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Kalloger SE, Ho C, Mitton C, Regier DA. Mapping the experiences of people with advanced cancer across multiple cancer types-a scoping review. J Cancer Surviv 2024; 18:318-324. [PMID: 36180762 DOI: 10.1007/s11764-022-01263-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/23/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Through the introduction of tumor agnostic therapies, people with metastatic cancer and their treating physicians are facing new treatment choices that have differing side effect and efficacy profiles from conventional chemotherapy. OBJECTIVE The present study undertakes a scoping review of research into the experiences of people with advanced or metastatic cancer across various solid tumor types with the goal of developing a tumor-agnostic conceptual model. DESIGN Automated queries on three internet search engines were performed to identify qualitative interview studies that focused on people with metastatic cancer. No limits were imposed for dates nor location of studies. RESULTS Of the 173 hits generated from the searches, 25 peer-reviewed papers were selected for the review with dates that ranged from 2007 to 2022. All papers originated from the USA, Europe, Australia, or Japan. Three major themes emerged that formed the basis for the tumor-agnostic conceptual model: symptoms, loss of autonomy, and adaptation/coping. CONCLUSIONS The explication of the interplay between the physical and emotional symptoms experienced by those with advanced and metastatic cancer using a multi-tumor approach provides the potential to make generalizations about the needs of this population. An opportunity exists to potentially address these needs through matching patient needs and preferences with the characteristics of novel therapeutics. IMPLICATIONS FOR CANCER SURVIVORS In the era of tumor agnostic therapies, the elicitation of patient preferences across the spectrum of anatomical origins has the potential to enhance shared decision making in the setting of metastatic disease.
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Affiliation(s)
- Steve E Kalloger
- School of Population and Public Health, University of British Columbia, Vancouver, Canada.
- Cancer Control Research, BC Cancer, Vancouver, Canada.
- Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, Canada.
| | - Cheryl Ho
- Department of Medicine, University of British Columbia, Vancouver, Canada
- Department of Medical Oncology, BC Cancer, Vancouver, Canada
| | - Craig Mitton
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Dean A Regier
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Cancer Control Research, BC Cancer, Vancouver, Canada
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2
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Smith N, Donaldson M, Mitton C, Lee E. Communication in disasters to support families with children with medical complexity and special healthcare needs: a rapid scoping review. Front Public Health 2024; 12:1229738. [PMID: 38544735 PMCID: PMC10967951 DOI: 10.3389/fpubh.2024.1229738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 02/13/2024] [Indexed: 04/24/2024] Open
Abstract
Disasters can disrupt normal healthcare processes, with serious effects on children who depend upon regular access to the health care system. Children with medical complexity (CMC) are especially at risk. These children have chronic medical conditions, and may depend on medical technology, like feeding tubes. Without clear, evidence-based processes to connect with healthcare teams, families may struggle to access the services and supports they need during disasters. There is limited research about this topic, which has been pushed forward in importance as a result of the COVID-19 pandemic. The authors therefore conducted a rapid scoping review on this topic, with the intention to inform policy processes. Both the peer-reviewed and gray literatures on disaster, CMC, and communication were searched in summer 2020 and spring 2021. Twenty six relevant articles were identified, from which four main themes were extracted: 1. Cooperative and collaborative planning. 2. Proactive outreach, engagement, and response. 3. Use of existing social networks to connect with families. 4. Return to usual routines. Based on this review, good practices appear to involve including families, professionals, other stakeholders, and children themselves in pre-disaster planning; service providers using proactive outreach at the outset of a crisis event; working with existing peer and neighborhood networks for support; employing multiple and two-way communication channels, including social media, to connect with families; re-establishing care processes as soon as possible, which may include virtual connections; addressing mental health issues as well as physical functioning; and prioritizing the resumption of daily routines. Above all, a well-established and ongoing relationship among children, their caregivers, and healthcare teams could reduce disruptions when disaster strikes.
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Affiliation(s)
- Neale Smith
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Meghan Donaldson
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Esther Lee
- Complex Care Program, British Columbia Children’s Hospital, Vancouver, BC, Canada
- Canuck Place Children’s Hospice, Vancouver, BC, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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3
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Mitton C, Dionne F, Fallah N, Noonan VK. An Economic Analysis of the Association Among Secondary Health Conditions, Health Care Costs, and Quality of Life for Persons With Spinal Cord Injury. Top Spinal Cord Inj Rehabil 2023; 29:80-88. [PMID: 38076292 PMCID: PMC10644854 DOI: 10.46292/sci22-00039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Background A previous analysis using the Canadian Spinal Cord Injury (SCI) Community Survey data identified that there were individuals with a high number of secondary health conditions, high health care utilization, poor health outcomes, and unmet health care needs. Objectives The objectives of this study were to estimate the annual health care costs of persons with SCI who report secondary health conditions, and to determine the association between these secondary health conditions with health care utilization and self-reported life satisfaction and quality of life. Methods The survey respondents were divided into four groups: traumatic SCI (tSCI; those who said they received needed care and those who said they did not) and nontraumatic SCI (ntSCI; those who said they received needed care and those who said they did not). The average annual health care costs per respondent were estimated for each group. Using regression analysis, we estimated the change in average annual health care costs that were associated with an additional secondary health condition for respondents in each group. Results Participants who reported not receiving needed care had on average 23% more secondary health conditions than those receiving needed care. The increase in average annual health care costs associated with one additional secondary health conditions was between $428 ($37-$820) (ntSCI, receiving needed care) and $1240 ($739-$1741) (tSCI, not receiving needed care). Conclusion This study provides insight into potential cost savings associated with a reduction of secondary health conditions as well as an estimate of the reduction in health care costs associated with moving from not receiving all needed care to receiving needed care.
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Affiliation(s)
- Craig Mitton
- Centre for Clinical Epidemiology and Evaluation, Vancouver, British Columbia, Canada
| | - Francois Dionne
- Centre for Clinical Epidemiology and Evaluation, Vancouver, British Columbia, Canada
| | - Nader Fallah
- Praxis Spinal Cord Institute, Vancouver, British Columbia, Canada
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Vanessa K. Noonan
- Praxis Spinal Cord Institute, Vancouver, British Columbia, Canada
- Department of Orthopedics, University of British Columbia, Vancouver, British Columbia, Canada
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Tseng LO, Newton C, Hall D, Lee EJ, Chang H, Poureslami I, Vasarhelyi K, Lacaille D, Mitton C. Primary care family physicians' experiences with clinical integration in qualitative and mixed reviews: a systematic review protocol. BMJ Open 2023; 13:e067576. [PMID: 37433736 DOI: 10.1136/bmjopen-2022-067576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
INTRODUCTION Clinical (service) integration in primary care settings describes how comprehensive care is coordinated by family physicians (FPs) over time across healthcare contexts to meet patient care needs. To improve care integration and healthcare service planning, a systematic approach to understanding its numerous influencing factors is paramount. The objective of this study is to generate a comprehensive map of FP-perceived factors influencing clinical integration across diseases and patient demographics. METHODS AND ANALYSIS We developed the protocol with the guidance of the Joanna Briggs Institute systematic review methodology framework. An information specialist built search strategies for MEDLINE, EMBASE and CINAHL databases using keywords and MeSH terms iteratively collected from a multidisciplinary team. Two reviewers will work independently throughout the study process, from article selection to data analysis. The identified records will be screened by title and abstract and reviewed in the full text against the criteria: FP in primary care (population), clinical integration (concept) and qualitative and mixed reviews published in 2011-2021 (context). We will first describe the characteristics of the review studies. Then, we will extract qualitative, FP-perceived factors and group them by content similarities, such as patient factors. Lastly, we will describe the types of extracted factors using a custom framework. ETHICS AND DISSEMINATION Ethics approval is not required for a systematic review. The identified factors will help generate an item bank for a survey that will be developed in the Phase II study to ascertain high-impact factors for intervention(s), as well as evidence gaps to guide future research. We will share the study findings with various knowledge users to promote awareness of clinical integration issues through multiple channels: publications and conferences for researchers and care providers, an executive summary for clinical leaders and policy-makers, and social media for the public.
