Tools of the trade: a comparative analysis of approaches to priority setting in healthcare

Evaluation of a Nutrition Education and Skills Training programme in vulnerable adults who are at high risk of food insecurity

BACKGROUND

In Australia, the prevalence of food insecurity increased by 1.5% between 2014 and 2016 and 2018 and 2020 due to effects of the COVID-19 pandemic. OzHarvest offers a 6-week Nutrition Education and Skills Training (NEST) programme to adults at risk of food insecurity. NEST provides 2.5-h weekly cooking workshops on simple, healthy and affordable meals. This study aimed to determine the immediate (post) and longer-term (6 months) impacts of participation in NEST.

METHODS

A quasi-experimental study with pre-post surveys (n = 258) and 6-month follow-up surveys (n = 20) was conducted from June 2019 to July 2022. Survey results were obtained from NEST programme participants (≥18 years) from six major Australian cities.

RESULTS

Participants demonstrated immediate improvement in nutrition knowledge (p < 0.001), food preparation behaviours (p < 0.001) and confidence and self-efficacy (n = 222; p < 0.001). Intake of discretionary foods decreased (p < 0.001), whereas fruit, vegetable and water intake increased (p < 0.001). Food security improved from 57% to 68% immediately after the completion of the programme (p < 0.001). Participants demonstrated longer-term improvements in nutrition knowledge (p < 0.001), cooking confidence (n = 8; p = 0.03), food preparation behaviours (p = 0.003) and increased vegetable (p = 0.03) and fruit intake (p = 0.01).

CONCLUSIONS

Participation in OzHarvest's NEST programme results in short-term improvements in food security levels and dietary behaviours. Over the longer term, these changes were sustained but to a lesser degree, indicating that systemic changes are required to address underlying socio-economic disadvantages.

Developing a national health research agenda for Lao PDR: prioritising the research needs of stakeholders

Background

Currently the health research system in Lao PDR is fragmented and largely donor led. Capacity among national public health institutes is limited to select priority research questions for funding.

Objective

The objective of this capacity building and practice-oriented study is to describe the process and outcome of the first National Health Research Agenda for Lao PDR and how the agenda contributes to institutional capacity of the Ministry of Health, in order to contribute to evidence-informed public health policy making.

Method

This activity used a mixed-methods approach. The overall design is based on principles of the interactive Learning and Action approach and consists out of 6 phases: (1) identification of needs, (2) shared analysis and integration, (3) nation-wide prioritization of research domains, (4) exploring specific research questions, (5) prioritization of research avenues, (6) dialogue and planning for action. The process involved interviews with experts in health policy and research (n = 42), telephone-based survey with district, provincial and national health staff (n = 135), a two-round Delphi consultation with experts in health policy and research (n = 33), and a workshop with policymakers, researchers, international organisations and civil society (n = 45) were held to gather data and conduct shared analysis.

Results

11 research domains were identified and prioritised: Health-seeking behaviour; Health system research; Health service provision; Mother and child health (MCH); Sexual & reproductive health; Health education; Non-communicable diseases (NCDs); Irrational drug use; Communicable diseases (CDs); Road traffic accidents; Mental health. Within these domains over 200 unique research questions were identified.

Conclusion

Our approach led to a comprehensive, inclusive, public health agenda for Lao PDR to realise better informed health policies. Questions on the agenda are action-oriented, originating in a desire to understand the problem so that immediate improvements can be made. The agenda is used within the MoH as a tool to fund and approve research. 

Top ten priorities for anesthesia and perioperative research: a report from the Canadian Anesthesia Research Priority Setting Partnership

PURPOSE

The purpose of the Canadian Anesthesia Research Priority Setting Partnership (CAR PSP) was to identify a top ten list of shared priorities for research in anesthesia and perioperative care in Canada.

METHODS

We used the methods of the James Lind Alliance to involve patients, caregivers, healthcare professionals, and researchers in determining the research priorities in Canada. In a first survey, participants submitted questions that they want research to answer about anesthesia and perioperative care. We summarized those responses into a longlist of questions. We reviewed the literature to see if any of those questions were already answered. In a second survey, participants chose up to ten questions from the longlist that they thought were most important to be answered with research. From that list, the highest ranking questions were discussed and assigned a final rank at an in-person workshop.

RESULTS

A total of 254 participants submitted 574 research suggestions that were then summarized into 49 questions. Those questions were checked against the literature to be sure they were not already adequately addressed, and in a second survey of those 49 questions, participants chose up to 10 that they thought were most important. A total of 233 participants submitted their priorities, which were then used to choose 24 questions for discussion at the final workshop. At the final workshop, 22 participants agreed on a top ten list of priorities.

CONCLUSION

The CAR PSP top ten priorities reflect a wide variety of priorities captured by a broad spectrum of Canadians who receive and provide anesthesia care. The priorities are a tool to initiate and guide patient-oriented research in anesthesia and perioperative care.

