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Stafinski T, Deber R, Rhainds M, Martin J, Noseworthy T, Bryan S, Menon D. Decision-Making on New Non-Drug Health Technologies by Hospitals and Health Authorities in Canada. ACTA ACUST UNITED AC 2019; 15:82-94. [PMID: 31629458 PMCID: PMC7008692 DOI: 10.12927/hcpol.2019.25936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Introduction: Unlike those for publicly funded drugs in Canada, coverage decision-making processes for non-drug health technologies (NDTs) are not well understood. Objectives: This paper aims to describe existing NDT decision-making processes in different healthcare organizations across Canada. Methods: A self-administered survey was used to determine demographic and financial characteristics of organizations, followed by in-depth interviews with senior leadership of consenting organizations to understand the processes for making funding decisions on NDTs. Results: Seventy-three and 48 organizations completed self-administered surveys and telephone interviews, respectively (with 45 participating in both ways). Fifty-five different processes were identified, the majority of which addressed capital equipment. Most involved multidisciplinary committees (with medical and non-medical representation), but the types of information used to inform deliberations varied. Across all processes, decision-making criteria included local considerations such as alignment with organizational priorities. Conclusions: NDT decision-making processes vary in complexity, depending on characteristics of the healthcare organization and context.
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Affiliation(s)
- Tania Stafinski
- School of Public Health, University of Alberta, Edmonton, AB
| | - Raisa Deber
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON
| | - Marc Rhainds
- Unité d'évaluation des technologies et des modes d'intervention en santé , CHU de Québec - Université Laval, Laval, QC
| | - Janet Martin
- Director, Centre for Medical Evidence, Decision Integrity & Clinical Impact, Schulich School of Medicine & Dentistry, Western University, London, ON
| | - Tom Noseworthy
- Department of Community Health Sciences and Institute for Public Health, University of Calgary, Calgary, AB
| | - Stirling Bryan
- Centre for Clinical Epidemiology & Evaluation, University of British Columbia, Vancouver, BC
| | - Devidas Menon
- School of Public Health, University of Alberta, Edmonton, AB
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Sandoval GA, Brown AD, Wodchis WP, Anderson GM. The relationship between hospital adoption and use of high technology medical imaging and in-patient mortality and length of stay. J Health Organ Manag 2019; 33:286-303. [PMID: 31122120 DOI: 10.1108/jhom-08-2018-0232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to investigate the relationship between hospital adoption and use of computed tomography (CT) scanners, and magnetic resonance imaging (MRI) machines and in-patient mortality and length of stay. DESIGN/METHODOLOGY/APPROACH This study used panel data (2007-2010) from 124 hospital corporations operating in Ontario, Canada. Imaging use focused on medical patients accounting for 25 percent of hospital discharges. Main outcomes were in-hospital mortality rates and average length of stay. A model for each outcome-technology combination was built, and controlled for hospital structural characteristics, market factors and patient characteristics. FINDINGS In 2010, 36 and 59 percent of hospitals had adopted MRI machines and CT scanners, respectively. Approximately 23.5 percent of patients received CT scans and 3.5 percent received MRI scans during the study period. Adoption of these technologies was associated with reductions of up to 1.1 percent in mortality rates and up to 4.5 percent in length of stay. The imaging use-mortality relationship was non-linear and varied by technology penetration within hospitals. For CT, imaging use reduced mortality until use reached 19 percent in hospitals with one scanner and 28 percent in hospitals with 2+ scanners. For MRI, imaging use was largely associated with decreased mortality. The use of CT scanners also increased length of stay linearly regardless of technology penetration (4.6 percent for every 10 percent increase in use). Adoption and use of MRI was not associated with length of stay. RESEARCH LIMITATIONS/IMPLICATIONS These results suggest that there may be some unnecessary use of imaging, particularly in small hospitals where imaging is contracted out. In larger hospitals, the results highlight the need to further investigate the use of imaging beyond certain thresholds. Independent of the rate of imaging use, the results also indicate that the presence of CT and MRI devices within a hospital benefits quality and efficiency. ORIGINALITY/VALUE To the authors' knowledge, this study is the first to investigate the combined effect of adoption and use of medical imaging on outcomes specific to CT scanners and MRI machines in the context of hospital in-patient care.