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Affiliation(s)
- L Olivia Tseng
- Department of Family Practice, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
- Centre for Clinical Epidemiology and Evaluation (C2E2), Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Christie Newton
- Department of Family Practice, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - David Hall
- Department of Family Practice, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
- Department of Family & Community Practice, Vancouver Coastal Health Authority (VCHA), Vancouver, British Columbia, Canada
| | - Esther J Lee
- Complex Care Program, BC Children's Hospital, Vancouver, British Columbia, Canada
- Department of Pediatrics, Division of General Pediatrics, UBC, Vancouver, British Columbia, Canada
| | - Howard Chang
- Department of Family Practice, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Iraj Poureslami
- Respiratory Medicine Division, University of British Columbia, Vancouver, British Columbia, Canada
| | - Krisztina Vasarhelyi
- Department of Family & Community Practice, Vancouver Coastal Health Authority (VCHA), Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Diane Lacaille
- Arthritis Research Canada, Vancouver, British Columbia, Canada
- Department of Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation (C2E2), Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
- The University of British Columbia School of Population and Public Health, Vancouver, British Columbia, Canada
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Lancsar E, Huynh E, Swait J, Breunig R, Mitton C, Kirk M, Donaldson C. Preparing for future pandemics: A multi-national comparison of health and economic trade-offs. Health Econ 2023; 32:1434-1452. [PMID: 36922370 DOI: 10.1002/hec.4673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/13/2023] [Accepted: 02/27/2023] [Indexed: 06/04/2023]
Abstract
Government investment in preparing for pandemics has never been more relevant. The COVID-19 pandemic has stimulated debate regarding the trade-offs societies are prepared to make between health and economic activity. What is not known is: (1) how much the public in different countries are prepared to pay in forgone GDP to avoid mortality from future pandemics; and (2) which health and economic policies the public in different countries want their government to invest in to prepare for and respond to the next pandemic. Using a future-focused, multi-national discrete choice experiment, we quantify these trade-offs and find that the tax-paying public is prepared to pay $3.92 million USD (Canada), $4.39 million USD (UK), $5.57 million USD (US) and $7.19 million USD (Australia) in forgone GDP per death avoided in the next pandemic. We find the health policies that taxpayers want to invest in before the next pandemic and the economic policies they want activated once the next pandemic hits are relatively consistent across the countries, with some exceptions. Such results can inform economic policy responses and government investment in health policies to reduce the adverse impacts of the next pandemic.
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Affiliation(s)
- Emily Lancsar
- Department of Health Services Research and Policy, Research School of Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Elisabeth Huynh
- Department of Health Services Research and Policy, Research School of Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Joffre Swait
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Robert Breunig
- Crawford School of Public Policy, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Craig Mitton
- School of Population and Public Health, Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Martyn Kirk
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Cam Donaldson
- Department of Health Services Research and Policy, Research School of Population Health, Australian National University, Canberra, Australian Capital Territory, Australia
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
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Ling-I Tseng O, Lakzadeh P, Conte T, Naumann T, Kuo IF, Mitton C. Barriers and facilitators influencing the management of academic detailing programs: A descriptive analysis of four programs. J Am Pharm Assoc (2003) 2023; 63:1017-1025.e3. [PMID: 37121511 DOI: 10.1016/j.japh.2023.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 04/23/2023] [Accepted: 04/23/2023] [Indexed: 05/02/2023]
Abstract
BACKGROUND Educating prescribers is a key strategy to reduce inappropriate prescribing in selection, dose, type, timing, and duration. Academic detailing (AD) is a form of continuing medical education to educate prescribers. AD programs have been established in Canada, Australia, the United States, and other countries. Each program operates uniquely to reflect its local context and resources. It remains unclear how AD programs in universal health care systems differ from each other in their program components and experiences. OBJECTIVES To compare AD programs focusing on components of resources, activities, and services and to identify factors influencing program efficiency during the processes of program management, topic development, and service delivery among the selected Canadian and international AD programs. METHODS We adopted a process evaluation methodology with semistructured interviews and documents. We selected 4 well-established AD programs through an iterative discussion with the BC Ministry of Health: three provincial AD programs in the Canadian provinces of British Columbia, Ontario, and Saskatchewan, and an Australian program based in the State of South Australia. We invited one leader from each program to attend a 1-hour teleconferencing interview. RESULTS The 4 programs shared similarities of public government funding while differed in their operation models (centralized vs. decentralized), employment of detailers (part-time vs. full-time; hired by AD programs vs. hired by partnered multidisciplinary primary care teams) and staff who developed topics (detailers vs. nondetailers). The most common barriers were funding and reaching new participants, followed by team connection, detailer training resources, summarizing skills, and AD session scheduling. The most common facilitators were participant retention, participant recruitment through partnership, and easy access sessions. CONCLUSION AD programs can potentially guide a prescriber's choice of drug. A program's operation can be impacted by its access to resources and participants, activities, and service design.
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Apantaku G, Mitton C, Wong H, Ho K. Home Telemonitoring Technology for Patients With Heart Failure: Cost-Consequence Analysis of a Pilot Study. JMIR Form Res 2022; 6:e32147. [PMID: 35653179 PMCID: PMC9204565 DOI: 10.2196/32147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 01/14/2022] [Accepted: 03/14/2022] [Indexed: 11/18/2022] Open
Abstract
Background Heart failure (HF) is a costly health condition and a major public health problem. It is estimated that 2%-3% of the population in developed countries has HF, and the prevalence increases to 8% among patients aged ≥75 years. Home telemonitoring is a form of noninvasive, remote patient monitoring that aims to improve the care and management of patients with chronic HF. Telehealth for Emergency-Community Continuity of Care Connectivity via Home-Telemonitoring (TEC4Home) is a project that implements and evaluates a comprehensive home monitoring protocol designed to support patients with HF as they transition from the emergency department to home. Objective The aim of this study is to assess the cost of using the home monitoring platform (TEC4Home) relative to usual care for patients with HF. Methods This study is a cost-consequence analysis of the TEC4Home pilot study. The analysis was conducted from a partial societal perspective, including direct and indirect health care costs. The aim is to assess the costs of the home monitoring platform relative to usual care and track costs related to health care utilization during the 90-day postdischarge period. Results Economic analysis of the TEC4Home pilot study showed a positive trend in cost savings for patients using TEC4Home. From both the health system perspective (Pre TEC4Home cost per patient: CAD $2924 vs post TEC4Home cost per patient: CAD $1293; P=.01) and partial societal perspective (Pre TEC4Home cost per patient: CAD $2411 vs post TEC4Home cost per patient: CAD $1108; P=.01), we observed a statistically significant cost saving per patient. Conclusions In line with the advantages of conducting an economic analysis alongside a feasibility study, the economic analysis of the TEC4Home pilot study facilitated the piloting of patient questionnaires and informed the methodology for a full clinical trial.
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Affiliation(s)
- Glory Apantaku
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Craig Mitton
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Hubert Wong
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Kendall Ho
- Digital Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
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Li ECK, Grays S, Tagoola A, Komugisha C, Nabweteme AM, Ansermino JM, Mitton C, Kissoon N, Khowaja AR. Cost-effectiveness analysis protocol of the Smart Triage program: A point-of-care digital triage platform for pediatric sepsis in Eastern Uganda. PLoS One 2021; 16:e0260044. [PMID: 34788338 PMCID: PMC8598020 DOI: 10.1371/journal.pone.0260044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 11/01/2021] [Indexed: 12/03/2022] Open
Abstract
Background Sepsis is a clinical syndrome characterized by organ dysfunction due to presumed or proven infection. Severe cases can have case fatality ratio 25% or higher in low-middle income countries, but early diagnosis and timely treatment have a proven benefit. The Smart Triage program in Jinja Regional Referral Hospital in Uganda will provide expedited sepsis treatment in children through a data-driven electronic patient triage system. To complement the ongoing Smart Triage interventional trial, we propose methods for a concurrent cost-effectiveness analysis of the Smart Triage platform. Methods We will use a decision-analytic model taking a societal perspective, combining government and out-of-pocket costs, as patients bear a sizeable portion of healthcare costs in Uganda due to the lack of universal health coverage. Previously published secondary data will be used to link healthcare utilization with costs and intermediate outcomes with mortality. We will model uncertainty via probabilistic sensitivity analysis and present findings at various willingness-to-pay thresholds using a cost-effectiveness acceptability curve. Discussion Our proposed analysis represents a first step in evaluating the cost-effectiveness of an innovative digital triage platform designed to improve clinical outcomes in pediatric sepsis through expediting care in low-resource settings. Our use of a decision analytic model to link secondary costing data, incorporate post-discharge healthcare utilization, and model clinical endpoints is also novel in the pediatric sepsis triage literature for low-middle income countries. Our analysis, together with subsequent analyses modelling budget impact and scale up, will inform future modifications to the Smart Triage platform, as well as motivate scale-up to the district and national levels. Trial registration Trial registration of parent clinical trial: NCT04304235, https://clinicaltrials.gov/ct2/show/NCT04304235. Registered 11 March 2020.