The Modelled Population Obesity-Related Health Benefits of Reducing Consumption of Discretionary Foods in Australia

Over one third of Australians' daily energy intake is from discretionary foods and drinks. While many health promotion efforts seek to limit discretionary food intake, the population health impact of reductions in the consumption of different types of discretionary foods (e.g., sugar-sweetened beverages (SSBs), confectionery, sweet biscuits) has not been quantified. This study estimated the potential reductions in body weight, obesity-related disease incidence, and healthcare cost savings associated with consumption of one less serving per week of different discretionary foods. Reductions in the different types of discretionary food were modelled individually to estimate the impact on energy consumption and population body weight by 5-year age and sex groups. It was assumed that one serving of discretionary food each week was replaced with either a serving of fruit or popcorn, and a serving (375 mL) of SSBs was replaced with coffee, tea, or milk. Proportional multi-state multiple-cohort Markov modelling estimated likely resultant health adjusted life years (HALYs) gained and healthcare costs saved over the lifetime of the 2010 Australian population. A reduction of one serving of SSBs (375 mL) had the greatest potential impact in terms of weight reduction, particularly in ages 19-24 years (mean 0.31 kg, 95% UI: 0.23 kg to 0.37 kg) and overall healthcare cost savings of AUD 793.4 million (95% UI: 589.1 M to 976.1 M). A decrease of one serving of sweet biscuits had the second largest potential impact on weight change overall, with healthcare cost savings of $640.7 M (95% CI: $402.6 M to $885.8 M) and the largest potential weight reduction amongst those aged 75 years and over (mean 0.21 kg, 95% UI: 0.14 kg to 0.27 kg). The results demonstrate that small reductions in discretionary food consumption are likely to have substantial health benefits at the population level. Moreover, the study highlights that policy responses to improve population diets may need to be tailored to target different types of foods for different population groups.

Ethics education and moral decision-making in clinical commissioning: an interview study

BACKGROUND

Clinical commissioning involves ethically challenging decisions about health resource allocation. However, commissioners come from a range of professional backgrounds with varying levels of training and expertise in ethical decision-making. Hence, they may lack the relevant training and resources to feel fully prepared for this increasingly demanding role.

AIM

This study aims to provide insight into how prepared commissioners feel in making ethical decisions; what ethics learning needs they might have; and how these might be addressed.

DESIGN AND SETTING

This qualitative interview study explored the experiences of commissioners working for clinical commissioning groups (CCGs) in England.

METHOD

Eighteen participants were interviewed between December 2017 and July 2018 using a purposive sampling approach to participant selection. Transcriptions were coded and analysed using the constant comparative method of thematic analysis.

RESULTS

Most participants had not received ethics training in preparation for, or during, their commissioning role, and reported difficulties identifying and analysing ethical issues. Participants often felt uncomfortable about decisions they were involved in, attributing this to a number of factors: a sense of moral unease; concerns that CCGs' decision-making processes were not sufficiently transparent; and that CCGs were not fully accountable to the population served.

CONCLUSION

Commissioners face complex decisions involving ethical issues, and associated moral unease is exacerbated by a lack of ethics training and lack of confidence in identifying and analysing these. This study shows a clear need for additional support and ethics training for commissioners to support them in this area of decision-making.

Using decision methods to examine the potential impact of intersectoral action programs

Objectives

In public health today, there is a widespread call for intersectoral action (ISA) programs, in which two or more sectors cooperate to address a problem. This trend raises a question of how to appropriately assess the effectiveness and cost-effectiveness of ISA programs. To assess the impact of ISA, evaluation methods should provide a framework for simultaneously considering the impact of two or more interventions when selecting from a portfolio of programs. There is a gap in literature on such methods. In this research note, from a narrative review, we report and describe methods that could be useful for evaluating ISA programs. Subsequently, we present a hypothetical case study to demonstrate the use of these methods.

Results

We identified four methods that have potential to assess the joint impact of multiple interventions: economic evaluation, portfolio analysis, multiple-criteria decision analysis, and programme budgeting and marginal analysis. To keep pace with the desire to use strong evidence to inform the selection and design of ISA programs, methods must evolve to support these initiatives. This research note seeks to begin a dialogue on existing decision methods which may be used to assist decision makers with funding and resource allocation decisions of ISA programs.

Electronic supplementary material

The online version of this article (10.1186/s13104-018-3609-x) contains supplementary material, which is available to authorized users.

