Rationing and the health authority

Clinical leadership in reducing risk: Managing patient airways

Niagara Health, a multi-site hospital organization, has developed a multimodal, comprehensive strategy to manage patients with a Difficult Airway (DA) in a non-operative setting. The Difficult Airway Pathway (DAP) is an evidence-based strategy aimed to train staff to reduce critical events. The DAP initiative aligns with the LEADS framework for change management and includes an annual review of reported critical incidents and an Enterprise Risk Management (ERM) Assessment Summary, with the goal to "create a regional systematic approach to support personnel, equipment and education." The guiding vision is: "Right people, Right equipment, Right timing: No failed airway." Preliminary evaluation suggests the strategy reduces morbidity and mortality of difficulty airway incidents outside the operating room.

Factors explaining priority setting at community mental health centres: a quantitative analysis of referral assessments

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”).

Affordability as a discursive accomplishment in a changing National Health Service

Health systems worldwide face the challenges of rationing. The English National Health Service (NHS) was founded on three core principles: universality, comprehensiveness, and free at the point of delivery. Yet patients are increasingly hearing that some treatments are unaffordable on the NHS. We considered affordability as a social accomplishment and sought to explore how those charged with allocating NHS resources achieved this in practice. We undertook a linguistic ethnography to examine the work practices of resource allocation committees in three Primary Care Trusts (PCTs) in England between 2005 and 2012, specifically deliberations over 'individual funding requests' (IFRs)--requests by patients and their doctors for the PCT to support a treatment not routinely funded. We collected and analysed a diverse dataset comprising policy documents, legal judgements, audio recordings, ethnographic field notes and emails from PCT committee meetings, interviews and a focus group with committee members. We found that the fundamental values of universality and comprehensiveness strongly influenced the culture of these NHS organisations, and that in this context, accomplishing affordability was not easy. Four discursive practices served to confer legitimacy on affordability as a guiding value of NHS health care: (1) categorising certain treatments as only eligible for NHS funding if patients could prove 'exceptional' circumstances; (2) representing resource allocation decisions as being not (primarily) about money; (3) indexical labelling of affordability as an ethical principle, and (4) recontextualising legal judgements supporting refusal of NHS treatment on affordability grounds as 'rational'. The overall effect of these discursive practices was that denying treatment to patients became reasonable and rational for an organisation even while it continued to espouse traditional NHS values. We conclude that deliberations about the funding of treatments at the margins of NHS care have powerful consequences both for patients and for redrawing the ideological landscape of NHS care.

Pandemic influenza: implications for preparation and delivery of critical care services

In a 5-week span during the 1918 influenza A pandemic, more than 2000 patients were admitted to Cook County Hospital in Chicago, with a diagnosis of either influenza or pneumonia; 642 patients, approximately 31% of those admitted, died, with deaths occurring predominantly in patients of age 25 to 30 years. This review summarizes basic information on the biology, epidemiology, control, treatment and prevention of influenza overall, and then addresses the potential impact of pandemic influenza in an intensive care unit setting. Issues that require consideration include workforce staffing and safety, resource management, alternate sites of care surge of patients, altered standards of care, and crisis communication.

Currents in contemporary ethics. Should health care providers get treatment priority in an influenza pandemic?

The 2009 pandemic of influenza A (H1N1) was relatively mild, but a subsequent outbreak of pandemic influenza could be much worse. According to projections from the Department of Health and Human Services, the potential health consequences of a severe (1918-like) influenza pandemic in the United States could be literally overwhelming: up to 1.9 million deaths; 90 million people sick; 45 million people needing outpatient care; 9.9 million people hospitalized, of whom 1.485 million would need treatment in an intensive care unit (ICU); and 742,500 patients needing mechanical ventilators. Even a less cataclysmic, moderate pandemic (like 1958 or 1968) would result in 209,000 deaths; 90 million people sick; 45 million people needing outpatient care; 865,000 people hospitalized, of whom 128,750 would need treatment in an ICU; and 64,875 patients needing mechanical ventilators.