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Affiliation(s)
- Edmond C. K. Li
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sela Grays
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
- * E-mail:
| | | | | | | | - J. Mark Ansermino
- Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Craig Mitton
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health, Vancouver, Canada
| | - Niranjan Kissoon
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Asif R. Khowaja
- Faculty of Applied Health Sciences, Brock University, St. Catharines, Canada
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Khowaja AR, Krause C, Kennedy C, Ridout B, Carriere S, Mitton C. Cost-effectiveness of a Province-wide Quality Improvement Initiative for Reducing Potentially Inappropriate Use of Antipsychotics in Long-Term Care in British Columbia, Canada. Pharmacoecon Open 2021; 5:491-504. [PMID: 33914292 PMCID: PMC8333184 DOI: 10.1007/s41669-021-00267-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND Potentially inappropriate use of antipsychotics (PIUA) raises serious concerns about safety, quality, and cost of care for residents in long-term care (LTC). OBJECTIVE This study aimed to estimate the cost-effectiveness of the Call for Less Antipsychotics in Long-Term Care (Clear) initiative compared with the status quo (pre-Clear, baseline). METHODS A model-based cost-utility analysis, from a public-payer perspective in British Columbia, was conducted using secondary data of residents in LTC homes from 2013 to 2019. Residents' health resource utilization and quality-adjusted life-year (QALY) measures were extracted from multiple administrative databases. Six Markov states were modelled for post-antipsychotic progression representing PIUA, appropriate use of antipsychotic, complete withdrawal, and death. The primary outcome was the incremental cost per QALY gained. RESULTS A cohort of 35,669 residents was included in the primary analysis. The Clear initiative, over 10 years, was estimated to have an incremental cost-effectiveness ratio (ICER) of CA$26,055 (2020 Canadian dollars) per QALY gained at an incremental cost of CA$5211 per resident and a QALY gain of 0.20. In the subgroup analyses, our findings were even more favourable for Clear wave 2 (ICER of CA$24,447 per QALY gained) and Clear wave 3 (ICER of CA$25,933 per QALY gained). At a willingness-to-pay of CA$50,000 per QALY gained, the probabilities of Clear waves 2 and 3 were 82% cost-effective. CONCLUSION This study demonstrated incremental costs and yielded favourable ICERs for Clear compared with the baseline. More research is needed to understand the level of support for individual care homes to sustain the Clear initiative in the long run.
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Affiliation(s)
- Asif Raza Khowaja
- Department of Health Sciences at Brock University, 1812 Sir Isaac Brock Way, St. Catharines, ON L2S 3A1 Canada
| | - Christina Krause
- BC Patient Safety & Quality Council and School of Population & Public Health, Faculty of Medicine at the University of British Columbia, Vancouver, Canada
| | - Colleen Kennedy
- Health System improvement, BC Patient Safety & Quality Council, Vancouver, Canada
| | - Ben Ridout
- Analytics and Strategic Initiatives, BC Patient Safety & Quality Council, Vancouver, Canada
| | - Sarah Carriere
- Health Systems Improvement, BC Patient Safety & Quality Council, Vancouver, Canada
| | - Craig Mitton
- School of Population and Public Health; and Senior Scientist at the Centre for Clinical Epidemiology and Evaluation, Vancouver, Canada
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Jenei K, Peacock S, Burgess M, Mitton C. Describing Sources of Uncertainty in Cancer Drug Formulary Priority Setting across Canada. Curr Oncol 2021; 28:2708-2719. [PMID: 34287280 PMCID: PMC8293120 DOI: 10.3390/curroncol28040236] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/05/2021] [Accepted: 07/12/2021] [Indexed: 11/16/2022] Open
Abstract
Over the years, there have been significant advances in oncology. However, the rate that therapeutics come to market has increased, while the strength of evidence has decreased. Currently, there is limited understanding about how these uncertainties are managed in provincial funding decisions for cancer therapeutics. We conducted qualitative interviews with six senior officials from four different Canadian provinces (British Columbia, Alberta, Quebec, and Ontario) and a document review of the uncertainties found in submissions to the pan-Canadian Oncology Drug Review (pCODR). Participants reported considerable uncertainty related to a lack of solid clinical evidence (early-phase clinical trials: generalizability, immature data, and the use of unvalidated surrogate outcomes). Proposed strategies to deal with the uncertainty included risk-sharing agreements, collection of real-world evidence (RWE), and ongoing collaboration between federal groups and provinces. The document review added to the reported uncertainties by classifying them into five main categories: trial validity, population, comparators, outcomes, and intervention. This study highlights how decision makers must deal with significant amounts of uncertainty in funding decisions for cancer drugs, most of which stems from methodological limitations in clinical trials. There is a critical need for transparent priority-setting processes and mechanisms to reevaluate drugs to ensure benefit given the high level of uncertainty of novel therapeutics.
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Affiliation(s)
- Kristina Jenei
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (M.B.); (C.M.)
| | - Stuart Peacock
- Canadian Control Research, BC Cancer, Canadian Centre for Applied Research in Cancer Control (ARCC), Vancouver, BC V5Z 4E6, Canada;
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC V5A 1S6, Canada
| | - Michael Burgess
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (M.B.); (C.M.)
- W. Maurice Young Centre for Applied Ethics, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
| | - Craig Mitton
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada; (M.B.); (C.M.)
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Bone JN, Khowaja AR, Vidler M, Payne BA, Bellad MB, Goudar SS, Mallapur AA, Munguambe K, Qureshi RN, Sacoor C, Sevene E, Frederix GWJ, Bhutta ZA, Mitton C, Magee LA, von Dadelszen P. Economic and cost-effectiveness analysis of the Community-Level Interventions for Pre-eclampsia (CLIP) trials in India, Pakistan and Mozambique. BMJ Glob Health 2021; 6:bmjgh-2020-004123. [PMID: 34031134 PMCID: PMC8149358 DOI: 10.1136/bmjgh-2020-004123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 04/19/2021] [Accepted: 04/21/2021] [Indexed: 12/11/2022] Open
Abstract
Background The Community-Level Interventions for Pre-eclampsia (CLIP) trials (NCT01911494) in India, Pakistan and Mozambique (February 2014–2017) involved community engagement and task sharing with community health workers for triage and initial treatment of pregnancy hypertension. Maternal and perinatal mortality was less frequent among women who received ≥8 CLIP contacts. The aim of this analysis was to assess the incremental costs and cost-effectiveness of the CLIP intervention overall in comparison to standard of care, and by PIERS (Pre-eclampsia Integrated Estimate of RiSk) On the Move (POM) mobile health application visit frequency. Methods Included were all women enrolled in the three CLIP trials who had delivered with known outcomes by trial end. According to the number of POM-guided home contacts received (0, 1–3, 4–7, ≥8), costs were collected from annual budgets and spending receipts, with inclusion of family opportunity costs in Pakistan. A decision tree model was built to determine the cost-effectiveness of the intervention (vs usual care), based on the primary clinical endpoint of years of life lost (YLL) for mothers and infants. A probabilistic sensitivity analysis was used to assess uncertainty in the cost and clinical outcomes. Results The incremental per pregnancy cost of the intervention was US$12.66 (India), US$11.51 (Pakistan) and US$13.26 (Mozambique). As implemented, the intervention was not cost-effective due largely to minimal differences in YLL between arms. However, among women who received ≥8 CLIP contacts (four in Pakistan), the probability of health system and family (Pakistan) cost-effectiveness was ≥80% (all countries). Conclusion The intervention was likely to be cost-effective for women receiving ≥8 contacts in Mozambique and India, and ≥4 in Pakistan, supporting WHO guidance on antenatal contact frequency. Trial registration number NCT01911494.