Fit for purpose? Introducing a rational priority setting approach into a community care setting

Purpose - Program budgeting and marginal analysis (PBMA) is a priority setting approach that assists decision makers with allocating resources. Previous PBMA work establishes its efficacy and indicates that contextual factors complicate priority setting, which can hamper PBMA effectiveness. The purpose of this paper is to gain qualitative insight into PBMA effectiveness. Design/methodology/approach - A Canadian case study of PBMA implementation. Data consist of decision-maker interviews pre (n=20), post year-1 (n=12) and post year-2 (n=9) of PBMA to examine perceptions of baseline priority setting practice vis-à-vis desired practice, and perceptions of PBMA usability and acceptability. Findings - Fit emerged as a key theme in determining PBMA effectiveness. Fit herein refers to being of suitable quality and form to meet the intended purposes and needs of the end-users, and includes desirability, acceptability, and usability dimensions. Results confirm decision-maker desire for rational approaches like PBMA. However, most participants indicated that the timing of the exercise and the form in which PBMA was applied were not well-suited for this case study. Participant acceptance of and buy-in to PBMA changed during the study: a leadership change, limited organizational commitment, and concerns with organizational capacity were key barriers to PBMA adoption and thereby effectiveness. Practical implications - These findings suggest that a potential way-forward includes adding a contextual readiness/capacity assessment stage to PBMA, recognizing organizational complexity, and considering incremental adoption of PBMA's approach. Originality/value - These insights help us to better understand and work with priority setting conditions to advance evidence-informed decision making.

Sustainability in Health care by Allocating Resources Effectively (SHARE) 6: investigating methods to identify, prioritise, implement and evaluate disinvestment projects in a local healthcare setting

BACKGROUND

This is the sixth in a series of papers reporting Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. The SHARE program was established to investigate a systematic, integrated, evidence-based approach to disinvestment within a large Australian health service. This paper describes the methods employed in undertaking pilot disinvestment projects. It draws a number of lessons regarding the strengths and weaknesses of these methods; particularly regarding the crucial first step of identifying targets for disinvestment.

METHODS

Literature reviews, survey, interviews, consultation and workshops were used to capture and process the relevant information. A theoretical framework was adapted for evaluation and explication of disinvestment projects, including a taxonomy for the determinants of effectiveness, process of change and outcome measures. Implementation, evaluation and costing plans were developed.

RESULTS

Four literature reviews were completed, surveys were received from 15 external experts, 65 interviews were conducted, 18 senior decision-makers attended a data gathering workshop, 22 experts and local informants were consulted, and four decision-making workshops were undertaken. Mechanisms to identify disinvestment targets and criteria for prioritisation and decision-making were investigated. A catalogue containing 184 evidence-based opportunities for disinvestment and an algorithm to identify disinvestment projects were developed. An Expression of Interest process identified two potential disinvestment projects. Seventeen additional projects were proposed through a non-systematic nomination process. Four of the 19 proposals were selected as pilot projects but only one reached the implementation stage. Factors with potential influence on the outcomes of disinvestment projects are discussed and barriers and enablers in the pilot projects are summarised.

CONCLUSION

This study provides an in-depth insight into the experience of disinvestment in one local healthcare service. To our knowledge, this is the first paper to report the process of disinvestment from identification, through prioritisation and decision-making, to implementation and evaluation, and finally explication of the processes and outcomes.

Sustainability in Health care by Allocating Resources Effectively (SHARE) 2: identifying opportunities for disinvestment in a local healthcare setting

Background

This is the second in a series of papers reporting a program of Sustainability in Health care by Allocating Resources Effectively (SHARE) in a local healthcare setting. Rising healthcare costs, continuing advances in health technologies and recognition of ineffective practices and systematic waste are driving disinvestment of health technologies and clinical practices that offer little or no benefit in order to maximise outcomes from existing resources. However there is little information to guide regional health services or individual facilities in how they might approach disinvestment locally. This paper outlines the investigation of potential settings and methods for decision-making about disinvestment in the context of an Australian health service.

Methods

Methods include a literature review on the concepts and terminology relating to disinvestment, a survey of national and international researchers, and interviews and workshops with local informants. A conceptual framework was drafted and refined with stakeholder feedback.

Results

There is a lack of common terminology regarding definitions and concepts related to disinvestment and no guidance for an organisation-wide systematic approach to disinvestment in a local healthcare service.

A summary of issues from the literature and respondents highlight the lack of theoretical knowledge and practical experience and provide a guide to the information required to develop future models or methods for disinvestment in the local context.

A conceptual framework was developed. Three mechanisms that provide opportunities to introduce disinvestment decisions into health service systems and processes were identified. Presented in order of complexity, time to achieve outcomes and resources required they include 1) Explicit consideration of potential disinvestment in routine decision-making, 2) Proactive decision-making about disinvestment driven by available evidence from published research and local data, and 3) Specific exercises in priority setting and system redesign.

Conclusion

This framework identifies potential opportunities to initiate disinvestment activities in a systematic integrated approach that can be applied across a whole organisation using transparent, evidence-based methods. Incorporating considerations for disinvestment into existing decision-making systems and processes might be achieved quickly with minimal cost; however establishment of new systems requires research into appropriate methods and provision of appropriate skills and resources to deliver them.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2211-6) contains supplementary material, which is available to authorized users.

