Using programme budgeting and marginal analysis to assist population based strategic planning for coronary heart disease

Barriers and facilitators to implementing priority setting and resource allocation tools in hospital decisions: A systematic review

Health care budgets in high-income countries are having issues coping with unsustainable growth in demand, particularly in the hospital setting. Despite this, implementing tools systematising priority setting and resource allocation decisions has been challenging. This study answers two questions: (1) what are the barriers and facilitators to implementing priority setting tools in the hospital setting of high-income countries? and (2) what is their fidelity? A systematic review using the Cochrane methods was conducted including studies of hospital-related priority setting tools reporting barriers or facilitators for implementation, published after the year 2000. Barriers and facilitators were classified using the Consolidated Framework for Implementation Research (CFIR). Fidelity was assessed using priority setting tool's standards. Out of thirty studies, ten reported program budgeting and marginal analysis (PBMA), twelve multi-criteria decision analysis (MCDA), six health technology assessment (HTA) related frameworks, and two, an ad hoc tool. Barriers and facilitators were outlined across all CFIR domains. Implementation factors not frequently observed, such as 'evidence of previous successful tool application', 'knowledge and beliefs about the intervention' or 'external policy and incentives' were reported. Conversely, some constructs did not yield any barrier or facilitator including 'intervention source' or 'peer pressure'. PBMA studies satisfied the fidelity criteria between 86% and 100%, for MCDA it varied between 36% and 100%, and for HTA it was between 27% and 80%. However, fidelity was not related to implementation. This study is the first to use an implementation science approach. Results represent the starting point for organisations wishing to use priority setting tools in the hospital setting by providing an overview of barriers and facilitators. These factors can be used to assess readiness for implementation or to serve as the foundation for process evaluations. Through our findings, we aim to improve the uptake of priority setting tools and support their sustainable use.

Practices of decision making in priority setting and resource allocation: a scoping review and narrative synthesis of existing frameworks

BACKGROUND

Due to growing expenditures, health systems have been pushed to improve decision-making practices on resource allocation. This study aimed to identify which practices of priority setting and resource allocation (PSRA) have been used in healthcare systems of high-income countries.

METHODS

A scoping literature review (2007-2019) was conducted to map empirical PSRA activities. A two-stage screening process was utilized to identify existing approaches and cluster similar frameworks. That was complemented with a gray literature and horizontal scanning. A narrative synthesis was carried out to make sense of the existing literature and current state of PSRA practices in healthcare.

RESULTS

One thousand five hundred eighty five references were found in the peer-reviewed literature and 25 papers were selected for full-review. We identified three major types of decision-making framework in PSRA: 1) Program Budgeting and Marginal Analysis (PBMA); 2) Health Technology Assessment (HTA); and 3) Multiple-criteria value assessment. Our narrative synthesis indicates these formal frameworks of priority setting and resource allocation have been mostly implemented in episodic exercises with poor follow-up and evaluation. There seems to be growing interest for explicit robust rationales and ample stakeholder involvement, but that has not been the norm in the process of allocating resources within healthcare systems of high-income countries.

CONCLUSIONS

No single dominate framework for PSRA appeared as the preferred approach across jurisdictions, but common elements exist both in terms of process and structure. Decision-makers worldwide can draw on our work in designing and implementing PSRA processes in their contexts.

Using a Formal Strategy of Priority Setting to Mitigate Austerity Effects Through Gains in Value: The Role of Program Budgeting and Marginal Analysis (PBMA) in the Brazilian Public Healthcare System

The fiscal regime implemented in Brazil with the constitutional amendment 95 (EC-95) of December 2016 froze primary expenditures for 20 years, including healthcare spending. Previous studies have estimated strong negative effects of this policy on the health of Brazilians. Although there has been a constant pressure to repeal EC-95, this policy is unlikely to be changed in the near future. Thus, there is also a need to take actions within its own terms in order to mitigate its harmful consequences on population health. Shedding light on the existing evidence about the impact of austerity on health, the present work discusses how decision-makers can use a formal framework of decision making in priority setting and resource allocation to tackle the amplified budgetary strain. Drawing on principles of Program Budgeting and Marginal Analysis (PBMA), efficiency can be improved by shifting spending from low-value to higher-value areas, avoiding the "across-the-board cut" caused by non-differential consideration of expenditures in a context of mismatched growth of demand and supply of healthcare. By evaluating opportunity costs of investment and disinvestment proposals on the basis of multiple criteria and marginal analysis, the Brazilian public healthcare system could obtain gains in value, achieving better performance and attenuating the relative decline in spending on health brought by an austerity scenario.