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Affiliation(s)
- Jeffrey N Bone
- Department of Obstetrics and Gynaecology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Asif R Khowaja
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Beth A Payne
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mrutyunjaya B Bellad
- Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Shivaprasad S Goudar
- Women's and Children's Health Research Unit, KLE Academy of Higher Education and Research, Belgaum, Karnataka, India
| | - Ashalata A Mallapur
- S Nijalingappa Medical College and HSK Hospital and Research Centre, Bagalkot, Karnataka, India
| | - Khatia Munguambe
- Centro de Investigação em Saúde de Manhiça, Manhiça, Maputo, Mozambique
| | - Rahat N Qureshi
- Centre of Excellence, Division of Woman and Child Health, Aga Khan University, Karachi, Pakistan
| | - Charfudin Sacoor
- Centro de Investigação em Saúde de Manhiça, Manhiça, Maputo, Mozambique
| | - Esperanca Sevene
- Centro de Investigação em Saúde de Manhiça, Manhiça, Maputo, Mozambique.,Universidade Eduardo Mondlane, Maputo, Mozambique
| | - Geert W J Frederix
- Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Zulfiqar A Bhutta
- Centre of Excellence, Division of Woman and Child Health, Aga Khan University, Karachi, Pakistan.,Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Craig Mitton
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Laura A Magee
- Department of Obstetrics and Gynaecology, The University of British Columbia, Vancouver, British Columbia, Canada.,Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, The University of British Columbia, Vancouver, British Columbia, Canada .,Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
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12
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Ho K, Novak Lauscher H, Cordeiro J, Hawkins N, Scheuermeyer F, Mitton C, Wong H, McGavin C, Ross D, Apantaku G, Karim ME, Bhullar A, Abu-Laban R, Nixon S, Smith T. Testing the Feasibility of Sensor-Based Home Health Monitoring (TEC4Home) to Support the Convalescence of Patients With Heart Failure: Pre-Post Study. JMIR Form Res 2021; 5:e24509. [PMID: 34081015 PMCID: PMC8212633 DOI: 10.2196/24509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/18/2020] [Accepted: 03/16/2021] [Indexed: 01/29/2023] Open
Abstract
Background Patients with heart failure (HF) can be affected by disabling symptoms and low quality of life. Furthermore, they may frequently need to visit the emergency department or be hospitalized due to their condition deteriorating. Home telemonitoring can play a role in tracking symptoms, reducing hospital visits, and improving quality of life. Objective Our objective was to conduct a feasibility study of a home health monitoring (HHM) solution for patients with HF in British Columbia, Canada, to prepare for conducting a randomized controlled trial. Methods Patients with HF were recruited from 3 urban hospitals and provided with HHM technology for 60 days of monitoring postdischarge. Participants were asked to monitor their weight, blood pressure, and heart rate and to answer symptomology questions via Bluetooth sensors and a tablet computer each day. A monitoring nurse received this data and monitored the patient’s condition. In our evaluation, the primary outcome was the combination of unscheduled emergency department revisits of discharged participants or death within 90 days. Secondary outcomes included 90-day hospital readmissions, patient quality of life (as measured by Veterans Rand 12-Item Health Survey and Kansas City Cardiomyopathy Scale), self-efficacy (as measured by European Heart Failure Self-Care Behaviour Scale 9), end-user experience, and health system cost-effectiveness including cost reduction and hospital bed capacity. In this feasibility study, we also tested the recruitment strategy, clinical protocols, evaluation framework, and data collection methods. Results Seventy participants were enrolled into this trial. Participant engagement to monitoring was measured at 94% (N=70; ie, data submitted 56/60 days on average). Our evaluation framework allowed us to collect sound data, which also showed encouraging trends: a 79% reduction of emergency department revisits post monitoring, an 87% reduction in hospital readmissions, and a 60% reduction in the median hospital length of stay (n=36). Cost of hospitalization for participants decreased by 71%, and emergency department visit costs decreased by 58% (n=30). Overall health system costs for our participants showed a 56% reduction post monitoring (n=30). HF-specific quality of life (Kansas City Cardiomyopathy Scale) scores showed a significant increase of 101% (n=35) post monitoring (P<.001). General quality of life (Veterans Rand 12-Item Health Survey) improved by 19% (n=35) on the mental component score (P<.001) and 19% (n=35) on the physical component score (P=.02). Self-efficacy improved by 6% (n=35). Interviews with participants revealed that they were satisfied overall with the monitoring program and its usability, and participants reported being more engaged, educated, and involved in their self-management. Conclusions Results from this small-sample feasibility study suggested that our HHM intervention can be beneficial in supporting patients post discharge. Additionally, key insights from the trial allowed us to refine our methods and procedures, such as shifting our recruitment methods to in-patient wards and increasing our scope of data collection. Although these findings are promising, a more rigorous trial design is required to test the true efficacy of the intervention. The results from this feasibility trial will inform our next step as we proceed with a randomized controlled trial across British Columbia. Trial Registration ClinicalTrials.gov NCT03439384; https://clinicaltrials.gov/ct2/show/NCT03439384
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Affiliation(s)
- Kendall Ho
- Digital Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Helen Novak Lauscher
- Digital Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Jennifer Cordeiro
- Digital Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | | | - Craig Mitton
- Centre for Clinical Epidemiology & Evaluation, University of British Columbia, Vancouver, BC, Canada
| | - Hubert Wong
- Centre for Health Evaluation & Outcome Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Colleen McGavin
- BC Support for People & Patient-Oriented Research & Trials, Vancouver, BC, Canada
| | - Dianne Ross
- Vancouver General Hospital, Vancouver, BC, Canada
| | - Glory Apantaku
- Centre for Clinical Epidemiology & Evaluation, University of British Columbia, Vancouver, BC, Canada
| | - Mohammad Ehsan Karim
- Centre for Health Evaluation & Outcome Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Amrit Bhullar
- Digital Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Suzanne Nixon
- University of British Columbia, Vancouver, BC, Canada
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13
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Abstract
Trade-offs abound in healthcare yet depending on where one stands relative to the stages of a pandemic, choice making may be more or less constrained. During the early stages of COVID-19 when there was much uncertainty, healthcare systems faced greater constraints and focused on the singular criterion of “flattening the curve.” As COVID-19 progressed and the first wave diminished (relatively speaking depending on the jurisdiction), more opportunities presented for making explicit choices between COVID and non-COVID patients. Then, as the second wave surged, again decision makers were more constrained even as more information and greater understanding developed. Moving out of the pandemic to recovery, choice making becomes paramount as there are no set rules to lean back into historical patterns of resource allocation. In fact, the opportunity at hand, when using explicit tools for priority setting based on economic and ethical principles, is significant.
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Affiliation(s)
- Craig Mitton
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | | | - Francois Dionne
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Stuart Peacock
- Faculty of Health Sciences, Simon Fraser University, Vancouver, British Columbia, Canada.,Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, British Columbia, Canada.,Cancer Control Research, BC Cancer, Vancouver, British Columbia, Canada
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14
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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15
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Homayra F, Pearce LA, Wang L, Panagiotoglou D, Sambo TF, Smith N, McKendry R, Wilson B, Joe R, Hawkins K, Barrios R, Mitton C, Nosyk B. Cohort profile: The provincial substance use disorder cohort in British Columbia, Canada. Int J Epidemiol 2021; 49:1776. [PMID: 33097934 PMCID: PMC7825959 DOI: 10.1093/ije/dyaa150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 07/27/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
- Fahmida Homayra
- British Columbia Centre for Excellence in HIV/AIDS, St Paul’s Hospital, Vancouver, BC, Canada
| | - Lindsay A Pearce
- British Columbia Centre for Excellence in HIV/AIDS, St Paul’s Hospital, Vancouver, BC, Canada
| | - Linwei Wang
- British Columbia Centre for Excellence in HIV/AIDS, St Paul’s Hospital, Vancouver, BC, Canada
| | - Dimitra Panagiotoglou
- British Columbia Centre for Excellence in HIV/AIDS, St Paul’s Hospital, Vancouver, BC, Canada
| | - Tamunoibim F Sambo
- British Columbia Centre for Excellence in HIV/AIDS, St Paul’s Hospital, Vancouver, BC, Canada
| | - Neale Smith
- Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, BC, Canada
| | | | - Bonnie Wilson
- Vancouver Coastal Health Authority, Vancouver, BC, Canada
| | - Ronald Joe
- Vancouver Coastal Health Authority, Vancouver, BC, Canada
| | - Ken Hawkins
- Vancouver Coastal Health Authority, Vancouver, BC, Canada
| | | | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, BC, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Bohdan Nosyk
- British Columbia Centre for Excellence in HIV/AIDS, St Paul’s Hospital, Vancouver, BC, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
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16
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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 Econ Rev 2021; 11:2. [PMID: 33411161 PMCID: PMC7789400 DOI: 10.1186/s13561-020-00300-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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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17
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Seixas BV, Mitton C. Using a Formal Strategy of Priority Setting to Mitigate Austerity Effects Through Gains in Value: The Role of Program Budgeting and Marginal Analysis (PBMA) in the Brazilian Public Healthcare System. Appl Health Econ Health Policy 2021; 19:9-15. [PMID: 32468409 DOI: 10.1007/s40258-020-00591-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
The fiscal regime implemented in Brazil with the constitutional amendment 95 (EC-95) of December 2016 froze primary expenditures for 20 years, including healthcare spending. Previous studies have estimated strong negative effects of this policy on the health of Brazilians. Although there has been a constant pressure to repeal EC-95, this policy is unlikely to be changed in the near future. Thus, there is also a need to take actions within its own terms in order to mitigate its harmful consequences on population health. Shedding light on the existing evidence about the impact of austerity on health, the present work discusses how decision-makers can use a formal framework of decision making in priority setting and resource allocation to tackle the amplified budgetary strain. Drawing on principles of Program Budgeting and Marginal Analysis (PBMA), efficiency can be improved by shifting spending from low-value to higher-value areas, avoiding the "across-the-board cut" caused by non-differential consideration of expenditures in a context of mismatched growth of demand and supply of healthcare. By evaluating opportunity costs of investment and disinvestment proposals on the basis of multiple criteria and marginal analysis, the Brazilian public healthcare system could obtain gains in value, achieving better performance and attenuating the relative decline in spending on health brought by an austerity scenario.