Local prioritisation work in health care—Assessment of an implementation process

Political, horizontal prioritisation requires knowledge on local health care resource use on unit or patient group level. This in turn requires unit level structures (meeting forums) and processes for creation of knowledge and continuous, open decision-making on prioritisation. Ideally, for decisions to be legitimate, such procedures should meet the "Accountability for reasonableness"-criteria of Daniels and Sabin [Daniels N. Accountability for reasonableness. Establishing a fair process for priority setting is easier than agreeing on principles. British Medical Journal 2000;321:1300-1]. A strategy, aiming at shaping such an organisational culture, was developed and set to work within a regional health care organisation, responsible for around 250000 inhabitants. This pilot study regarding topic and methodology assesses the changes of knowledge in open prioritisation as well as structures, processes for and results of such work on unit level in that organisation 1998 through early 2005. Initial interviews and two consecutive surveys were analysed. Results indicate that only early adopters respond to the surveys and among them a growing knowledge in priority setting, acceptance of personal leadership for local priority setting work and recognition of a need for adequate structures and processes. Among respondents, one could note a development: A tentative model expressing different positions towards prioritisation was developed.

Ethics and opportunity costs: have NICE grasped the ethics of priority setting?

The Social Value Judgments consultation document reveals NICE's failure to understand its role in healthcare prioritisation

"Saying no is no easy matter" a qualitative study of competing concerns in rationing decisions in general practice

Background

The general practitioner in Norway is expected to ensure equity and effectiveness through fair rationing. At the same time, due to recent reforms of the Norwegian health care sector, both the role of economic incentives and patient autonomy have been strengthened. Studies indicate that modern general practitioners, both in Norway and in other countries are uncomfortable with the gatekeeper role, but there is little knowledge about how general practitioners experience rationing in practice.

Methods

Through focus group interviews with Norwegian general practitioners, we explore physicians' attitudes toward factors of influence on medical decision making and how rationing dilemmas are experienced in everyday practice.

Results

Four major concerns appeared in the group discussions: The obligation to ration health care, professional autonomy, patient autonomy, and competition. A central finding was that the physicians find rationing difficult because saying no in face to face relations often is felt uncomfortable and in conflict with other important objectives for the general practitioner.

Conclusion

It is important to understand the association between using economic incentives in the management of health care, increasing patient autonomy, and the willingness among physicians to contribute to efficient, fair and legitimate resource allocation.

What do hospital decision-makers in Ontario, Canada, have to say about the fairness of priority setting in their institutions?

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.

Reimbursement decisions in health policy--extending our understanding of the elements of decision-making

Previous theoretical and empirical work on health policy decisions about reimbursement focuses on specific rationales such as effectiveness, economic considerations and equal access for equal needs. As reimbursement decisions take place in a social and political context we propose that the analysis of decision-making should incorporate factors, which go beyond those commonly discussed. As an example we chose three health technologies (sildenafil, rivastigmine and statins) to investigate how decisions about reimbursement of medicines are made in the United Kingdom National Health Service and what factors influence these decisions. From face-to-face, in-depth interviews with a purposive sample of 20 regional and national policy makers and stakeholders we identified two dimensions of decision-making, which extend beyond the rationales conventionally cited. The first dimension relates to the role of 'subjectivity' or 'the personal' in the decisions, including personal experiences of the condition and excitement about the novelty or potential benefit of the technology-these factors affect what counts as evidence, or how evidence is interpreted, in practice. The second dimension relates to the social and political function of decision-making and broadens what counts as the relevant ends of decision-making to include such things as maintaining relationships, avoiding organisational burden, generating politically and legally defensible decisions and demonstrating the willingness to care. More importantly, we will argue that these factors should not be treated as contaminants of an otherwise rational decision-making. On the contrary we suggest that they seem relevant, reasonable and also of substantial importance in considering in decision-making. Complementing the analysis of decision-making about reimbursement by incorporating these factors could increase our understanding and potentially improve decision-making.

Hospital priority setting with an appeals process: a qualitative case study and evaluation

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.

Setting priorities in health care organizations: criteria, processes, and parameters of success

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.

Clinical management and prioritization criteria. Finnish experiences

The aim of this study was to investigate the acceptability of 14 prioritization criteria from nurses', doctors', local politicians' and the general public's perspective. Respondents (nurses, n = 682, doctors, n = 837 politicians, n = 1,133 and the general public, n = 1,178) received a questionnaire with 16 imaginary patient cases, each containing 2-3 different prioritization criteria. The subjects were asked to indicate how important it was for them that the treatments in the presented patient cases be subsidized by the community. All respondents preferred treatments for poor people and children. With the exception of the doctors, the three other study groups also prioritized elderly patients. Treatment for institutionalised patients, those with self-induced disease, diseases with both poor and good prognosis, and mild disease were given low priorities. Priority setting in health care should be regarded as a continuous process because of changes in attitudes. However, the best method for surveying opinions and ethical principles concerning prioritization has not yet been discovered.