Using decision methods to examine the potential impact of intersectoral action programs

Objectives

In public health today, there is a widespread call for intersectoral action (ISA) programs, in which two or more sectors cooperate to address a problem. This trend raises a question of how to appropriately assess the effectiveness and cost-effectiveness of ISA programs. To assess the impact of ISA, evaluation methods should provide a framework for simultaneously considering the impact of two or more interventions when selecting from a portfolio of programs. There is a gap in literature on such methods. In this research note, from a narrative review, we report and describe methods that could be useful for evaluating ISA programs. Subsequently, we present a hypothetical case study to demonstrate the use of these methods.

Results

We identified four methods that have potential to assess the joint impact of multiple interventions: economic evaluation, portfolio analysis, multiple-criteria decision analysis, and programme budgeting and marginal analysis. To keep pace with the desire to use strong evidence to inform the selection and design of ISA programs, methods must evolve to support these initiatives. This research note seeks to begin a dialogue on existing decision methods which may be used to assist decision makers with funding and resource allocation decisions of ISA programs.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3609-x) contains supplementary material, which is available to authorized users.

How have systematic priority setting approaches influenced policy making? A synthesis of the current literature

BACKGROUND

There is a growing body of literature on systematic approaches to healthcare priority setting from various countries and different levels of decision making. This paper synthesizes the current literature in order to assess the extent to which program budgeting and marginal analysis (PBMA), burden of disease & cost-effectiveness analysis (BOD/CEA), multi-criteria decision analysis (MCDA), and accountability for reasonableness (A4R), are reported to have been institutionalized and influenced policy making and practice.

METHODS

We searched for English language publications on health care priority setting approaches (2000-2017). Our sources of literature included PubMed and Ovid databases (including Embase, Global Health, Medline, PsycINFO, EconLit).

FINDINGS

Of the four approaches PBMA and A4R were commonly applied in high income countries while BOD/CEA was exclusively applied in low income countries. PBMA and BOD/CEA were most commonly reported to have influenced policy making. The explanations for limited adoption of an approach were related to its complexity, poor policy maker understanding and resource requirements.

CONCLUSIONS

While systematic approaches have the potential to improve healthcare priority setting; most have not been adopted in routine policy making. The identified barriers call for sustained knowledge exchange between researchers and policy-makers and development of practical guidelines to ensure that these frameworks are more accessible, applicable and sustainable in informing policy making.

Evaluating 'success' in programme budgeting and marginal analysis: a literature review

OBJECTIVES

Programme budgeting and marginal analysis (PBMA) is a priority-setting toolkit which aims to assist decision-makers in identifying the most efficient use of resources. The last systematic literature review on PBMA was published in 2001 and evaluated success in applying PBMA using the criteria of 'reallocation of resources' or the 'setting of priorities'. Our objective was to re-evaluate applications of PBMA in terms of these criteria separately, summarize different evaluation methods of PBMA and extend the above review by considering all PBMA applications since 2001.

METHODS

Systematic literature review. Information was sought from four general medical electronic databases. Descriptive statistics and content analysis were used.

RESULTS

PBMA was successful in 52% of cases when success was defined in terms of the participants gaining a better understanding of the area under interest; in 65% of cases when success was defined as 'implementation of all or some of the advisory panel's recommendations'; in 48% of the studies when success was defined in terms of disinvesting or resource reallocation; and in 22% when success was defined in terms of adopting the framework for future use.

CONCLUSIONS

The rate of success is clearly influenced by how success is defined. There is a need for a broadly accepted definition of success to be used when evaluating PBMA applications so to enable direct comparisons of studies. This evaluatory component needs to be adjacent to PBMA and not a separate procedure.