Implementing priority setting frameworks: Insights from leading researchers

In spite of a substantial literature developing frameworks for policymakers to use in resource allocation decisions in healthcare, there remains limited published work reporting on the implementation or evaluation of such frameworks in practice. This paper presents findings of a targeted survey of 18 leading researchers around the implementation and evaluation of priority-setting exercises. Approximately one third of respondents knew of situations where recommendations of priority-setting exercises had been implemented, one third knew that recommendations had not been implemented and the final third responded that they did not know whether recommendations had been adopted. The lack of evidence linking the implementation of priority-setting recommendations to equity and efficiency outcomes was highlighted by all respondents. Features identified as facilitating successful implementation of priority-setting recommendations included having a climate ready to accept priority-setting, good leadership or a 'champion' for the priority-setting process and having a health economist to guide the process. Successful disinvestment was very uncommon in the experience of the researchers surveyed. Recommendations emerging from Program Budgeting and Marginal Analysis exercises appeared to be more widely implemented than those coming from alternative processes. Identifying if the process was repeated following the initial process was suggested as a means to measure success.

Setting Healthcare Priorities at the Macro and Meso Levels: A Framework for Evaluation

BACKGROUND

Priority setting in healthcare is a key determinant of health system performance. However, there is no widely accepted priority setting evaluation framework. We reviewed literature with the aim of developing and proposing a framework for the evaluation of macro and meso level healthcare priority setting practices.

METHODS

We systematically searched Econlit, PubMed, CINAHL, and EBSCOhost databases and supplemented this with searches in Google Scholar, relevant websites and reference lists of relevant papers. A total of 31 papers on evaluation of priority setting were identified. These were supplemented by broader theoretical literature related to evaluation of priority setting. A conceptual review of selected papers was undertaken.

RESULTS

Based on a synthesis of the selected literature, we propose an evaluative framework that requires that priority setting practices at the macro and meso levels of the health system meet the following conditions: (1) Priority setting decisions should incorporate both efficiency and equity considerations as well as the following outcomes; (a) Stakeholder satisfaction, (b) Stakeholder understanding, (c) Shifted priorities (reallocation of resources), and (d) Implementation of decisions. (2) Priority setting processes should also meet the procedural conditions of (a) Stakeholder engagement, (b) Stakeholder empowerment, (c) Transparency, (d) Use of evidence, (e) Revisions, (f) Enforcement, and (g) Being grounded on community values.

CONCLUSION

Available frameworks for the evaluation of priority setting are mostly grounded on procedural requirements, while few have included outcome requirements. There is, however, increasing recognition of the need to incorporate both consequential and procedural considerations in priority setting practices. In this review, we adapt an integrative approach to develop and propose a framework for the evaluation of priority setting practices at the macro and meso levels that draws from these complementary schools of thought.

Community Priority Index: Utility, Applicability and Validation for Priority Setting in Community-Based Participatory Research

Background

Providing practitioners with an intuitive measure for priority setting that can be combined with diverse data collection methods is a necessary step to foster accountability of the decision-making process in community settings. Yet, there is a lack of easy-to-use, but methodologically robust measures, that can be feasibly implemented for reliable decision-making in community settings. To address this important gap in community based participatory research (CBPR), the purpose of this study was to demonstrate the utility, applicability, and validation of a community priority index in a community-based participatory research setting.

Design and Methods

Mixed-method study that combined focus groups findings, nominal group technique with six key informants, and the generation of a Community Priority Index (CPI) that integrated community importance, changeability, and target populations. Bootstrapping and simulation were performed for validation.

Results

For pregnant mothers, the top three highly important and highly changeable priorities were: stress (CPI=0.85; 95%CI: 0.70, 1.00), lack of affection (CPI=0.87; 95%CI: 0.69, 1.00), and nutritional issues (CPI=0.78; 95%CI: 0.48, 1.00). For non-pregnant women, top priorities were: low health literacy (CPI=0.87; 95%CI: 0.69, 1.00), low educational attainment (CPI=0.78; 95%CI: 0.48, 1.00), and lack of self-esteem (CPI=0.72; 95%CI: 0.44, 1.00). For children and adolescents, the top three priorities were: obesity (CPI=0.88; 95%CI: 0.69, 1.00), low self-esteem (CPI=0.81; 95%CI: 0.69, 0.94), and negative attitudes toward education (CPI=0.75; 95%CI: 0.50, 0.94).

Conclusions

This study demonstrates the applicability of the CPI as a simple and intuitive measure for priority setting in CBPR.

'Real-world' health care priority setting using explicit decision criteria: a systematic review of the literature

Background

Health care decision making requires making resource allocation decisions among programs, services, and technologies that all compete for a finite resource pool. Methods of priority setting that use explicitly defined criteria can aid health care decision makers in arriving at funding decisions in a transparent and systematic way. The purpose of this paper is to review the published literature and examine the use of criteria-based methods in ‘real-world’ health care allocation decisions.

Methods

A systematic review of the published literature was conducted to find examples of ‘real-world’ priority setting exercises that used explicit criteria to guide decision-making.