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Affiliation(s)
- Brayan V Seixas
- Department of Health Policy and Management, University of California, Los Angeles (UCLA), Los Angeles, CA, USA.
- UCLA Center for Health Policy Research (CHPR), Los Angeles, CA, USA.
| | - Craig Mitton
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
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18
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Abstract
As the coronavirus disease 2019 (COVID-19) pandemic continues to unfold there is an untold number of trade-offs being made in every country around the globe. The experience in the United Kingdom and Canada to date has not seen much uptake of health economics methods. We provide some thoughts on how this could take place, specifically in three areas. Firstly, this can involve understanding the impact of lockdown policies on national productivity. Secondly, there is great importance in studying trade-offs with respect to enhancing health system capacity and the impact of the mix of private-public financing. Finally, there are key trade-offs that will continue to be made both in terms of access to testing and ventilators which would benefit greatly from economic appraisal. In short, health economics could – and we would argue most certainly should – play a much more prominent role in policy-making as it relates to the current as well as future pandemics.
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Affiliation(s)
- Cam Donaldson
- Yunus Centre for Social Business & Health, Glasgow Caledonian University, Glasgow, UK
| | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada
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19
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Latimer EA, Rabouin D, Cao Z, Ly A, Powell G, Aubry T, Distasio J, Hwang SW, Somers JM, Bayoumi AM, Mitton C, Moodie EEM, Goering PN. Cost-Effectiveness of Housing First With Assertive Community Treatment: Results From the Canadian At Home/Chez Soi Trial. Psychiatr Serv 2020; 71:1020-1030. [PMID: 32838679 DOI: 10.1176/appi.ps.202000029] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The At Home/Chez Soi trial for homeless individuals with mental illness showed scattered-site Housing First with Assertive Community Treatment (ACT) to be more effective than treatment as usual. This study evaluated the cost-effectiveness of Housing First with ACT and treatment as usual. METHODS Between October 2009 and June 2011, a total of 950 homeless individuals with serious mental illness were recruited in five Canadian cities: Vancouver, Winnipeg, Toronto, Montreal, and Moncton. Participants were randomly assigned to Housing First (N=469) or treatment as usual (N=481) and followed up for up to 24 months. The intervention consisted of scattered-site Housing First, using rent supplements, with ACT. The treatment-as-usual group had access to all other services. The perspective of society was adopted for the cost-effectiveness analysis. Days of stable housing served as the outcome measure. Retrospective questionnaires captured service use data. RESULTS Most (69%) of the costs of the intervention were offset by savings in other costs, such as emergency shelters, reducing the net annual cost of the intervention to about Can$6,311 per person. The incremental cost-effectiveness ratio was Can$41.73 per day of stable housing (95% confidence interval=Can$1.96-$83.70). At up to Can$60 per day, Housing First had more than an 80% chance of being cost-effective, compared with treatment as usual. Cost-effectiveness did not vary by participant characteristics. CONCLUSIONS Housing First with ACT appeared about as cost-effective as Housing First with intensive case management for people with moderate needs. The optimal mix between the two remains to be determined.
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Affiliation(s)
- Eric A Latimer
- Department of Psychiatry, McGill University, Montreal (Latimer); Douglas Research Centre, Montreal (Latimer, Rabouin, Cao); Montreal West Island Integrated University Health and Social Services Centre, Montreal (Ly); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal (Powell, Moodie); Department of Psychology, University of Ottawa, Ottawa (Aubry); Department of Geography, University of Winnipeg, Winnipeg, Manitoba (Distasio); Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto (Hwang); Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Hwang, Bayoumi); Department of Psychiatry, Simon Fraser University, Burnaby, British Columbia (Somers); Dalla Lana School of Public Health, University of Toronto, Toronto (Bayoumi); School of Population and Public Health, University of British Columbia, Vancouver (Mitton); Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto (Goering, who died in May 2016)
| | - Daniel Rabouin
- Department of Psychiatry, McGill University, Montreal (Latimer); Douglas Research Centre, Montreal (Latimer, Rabouin, Cao); Montreal West Island Integrated University Health and Social Services Centre, Montreal (Ly); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal (Powell, Moodie); Department of Psychology, University of Ottawa, Ottawa (Aubry); Department of Geography, University of Winnipeg, Winnipeg, Manitoba (Distasio); Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto (Hwang); Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Hwang, Bayoumi); Department of Psychiatry, Simon Fraser University, Burnaby, British Columbia (Somers); Dalla Lana School of Public Health, University of Toronto, Toronto (Bayoumi); School of Population and Public Health, University of British Columbia, Vancouver (Mitton); Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto (Goering, who died in May 2016)
| | - Zhirong Cao
- Department of Psychiatry, McGill University, Montreal (Latimer); Douglas Research Centre, Montreal (Latimer, Rabouin, Cao); Montreal West Island Integrated University Health and Social Services Centre, Montreal (Ly); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal (Powell, Moodie); Department of Psychology, University of Ottawa, Ottawa (Aubry); Department of Geography, University of Winnipeg, Winnipeg, Manitoba (Distasio); Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto (Hwang); Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Hwang, Bayoumi); Department of Psychiatry, Simon Fraser University, Burnaby, British Columbia (Somers); Dalla Lana School of Public Health, University of Toronto, Toronto (Bayoumi); School of Population and Public Health, University of British Columbia, Vancouver (Mitton); Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto (Goering, who died in May 2016)
| | - Angela Ly
- Department of Psychiatry, McGill University, Montreal (Latimer); Douglas Research Centre, Montreal (Latimer, Rabouin, Cao); Montreal West Island Integrated University Health and Social Services Centre, Montreal (Ly); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal (Powell, Moodie); Department of Psychology, University of Ottawa, Ottawa (Aubry); Department of Geography, University of Winnipeg, Winnipeg, Manitoba (Distasio); Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto (Hwang); Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Hwang, Bayoumi); Department of Psychiatry, Simon Fraser University, Burnaby, British Columbia (Somers); Dalla Lana School of Public Health, University of Toronto, Toronto (Bayoumi); School of Population and Public Health, University of British Columbia, Vancouver (Mitton); Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto (Goering, who died in May 2016)
| | - Guido Powell
- Department of Psychiatry, McGill University, Montreal (Latimer); Douglas Research Centre, Montreal (Latimer, Rabouin, Cao); Montreal West Island Integrated University Health and Social Services Centre, Montreal (Ly); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal (Powell, Moodie); Department of Psychology, University of Ottawa, Ottawa (Aubry); Department of Geography, University of Winnipeg, Winnipeg, Manitoba (Distasio); Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto (Hwang); Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Hwang, Bayoumi); Department of Psychiatry, Simon Fraser University, Burnaby, British Columbia (Somers); Dalla Lana School of Public Health, University of Toronto, Toronto (Bayoumi); School of Population and Public Health, University of British Columbia, Vancouver (Mitton); Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto (Goering, who died in May 2016)
| | - Tim Aubry
- Department of Psychiatry, McGill University, Montreal (Latimer); Douglas Research Centre, Montreal (Latimer, Rabouin, Cao); Montreal West Island Integrated University Health and Social Services Centre, Montreal (Ly); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal (Powell, Moodie); Department of Psychology, University of Ottawa, Ottawa (Aubry); Department of Geography, University of Winnipeg, Winnipeg, Manitoba (Distasio); Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto (Hwang); Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Hwang, Bayoumi); Department of Psychiatry, Simon Fraser University, Burnaby, British Columbia (Somers); Dalla Lana School of Public Health, University of Toronto, Toronto (Bayoumi); School of Population and Public Health, University of British Columbia, Vancouver (Mitton); Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto (Goering, who died in May 2016)
| | - Jino Distasio
