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Collins M, Mazzei M, Baker R, Morton A, Frith L, Syrett K, Leak P, Donaldson C. Developing a combined framework for priority setting in integrated health and social care systems. BMC Health Serv Res 2023; 23:879. [PMID: 37605123 PMCID: PMC10440867 DOI: 10.1186/s12913-023-09866-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 07/31/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND There is an international move towards greater integration of health and social care to cope with the increasing demand on services.. In Scotland, legislation was passed in 2014 to integrate adult health and social care services resulting in the formation of 31 Health and Social Care Partnerships (HSCPs). Greater integration does not eliminate resource scarcity and the requirement to make (resource) allocation decisions to meet the needs of local populations. There are different perspectives on how to facilitate and improve priority setting in health and social care organisations with limited resources, but structured processes at the local level are still not widely implemented. This paper reports on work with new HSCPs in Scotland to develop a combined multi-disciplinary priority setting and resource allocation framework. METHODS To develop the combined framework, a scoping review of the literature was conducted to determine the key principles and approaches to priority setting from economics, decision-analysis, ethics and law, and attempts to combine such approaches. Co-production of the combined framework involved a multi-disciplinary workshop including local, and national-level stakeholders and academics to discuss and gather their views. RESULTS The key findings from the literature review and the stakeholder workshop were taken to produce a final combined framework for priority setting and resource allocation. This is underpinned by principles from economics (opportunity cost), decision science (good decisions), ethics (justice) and law (fair procedures). It outlines key stages in the priority setting process, including: framing the question, looking at current use of resources, defining options and criteria, evaluating options and criteria, and reviewing each stage. Each of these has further sub-stages and includes a focus on how the combined framework interacts with the consultation and involvement of patients, public and the wider staff. CONCLUSIONS The integration agenda for health and social care is an opportunity to develop and implement a combined framework for setting priorities and allocating resources fairly to meet the needs of the population. A key aim of both integration and the combined framework is to facilitate the shifting of resources from acute services to the community.
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Affiliation(s)
- Marissa Collins
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK.
| | - Micaela Mazzei
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Rachel Baker
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Alec Morton
- Department of Management Science, University of Strathclyde, Glasgow, UK
| | - Lucy Frith
- Centre for Social Ethics & Policy, University of Manchester, Manchester, UK
| | - Keith Syrett
- University of Bristol Law School, University of Bristol, Bristol, UK
| | - Paul Leak
- Directorate of Health and Social Care, Scottish Government, Edinburgh, UK
| | - Cam Donaldson
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
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Seixas BV, Regier DA, Bryan S, Mitton C. Describing practices of priority setting and resource allocation in publicly funded health care systems of high-income countries. BMC Health Serv Res 2021; 21:90. [PMID: 33499854 PMCID: PMC7839200 DOI: 10.1186/s12913-021-06078-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 01/12/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Healthcare spending has grown over the last decades in all developed countries. Making hard choices for investments in a rational, evidence-informed, systematic, transparent and legitimate manner constitutes an important objective. Yet, most scientific work in this area has focused on developing/improving prescriptive approaches for decision making and presenting case studies. The present work aimed to describe existing practices of priority setting and resource allocation (PSRA) within the context of publicly funded health care systems of high-income countries and inform areas for further improvement and research. METHODS An online qualitative survey, developed from a theoretical framework, was administered with decision-makers and academics from 18 countries. 450 individuals were invited and 58 participated (13% of response rate). RESULTS We found evidence that resource allocation is still largely carried out based on historical patterns and through ad hoc decisions, despite the widely held understanding that decisions should be based on multiple explicit criteria. Health technology assessment (HTA) was the tool most commonly indicated by respondents as a formal priority setting strategy. Several approaches were reported to have been used, with special emphasis on Program Budgeting and Marginal Analysis (PBMA), but limited evidence exists on their evaluation and routine use. Disinvestment frameworks are still very rare. There is increasing convergence on the use of multiple types of evidence to judge the value of investment options. CONCLUSIONS Efforts to establish formal and explicit processes and rationales for decision-making in priority setting and resource allocation have been still rare outside the HTA realm. Our work indicates the need of development/improvement of decision-making frameworks in PSRA that: 1) have well-defined steps; 2) are based on multiple criteria; 3) are capable of assessing the opportunity costs involved; 4) focus on achieving higher value and not just on adoption; 5) engage involved stakeholders and the general public; 6) make good use and appraisal of all evidence available; and 6) emphasize transparency, legitimacy, and fairness.