Results

We found thirty-three examples in the peer-reviewed and grey literature, using a variety of methods and criteria. Program effectiveness, equity, affordability, cost-effectiveness, and the number of beneficiaries emerged as the most frequently-used decision criteria. The relative importance of criteria in the ‘real-world’ trials differed from the frequency in preference elicitation exercises. Neither the decision-making method used, nor the relative economic strength of the country in which the exercise took place, appeared to have a strong effect on the type of criteria chosen.

Conclusions

Health care decisions are made based on criteria related both to the health need of the population and the organizational context of the decision. Following issues related to effectiveness and affordability, ethical issues such as equity and accessibility are commonly identified as important criteria in health care resource allocation decisions.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0814-3) contains supplementary material, which is available to authorized users.

Managing healthcare budgets in times of austerity: the role of program budgeting and marginal analysis

Given limited resources, priority setting or choice making will remain a reality at all levels of publicly funded healthcare across countries for many years to come. The pressures may well be even more acute as the impact of the economic crisis of 2008 continues to play out but, even as economies begin to turn around, resources within healthcare will be limited, thus some form of rationing will be required. Over the last few decades, research on healthcare priority setting has focused on methods of implementation as well as on the development of approaches related to fairness and legitimacy and on more technical aspects of decision making including the use of multi-criteria decision analysis. Recently, research has led to better understanding of evaluating priority setting activity including defining 'success' and articulating key elements for high performance. This body of research, however, often goes untapped by those charged with making challenging decisions and as such, in line with prevailing public sector incentives, decisions are often reliant on historical allocation patterns and/or political negotiation. These archaic and ineffective approaches not only lead to poor decisions in terms of value for money but further do not reflect basic ethical conditions that can lead to fairness in the decision-making process. The purpose of this paper is to outline a comprehensive approach to priority setting and resource allocation that has been used in different contexts across countries. This will provide decision makers with a single point of access for a basic understanding of relevant tools when faced with having to make difficult decisions about what healthcare services to fund and what not to fund. The paper also addresses several key issues related to priority setting including how health technology assessments can be used, how performance can be improved at a practical level, and what ongoing resource management practice should look like. In terms of future research, one of the most important areas of priority setting that needs further attention is how best to engage public members.

Health sector priority setting at meso-level in lower and middle income countries: lessons learned, available options and suggested steps

Setting priority for health programming and budget allocation is an important issue, but there is little consensus on related processes. It is particularly relevant in low resource settings and at province- and district- or "meso-level", where contextual influences may be greater, information scarce and capacity lower. Although recent changes in disease epidemiology and health financing suggest even greater need to allocate resources effectively, the literature is relatively silent on evidence-based priority-setting in low and middle income countries (LMICs). We conducted a comprehensive review of the peer-reviewed and grey literature on health resource priority-setting in LMICs, focussing on meso-level and the evidence-based priority-setting processes (PSPs) piloted or suggested there. Our objective was to assess PSPs according to whether they have influenced resource allocation and impacted the outcome indicators prioritised. An exhaustive search of the peer-reviewed and grey literature published in the last decade yielded 57 background articles and 75 reports related to priority-setting at meso-level in LMICs. Although proponents of certain PSPs still advocate their use, other experts instead suggest broader elements to guide priority-setting. We conclude that currently no process can be confidently recommended for such settings. We also assessed the common reasons for failure at all levels of priority-setting and concluded further that local authorities should additionally consider contextual and systems limitations likely to prevent a satisfactory process and outcomes, particularly at meso-level. Recent literature proposes a list of related attributes and warning signs, and facilitated our preparation of a simple decision-tree or roadmap to help determine whether or not health systems issues should be improved in parallel to support for needed priority-setting; what elements of the PSP need improving; monitoring, and evaluation. Health priority-setting at meso-level in LMICs can involve common processes, but will often require additional attention to local health systems.

Prioritizing information for quality improvement using resident assessment instrument data: experiences in one canadian province

PURPOSE

To elicit priority rankings of indicators of quality of care among providers and decision-makers in continuing care in Alberta, Canada.

METHODS

We used modified nominal group technique to elicit priorities and criteria for prioritization among the quality indicators and resident/client assessment protocols developed by the interRAI consortium for use in long-term care and home care.

RESULTS

The top-ranked items from the long-term care assessment data were pressure ulcers, pain and incontinence. The top-ranked items from the home care data were pain, falls and proportion of clients at high risk for residential placement. Participants considered a variety of issues in deciding how to rank the indicators.

IMPLICATIONS

This work reflects the beginning of a process to better understand how providers and policy makers can work together to assess priorities for quality improvement within continuing care.

Balancing quality and cost effectiveness

It is not uncommon to open a nursing journal and be faced with dominating articles that focus on discussions around quality and cost-effective care. During this time of austerity, tissue viability services are not immune from the increasing pressure to improve patient care while reducing costs.