A strategy to improve priority setting in health care institutions

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.

Eliciting reasons: empirical methods in priority setting

In this paper I review empirical methods applied in recent analysis of decision-making on priorities in health care. I outline a number of discrete methods and discuss their applicability and efficacy in the field of bioethics. Three key methodological issues seem to be important: choice of subject group; choice of approach and the extent of background information given to respondents. I conclude that a combination method is needed to give a comprehensive representation of values in priority setting and thus to meet the overall objectives of empirical ethics.

Seasonal bed closures in an intensive care unit: a qualitative study

OBJECTIVE

To describe perceptions of the administrative procedures for seasonal bed closures and their consequences in the intensive care unit (ICU), and to critique this example of health care priority setting for legitimacy and fairness.

DESIGN

A qualitative study using case study methods and interviews with key participants. We evaluated fairness and legitimacy of the bed closure process using 4 domains of the ethical framework of "accountability for reasonableness."

SETTING

An university-affiliated medical/surgical ICU in Eastern Canada.

PARTICIPANTS

ICU clinicians (9 bedside nurses and 5 physicians), and administrators (3 ICU managers and 2 senior hospital executives).

MAIN OUTCOME MEASURES

Perceptions of ICU clinicians and administrators regarding the ICU bed closure decision-making process and its consequences.

RESULTS

Emerging themes concerned: (1) bed closure rationale (including arbitrary decision making, bed closure masquerading as a code for a nursing shortage, and suboptimal evidence base for implementing closures); (2) bed closure process (viewed as unclear with insufficient prior publicity and inadequate subsequent review); and (3) adverse consequences (including safety issues, negative professional working relationships, and poor morale). Although an appeals mechanism existed, nurses were not available to staff reopened beds so this condition is only partially met. The relevance, publicity, and enforcement conditions for accountability of reasonableness were not satisfied, offering opportunities for improvement.

CONCLUSION

Clinicians and administrators are readily able to identify shortcomings in the seasonal bed closure process in the ICU. These shortcomings should be targeted for improvement so that intensive care health services delivery is legitimate and fair.

Interpreting public input into priority-setting: the role of mediating institutions

Discussions about public participation in health priority-setting have tended to assume that the best type of information about public values is that in which the public 'speaks for itself'. However, wherever public input has been used in priority-setting, the way in which it is used is far from transparent. Those jurisdictions that have initiated priority-setting processes have been characterised by the substantial involvement of 'mediating bodies' i.e. bodies such as the Oregon Health Services Commission or the New Zealand National Health Committee, that take on the role of interpreting information about public values. The information that they interpret is usually presented in a highly ambiguous form and most definitely does not 'speak for itself'. In the priority-setting literature, however, little attention has been paid to the role of these bodies and the way in which they interpret and digest information about public values. This article argues that these bodies are essential, but that their decision-making processes are necessarily opaque and should not be judged according to the criterion of transparency.

Rationing of expensive medical care in a transition country--nihil novum?

This article focuses on rationing of expensive medical care in the Czech Republic. It distinguishes between political and clinical decision levels and reviews the debate in the Western literature on explicit and implicit rules. The contemporary situation of the Czech health care system is considered from this perspective. Rationing reoccurred in the mid 90s after the shift in health care financing from fee-for-service to prospective budgets. The lack of explicit rules is obvious. Implicit forms of rationing, done by physicians at the clinical level prevail, implying uncontrolled power of the medical profession and lacking transparency for ethical considerations of equity to access. It seems to be acceptable for physicians to play the role of allocators, probably because of their experience with rationing during the socialist period. Traditional rationing stereotypes from the previous regime seem to persist despite the health care system transformation during the 90s.

Fairness, accountability for reasonableness, and the views of priority setting decision-makers

Fairness is a key goal of priority setting and 'accountability for reasonableness' has emerged as the leading framework for fair priority setting. However, it has not been shown acceptable to those engaged in priority setting. In particular, since it was developed in the context of a primarily privately funded health system, its applicability in a primarily publicly funded system is uncertain. In this paper, we describe elements of fairness identified by decision-makers engaged in priority setting for new technologies in Canada (a primarily publicly funded system). According to these decision makers, accountability for reasonableness is acceptable and applicable. Our findings also provide refinements to accountability for reasonableness.