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Affiliation(s)
- Brayan V Seixas
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles (UCLA), USA.
| | - Dean A Regier
- Cancer Control Research, BC Cancer and the Canadian Centre for Applied Research in Cancer Control (ARCC), Vancouver, Canada
- School of Population and Public Health, University of British Columbia (UBC), Vancouver, Canada
| | - Stirling Bryan
- School of Population and Public Health, University of British Columbia (UBC), Vancouver, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - Craig Mitton
- School of Population and Public Health, University of British Columbia (UBC), Vancouver, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada
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Seixas BV, Dionne F, Mitton C. Practices of decision making in priority setting and resource allocation: a scoping review and narrative synthesis of existing frameworks. HEALTH ECONOMICS REVIEW 2021; 11:2. [PMID: 33411161 PMCID: PMC7789400 DOI: 10.1186/s13561-020-00300-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/16/2020] [Indexed: 05/07/2023]
Abstract
BACKGROUND Due to growing expenditures, health systems have been pushed to improve decision-making practices on resource allocation. This study aimed to identify which practices of priority setting and resource allocation (PSRA) have been used in healthcare systems of high-income countries. METHODS A scoping literature review (2007-2019) was conducted to map empirical PSRA activities. A two-stage screening process was utilized to identify existing approaches and cluster similar frameworks. That was complemented with a gray literature and horizontal scanning. A narrative synthesis was carried out to make sense of the existing literature and current state of PSRA practices in healthcare. RESULTS One thousand five hundred eighty five references were found in the peer-reviewed literature and 25 papers were selected for full-review. We identified three major types of decision-making framework in PSRA: 1) Program Budgeting and Marginal Analysis (PBMA); 2) Health Technology Assessment (HTA); and 3) Multiple-criteria value assessment. Our narrative synthesis indicates these formal frameworks of priority setting and resource allocation have been mostly implemented in episodic exercises with poor follow-up and evaluation. There seems to be growing interest for explicit robust rationales and ample stakeholder involvement, but that has not been the norm in the process of allocating resources within healthcare systems of high-income countries. CONCLUSIONS No single dominate framework for PSRA appeared as the preferred approach across jurisdictions, but common elements exist both in terms of process and structure. Decision-makers worldwide can draw on our work in designing and implementing PSRA processes in their contexts.
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Affiliation(s)
- Brayan V. Seixas
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles (UCLA), Los Angeles, USA
| | | | - Craig Mitton
- Center for Clinical Epidemiology and Evaluation, Vancouver, Canada
- School of Population and Public Health, University of British Columbia (UBC), Vancouver, Canada
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Razavi SD, Kapiriri L, Wilson M, Abelson J. Applying priority-setting frameworks: A review of public and vulnerable populations' participation in health-system priority setting. Health Policy 2019; 124:133-142. [PMID: 31874742 DOI: 10.1016/j.healthpol.2019.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 11/27/2019] [Accepted: 12/13/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is a growing body of literature that describes, applies, and evaluates applications of health-system priority-setting frameworks in different contexts. However, little explicit focus has been given to examining operationalization of the stakeholder participation component of these frameworks. The literature identifies the public as a stakeholder group and recommends their participation when applying the frameworks. METHODS We conducted a scoping review to search the PubMed, EMBASE, HealthSTAR, Medline, and PsycINFO databases for cases where priority-setting frameworks were applied (2000-2017). We aimed to synthesize current literature to examine the degree to which the public and vulnerable populations have been engaged through applications of these frameworks FINDINGS: The following stakeholders commonly participated: managers, administrators/coordinators, clinicians/physicians, non-physician health care providers, health economists, academics/researchers, experts, decision-makers, and policy-makers. Few papers reported on public participation, and even fewer identified vulnerable groups that participate. Stakeholders were most commonly reported to participate in identifying areas for prioritization. CONCLUSIONS While the frameworks were developed with stakeholder participation in mind, in practice not all stakeholders are participating in priority-setting processes as envisioned by the frameworks. The public and vulnerable groups do not consistently participate, challenging the utility of the participation component of frameworks in guiding stakeholder participation in health-system priority setting. Frameworks can be more explicit about which stakeholders should participate and detailing how their participation should be operationalized.