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Affiliation(s)
- Guillermo A Sandoval
- Institute of Health Policy, Management and Evaluation, University of Toronto , Toronto, Canada
| | - Adalsteinn D Brown
- Institute of Health Policy, Management and Evaluation, University of Toronto , Toronto, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto , Toronto, Canada
| | - Geoffrey M Anderson
- Institute of Health Policy, Management and Evaluation, University of Toronto , Toronto, Canada
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Sandoval GA, Brown AD, Wodchis WP, Anderson GM. Adoption of high technology medical imaging and hospital quality and efficiency: Towards a conceptual framework. Int J Health Plann Manage 2018; 33. [PMID: 29770971 DOI: 10.1002/hpm.2547] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 04/20/2018] [Indexed: 11/11/2022] Open
Abstract
Measuring the value of medical imaging is challenging, in part, due to the lack of conceptual frameworks underlying potential mechanisms where value may be assessed. To address this gap, this article proposes a framework that builds on the large body of literature on quality of hospital care and the classic structure-process-outcome paradigm. The framework was also informed by the literature on adoption of technological innovations and introduces 2 distinct though related aspects of imaging technology not previously addressed specifically in the literature on quality of hospital care: adoption (a structural hospital characteristic) and use (an attribute of the process of care). The framework hypothesizes a 2-part causality where adoption is proposed to be a central, linking factor between hospital structural characteristics, market factors, and hospital outcomes (ie, quality and efficiency). The first part indicates that hospital structural characteristics and market factors influence or facilitate the adoption of high technology medical imaging within an institution. The presence of this technology, in turn, is hypothesized to improve the ability of the hospital to deliver high quality and efficient care. The second part describes this ability throughout 3 main mechanisms pointing to the importance of imaging use on patients, to the presence of staff and qualified care providers, and to some elements of organizational capacity capturing an enhanced clinical environment. The framework has the potential to assist empirical investigations of the value of adoption and use of medical imaging, and to advance understanding of the mechanisms that produce quality and efficiency in hospitals.
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Affiliation(s)
- Guillermo A Sandoval
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Ontario, Canada
| | - Adalsteinn D Brown
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Ontario, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Ontario, Canada
| | - Geoffrey M Anderson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Ontario, Canada
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Grepperud S, Holman PA, Wangen KR. Factors explaining priority setting at community mental health centres: a quantitative analysis of referral assessments. BMC Health Serv Res 2014; 14:620. [PMID: 25496562 PMCID: PMC4272526 DOI: 10.1186/s12913-014-0620-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 11/19/2014] [Indexed: 11/28/2022] Open
Abstract
Background Clinicians at Norwegian community mental health centres assess referrals from general practitioners and classify them into three priority groups (high priority, low priority, and refusal) according to need where need is defined by three prioritization criteria (severity, effect, and cost-effectiveness). In this study, we seek to operationalize the three criteria and analyze to what extent they have an effect on clinical-level priority setting after controlling for clinician characteristics and organisational factors. Methods Twenty anonymous referrals were rated by 42 admission team members employed at 14 community mental health centres in the South-East Health Region of Norway. Intra-class correlation coefficients were calculated and logistic regressions were performed. Results Variation in clinicians’ assessments of the three criteria was highest for effect and cost-effectiveness. An ordered logistic regression model showed that all three criteria for prioritization, three clinician characteristics (education, being a manager or not, and “guideline awareness”), and the centres themselves (fixed effects), explained priority decisions. The relative importance of the explanatory factors, however, depended on the priority decision studied. For the classification of all admitted patients into high- and low-priority groups, all clinician characteristics became insignificant. For the classification of patients, into those admitted and non-admitted, one criterion (effect) and “being a manager or not” became insignificant, while profession (“being a psychiatrist”) became significant. Conclusions Our findings suggest that variation in priority decisions can be reduced by: (i) reducing the disagreement in clinicians’ assessments of cost-effectiveness and effect, and (ii) restricting priority decisions to clinicians with a similar background (education, being a manager or not, and “guideline awareness”).