Evaluating 'success' in programme budgeting and marginal analysis: a literature review

OBJECTIVES

Programme budgeting and marginal analysis (PBMA) is a priority-setting toolkit which aims to assist decision-makers in identifying the most efficient use of resources. The last systematic literature review on PBMA was published in 2001 and evaluated success in applying PBMA using the criteria of 'reallocation of resources' or the 'setting of priorities'. Our objective was to re-evaluate applications of PBMA in terms of these criteria separately, summarize different evaluation methods of PBMA and extend the above review by considering all PBMA applications since 2001.

METHODS

Systematic literature review. Information was sought from four general medical electronic databases. Descriptive statistics and content analysis were used.

RESULTS

PBMA was successful in 52% of cases when success was defined in terms of the participants gaining a better understanding of the area under interest; in 65% of cases when success was defined as 'implementation of all or some of the advisory panel's recommendations'; in 48% of the studies when success was defined in terms of disinvesting or resource reallocation; and in 22% when success was defined in terms of adopting the framework for future use.

CONCLUSIONS

The rate of success is clearly influenced by how success is defined. There is a need for a broadly accepted definition of success to be used when evaluating PBMA applications so to enable direct comparisons of studies. This evaluatory component needs to be adjacent to PBMA and not a separate procedure.

Allocating funds for HIV/AIDS: a descriptive study of KwaDukuza, South Africa

OBJECTIVE

through a descriptive study, we determined the factors that influence the decision-making process for allocating funds to HIV/AIDS prevention and treatment programmes, and the extent to which formal decision tools are used in the municipality of KwaDukuza, South Africa.

METHODS

we conducted 35 key informant interviews in KwaDukuza. The interview questions addressed specific resource allocation issues while allowing respondents to speak openly about the complexities of the HIV/AIDS resource allocation process.

RESULTS

donors have a large influence on the decision-making process for HIV/AIDS resource allocation. However, advocacy groups, governmental bodies and local communities also play an important role. Political power, culture and ethics are among a set of intangible factors that have a strong influence on HIV/AIDS resource allocation. Formal methods, including needs assessment, best practice approaches, epidemiologic modelling and cost-effectiveness analysis are sometimes used to support the HIV/AIDS resource allocation process. Historical spending patterns are an important consideration in future HIV/AIDS allocation strategies.

CONCLUSIONS

several factors and groups influence resource allocation in KwaDukuza. Although formal economic and epidemiologic information is sometimes used, in most cases other factors are more important for resource allocation decision-making. These other factors should be considered in any attempts to improve the resource allocation processes.

Evaluating priority setting success in healthcare: a pilot study

Background

In healthcare today, decisions are made in the face of serious resource constraints. Healthcare managers are struggling to provide high quality care, manage resources effectively, and meet changing patient needs. Healthcare managers who are constantly making difficult resource decisions desire a way to improve their priority setting processes. Despite the wealth of existing priority setting literature (for example, program budgeting and marginal analysis, accountability for reasonableness, the 'describe-evaluate-improve' strategy) there are still no tools to evaluate how healthcare resources are prioritised. This paper describes the development and piloting of a process to evaluate priority setting in health institutions. The evaluation process was designed to examine the procedural and substantive dimensions of priority setting using a multi-methods approach, including a staff survey, decision-maker interviews, and document analysis.

Methods

The evaluation process was piloted in a mid-size community hospital in Ontario, Canada while its leaders worked through their annual budgeting process. Both qualitative and quantitative methods were used to analyze the data.

Results

The evaluation process was both applicable to the context and it captured the budgeting process. In general, the pilot test provided support for our evaluation process and our definition of success, (i.e., our conceptual framework).

Conclusions

The purpose of the evaluation process is to provide a simple, practical way for an organization to better understand what it means to achieve success in its priority setting activities and identify areas for improvement. In order for the process to be used by healthcare managers today, modification and contextualization of the process are anticipated. As the evaluation process is applied in more health care organizations or applied repeatedly in an organization, it may become more streamlined.

Qualitative methodologies in health-care priority setting research

Priority setting research in health economics has traditionally employed quantitative methodologies and been informed by post-positivist philosophical assumptions about the world and the nature of knowledge. These approaches have been rewarded with well-developed and validated tools. However, it is now commonly noted that there has been limited uptake of economic analysis into actual priority setting and resource allocation decisions made by health-care systems. There seem to be substantial organizational and political barriers. The authors argue in this paper that understanding and addressing these barriers will depend upon the application of qualitative research methodologies. Some efforts in this direction have been attempted; however these are theoretically under-developed and seldom rooted in any of the established qualitative research traditions. Two such approaches - narrative inquiry and discourse analysis - are highlighted here. These are illustrated with examples drawn from a real-world priority setting study. The examples demonstrate how such conceptually powerful qualitative traditions produce distinctive findings that offer unique insight into organizational contexts and decision-maker behavior. We argue that such investigations offer untapped benefits for the study of organizational priority setting and thus should be pursued more frequently by the health economics research community.

Priority setting: what constitutes success? A conceptual framework for successful priority setting

Background

The sustainability of healthcare systems worldwide is threatened by a growing demand for services and expensive innovative technologies. Decision makers struggle in this environment to set priorities appropriately, particularly because they lack consensus about which values should guide their decisions. One way to approach this problem is to determine what all relevant stakeholders understand successful priority setting to mean. The goal of this research was to develop a conceptual framework for successful priority setting.