- Department of Psychiatry, McGill University, Montreal (Latimer); Douglas Research Centre, Montreal (Latimer, Rabouin, Cao); Montreal West Island Integrated University Health and Social Services Centre, Montreal (Ly); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal (Powell, Moodie); Department of Psychology, University of Ottawa, Ottawa (Aubry); Department of Geography, University of Winnipeg, Winnipeg, Manitoba (Distasio); Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto (Hwang); Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Hwang, Bayoumi); Department of Psychiatry, Simon Fraser University, Burnaby, British Columbia (Somers); Dalla Lana School of Public Health, University of Toronto, Toronto (Bayoumi); School of Population and Public Health, University of British Columbia, Vancouver (Mitton); Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto (Goering, who died in May 2016)
| | - Stephen W Hwang
- Department of Psychiatry, McGill University, Montreal (Latimer); Douglas Research Centre, Montreal (Latimer, Rabouin, Cao); Montreal West Island Integrated University Health and Social Services Centre, Montreal (Ly); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal (Powell, Moodie); Department of Psychology, University of Ottawa, Ottawa (Aubry); Department of Geography, University of Winnipeg, Winnipeg, Manitoba (Distasio); Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto (Hwang); Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Hwang, Bayoumi); Department of Psychiatry, Simon Fraser University, Burnaby, British Columbia (Somers); Dalla Lana School of Public Health, University of Toronto, Toronto (Bayoumi); School of Population and Public Health, University of British Columbia, Vancouver (Mitton); Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto (Goering, who died in May 2016)
| | - Julian M Somers
- Department of Psychiatry, McGill University, Montreal (Latimer); Douglas Research Centre, Montreal (Latimer, Rabouin, Cao); Montreal West Island Integrated University Health and Social Services Centre, Montreal (Ly); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal (Powell, Moodie); Department of Psychology, University of Ottawa, Ottawa (Aubry); Department of Geography, University of Winnipeg, Winnipeg, Manitoba (Distasio); Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto (Hwang); Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Hwang, Bayoumi); Department of Psychiatry, Simon Fraser University, Burnaby, British Columbia (Somers); Dalla Lana School of Public Health, University of Toronto, Toronto (Bayoumi); School of Population and Public Health, University of British Columbia, Vancouver (Mitton); Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto (Goering, who died in May 2016)
| | - Ahmed M Bayoumi
- Department of Psychiatry, McGill University, Montreal (Latimer); Douglas Research Centre, Montreal (Latimer, Rabouin, Cao); Montreal West Island Integrated University Health and Social Services Centre, Montreal (Ly); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal (Powell, Moodie); Department of Psychology, University of Ottawa, Ottawa (Aubry); Department of Geography, University of Winnipeg, Winnipeg, Manitoba (Distasio); Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto (Hwang); Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Hwang, Bayoumi); Department of Psychiatry, Simon Fraser University, Burnaby, British Columbia (Somers); Dalla Lana School of Public Health, University of Toronto, Toronto (Bayoumi); School of Population and Public Health, University of British Columbia, Vancouver (Mitton); Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto (Goering, who died in May 2016)
| | - Craig Mitton
- Department of Psychiatry, McGill University, Montreal (Latimer); Douglas Research Centre, Montreal (Latimer, Rabouin, Cao); Montreal West Island Integrated University Health and Social Services Centre, Montreal (Ly); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal (Powell, Moodie); Department of Psychology, University of Ottawa, Ottawa (Aubry); Department of Geography, University of Winnipeg, Winnipeg, Manitoba (Distasio); Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto (Hwang); Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Hwang, Bayoumi); Department of Psychiatry, Simon Fraser University, Burnaby, British Columbia (Somers); Dalla Lana School of Public Health, University of Toronto, Toronto (Bayoumi); School of Population and Public Health, University of British Columbia, Vancouver (Mitton); Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto (Goering, who died in May 2016)
| | - Erica E M Moodie
- Department of Psychiatry, McGill University, Montreal (Latimer); Douglas Research Centre, Montreal (Latimer, Rabouin, Cao); Montreal West Island Integrated University Health and Social Services Centre, Montreal (Ly); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal (Powell, Moodie); Department of Psychology, University of Ottawa, Ottawa (Aubry); Department of Geography, University of Winnipeg, Winnipeg, Manitoba (Distasio); Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto (Hwang); Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Hwang, Bayoumi); Department of Psychiatry, Simon Fraser University, Burnaby, British Columbia (Somers); Dalla Lana School of Public Health, University of Toronto, Toronto (Bayoumi); School of Population and Public Health, University of British Columbia, Vancouver (Mitton); Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto (Goering, who died in May 2016)
| | - Paula N Goering
- Department of Psychiatry, McGill University, Montreal (Latimer); Douglas Research Centre, Montreal (Latimer, Rabouin, Cao); Montreal West Island Integrated University Health and Social Services Centre, Montreal (Ly); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal (Powell, Moodie); Department of Psychology, University of Ottawa, Ottawa (Aubry); Department of Geography, University of Winnipeg, Winnipeg, Manitoba (Distasio); Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto (Hwang); Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Hwang, Bayoumi); Department of Psychiatry, Simon Fraser University, Burnaby, British Columbia (Somers); Dalla Lana School of Public Health, University of Toronto, Toronto (Bayoumi); School of Population and Public Health, University of British Columbia, Vancouver (Mitton); Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto (Goering, who died in May 2016)
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- Department of Psychiatry, McGill University, Montreal (Latimer); Douglas Research Centre, Montreal (Latimer, Rabouin, Cao); Montreal West Island Integrated University Health and Social Services Centre, Montreal (Ly); Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal (Powell, Moodie); Department of Psychology, University of Ottawa, Ottawa (Aubry); Department of Geography, University of Winnipeg, Winnipeg, Manitoba (Distasio); Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto (Hwang); Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto (Hwang, Bayoumi); Department of Psychiatry, Simon Fraser University, Burnaby, British Columbia (Somers); Dalla Lana School of Public Health, University of Toronto, Toronto (Bayoumi); School of Population and Public Health, University of British Columbia, Vancouver (Mitton); Centre for Addiction and Mental Health and Department of Psychiatry, University of Toronto, Toronto (Goering, who died in May 2016)
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Dionne F, Mitton C. Is Multicriteria Decision Analysis a Resource Allocation Framework? Value Health 2020; 23:1400-1401. [PMID: 33032785 DOI: 10.1016/j.jval.2020.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 02/05/2020] [Indexed: 06/11/2023]
Affiliation(s)
- François Dionne
- Centre for Clinical Epidemiology and Evaluation, The University of British Columbia, Vancouver, British Columbia.
| | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation, The University of British Columbia, Vancouver, British Columbia
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21
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Best A, Ong N, Cooper P, Davison C, Coatta K, Berland A, Herbert C, Mitton C, Millar J, Reichert S, Cano A. Evaluating complex transformation. J Health Organ Manag 2020; 34:313-324. [PMID: 32364344 DOI: 10.1108/jhom-05-2019-0139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE The purpose of this paper is to present a detailed case study of the evaluation strategies of a complex, multi-faceted response to a public health emergency: drug-related overdose deaths. It sets out the challenges of evaluating such a complex response and how they were overcome. It provides a pragmatic example of the rationale and issues faced to address the what, the why and particularly the how of the evaluation. DESIGN/METHODOLOGY/APPROACH The case study overviews British Columbia's Provincial Response to the Overdose Public Health Emergency, and the aims and scope of its evaluation. It then outlines the conceptual approach taken to the evaluation, setting out key methodological challenges in evaluating large-scale, multi-level, multisectoral change. FINDINGS The evaluation is developmental and summative, utilization focused and system informed. Defining the scope of the evaluation required a strong level of engagement with government leads, grantees and other evaluation stakeholders. Mixed method evaluation will be used to capture the complex pattern of relationships that have informed the overdose response. Working alongside people with drug use experience to both plan and inform the evaluation is critical to its success. ORIGINALITY/VALUE This case study builds on a growing literature on evaluating large-scale and complex service transformation, providing a practical example of this.