Difficult decisions in times of constraint: criteria based resource allocation in the Vancouver Coastal Health Authority

OBJECTIVES

The aim of the project was to develop a plan to address a forecasted deficit of approximately $4.65 million for fiscal year 2010/11 in the Vancouver Communities division of the Vancouver Coastal Health Authority. For disinvestment opportunities identified beyond the forecasted deficit, a commitment was made to consider options for resource re-allocation within the Vancouver Communities division.

METHODS

A standard approach to program budgeting and marginal analysis (PBMA) was taken with a priority setting working committee and a broader advisory panel. An experienced, non-vested internal project manager worked closely with the two-member external research team throughout the process. Face to face evaluation interviews were held with 10 decision makers immediately following the process.

RESULTS

The recommendations of the working committee included the implementation of 44 disinvestment initiatives with an annualized value of CAD $4.9 million, as well as consideration of possible investments if the realized savings match expectations. Overall, decision makers viewed the process favorably and the primary aim of addressing the deficit gap was met.

DISCUSSION

A key challenge was the tight timeline which likely lead to less evidence informed decision making then one would hope for. Despite this, decision makers felt that better decisions were made then had the process not been in place. In the end, this project adds value in finding that PBMA can be used to cover a deficit and minimize opportunity cost through systematic application of criteria whilst ensuring process fairness through focusing on communication, transparency and decision maker engagement.

Priority setting in healthcare: towards guidelines for the program budgeting and marginal analysis framework

Economists' approaches to priority setting focus on the principles of opportunity cost, marginal analysis and choice under scarcity. These approaches are based on the premise that it is possible to design a rational priority setting system that will produce legitimate changes in resource allocation. However, beyond issuing guidance at the national level, economic approaches to priority setting have had only a moderate impact in practice. In particular, local health service organizations - such as health authorities, health maintenance organizations, hospitals and healthcare trusts - have had difficulty implementing evidence from economic appraisals. Yet, in the context of making decisions between competing claims on scarce health service resources, economic tools and thinking have much to offer. The purpose of this article is to describe and discuss ten evidence-based guidelines for the successful design and implementation of a program budgeting and marginal analysis (PBMA) priority setting exercise. PBMA is a framework that explicitly recognizes the need to balance pragmatic and ethical considerations with economic rationality when making resource allocation decisions. While the ten guidelines are drawn from the PBMA framework, they may be generalized across a range of economic approaches to priority setting.

Priority setting in practice: what is the best way to compare costs and benefits?

Prioritizing candidates for health-care expenditure using cost per Quality-Adjusted Life Year (QALY) is a helpful but insufficient means of ranking alternative uses for scarce health-care funds at the local level. This is because QALYs do not by themselves capture all criteria decision makers need to take into account. Other criteria such as reducing inequalities, meeting national and local priorities and public acceptability also feature in the decision maker's utility function. Programme budgeting and marginal analysis (PBMA) is an established framework for systematic priority setting in which a 'weighted benefit score' for each option is calculated based on all relevant decision-making criteria. Ranking options as a ratio of cost to benefit is desirable and necessary to ensure efficiency. In this paper we review a number of approaches to scoring costs and benefits of options in a PBMA context. Several approaches rank by benefit score alone, rather than efficiency (cost per unit of benefit). Of those that do rank by efficiency, we discuss the benefits and drawbacks. The optimal approach is far from clear, with each technique having its own strengths and weaknesses. A deliberative approach using summaries of costs and benefits of options as a basis for discussion may be preferable.

Is it feasible to pool funds for local children's services in England? Evidence from the national evaluation of children's trust pathfinders

OBJECTIVES

To describe how funds were pooled or otherwise jointly managed by National Health Service (NHS) primary care trusts and local authorities in England. To compare expenditure on local children's services by health, education and social services.

METHODS

We conducted a questionnaire survey of all 35 children's trust pathfinders, six months after they were launched, with a follow-up at 2.5 years. We also undertook an in-depth analysis of local authorities and primary care trusts, within eight pathfinder areas and three non-pathfinder areas, whereby we compared expenditure on children's services, interviewed managers and professionals and examined financial documents.