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Affiliation(s)
- Sverre Grepperud
- Department of Health Management and Health Economics, University of Oslo, PO 1089, N-0317, Oslo, Norway.
| | | | - Knut Reidar Wangen
- Department of Health Management and Health Economics, University of Oslo, PO 1089, N-0317, Oslo, Norway.
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Reeleder D, Martin DK, Keresztes C, Singer PA. What do hospital decision-makers in Ontario, Canada, have to say about the fairness of priority setting in their institutions? BMC Health Serv Res 2005; 5:8. [PMID: 15663792 PMCID: PMC548272 DOI: 10.1186/1472-6963-5-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2004] [Accepted: 01/21/2005] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Priority setting, also known as rationing or resource allocation, occurs at all levels of every health care system. Daniels and Sabin have proposed a framework for priority setting in health care institutions called 'accountability for reasonableness', which links priority setting to theories of democratic deliberation. Fairness is a key goal of priority setting. According to 'accountability for reasonableness', health care institutions engaged in priority setting have a claim to fairness if they satisfy four conditions of relevance, publicity, appeals/revision, and enforcement. This is the first study which has surveyed the views of hospital decision makers throughout an entire health system about the fairness of priority setting in their institutions. The purpose of this study is to elicit hospital decision-makers' self-report of the fairness of priority setting in their hospitals using an explicit conceptual framework, 'accountability for reasonableness'. METHODS 160 Ontario hospital Chief Executive Officers, or their designates, were asked to complete a survey questionnaire concerning priority setting in their publicly funded institutions. Eight-six Ontario hospitals completed this survey, for a response rate of 54%. Six close-ended rating scale questions (e.g. Overall, how fair is priority setting at your hospital?), and 3 open-ended questions (e.g. What do you see as the goal(s) of priority setting in your hospital?) were used. RESULTS Overall, 60.7% of respondents indicated their hospitals' priority setting was fair. With respect to the 'accountability for reasonableness' conditions, respondents indicated their hospitals performed best for the relevance (75.0%) condition, followed by appeals/revision (56.6%), publicity (56.0%), and enforcement (39.5%). CONCLUSIONS For the first time hospital Chief Executive Officers within an entire health system were surveyed about the fairness of priority setting practices in their institutions using the conceptual framework 'accountability for reasonableness'. Although many hospital CEOs felt that their priority setting was fair, ample room for improvement was noted, especially for the enforcement condition.
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Affiliation(s)
- David Reeleder
- Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Douglas K Martin
- Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- University of Toronto Joint Centre for Bioethics, University of Toronto, Toronto, Canada
| | - Christian Keresztes
- Centre for Health Services and Policy Research, Queen's University, Kingston, Canada
| | - Peter A Singer
- University of Toronto Joint Centre for Bioethics, University of Toronto, Toronto, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
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SARS and hospital priority setting: a qualitative case study and evaluation. BMC Health Serv Res 2004; 4:36. [PMID: 15606924 PMCID: PMC544195 DOI: 10.1186/1472-6963-4-36] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2004] [Accepted: 12/19/2004] [Indexed: 11/18/2022] Open
Abstract
Background Priority setting is one of the most difficult issues facing hospitals because of funding restrictions and changing patient need. A deadly communicable disease outbreak, such as the Severe Acute Respiratory Syndrome (SARS) in Toronto in 2003, amplifies the difficulties of hospital priority setting. The purpose of this study is to describe and evaluate priority setting in a hospital in response to SARS using the ethical framework 'accountability for reasonableness'. Methods This study was conducted at a large tertiary hospital in Toronto, Canada. There were two data sources: 1) over 200 key documents (e.g. emails, bulletins), and 2) 35 interviews with key informants. Analysis used a modified thematic technique in three phases: open coding, axial coding, and evaluation. Results Participants described the types of priority setting decisions, the decision making process and the reasoning used. Although the hospital leadership made an effort to meet the conditions of 'accountability for reasonableness', they acknowledged that the decision making was not ideal. We described good practices and opportunities for improvement. Conclusions 'Accountability for reasonableness' is a framework that can be used to guide fair priority setting in health care organizations, such as hospitals. In the midst of a crisis such as SARS where guidance is incomplete, consequences uncertain, and information constantly changing, where hour-by-hour decisions involve life and death, fairness is more important rather than less.
