Decision Making in Pathways Development

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Decision Making in Pathways Development

• Dr Andrew J Taylor
• Assistant Director Public Health Science, Hull
  Teaching PCT

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Slides On Website

• http//www.hullpublichealth.org

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Decision Making in Pathways Development

• Objectives
• Describe an Economic view of Decision Making in
  Health Care
• Offer a potential approach
• Describe simple approach
• Pull together main recommendations

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Economists Perspective

• More Demands on resources than there are
  resources available
• A view not always accepted by participants in NHS
• Patients needs must come first!
• Which patients needs come first?
• Cardiac Pathway ?
• Cancer Pathway ?

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Economists Perspective2 key economic principles

• Opportunity Cost
• Investing resources in one way or on one group of
  patients means that resources not available for
  another

• The Margin
• About changes to the resource mix
• If budget increases how to spend new resources
• If budget decreases where to reduce resources
• If budget stays constant how to reconfigure for
  improved service

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Marginal Analysis

• Aim to allocate resources to the point when no
  further change will result in a health gain
• Without explicit adherence to the two economic
  principles, resources will be unlikely to be
  allocated in the best possible configuration.
• Opportunity Cost - The Margin

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Program Budgeting Marginal Analysis (PBMA)

• Approach used in UK Australia, New Zealand and
  Canada
• Hull is participant in National PBMA Pilot with
  York Observatory - Diabetes
• Similar principles to economic evaluation but
  suggested to be more pragmatic and applicable to
  various levels through organisation
• Key is to ensure that opportunity cost and the
  margin are used in decision making process

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PBMA Steps

• Determine aim and scope of decision process
• Define budget (map current activity and spending)
• Form marginal analysis advisory panel
  (representative)
• Determine locally relevant decision criteria
• input from decision makers, board, public, etc
• Advisory Panel identify
• Areas for service growth
• Areas for savings through using less resources
  for same service level
• Areas for resource release through scaling back /
  stopping services
• Advisory Panel make recommendations in terms of
• Funding growth areas from new resources
• Moving resources from 5b to 5a
• Trade off decisions to move resources from 5c to
  5a if considered to be an improvement
• Validity checks with stakeholders

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Determine Scope

• Aims need to be clearly stated
• Might be
• To determine optimum investment across all
  programs within Trust (PCT or Provider)
• Or
• To identify priorities for new technologies
• Both important for Pathways Development
• Map current activity and spending
• Starting point for decisions

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Advisory Panel (Pathways Group)

• Representative group but not too large
• Group dependent on question under consideration
  and scope of exercise
• Necessary to restate economic principles

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Decision Making Criteria

• Need to clearly state dependent criteria and make
  explicit (some examples)
• Cost-effectiveness/Clinical efficacy
• Deprivation/Equity
• Innovation
• Ethics
• Political Imperatives
• May be put into a decision making pro-forma to
  ensure fair consideration and avoid the loudest
  voice dominating
• Or use Qualitative (Delphi?) methods

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Identify options for change

• Stage 5 in the PBMA process
• Prioritised list of service growth options
• Examine current expenditure to improve
  operational efficiency
• Identify options for service reductions or
  scaling back

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Rating Options for Change

• Part 6 in the PBMA process
• Each planning group member to explicitly rate
  each option from stage 5 according to the
  pre-defined criteria
• All decision matrix forms summed and total score
  averaged to give a score per option51121

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Ranking and Decisions

• If, for example service growth items A, B and C
  get scores of 900, 800 and 700 and service
  reduction options X, Y and Z get average scores
  of 850, 750 and 650 respectively
• Ranking of options is then A X B Y C Z
• Service A should be financed from lowest ranked
  service reduction (Z) still getting funding
• Continue comparing growth and service reduction
  until no further gains can be had by switching
  resources between options

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Why and What Challenges

• Notion of freeing resources through improving
  operational efficiency commonplace in health
  organisations
• But Still
• Challenge to obtain resource releases through
  service reductions / disinvestments
• Need good information

