Priority Setting: Beyond Evidence-based Medicine and Cost-effectiveness Analysis

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Priority Setting Beyond Evidence-based Medicine
and Cost-effectiveness Analysis

• Douglas K. Martin, PhD
• Director, Collaborative Program in Bioethics,
• Assistant Professor, Department of Health Policy,
  Management and Evaluation,
• and the Joint Centre for Bioethics, University of
  Toronto
• Career Scientist, Ontario Ministry of Health and
  Long-Term Care

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Outline

• Where we have been the 1980s 1990s
• Where we are going 2000 to 2010
• Improving priority setting

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Where we have been

• PS Distribution of goods and services among
  competing needs
• PS occurs at all levels of system
• government, RHAs, disease management
  organizations, research agencies, PBM,
  hospitals, clinical programs
• rationing resource allocation
  priority setting sustainabilit
  y

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Evidence-based Medicine Cost-effectiveness
Analysis

• Dominant tradition HTA TAH
• Technical problems
• Levels of evidence types of benefits
  availability
• WB The Economics of Priority Setting for Health
  Care (2003) problems with economic evaluations
  incorporating equity practical constraints
• PaussJensen, Singer, Detsky. Ontarios Formulary
  Committee How Recommendations are Made.
  Pharmacoeconomics (2003).
• Complex economic analyses played a limited
  role.
• Helpful but limited necessary but not sufficient

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Lets be clear PS decisions are . . .
VALUE-BASED DECISIONS
NOT information-based decisions
Compassion for the Vulnerable
Rule-of-Rescue
Equity
Risk
Democratic deliberation
Evidence
Equality
Efficiency
Solidarity
Benefit
Individual Responsibility
Access
Need
AND THESE VALUES OFTEN CONFLICT
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Gaps in knowledge

• Goodbye to simple solutions (Holm, BMJ 2000)
• Normative approaches (e.g. philosophy, health
  economics)
• help identify values
• but conflict, no consensus, too abstract
• Empirical approaches
• what is done \ what can be done
• but not what should be done
• International experience shows difficulty
  reaching agreement on what decision
  should be made (Ham, Coulter, JHSRP
  2001)

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Can agree on how Fair process

• But,
• what is fair?

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Accountability for reasonableness

• Relevance based on reasons upon which
  stakeholders can agree in the circumstances
• Publicity reasons publicly accessible
• Revision/Appeals mechanism for
  challenging/revising reasons
• Enforcement to ensure 3 conditions met

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Where we are going

• Simple solutions on one hand and muddling
  through on the other, or substantive versus
  procedural criteria, represent dialectically
  opposite extremes. A synthesized conceptual model
  or framework, grounded in real experience and
  taking account of various discipline-specific
  perspectives, represents the next phase
  of priority setting.

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Criteria Process Parameters of Success

• Competing goals and multiple stakeholder
  relationships
• Efficiency considerations or technical solutions
  limited influence, not sufficient
• An evaluation of the normative 'rightness' of ps
  criteria depends on the specific institutional
  circumstances, the stakeholders who are affected,
  and the strategic goals that are being pursued.
• Underscores the importance of procedural fairness
  to secure socially acceptable priority setting
  decisions and to ensure public accountability.

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Informal Networks of Deliberation

• Beyond formal institutional structures
• Emphasizes public good over private interests
• Context where claims must be justified actions
  shaped by requirements of justification Chaves,
  1974
• Provides more information about
  others preferences
• Engages inherent human ability to
  assess different reasons Manin, 1987
• Renders decision legitimate in the
  eyes of participants
• Groups can pool their experience
  and creativity
• Enhances buy-in

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Improving Priority Setting

• Describe
• Case study methods
• What groups actually do
• Evaluate
• Accountability for reasonableness
• What groups should do
• Correspondence good practices
• Gaps opportunities for improvement
• Improve
• Implement strategies to close gaps

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Benefits of describe/evaluate/improve

• Institution
• quality improvement
• political involvement
• learning organization
• leadership
• Other health care organizations
• share good practices

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Example 1 PS and Hospital Strategic Planning

• Relevance
• ensure info captures impact on academic programs
  and hospitals community
• optimize inclusivity / exclusivity
• revise agreement mechanism
• Publicity
• comprehensive communication plan
• clarify op and strategic plan
• Appeals
• develop appeals grounds / process
• Enforcement
• start data consultation data collection earlier
• describe, evaluate, and improve again!

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Other examples

• Health System
• Martin, Singer Canada in Ham Roberts (eds)
  Reasonable Rationing. 2003
• Provincial Drug Formulary
• PaussJensen, Detsky, Singer Pharmacoeconomics
  2002
• Hospital Drug Formulary
• Martin, Hollenberg, MacRae, Madden, Singer Health
  Policy 2003
• Cancer Drugs
• Martin, Pater, Singer Lancet 2001
• ICU
• Mielke, Martin, Singer Critical Care Medicine
  2003
• Martin, Bernstein, Singer J Neur, Neurosurg,
  Psych 2003

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Database of Learning
Relevance Publicity Appeals Enforce
Health system
MoH
PBM
Disease Manag. Orgs
RHAs
Hosp Strat Plan
Hosp Oper Plan
Hosp drug formulary
Clinical Programs
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Social Policy Learning

• Make private decisions public
• Educative function
• Body of case law institutional reflective
  equilibrium
• Iterative - improves over time

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Beyond and Forward

• Synthesis Criteria Process
• Value-based decisions about which there
  is much conflict
• EBM CEA necessary but insufficient
• Fair process enhances legitimacy accountability
• Informal networks of deliberation
• creates climate of public good, assessment
  of reasons enhanced problem-solving
  increased buy-in
• Describe-evaluate-improve approach
• Ongoing process of social policy learning

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Acknowledgements

• The JCB PS Research Team
• Mark Bernstein, Scott Berry, Jennifer Gibson,
  Heather Gordon, Lydia Kapiriri, Shannon Madden,
  David Reeleder, Zahava Rosenberg-Yunger, Peter A.
  Singer, Ross Upshur, Nancy Walton
• Norman Daniels has contributed enormously to
  our understanding
• www.canadianprioritysetting.ca

Funded by grants from CIHR