Priority setting for new technologies in medicine: a transdisciplinary study

BACKGROUND

Decision makers in health care organizations struggle with how to set priorities for new technologies in medicine. Traditional approaches to priority setting for new technologies in medicine are insufficient and there is no widely accepted model that can guide decision makers.

DISCUSSION

Daniels and Sabin have developed an ethically based account about how priority setting decisions should be made. We have developed an empirically based account of how priority setting decisions are made. In this paper, we integrate these two accounts into a transdisciplinary model of priority setting for new technologies in medicine that is both ethically and empirically based.

SUMMARY

We have developed a transdisciplinary model of priority setting that provides guidance to decision makers that they can operationalize to help address priority setting problems in their institution.

Priority-setting decisions for new cancer drugs: a qualitative case study

BACKGROUND

Frameworks for legitimate and fair priority setting emphasise the importance of the rationales for priority setting decisions. However, priority setting rationales, in particular for new cancer drugs, are not well described. We describe the rationales used by a committee making funding decisions for new cancer drugs.

METHODS

We did a qualitative case study of a priority setting committee (Cancer Care Ontario Policy Advisory Committee for the New Drug Funding Program) by analysing documents, interviewing committee members, and observing committee meetings.

FINDINGS

We identified and described decisions and rationales related to 14 drugs in eight disease conditions over 3 years. Our main findings were that: priority setting existed in relation to resource mobilisation; clinical benefit was the primary factor in decisions; in the context of an expanding budget, rationales changed; rationales could change as costs for individual treatments increased; when all options were reasonable, groups funded a range of options and let patients decide; and priority setting rationales involve clusters of factors, not simple trade-offs.

INTERPRETATION

Observing priority-setting decisions and their rationales in actual practice reveals lessons not contained in theoretical accounts.

Rationing and life-saving treatments: should identifiable patients have higher priority?

Health care systems across the world are unable to afford the best treatment for all patients in all situations. Choices have to be made. One key ethical issue that arises for health authorities is whether the principle of the "rule of rescue" should be adopted or rejected. According to this principle more funding should be available in order to save lives of identifiable, compared with unidentifiable, individuals. Six reasons for giving such priority to identifiable individuals are considered. All are rejected. It is concluded that the principle of the rule of rescue should not be used in determining the allocation of health resources.

Clinical ethics revisited

A decade ago, we reviewed the field of clinical ethics; assessed its progress in research, education, and ethics committees and consultation; and made predictions about the future of the field. In this article, we revisit clinical ethics to examine our earlier observations, highlight key developments, and discuss remaining challenges for clinical ethics, including the need to develop a global perspective on clinical ethics problems.

Priority setting for new technologies in medicine: qualitative case study

OBJECTIVE

To describe priority setting for new technologies in medicine.

DESIGN

Qualitative study using case studies and grounded theory.

SETTING

Two committees advising on priorities for new technologies in cancer and cardiac care in Ontario, Canada.

PARTICIPANTS

The two committees and their 26 members.

MAIN OUTCOME MEASURES

Accounts of priority setting decision making gathered by reviewing documents, interviewing members, and observing meetings.

RESULTS

Six interrelated domains were identified for priority setting for new technologies in medicine: the institutions in which the decision are made, the people who make the decisions, the factors they consider, the reasons for the decisions, the process of decision making, and the appeals mechanism for challenging the decisions.

CONCLUSION

These domains constitute a model of priority setting for new technologies in medicine. The next step will be to harmonise this description of how priority setting decisions are made with ethical accounts of how they should be made.

Limits to rationality: economics, economists and priority setting

This paper investigates why economic approaches to priority setting have had only limited impact in practice. It argues that obstacles to the take-up of the economic approach centre on (1) limitations in the theory and practice of economic evaluations, and (2) the nature of the wider context within which decisions on priority setting take place. On the first point, it argues that, despite advances in research methods, there is still debate about the theoretical basis of measures typically used in economic evaluations, such as QALYs, and that much of the extant empirical data is of questionable quality. On the second point, it maintains that politicians, health care professionals and local people attach importance to other factors besides allocative efficiency. If economic approaches are to have more impact in the future, it argues that health economists need to adopt a wider research agenda, focusing on public sector decision-making and, in particular, the incentives and constraints governing the use of economic data in different types of health care organisation.