RESULTS

Local authorities and NHS trusts coordinated expenditure in various ways, most commonly through informal agreements and aligning budgets but also by formally pooling budgets. The latter were usually for selected services such as child and adolescent mental health services, though four children's trusts pathfinders pooled (or aligned) their budgets for all children's services. Total expenditure per child was greatest for education, lowest for social services and intermediate for health. However, it was difficult to quantify education expenditure on children with health and social care needs, and health care expenditure on children.

CONCLUSIONS

Sharing money for local children's services requires shared objectives, trust, and legal and accounting expertise. Several different mechanisms are permitted and many are feasible but programme budgeting for children's services could make them more effective.

Comparing the preferences of health professionals and members of the public for setting health care priorities : experiences from Australia

INTRODUCTION

This article reports on a priority-setting exercise involving members of the general public and health professionals. The aim is to compare the healthcare priorities of these two groups, as well as their attitudes towards public involvement in priority setting.

METHODS

A convenience sample of 373 members of the public attending two central Sydney, Australia, medical clinics were asked to complete a structured, interviewer-administered questionnaire. Forty-four purposively sampled healthcare professionals working in central Sydney completed the same questionnaire. Both groups were asked whether the preferences of the public should inform priority-setting decisions. They then had to allocate an additional (but fixed) amount of healthcare resources across competing programmes, medical procedures and population groups and their preferences were compared.

RESULTS

The health professionals and members of the public strongly supported using public preferences to inform priorities in healthcare. Both groups expressed a slightly stronger preference for using public preferences to inform priorities across healthcare programmes and population groups than for medical interventions.

DISCUSSION/CONCLUSION

Considerable uniformity of preferences was revealed between the health professionals and the members of the public. However, it is argued that, even where the preferences of health professionals are consistent with and representative of those of the wider community, public involvement is important in terms of procedural justice, as it helps to legitimise both the process and the resultant priorities.

Listening to the decision makers: sustainability of PBMA in Alberta

BACKGROUND

Decision makers within the Calgary Health Region adopted and applied programme budgeting and marginal analysis (PBMA) for priority-setting activity across major service portfolios within the Region.

METHODS

Seventeen in-depth qualitative interviews were conducted with senior managers and clinicians to gain a user perspective and identify specific areas for process refinement. Data were thematically coded and categorised into relevant themes.

RESULTS

Key strengths included a culture shift in thinking about the need to reallocate resources within a fixed funding envelope, whereas a key challenge identified was in putting forth genuine disinvestment options. Areas suggested for improvement included evoking an incentive system for stakeholder engagement and having a mechanism for tracking the effect of resource reallocations.

CONCLUSIONS

Both an evidence-based approach to priority setting, as well as a way of thinking around managing resource scarcity, can be integrated into organisational processes. Findings reported in this article will influence further application in Calgary and should provide insight for those attempting such activity elsewhere.

Setting priorities and allocating resources in health regions: lessons from a project evaluating program budgeting and marginal analysis (PBMA)

BACKGROUND

Program budgeting and marginal analysis (PBMA) is a framework for setting priorities in health care, used internationally over the last 25 years in Britain, Australia and New Zealand. However, the framework has undergone limited evaluation, and insight into how such evaluation should even take place is not found in the literature.

METHODS

Seven PBMA case studies were conducted in three Canadian health regions to examine the feasibility of applying the PBMA framework. Structured follow-up surveys with the users of the framework were carried out following the priority setting exercises.

RESULTS

The PBMA framework was feasibly implemented in three regionalized contexts and was generally viewed favorably by managers and clinicians who participated in the case studies. Numerous methodological lessons were learned and it was found that successful implementation hinges on organizational context. An empirically derived model describing PBMA is outlined and put forth as an evaluation framework for future exercises.

CONCLUSIONS

Comparisons to the health care management literature indicate that the derived PBMA model is a novel addition to this broader literature. Overall, managers in health organizations internationally would be well-served to consider PBMA to aid regional decision-making processes, but should do so with explicit consideration of the context in which such activity is to occur.