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Affiliation(s)
- S Donya Razavi
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada.
| | - Lydia Kapiriri
- Department of Health, Aging and Society, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Michael Wilson
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster Health Forum, Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Julia Abelson
- Department of Health Research Methods, Evidence, and Impact (HEI), Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
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How have systematic priority setting approaches influenced policy making? A synthesis of the current literature. Health Policy 2017; 121:937-946. [PMID: 28734682 DOI: 10.1016/j.healthpol.2017.07.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Revised: 06/30/2017] [Accepted: 07/03/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND There is a growing body of literature on systematic approaches to healthcare priority setting from various countries and different levels of decision making. This paper synthesizes the current literature in order to assess the extent to which program budgeting and marginal analysis (PBMA), burden of disease & cost-effectiveness analysis (BOD/CEA), multi-criteria decision analysis (MCDA), and accountability for reasonableness (A4R), are reported to have been institutionalized and influenced policy making and practice. METHODS We searched for English language publications on health care priority setting approaches (2000-2017). Our sources of literature included PubMed and Ovid databases (including Embase, Global Health, Medline, PsycINFO, EconLit). FINDINGS Of the four approaches PBMA and A4R were commonly applied in high income countries while BOD/CEA was exclusively applied in low income countries. PBMA and BOD/CEA were most commonly reported to have influenced policy making. The explanations for limited adoption of an approach were related to its complexity, poor policy maker understanding and resource requirements. CONCLUSIONS While systematic approaches have the potential to improve healthcare priority setting; most have not been adopted in routine policy making. The identified barriers call for sustained knowledge exchange between researchers and policy-makers and development of practical guidelines to ensure that these frameworks are more accessible, applicable and sustainable in informing policy making.
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Cornelissen E, Mitton C, Davidson A, Reid C, Hole R, Visockas AM, Smith N. Fit for purpose? Introducing a rational priority setting approach into a community care setting. J Health Organ Manag 2017; 30:690-710. [PMID: 27296887 DOI: 10.1108/jhom-05-2013-0103] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Evelyn Cornelissen
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, Canada AND Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, Canada
| | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, Canada and School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Alan Davidson
- Faculty of Health and Social Development, University of British Columbia - Okanagan, Kelowna, Canada
| | - Colin Reid
- Faculty of Health and Social Development, University of British Columbia - Okanagan, Kelowna, Canada
| | - Rachelle Hole
- Faculty of Health and Social Development, University of British Columbia - Okanagan, Kelowna, Canada
| | | | - Neale Smith
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, Canada
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Abstract
Purpose Using the example of community access programs (CAPs), the purpose of this paper is to describe resource allocation and policy decisions related to providing health services for the uninsured in the USA and the organizational values affecting these decisions. Design/methodology/approach The study used comparative case study methodology at two geographically diverse sites. Researchers collected data from program documents, meeting observations, and interviews with program stakeholders. Findings Five resource allocation or policy decisions relevant to providing healthcare services were described at each site across three categories: designing the health plan, reacting to funding changes, and revising policies. Organizational values of access to care and stewardship most frequently affected resource allocation and policy decisions, while economic and political pressures affect the relative prioritization of values. Research limitations/implications Small sample size, the potential for social desirability or recall bias, and the exclusion of provider, member or community perspectives beyond those represented among participating board members. Practical implications Program directors or researchers can use this study to assess the extent to which resource allocation and policy decisions align with organizational values and mission statements. Social implications The description of how healthcare decisions are actually made can be matched with literature that describes how healthcare resource decisions ought to be made, in order to provide a normative grounding for future decisions. Originality/value This study addresses a gap in literature regarding how CAPs actually make resource allocation decisions that affect access to healthcare services.