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Information and PBMA

• Economic Evaluations
• Systematic Overviews
• Outcome studies
• Health technology assessments
• Quality reports
• DoH or other guidelines
• Local utilisation data
• Informal input
• Expert opinion
• Business cases
• Etc as relevant

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Other Challenges

• Data Requirements - Cost of Information
• Need to make decisions when there is little
  evidence (Bounded rationality)
• Identifying areas for resource release (sacred
  cows and protection of interests)
• Might be better approached by informal
  consultation with key personnel or by anonymous
  questionnaire
• How to incorporate patient views without
  distorting a rational or dispassionate view

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Barriers and Facilitators

• Barriers
• Lack of trust between facilitators
• Physicians not on board
• Advisory panel lacking in health economics and/or
  allocation experience
• Politics preventing program evolution
• Discontinuity of personnel
• Too many admin demands leaving priority setting
  as a low priority activity

• Facilitators
• Senior level managerial/clinical champions
• Strong leadership
• Culture to learn and change
• Integrated budgets
• Resources earmarked for PBMA process itself
• Built in incentives for appropriate and efficient
  spending

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Advantages of PBMA

• Explicit recognition of opportunity cost and the
  margin
• Transparent process
• Stakeholder consultation
• Enables public input
• Can be coupled with an ethical framework to
  examine the fairness of the process
• Improvement on common unstructured decision
  processes

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Decision Tree Approach
Square Decision Node Circle Chance Node with
probability
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Decision Trees1 Year Timescale in this case for
simplicity
Die
A
Live
Decision
Die
B
Live
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Decision Trees ProbabilitiesMust Sum to 1
Die
0.05
A
Live
0.95
Decision
Die
0.1
B
Live
0.9
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Decision Trees OutcomesMeasured using HUI SF36
Euroqol etc
Die
0
0.05
A
Live
0.85
0.95
Decision
Die
0
0.1
B
Live
0.80
0.9
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Decision Trees CostImportant in every Pathway
Die
0
0.05
A
Live
0.85
0.95
1000
Decision
Die
0
0.1
100
B
Live
0.80
0.9
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Decision Trees OutcomesMeasured using HUI SF36
Euroqol etc
Die
0
0.05
Outcome 0.81
A
Live
0.85
0.95
1000
new treatment
Decision
Die
0
Existing treatment
0.1
100
B
Live
0.80
Outcome 0.72
0.9
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Decision Trees OutcomesMeasured using HUI SF36
Euroqol etc
Die
0
0.05
Outcome 0.81
A
Live
0.85
0.95
1000
Expensive Treatment
Decision
Cheap Treatment
Die
0
0.1
100
B
Live
0.80
Outcome 0.72
0.9
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Decision Trees OutcomesMeasured using HUI SF36
Euroqol etc
Die
0
0.05
Outcome 0.81
A
Live
0.85
0.95
1000
Expensive Treatment
1 Patient Or 1000 ?
Decision
Die
0
Cheap Treatment
0.1
100
B
Live
0.80
Outcome 0.72
0.9
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What Next??

• Difference in Health Related Quality of Life
  Outcome 0.09 on scale (between 0 death and 1 full
  health
• Cost difference 900
• Cost per QALY ?
• 900 for 0.09 improvement in Quality of life
• 9,999 cost per QALY
• ????? NIHCE Boundary 30,000 per QALY
• 9999.9999999

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What Next?? Whats important?

• PBMA - Allows consideration and input of
  pathway for all members of group avoid dominance
  by any group
• Finite Resources Probably shrinking in real
  terms due to increases in costs
• Evidence Based From Studies and Measured Local
  Outcomes
• Costed Essential, but not always considered but
  relatively easy?
• Gold Standard, Silver Standard or Bronze ? -
  Based on Maximisation of benefit to patients

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What Next?? Whats important?

• Cost of Information Not always possible to meet
  all the important points but should attempt to
  find ways where we can
• Innovation and Change? Can it be accommodated
  in a tariff based system?
• Others?

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