that I undertook to write this book’, but from ‘the happy state’ of his retirement, he felt he was recalled by ‘the urgent need, insistently and repeatedly brought to my attention, for a brief, coherent account of quality assurance in health care for use by students of the subject in my native Armenia’.  

Donabedian wrote the book during the end stages of what his editor describes as ‘combat with an avaricious cancer that weakened his musculature but left his mind untouched’, and the book was published in the year 2000, three years after his death at the age of 81.  The book is outstanding, only 200 pages long, but pulling together a lifetime’s work of clear thinking.   Donabedian’s previous classic was his three volume Explorations in Quality Assessment and Monitoring, published in 1980 (9), and it was in this work that he described not only structure, process, and outcome but also his ‘unifying model of benefit, risk and cost’. The power of this model is that it described for the first time the fact that as resources are increased in healthcare, benefit increases, but the increase in benefit then flattens off, illustrating what some people have called the law of diminishing returns.

In contrast, the amount of harm done increases in direct proportion to the investment of resources.  For each unit of increase in resource, there is a unit increase in the volume of care, and a unit increase in the amount of harm.   In fact there may be a progressive increase in the amount of harm if, with each unit of increase in the availability of care, patients who are less fit and more at risk of harm are covered by the service.

As a consequence, there may come a point where the investment of additional resources will lead to a reduction in the net benefit, calculated by subtracting the harm from the benefit. This is sometimes called the ‘health gain’.  Donabedian’s prose is crystal clear:  

In his last book, Donabedian describes optimality explicitly as:

            ‘The balancing of improvements in health against the cost of such improvements.   The definition implies there is a ‘best’ or ‘optimum relationship’ between costs and benefits of health care, a point below which more benefits could be obtained at costs that are low relative to benefits and above which additional benefits are obtained at costs too large relative to corresponding benefits.’ 

Clinicians and patient groups often desire maximally effective healthcare, but for those who pay for healthcare, in a time in which need and demand are greater than the resources that are available, optimality is a more appropriate objective.  When optimality is achieved, value is at a maximum.”

References:

(8)   Donabedian, A. (2002)  An Introduction To Quality Assurance In Health Care.   Oxford Univ. Press

(9)   Donabedian, A. (1980)  Explorations In Quality Assessment & Monitoring (3 vols.)     Health Administration Press

Source:  Gray, J.A.M.   (2007)    How to Get Better Value Healthcare.  Offox Press.  (pp. 22-5)