Methods

Three separate empirical studies were completed using qualitative data collection methods (one-on-one interviews with healthcare decision makers from across Canada; focus groups with representation of patients, caregivers and policy makers; and Delphi study including scholars and decision makers from five countries).

Results

This paper synthesizes the findings from three studies into a framework of ten separate but interconnected elements germane to successful priority setting: stakeholder understanding, shifted priorities/reallocation of resources, decision making quality, stakeholder acceptance and satisfaction, positive externalities, stakeholder engagement, use of explicit process, information management, consideration of values and context, and revision or appeals mechanism.

Conclusion

The ten elements specify both quantitative and qualitative dimensions of priority setting and relate to both process and outcome components. To our knowledge, this is the first framework that describes successful priority setting. The ten elements identified in this research provide guidance for decision makers and a common language to discuss priority setting success and work toward improving priority setting efforts.

Introducing priority setting and resource allocation in home and community care programs

OBJECTIVE

To use evidence from research to identify and implement priority setting and resource allocation that incorporates both ethical practices and economic principles.

METHOD

Program budgeting and marginal analysis (PBMA) is based on two key economic principles: opportunity cost (i.e. doing one thing instead of another) and the margin (i.e. resource allocation should result in maximum benefit for available resources). An ethical framework for priority setting and resource allocation known as Accountability for Reasonableness (A4R) focuses on making sure that resource allocations are based on a fair decision-making process. It includes the following four conditions: publicity; relevance; appeals; and enforcement. More recent literature on the topic suggests that a fifth condition, that of empowerment, should be added to the Framework. The 2007-08 operating budget for Home and Community Care, excluding the residential sector, was developed using PBMA and incorporating the A4R conditions.

RESULTS

Recommendations developed using PBMA were forwarded to the Executive Committee, approved and implemented for the 2007-08 fiscal year operating budget. In addition there were two projects approved for approximately $200,000.

CONCLUSION

PBMA is an improvement over previous practice. Managers of Home and Community Care are committed to using the process for the 2008-09 fiscal year operating budget and expanding its use to include mental health and addictions services. In addition, managers of public health prevention and promotion services are considering using the process.

Challenges in Australian policy processes for disinvestment from existing, ineffective health care practices

BACKGROUND

Internationally, many health care interventions were diffused prior to the standard use of assessments of safety, effectiveness and cost-effectiveness. Disinvestment from ineffective or inappropriately applied practices is a growing priority for health care systems for reasons of improved quality of care and sustainability of resource allocation. In this paper we examine key challenges for disinvestment from these interventions and explore potential policy-related avenues to advance a disinvestment agenda.

RESULTS

We examine five key challenges in the area of policy driven disinvestment: 1) lack of resources to support disinvestment policy mechanisms; 2) lack of reliable administrative mechanisms to identify and prioritise technologies and/or practices with uncertain clinical and cost-effectiveness; 3) political, clinical and social challenges to removing an established technology or practice; 4) lack of published studies with evidence demonstrating that existing technologies/practices provide little or no benefit (highlighting complexity of design) and; 5) inadequate resources to support a research agenda to advance disinvestment methods. Partnerships are required to involve government, professional colleges and relevant stakeholder groups to put disinvestment on the agenda. Such partnerships could foster awareness raising, collaboration and improved health outcome data generation and reporting. Dedicated funds and distinct processes could be established within the Medical Services Advisory Committee and Pharmaceutical Benefits Advisory Committee to, a) identify technologies and practices for which there is relative uncertainty that could be the basis for disinvestment analysis, and b) conduct disinvestment assessments of selected item(s) to address existing practices in an analogous manner to the current focus on new and emerging technology. Finally, dedicated funding and cross-disciplinary collaboration is necessary to build health services and policy research capacity, with a focus on advancing disinvestment research methodologies and decision support tools.

CONCLUSION

The potential over-utilisation of less than effective clinical practices and the potential under-utilisation of effective clinical practices not only result in less than optimal care but also fragmented, inefficient and unsustainable resource allocation. Systematic policy approaches to disinvestment will improve equity, efficiency, quality and safety of care, as well as sustainability of resource allocation.

A pathway to a stronger research culture in health policy

BACKGROUND

There are currently limited pathways into a career in health policy research in Australia, due in part to a serious absence of health policy research capability in Australian universities.

DISCUSSION

We define what we consider health policy research and education should comprise. We then examine what is currently on offer and propose ways to strengthen health policy research in Australia.

SUMMARY

This paper, which is part analysis and part commentary, is offered to provoke wider debate about how health policy research can be nurtured in Australia.

A population-based model for priority setting across the care continuum and across modalities

BACKGROUND

The Health-sector Wide (HsW) priority setting model is designed to shift the focus of priority setting away from 'program budgets'--that are typically defined by modality or disease-stage--and towards well-defined target populations with a particular disease/health problem.