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Affiliation(s)
- Krista Lyn Harrison
- Division of Geriatrics, University of California , San Francisco, California, USA
- San Francisco VA Medical Center, San Francisco, California, USA
| | - Holly A Taylor
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Berman Institute of Bioethics, Johns Hopkins University , Baltimore, Maryland, USA
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Cumming JM. Priority Setting Meets Multiple Streams: A Match to Be Further Examined? Comment on "Introducing New Priority Setting and Resource Allocation Processes in a Canadian Healthcare Organization: A Case Study Analysis Informed by Multiple Streams Theory. Int J Health Policy Manag 2016; 5:497-499. [PMID: 27694663 DOI: 10.15171/ijhpm.2016.58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Accepted: 05/09/2016] [Indexed: 11/09/2022] Open
Abstract
With demand for health services continuing to grow as populations age and new technologies emerge to meet health needs, healthcare policy-makers are under constant pressure to set priorities, ie, to make choices about the health services that can and cannot be funded within available resources. In a recent paper, Smith et al apply an influential policy studies framework - Kingdon's multiple streams approach (MSA) - to explore the factors that explain why one health service delivery organization adopted a formal priority setting framework (in the form of programme budgeting and marginal analysis [PBMA]) to assist it in making priority setting decisions. MSA is a theory of agenda-setting, ie, how it is that different issues do or do not reach a decision-making point. In this paper, I reflect on the use of the MSA framework to explore priority setting processes and how the framework might be applied to similar cases in future.
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Hunter DJ, Marks L, Brown J, Scalabrini S, Salway S, Vale L, Gray J, Payne N. The potential value of priority-setting methods in public health investment decisions: qualitative findings from three English local authorities. CRITICAL PUBLIC HEALTH 2016. [DOI: 10.1080/09581596.2016.1164299] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Smith N, Mitton C, Dowling L, Hiltz MA, Campbell M, Gujar SA. Introducing New Priority Setting and Resource Allocation Processes in a Canadian Healthcare Organization: A Case Study Analysis Informed by Multiple Streams Theory. Int J Health Policy Manag 2015; 5:23-31. [PMID: 26673646 DOI: 10.15171/ijhpm.2015.169] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 09/14/2015] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND In this article, we analyze one case instance of how proposals for change to the priority setting and resource allocation (PSRA) processes at a Canadian healthcare institution reached the decision agenda of the organization's senior leadership. We adopt key concepts from an established policy studies framework - Kingdon's multiple streams theory - to inform our analysis. METHODS Twenty-six individual interviews were conducted at the IWK Health Centre in Halifax, NS, Canada. Participants were asked to reflect upon the reasons leading up to the implementation of a formal priority setting process - Program Budgeting and Marginal Analysis (PBMA) - in the 2012/2013 fiscal year. Responses were analyzed qualitatively using Kingdon's model as a template. RESULTS The introduction of PBMA can be understood as the opening of a policy window. A problem stream - defined as lack of broad engagement and information sharing across service lines in past practice - converged with a known policy solution, PBMA, which addressed the identified problems and was perceived as easy to use and with an evidence-base from past applications across Canada and elsewhere. Conditions in the political realm allowed for this intervention to proceed, but also constrained its potential outcomes. CONCLUSION Understanding in a theoretically-informed way how change occurs in healthcare management practices can provide useful lessons to researchers and decision-makers whose aim is to help health systems achieve the most effective use of available financial resources.