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Madden S, Martin DK, Downey S, Singer PA. Hospital priority setting with an appeals process: a qualitative case study and evaluation. Health Policy 2004; 73:10-20. [PMID: 15911053 DOI: 10.1016/j.healthpol.2004.11.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2004] [Accepted: 10/21/2004] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To describe and evaluate priority setting in the context of hospital priority setting and more specifically to evaluate the use of an appeals process. DESIGN Qualitative case study and evaluation using the ethical framework 'accountability for reasonableness'. SETTING The University Health Network (UHN), a network of three large urban teaching hospitals affiliated with the University of Toronto in Toronto, Canada. This study focused on Clinical Activity Target Setting (CATS), the final component of the strategic planning process. PARTICIPANTS Sixty-six board members, senior administrators, managers, clinical leaders and other hospital staff who participated in the hospital strategic planning exercise. DATA COLLECTION Three primary sources of data were used: key documents, interviews with participants and stakeholders and observations of group deliberations. DATA ANALYSIS Open and axial coding using an explicit conceptual framework 'accountability for reasonableness'. RESULTS This was the first time an appeal process has been described and evaluated. The appeals process was found to be a fundamental component to overall perceived fairness of the priority setting process. The appeals process also enhanced the involvement of stakeholders and increased overall participant satisfaction. In addition, four areas of 'good practice' and ten recommendations for improvement of the larger priority setting process were identified. CONCLUSIONS This case study has provided an in-depth analysis of a priority setting process at a hospital, with a particular focus on the appeals process. Also, we compared the lessons learned from this study with those from a previous study at a different hospital.
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Affiliation(s)
- Shannon Madden
- Department of Health Policy, Management and Evaluation and the Joint Centre for Bioethics, University of Toronto, 88 College Street, Toronto, Ont., Canada M5G 1L4
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Gibson JL, Martin DK, Singer PA. Setting priorities in health care organizations: criteria, processes, and parameters of success. BMC Health Serv Res 2004; 4:25. [PMID: 15355544 PMCID: PMC518972 DOI: 10.1186/1472-6963-4-25] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2004] [Accepted: 09/08/2004] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Hospitals and regional health authorities must set priorities in the face of resource constraints. Decision-makers seek practical ways to set priorities fairly in strategic planning, but find limited guidance from the literature. Very little has been reported from the perspective of Board members and senior managers about what criteria, processes and parameters of success they would use to set priorities fairly. DISCUSSION We facilitated workshops for board members and senior leadership at three health care organizations to assist them in developing a strategy for fair priority setting. Workshop participants identified 8 priority setting criteria, 10 key priority setting process elements, and 6 parameters of success that they would use to set priorities in their organizations. Decision-makers in other organizations can draw lessons from these findings to enhance the fairness of their priority setting decision-making. SUMMARY Lessons learned in three workshops fill an important gap in the literature about what criteria, processes, and parameters of success Board members and senior managers would use to set priorities fairly.
