2.2 methods in priority setting (t)

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2.2 methods in priority setting (t)

  1. 1. Methods in priority setting Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 1
  2. 2. The goal in resource allocation decisionsDecision-makers need to determine: what health care services to provide for whom to provide services how to provide services where services should be provided… in order to meet local and/ or system levelobjectives including access, health gain… Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 2
  3. 3. How is that typically done?Resource allocation decisions are typically based on: Historical patterns with incremental adjustment Politics and the ‘squeaky wheel’ Needs assessment Core services economic evaluation (limited) Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 3
  4. 4. What is required?A pragmatic decision-making approach that….– Aligns resources strategically with system goals and community needs– Leads to publicly defensible decisions based on available evidence and community values– Facilitates stakeholder engagement around improving benefit with limited resources– Supports the public accountability of health care decision- makers Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 4
  5. 5. This leads us in the direction of Program Budgeting and Marginal Analysis (PBMA) Formal framework to assist decision-makers in making resource allocations decisions Combines medicine, economics and ethics Used since the 1970’s in health care Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 5
  6. 6. Basic thinking behind PBMA1. What resources are available in total?2. In what ways are these resources currently spent?3. What are the main candidates for more resources and what would be their effectiveness?4. Are there any areas of care which could be provided to the same level of effectiveness but with less resources, so releasing resources to fund candidates in (3)?5. Are there areas of care which, despite being effective, should have less resources because a proposal in (3) is more effective (per $ spent)? Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 6
  7. 7. PBMA: Practical StepsDetermine aim and scope of activityIdentify and map resource useForm an advisory panelDefine and weight decision making criteriaIdentify options for service growth and resource releaseEvaluate proposed investments and disinvestmentValidate results, recommendations for (re)-allocation,communicate decisionsEvaluation, refinement and ongoing revision Peacock et al. 2006 Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 7
  8. 8. Determine aim and scope of activityIs the aim to bridge a deficit situation, toallocate new funding, to consider possible re-allocations of existing funding…What parts of the organization are included inthe process implementation? Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 8
  9. 9. Mapping resource useObjective is to have an accurate summary ofinformation about services provided across thecontinuum of care- Costs and benefits May not have a clear picture of how many services are provided and by whom Splitting costs in different ways Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 9
  10. 10. The Advisory Panel Multi-disciplinary mix of stakeholders Decision-makers, policy-makers, clinician leaders Finance/information personnel Consumer/community representatives Key responsibilities are: -Establishing assessment criteria (process to do thiscritical for buy-in) - Identify and assess service growth and resourcerelease options Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 10
  11. 11. Benefit measurementMulti-attribute decision analysis (MCDA) Limited ‘real’ health care examples published Reflects multiple objectivesScore service options for investment anddisinvestment in terms of benefits for patientsagainst pre-defined set of criteriaTo get a single measure of each service’s benefitneed to combine the scores Mitton and Donaldson 2004 Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 11
  12. 12. Assessment CriteriaBasis for priority setting decisionsShould be specified at outset of process in explicitmannerOperational enough to assess services againstShould not overlap (mutually exclusive)Need to clearly defineEmbody organizational values Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 12
  13. 13. Use of ‘evidence’ Stakeholder Input Rating options against The Community pre-defined criteria Staff / Doctors Board Population Business Plan Needs Priorities Determining Operational Priorities: Identifying Margins Provincial for Change PracticeRequirements / Guidelines & Targets Standards Service Utilization Output / Outcomes Data Financial Data Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 13
  14. 14. ValidationPrior to final decisions, recommendations should betaken to various stakeholders More than ‘face validity’ feedback Don’t go unless willing to re-assessSeek stakeholder feedback on recommendationsusing a formal decision review process New data/information; errors Failure of due process Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 14
  15. 15. Physician rolesAdvocacy vs. system perspectiveCritical appraisal of competing evidence from arange of sources and settingsAssessment of clinical evidence from systematicreviewsExpert judgment when ‘good evidence’ lacking Ruta et al. 2005 Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 15
  16. 16. Board rolesEndorsement and support of the processPolicy approval – direction and monitoringAssure alignment with organizational prioritiesExplicit fiscal frameworkInvolved and engaged stakeholdersBuy in for investment and disinvestment Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 16
  17. 17. Public roleOnly go there if really want input!Values in relation health care objectivesPossible input on assessment criteriaPossible participation on advisory panelsFocus groups to provide viewpoint on clinical areas Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 17
  18. 18. Expected OutcomesPrimary benefit of PBMA • Achieving real resource shifts that are consistent with strategic decision-making objectivesSecondary benefits of PBMA • Ownership of planning process • Evidence driven decisions • Transparent and defensible decision making • Clinician engagement and partnership Gibson et al. JHSRP 2006 Ruta et al. BMJ 2005 Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 18
  19. 19. Lessons from experience-key success factorsShared vision Stakeholder buy-in TransparencyCredible commitment Resources for process (training, ongoing support, time freed up) Incentives to encourage participationFollow-through (execution) Facilitating change processLearning/ quality improvement Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 19
  20. 20. Canadian examplesChinook Health Region (Alberta) Home and community care Surgery, chronic disease Menno Home and Hospital (BC)Headwaters Health Authority (Alberta) Seniors’ care Surgery, long term care BC Cancer Agency (BC)Calgary Health Region (Alberta) Screening, select drug therapies Macro, children’s services St. Joseph’s Health Centre (Toronto)Vancouver Island Health Authority (BC) All clinical service areas Macro, within portfolios North West, Central West and Champlain LHINsInterior Health Authority (BC) Urgent priorities, Aging at Home, Community care services Alternative levels of careNorthern Health Authority (BC) Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 20
  21. 21. SummaryHealth care environment is politically charged andcomplex Need a pragmatic framework that can introduce evidence based decision makingPBMA is one way to take on an explicit approach topriority setting Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 21
  22. 22. What’s in a name?Point is not ‘PBMA’ or ‘no PBMA’. It is about: Use of explicit criteria (e.g., MCDA) Fit within a broader process of decision making  Priority setting committee  Evidence based  Transparent  Appeals mechanism Ownership of recommendations Craig Mitton & Francois Dionne | Priority Setting & Resource Allocation | 22

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