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Affiliation(s)
- Neale Smith
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Craig Mitton
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | | | - Mary-Ann Hiltz
- Strategy and Organizational Performance, IWK Health Centre, Halifax, NS, Canada
| | - Matthew Campbell
- Strategy and Organizational Performance, IWK Health Centre, Halifax, NS, Canada
| | - Shashi Ashok Gujar
- Strategy and Organizational Performance, IWK Health Centre, Halifax, NS, Canada.,Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
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Cromwell I, Peacock SJ, Mitton C. 'Real-world' health care priority setting using explicit decision criteria: a systematic review of the literature. BMC Health Serv Res 2015; 15:164. [PMID: 25927636 PMCID: PMC4433097 DOI: 10.1186/s12913-015-0814-3] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 03/23/2015] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Ian Cromwell
- Canadian Centre for Applied Research in Cancer Control, British Columbia Cancer Agency, Vancouver, Canada. .,Department of Cancer Control Research, British Columbia Cancer Agency, Vancouver, Canada.
| | - Stuart J Peacock
- Canadian Centre for Applied Research in Cancer Control, British Columbia Cancer Agency, Vancouver, Canada. .,Department of Cancer Control Research, British Columbia Cancer Agency, Vancouver, Canada. .,School of Population and Public Health, University of British Columbia, Vancouver, Canada.
| | - Craig Mitton
- School of Population and Public Health, University of British Columbia, Vancouver, Canada. .,Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, Canada.
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Cornelissen E, Mitton C, Davidson A, Reid C, Hole R, Visockas AM, Smith N. Determining and broadening the definition of impact from implementing a rational priority setting approach in a healthcare organization. Soc Sci Med 2014; 114:1-9. [PMID: 24887012 DOI: 10.1016/j.socscimed.2014.05.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2013] [Revised: 04/09/2014] [Accepted: 05/19/2014] [Indexed: 11/16/2022]
Abstract
Techniques to manage scarce healthcare resources continue to evolve in response to changing, growing and competing demands. Yet there is no standard definition in the priority setting literature of what might constitute the desired impact or success of resource management activities. In this 2006-09 study, using action research methodology, we determined the impact of implementing a formal priority setting model, Program Budgeting and Marginal Analysis (PBMA), in a Canadian health authority. Qualitative data were collected through post year-1 (n = 12) and year-2 (n = 9) participant interviews, meeting observation and document review. Interviews were analyzed using a constant comparison technique to identify major themes. Impact can be defined as effects at three levels: system, group, and individual. System-level impact can be seen in the actual selection of priorities and resource re-allocation. In this case, participants prioritized a list of $760,000 worth of investment proposals and $38,000 of disinvestment proposals; however, there was no clear evidence as to whether financial resources were reallocated as a result. Group and individual impacts, less frequently reported in the literature, included changes in priority setting knowledge, attitudes and practice. PBMA impacts at these three levels were found to be interrelated. This work argues in favor of attempts to expand the definition of priority setting success by including both desired system-level outcomes like resource re-allocation and individual or group level impacts like changes to priority setting knowledge, attitudes and practice. These latter impacts are worth pursuing as they appear to be intrinsic to successful system-wide priority setting. A broader definition of PBMA impact may also suggest conceptualizing PBMA as both a priority setting approach and as a tool to develop individual and group priority setting knowledge and practice. These results should be of interest to researchers and decision makers using or considering a formal priority setting approach to manage scarce healthcare resources.
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Affiliation(s)
- Evelyn Cornelissen
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, 7th Floor, 828 West 10th Ave., Research Pavilion, Vancouver, British Columbia, Canada V5Z 1M9.
| | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, 7th Floor, 828 West 10th Ave., Research Pavilion, Vancouver, British Columbia, Canada V5Z 1M9; School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Alan Davidson
- Faculty of Health and Social Development, University of British Columbia - Okanagan, 3333 University Way, Kelowna, British Columbia, Canada V1V 1V7.
| | - Colin Reid
- Faculty of Health and Social Development, University of British Columbia - Okanagan, 3333 University Way, Kelowna, British Columbia, Canada V1V 1V7.
| | - Rachelle Hole
- Faculty of Health and Social Development, University of British Columbia - Okanagan, 3333 University Way, Kelowna, British Columbia, Canada V1V 1V7.
| | - Anne-Marie Visockas
- Alberta Health Services, #2523, 10101 Southport Road SW, Calgary, Alberta, Canada T2W 3N2.
| | - Neale Smith
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, 7th Floor, 828 West 10th Ave., Research Pavilion, Vancouver, British Columbia, Canada V5Z 1M9.