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Affiliation(s)
- Jennifer L Gibson
- University of Toronto Joint Centre for Bioethics, 88 College Street, Toronto, Ontario, M5G 1L4, Canada
| | - Douglas K Martin
- University of Toronto Joint Centre for Bioethics, 88 College Street, Toronto, Ontario, M5G 1L4, Canada
- Department of Health Policy, Management and Evaluation, University of Toronto, 88 College Street, Toronto, Ontario, M5G 1L4, Canada
| | - Peter A Singer
- University of Toronto Joint Centre for Bioethics, 88 College Street, Toronto, Ontario, M5G 1L4, Canada
- Department of Medicine, University of Toronto, 88 College Street, Toronto, Ontario, M5G 1L4, Canada
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Abstract
Priority setting (also known as resource allocation or rationing) occurs at every level of every health system and is one of the most significant health care policy questions of the 21st century. Because it is so prevalent and context specific, improving priority setting in a health system entails improving it in the institutions that constitute the system. But, how should this be done? Normative approaches are necessary because they help identify key values that clarify policy choices, but insufficient because different approaches lead to different conclusions and there is no consensus about which ones are correct, and they are too abstract to be directly used in actual decision making. Empirical approaches are necessary because they help to identify what is being done and what can be done, but are insufficient because they cannot identify what should be done. Moreover, to be really helpful, an improvement strategy must utilize rigorous research methods that are able to analyze and capture experience so that past problems are corrected and lessons can be shared with others. Therefore, a constructive, practical and accessible improvement strategy must be research-based and combine both normative and empirical methods. In this paper we propose a research-based improvement strategy that involves combining three linked methods: case study research to describe priority setting; interdisciplinary research to evaluate the description using an ethical framework; and action research to improve priority setting. This describe-evaluate-improve strategy is a generalizable method that can be used in different health care institutions to improve priority setting in that context.
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Affiliation(s)
- Doug Martin
- Collaborative Program in Bioethics, Department of Health Policy, Management and Evaluation, Joint Centre for Bioethics, University of Toronto, Ontario, Canada M5G IL4.
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Ng SW, Esmail R, Sibbald WJ, Doig GS. Potential savings involved in the purchase of low-cost, high-volume medical commodities as established from a community hospital survey. Healthc Manage Forum 1996; 9:24-9. [PMID: 10164210 DOI: 10.1016/s0840-4704(10)60758-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Health technology refers to the instruments, equipment, drugs and procedures used in health care delivery, as well as the organizations supporting it. Health technology assessment, which is the process of conducting investigations to establish the criteria for efficacious, effective and efficient patient care, is becoming increasingly important in an era of diminishing resources. This survey of 39 community hospitals in southwestern Ontario found that improved purchasing strategies can result in substantial cost savings which can in turn be used to improve patient care. The study shows that optimizing the price of basic hospital commodities could save an average community hospital as much as $625,000 per year.
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Affiliation(s)
- S W Ng
- Michael G. DeGroote School of Business, McMaster University, Hamilton, Ontario
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Deber R, Wiktorowicz M, Leatt P, Champagne F. Technology acquisition in Canadian hospitals: how are we doing? Healthc Manage Forum 1996; 8:23-8. [PMID: 10144218 DOI: 10.1016/s0840-4704(10)60905-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
We surveyed attitudes of decision makers involved in making decisions about technology acquisition in hospitals, receiving replies from 989 (72%) anglophone respondents and 201 (68%) from francophone respondents. Respondents split on whether to try unverified procedures, strongly agreed that medical technology should be evaluated, and expressed a desire for technology assessment data. The quality of health care, need, and compatibility with the institution's role and mission were seen as the most important factors affecting acquisitions. Our study suggests that half the battle has been won; decision makers appear convinced that technologies must be evaluated. Organizational mechanisms, however, may still be required to ensure implementation.
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Affiliation(s)
- R Deber
- Department of Health Administration, University of Toronto
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