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Affiliation(s)
- Allan Best
- InSource Research Group, West Vancouver, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | | | | | - Carolyn Davison
- Ministry of Mental Health and Addictions, Government of British Columbia, Victoria, Canada
| | | | | | | | - Craig Mitton
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - John Millar
- Department of Population Health, InSource Research Group, West Vancouver, Canada
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22
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Laba TL, Jiwani B, Crossland R, Mitton C. Can multi-criteria decision analysis (MCDA) be implemented into real-world drug decision-making processes? A Canadian provincial experience. Int J Technol Assess Health Care 2020; 36:1-6. [PMID: 32762789 DOI: 10.1017/s0266462320000525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE To describe the implementation of multi-criteria decision analysis (MCDA) into a Canadian public drug reimbursement decision-making process, identifying the aspects of the MCDA approach, and the context that promoted uptake. METHODS Narrative summary of case study describing the how, when, and why of implementing MCDA. RESULTS Faced with a fixed budget, a pipeline of expensive but potentially valuable drugs, and potential delays to drug decision making, the Ministry of Health (i.e., decision makers) and its independent expert advisory committee (IAB) sought alternative values-based decision processes. MCDA was considered highly compatible with current processes, but the ability as a stand-alone intervention to address issues of opportunity cost was unclear. The IAB nevertheless collaboratively voted to implement an externally developed MCDA with support from decision makers. After several months of engagement and piloting, implementation was rapid and leveraged strong pre-existing formal and informal communication networks. The IAB as a whole rates new submissions which serves as an input into the deliberative process. CONCLUSIONS MCDA can be a highly adaptable approach that can be implemented into a functioning drug reimbursement setting when facilitated by (i) a truly limited budget; (ii) a shared vision for change by end-users and decision makers; (iii) using pre-existing deliberative processes; and (iv) viewing the approach as a decision framework rather than the decision (when appropriate). Given the current limitations of MCDA, implementing an academically imperfect tool first and evaluating later reflects a practical solution to real-time fiscal constraints and impending delays to drug approvals that may be faced by decision makers.
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Affiliation(s)
- Tracey-Lea Laba
- The University of British Columbia, Centre for Clinical Epidemiology and Evaluation, Vancouver, Canada
- The Centre for Health Economics Research and Evaluation, Business School, The University of Technology, Sydney, Australia
| | - Bashir Jiwani
- Fraser Health, Ethics and Diversity Services, Surrey, Canada
| | | | - Craig Mitton
- The University of British Columbia, Centre for Clinical Epidemiology and Evaluation, Vancouver, Canada
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23
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Mitton C, Dionne F. Priority setting and resource allocation in the US health system: is there a place for hard caps? J Health Organ Manag 2020; ahead-of-print. [DOI: 10.1108/jhom-01-2020-0016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeThe United States devotes a larger share of its GDP to health care and spends more on health care per capita than any other country. The sheer size of the total spending on health care, at approximately $3.5 trillion in 2017, puts significant pressure on all payers and crowds out other forms of public and private spending.Design/methodology/approachIn this brief commentary the authors suggest that, as part of the effort to deal with this pressure, the United States should look at borrowing a cost containment strategy from other countries: the use of hard caps on spending growth. The authors draw on our their experience of working with decision-makers over the last 20 years on the topic of priority setting to put forward some ideas on whether there is potential for application of trade-offs in the United States.FindingsAs hard caps force choices to be made, a necessary condition for successful implementation of this policy is the presence of an effective priority-setting framework to ensure that the right choices are made in operationalizing spending limitations. Work on this topic elsewhere can provide some insight into the use of a criteria-based framework for priority setting that purports transparency in decision-making to achieve value-based decisions.Originality/valueOther countries still have much work to do, but there is a substantial track record of using formal priority-setting approaches that could potentially inform practice in the United States. We suggest that there are key segments of the US healthcare system where the adoption of formal priority-setting frameworks to guide trade-off decisions is feasible. Piloting such activity in these contexts is the next natural step in this line of inquiry.
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Ezeife DA, Dionne F, Fares AF, Cusano ELR, Fazelzad R, Ng W, Husereau D, Ali F, Sit C, Stein B, Law JH, Le L, Ellis PM, Berry S, Peacock S, Mitton C, Earle CC, Chan KKW, Leighl NB. Value assessment of oncology drugs using a weighted criterion-based approach. Cancer 2019; 126:1530-1540. [PMID: 31860138 DOI: 10.1002/cncr.32639] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Revised: 10/09/2019] [Accepted: 10/24/2019] [Indexed: 11/09/2022]
Abstract
BACKGROUND Globally, the rising cost of anticancer therapy has motivated efforts to quantify the overall value of new cancer treatments. Multicriteria decision analysis offers a novel approach to incorporate multiple criteria and perspectives into value assessment. METHODS The authors recruited a diverse, multistakeholder group who identified and weighted key criteria to establish the drug assessment framework (DAF). Construct validity assessed the degree to which DAF scores were associated with past pan-Canadian Oncology Drug Review (pCODR) funding recommendations and European Society for Medical Oncology Magnitude of Clinical Benefit Scale (ESMO-MCBS; version 1.1) scores. RESULTS The final DAF included 10 criteria: overall survival, progression-free survival, response rate, quality of life, toxicity, unmet need, equity, feasibility, disease severity, and caregiver well-being. The first 5 clinical benefit criteria represent approximately 64% of the total weight. DAF scores ranged from 0 to 300, reflecting both the expected impact of the drug and the quality of supporting evidence. When the DAF was applied to the last 60 drugs (with reviewers blinded) reviewed by pCODR (2015-2018), those drugs with positive pCODR funding recommendations were found to have higher DAF scores compared with drugs not recommended (103 vs 63; Student t test P = .0007). DAF clinical benefit criteria mildly correlated with ESMO-MCBS scores (correlation coefficient, 0.33; 95% CI, 0.009-0.59). Sensitivity analyses that varied the criteria scores did not change the results. CONCLUSIONS Using a structured and explicit approach, a criterion-based valuation framework was designed to provide a transparent and consistent method with which to value and prioritize cancer drugs to facilitate the delivery of affordable cancer care.
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Affiliation(s)
- Doreen A Ezeife
- Department of Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Francois Dionne
- Prioritize Consulting Ltd, Vancouver, British Columbia, Canada
| | - Aline Fusco Fares
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | | | - Rouhi Fazelzad
- Department of Medical Oncology and Hematology, Library and Information Services, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Wenzie Ng
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Don Husereau
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | | | | | - Barry Stein
- Colorectal Cancer Canada, Montreal, Quebec, Canada
| | - Jennifer H Law
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Lisa Le
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | | | - Scott Berry
- Cancer Centre of Southeastern Ontario, Kingston, Ontario, Canada
| | - Stuart Peacock
- British Columbia Cancer Agency, Vancouver, British Columbia, Canada
| | - Craig Mitton
- The University of British Columbia, Vancouver, British Columbia, Canada
| | - Craig C Earle
- Sunnybrook Odette Cancer Centre, Toronto, Ontario, Canada
| | | | - Natasha B Leighl
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
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Shaw G, Smith N, Khowaja A, Mitton C, Denis JL, Lovato C. Strategies to increase physician engagement in acute care settings: a scoping review. J Health Organ Manag 2019. [DOI: 10.1108/jhom-08-2019-0237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
Despite growing attention to physician engagement there is a lack of literature to guide the development of physician-led interventions. A scoping review was conducted to describe physician-led strategies that have been implemented to promote increased physician engagement in acute care settings. Strategies are viewed through the theoretical lens of institutional work to advance the understanding about how the theory can be applied. The paper aims to discuss this issue.
Design/methodology/approach
Searches were conducted in English-language publications (2012–2017). Of 35 retained articles, 15 were from the gray literature; and 20 were peer reviewed. The review was guided by Arskey and O’Malley’s (2005) five-stage process.
Findings
Five themes reflecting different foci of physician-led activity were examined from the perspective of institutional work: systematically analyze context using participatory methods; work collaboratively toward locally defined, shared targets and build in processes to monitor progress; expand physicians’ role and capacity to include leadership toward shared organizational goals; promote appropriate rewards and incentives for work that builds engagement; and invest in opportunities for formal and informal communication and interaction.
Practical implications
Physicians considering action to increase their engagement in system improvement may benefit from analysis of local opportunities and barriers in selecting context-relevant activities that will motivate participation and build engagement through a balance of institutional work.
Originality/value
The paper considers the potential for physicians to initiate and support activity that will increase their engagement. It provides pragmatic strategies for designing intervention and research using the theoretical lens of institutional work.
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Mitton C, Seixas BV, Peacock S, Burgess M, Bryan S. Health Technology Assessment as Part of a Broader Process for Priority Setting and Resource Allocation. Appl Health Econ Health Policy 2019; 17:573-576. [PMID: 31161365 DOI: 10.1007/s40258-019-00488-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Over the last two decades, economic evaluation of health technologies has developed enormously, affirming its importance within the pursuit of efficiency in the management of health care systems. One concern that has been raised with health technology assessment (HTA) has been its operationalization within the realm of decision making. Here, we suggest a mechanism by which HTA can be understood as an input into a broader framework for priority setting and resource allocation. When HTA is seen in this light, topics that at times have had some lack of clarity, such as public engagement and disinvestment, simply become steps in the overall decision-making process.
