Healthcare Quarterly Vol.18 No.2 2015 Olly Olly Oxen Free (or Ally Ally in Free): Playing Hide and Seek in Allocating Resources for Child and Youth Health Mary-Ann Hiltz, Craig Mitton, Neale Smith, Laura Dowling, Matthew Campbell, J. Fergall Magee, Jennifer L. Gibson, Shashi Ashok Gujar and Adrian Levy CHILD AND YOUTH HEALTH TABLE 1. Characteristics of residents in accredited and non-accredited LTC homes in Ontario, 2010 *† Theme Subthemes Description Diversity Economies of scale • Pediatrics is less able to capitalize on economies of scale. > Small populations require developmentally-appropriate resources (e.g., multiple sizes of hospital gowns). – Small runs mean fewer vendors and a lack of substitutable products. – Variability in individual levels of development makes it difficult to standardize processes of care through clinical practice guidelines or measures of effectiveness. • Delivery of healthcare to children is often more service-intensive, such as requiring overnight stays that may not be necessary when the same procedure is performed in the adult population. > This has implications for staffing and remuneration of pediatric healthcare providers. > Some procedures may be rare but qualified personnel must stand ready to do them. Small populations require developmentally-appropriate resources (e.g., multiple sizes of hospital gowns). Timeliness • Many pediatric services require timely delivery; these health problems have to be addressed and managed within a certain critical window. Waiting can lead to chronic effects and child patients may be forever profoundly impacted. > Celiac disease is an example of this trajectory. If untreated in childhood, patients develop osteopenia – thinning of the bones – which cannot be reversed even by subsequently improved diet and nutrition. > Another example is PKU (phenylketonuria), which has now long been known to lead to irreversible impairment if not treated in timely manner. Thus, traditional wait-time management strategies may not always be appropriate in the pediatric context. Outcome measures Long time horizons • Measurement in the pediatric healthcare context is challenging. Long time horizons for assessing the outcomes of services are typical: costs accrue early but gains are realized often years or decades in the future, well beyond the term of one political cycle. > Obesity and mental health are examples. In both of these instances, the experience in the developmental years manifests during adulthood. • In other cases, interventions in child health come with long-term and unexpected health effects. We saw the emergence of post-polio syndrome in the past; more recently, the after-effects of childhood cancer treatments have been recognized as a concern for patients and families (Bellett, 2015).