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Changing priority setting practice: the role of implementation in practice change. Health Policy 2014; 117:266-74. [PMID: 24815208 DOI: 10.1016/j.healthpol.2014.04.010] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Revised: 03/02/2014] [Accepted: 04/15/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Programme budgeting and marginal analysis (PBMA) is a priority setting approach that assists decision makers in choosing among resource demands. This paper describes and evaluates the process of implementing PBMA in a Canadian regional health authority, and draws out key lessons learned from this experience. METHODS Qualitative data were collected through semi-structured participant interviews (twelve post year-1; nine post year-2), meeting attendance, and document review. Interview transcripts were analyzed using a constant comparison technique. Other data were analyzed to evaluate PBMA implementation. RESULTS Desire for more clarity and for PBMA adaptations emerged as overarching themes. Participants desired greater clarity of their roles and how PBMA should be used to achieve PBMA's potential benefits. They argued that each PBMA stage should be useful independent of the others so that implementation could be adapted. To help improve clarity and ensure that resources were available to support PBMA, participants requested an organizational readiness and capacity assessment. CONCLUSION We suggest tactics by which PBMA may be more closely aligned with real-world priority setting practice. Our results also contribute to the literature on PBMA use in various healthcare settings. Highlighting implementation issues and potential responses to these should be of interest to decision makers implementing PBMA and other evidence-informed practices.
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Health sector priority setting at meso-level in lower and middle income countries: lessons learned, available options and suggested steps. Soc Sci Med 2013; 102:190-200. [PMID: 24565157 DOI: 10.1016/j.socscimed.2013.11.056] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Revised: 11/25/2013] [Accepted: 11/29/2013] [Indexed: 11/23/2022]
Abstract
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.
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Smith N, Mitton C, Bryan S, Davidson A, Urquhart B, Gibson JL, Peacock S, Donaldson C. Decision maker perceptions of resource allocation processes in Canadian health care organizations: a national survey. BMC Health Serv Res 2013; 13:247. [PMID: 23819598 PMCID: PMC3750381 DOI: 10.1186/1472-6963-13-247] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Accepted: 06/06/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Resource allocation is a key challenge for healthcare decision makers. While several case studies of organizational practice exist, there have been few large-scale cross-organization comparisons. METHODS Between January and April 2011, we conducted an on-line survey of senior decision makers within regional health authorities (and closely equivalent organizations) across all Canadian provinces and territories. We received returns from 92 individual managers, from 60 out of 89 organizations in total. The survey inquired about structures, process features, and behaviours related to organization-wide resource allocation decisions. We focus here on three main aspects: type of process, perceived fairness, and overall rating. RESULTS About one-half of respondents indicated that their organization used a formal process for resource allocation, while the others reported that political or historical factors were predominant. Seventy percent (70%) of respondents self-reported that their resource allocation process was fair and just over one-half assessed their process as 'good' or 'very good'. This paper explores these findings in greater detail and assesses them in context of the larger literature. CONCLUSION Data from this large-scale cross-jurisdictional survey helps to illustrate common challenges and areas of positive performance among Canada's health system leadership teams.
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Affiliation(s)
- Neale Smith
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, 7th floor, 828 W 10 Avenue, V5Z1M9, Vancouver, BC, Canada.
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Sales A, O'Rourke HM, Draper K, Teare GF, Maxwell C. Prioritizing information for quality improvement using resident assessment instrument data: experiences in one canadian province. Healthc Policy 2012; 6:55-69. [PMID: 22294992 DOI: 10.12927/hcpol.2011.22221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
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.
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Affiliation(s)
- Anne Sales
- Faculty of Nursing, University of Alberta, Edmonton, AB
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Tsourapas A, Frew E. Evaluating 'success' in programme budgeting and marginal analysis: a literature review. J Health Serv Res Policy 2011; 16:177-83. [PMID: 21719479 DOI: 10.1258/jhsrp.2010.009053] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Angelos Tsourapas
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK
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