METHODS

The key features of the HsW model are i) a disease/health problem framework, ii) a sequential approach to covering the entire health sector, iii) comprehensiveness of scope in identifying intervention options and iv) the use of objective evidence. The HsW model redefines the unit of analysis over which priorities are set to include all mutually exclusive and complementary interventions for the prevention and treatment of each disease/health problem under consideration. The HsW model is therefore incompatible with the fragmented approach to priority setting across multiple program budgets that currently characterises allocation in many health systems. The HsW model employs standard cost-utility analyses and decision-rules with the aim of maximising QALYs contingent upon the global budget constraint for the set of diseases/health problems under consideration. It is recognised that the objective function may include non-health arguments that would imply a departure from simple QALY maximisation and that political constraints frequently limit degrees of freedom. In addressing these broader considerations, the HsW model can be modified to maximise value-weighted QALYs contingent upon the global budget constraint and any political constraints bearing upon allocation decisions.

RESULTS

The HsW model has been applied in several contexts, recently to osteoarthritis, that has demonstrated both its practical application and its capacity to derive clear evidenced-based policy recommendations.

CONCLUSION

Comparisons with other approaches to priority setting, such as Programme Budgeting and Marginal Analysis (PBMA) and modality-based cost-effectiveness comparisons, as typified by Australia's Pharmaceutical Benefits Advisory Committee process for the listing of pharmaceuticals for government funding, demonstrate the value added by the HsW model notably in its greater likelihood of contributing to allocative efficiency.

Healthcare rationing in Spain: framework, descriptive analysis and consequences

This paper describes the main healthcare rationing policies implemented in Spain over the last 2 decades, and analyses the consequences of these policies on the healthcare system, patients, healthcare practitioners, the pharmaceutical industry and policymakers. The primary explicit healthcare rationing policies utilised in Spain include a catalogue that defines the healthcare rights of citizens. However, the existing system may lead to inequity between regions, and is not structured to direct resources towards the most cost-effective options. Health technology assessment requires further work before it can be utilised widely for the development of rationing strategies. Selective reimbursement of drugs and drug co-payments provide only short-term results and appear to have little long-term impact on expenditure. Implicit rationing instruments, especially waiting lists, have had a significant effect on healthcare quality and the welfare of citizens, and have contributed to keeping the Spanish healthcare budget under control. Newer regulations should integrate some form of economic evaluation within the policy-making processes associated with healthcare. Further research is needed to identify those efficient and equitable rationing instruments that are most likely to improve health interventions for an aging society that is increasingly demanding of health services.

Health care priority setting: principles, practice and challenges

BACKGROUND: Health organizations the world over are required to set priorities and allocate resources within the constraint of limited funding. However, decision makers may not be well equipped to make explicit rationing decisions and as such often rely on historical or political resource allocation processes. One economic approach to priority setting which has gained momentum in practice over the last three decades is program budgeting and marginal analysis (PBMA). METHODS: This paper presents a detailed step by step guide for carrying out a priority setting process based on the PBMA framework. This guide is based on the authors' experience in using this approach primarily in the UK and Canada, but as well draws on a growing literature of PBMA studies in various countries. RESULTS: At the core of the PBMA approach is an advisory panel charged with making recommendations for resource re-allocation. The process can be supported by a range of 'hard' and 'soft' evidence, and requires that decision making criteria are defined and weighted in an explicit manner. Evaluating the process of PBMA using an ethical framework, and noting important challenges to such activity including that of organizational behavior, are shown to be important aspects of developing a comprehensive approach to priority setting in health care. CONCLUSION: Although not without challenges, international experience with PBMA over the last three decades would indicate that this approach has the potential to make substantial improvement on commonly relied upon historical and political decision making processes. In setting out a step by step guide for PBMA, as is done in this paper, implementation by decision makers should be facilitated.

Priority setting in health authorities: a novel approach to a historical activity

As resources in health care are scarce, health authorities and other health organizations are charged with determining how best to spend limited resources. While a number of formal approaches to priority setting within health authorities have been used internationally, there has been limited success with such activity, particularly across major service portfolios. This participatory action research project instituted a novel priority setting framework, coined macro-marginal analysis (MMA), in a fully integrated urban health region in Alberta, Canada. The focus of MMA is on identifying areas for service growth and areas for resource release, then determining, based on pre-defined, locally generated criteria, if actual shifts or re-allocation of resources should occur. For fiscal year 2002/03, the Calgary Health Region identified over 40 M dollars in resource releases (approximately 3% of the total budget), which were made available for servicing the deficit, and more importantly for our purposes, re-investing in service growth areas. The MMA framework is pragmatic in nature and has the ability to incorporate relevant evidence directly into the decision-making process. This work constitutes a significant advancement in health economics, and responds where previous priority setting approaches have failed in that it allows decision-makers to achieve genuine re-allocation of resources with the aim of improving population health or better meeting other important criteria.