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Affiliation(s)
- Craig Mitton
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Brayan V Seixas
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.
| | - Stuart Peacock
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
- Canadian Centre for Applied Research in Cancer Control, BC Cancer, Vancouver, BC, Canada
| | - Michael Burgess
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- W. Maurice Young Centre for Applied Ethics, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Stirling Bryan
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
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Seixas BV, Dionne F, Conte T, Mitton C. Assessing value in health care: using an interpretive classification system to understand existing practices based on a systematic review. BMC Health Serv Res 2019; 19:560. [PMID: 31409369 PMCID: PMC6693163 DOI: 10.1186/s12913-019-4405-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Accepted: 08/06/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementing adequate strategies to assess the value of health services plays a central role in the effort to deal with the financial pressures faced by health care systems worldwide. This study aimed to understand which approaches to value assessment have been used in developed countries. METHODS We conducted a rapid review and a gray literature search to identify value assessment frameworks. A two-stage screening process was utilized to identify existing approaches and cluster similar frameworks. In addition, we developed an interpretive classification system to make sense of existing approaches. RESULTS One thousand one hundred seventy-six references were identified and 38 papers were selected for full-review. Among these 38 articles, 22 distinct approaches to assess value of health care interventions were identified and classified according to four points: 1) use of single or multiple considerations to base value estimates; 2) use of disease-specific or generic criteria; 3) reliance on process-based or outcomes-based consideration; and 4) type of input and evidence considered. CONCLUSIONS The contextual nature of value assessment in health care becomes evident with the diversity of existing approaches. Despite the predominance of cases relying on the Incremental cost-effectiveness ratio as the measure of value, this approach has not been sufficient to meet the needs of decision-makers. The use of multiple criteria has become more and more important, as well as the consideration of patient-reported measures. Considerations of costs are not always explicit and consistent.
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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.
| | | | - Tania Conte
- Center for Clinical Epidemiology and Evaluation, Vancouver, Canada
| | - Craig Mitton
- School of Population and Public Health, University of British Columbia (UBC), Vancouver, Canada
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Wang L, Homayra F, Pearce LA, Panagiotoglou D, McKendry R, Barrios R, Mitton C, Nosyk B. Identifying mental health and substance use disorders using emergency department and hospital records: a population-based retrospective cohort study of diagnostic concordance and disease attribution. BMJ Open 2019; 9:e030530. [PMID: 31300509 PMCID: PMC6629422 DOI: 10.1136/bmjopen-2019-030530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Administrative data are increasingly being used for surveillance and monitoring of mental health and substance use disorders (MHSUD) across Canada. However, the validity of the diagnostic codes specific to MHSUD is unknown in emergency departments (EDs). Our objective was to determine the concordance, and individual-level and hospital-level factors associated with concordance, between diagnosis codes assigned in ED and at discharge from hospital for MHSUD-related conditions. DESIGN Population-based retrospective cohort study. SETTING EDs and hospitals within Vancouver Coastal Health Authority (VCH), British Columbia, Canada. PARTICIPANTS 16 926 individuals who were admitted into a VCH hospital following an ED visit from 1 April 2009 to 31 March 2017, contributing to 48 116 pairs of ED and hospital discharge diagnoses. PRIMARY AND SECONDARY OUTCOME MEASURES We examined concordance in identifying MHSUD between the primary discharge diagnosis codes based on the International Statistical Classification of Diseases, 9th and 10th Revisions (Canada) assigned in the ED and those assigned in the hospital among all ED visits resulting in a hospital admission. We calculated the percent overall agreement, positive agreement, negative agreement and Cohen's kappa coefficient. We performed multiple regression analyses to identify factors independently associated with discordance. RESULTS We found a high level of concordance for broad categories of MH conditions (overall agreement=0.89, positive agreement=0.74 and kappa=0.67), and a fair level of concordance for SUDs (overall agreement=0.89, positive agreement=0.31 and kappa=0.27). SUDs were less likely to be indicated as the primary cause in ED as opposed to in hospital (3.8% vs 11.7%). In multiple regression analyses, ED visits occurring during holidays, weekends and overnight (21:00-8:59 hours) were associated with increased odds of discordance in identifying MH conditions (adjusted OR 1.47, 95% CI 1.11 to 1.93; 1.27, 95% CI 1.16 to 1.40; 1.30, 95% CI 1.19 to 1.42, respectively). CONCLUSIONS ED data could be used to improve surveillance and monitoring of MHSUD. Future efforts are needed to improve screening for individuals with MHSUD and subsequently connect them to treatment and follow-up care.
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Affiliation(s)
- Linwei Wang
- Epidemiology and Population Health Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Fahmida Homayra
- Epidemiology and Population Health Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Lindsay A Pearce
- Epidemiology and Population Health Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Dimitra Panagiotoglou
- Epidemiology and Population Health Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
| | - Rachael McKendry
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Rolando Barrios
- Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada
| | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Epidemiology and Population Health Unit, British Columbia Centre for Excellence in HIV/AIDS, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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Ezeife DA, Cusano ER, Fares AF, Sung M, Dionne F, Mitton C, Earle C, Chan KK, Leighl NB. A weighted criterion-based approach to value assessment of oncology drugs. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.15_suppl.6627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6627 Background: The rising cost of anti-cancer therapy has motivated recent efforts to quantify the overall value of new cancer treatments. Multi-criteria decision analysis offers a novel approach to establish an explicit framework to evaluate new cancer treatments. Methods: We recruited a diverse multi-stakeholder group who identified and weighted key criteria to establish the Drug Assessment Framework (DAF). Strength of evidence (SOE) modifiers deducted points for lower quality evidence. Through one-on-one meetings with stakeholders, face and content validity of the DAF were established in an iterative process. Construct validity assessed the degree to which DAF scores were associated with the pan-Canadian oncology drug review (pCODR) funding decisions and European Society for Medical Oncology Magnitude of Clinical Benefit score (ESMO-MCBS, version 1.1). Sensitivity analyses were performed on the final results. Results: The final validated DAF includes ten criteria: overall survival, progression-free survival, response rate, quality-of-life, toxicity, unmet need, equity, feasibility, disease severity and caregiver well-being. The first five clinical benefit criteria represent 64% of the total weight. DAF scores range from 0 to 300, reflecting both the expected impact of the drug and the quality of the supporting evidence. When the DAF was retrospectively applied to the last 60 drugs (in blinded fashion) reviewed by pCODR (2015-2018), the mean total DAF score was 94 (range, 18-179). Drugs with positive pCODR funding recommendation had higher DAF scores than drugs not recommended for reimbursement (103 vs. 63, t-test p = 0.0007). Funded drugs had fewer SOE points deducted than those that were not funded (median 0 vs. 24 points deducted, Wilcoxon p = 0.03). The correlation coefficient for DAF and ESMO-MCBS was 0.37 (95% CI, 0.10 to 0.59). Sensitivity analyses that varied the subjective criteria either positively or negatively did not change the results. Conclusions: Using a structured and explicit approach, a criterion-based valuation framework was designed and validated. The DAF can provide a transparent and consistent method to value and prioritize cancer drugs, in order to facilitate the delivery of affordable cancer care.
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Affiliation(s)
| | | | | | - Mike Sung
- University of Toronto, Toronto, ON, Canada
| | - Francois Dionne
- Centre for Clinical Epidemiology and Evaluation, Vancouver, BC, Canada
| | - Craig Mitton
- University of British Columbia, Vancouver, BC, Canada
| | - Craig Earle
- Ontario Institute for Cancer Research, Toronto, ON, Canada
| | - Kelvin K. Chan
- Sunnybrook Health Sciences Centre, Odette Cancer Centre, University of Toronto, Toronto, ON, Canada
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Rizzardo S, Bansback N, Dragojlovic N, Douglas C, Li KH, Mitton C, Marra C, Blanis L, Lynd LD. Evaluating Canadians' Values for Drug Coverage Decision Making. Value Health 2019; 22:362-369. [PMID: 30832975 DOI: 10.1016/j.jval.2018.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 05/28/2023]
Abstract
BACKGROUND Decision makers are facing growing challenges in prioritizing drugs for reimbursement because of soaring drug costs and increasing pressures on financial resources. In addition to cost and effectiveness, payers are using other values to dictate which drugs are prioritized for funding, yet there are limited data on the Canadian public's priorities. OBJECTIVES To measure the relative societal importance of values considered most relevant in informing drug reimbursement decisions in a representative sample of Canadians. METHODS An online survey of 2539 Canadians aged 19 years and older was performed in which 13 values used in drug funding prioritization were ranked and then weighted using an analytic hierarchy process. RESULTS Canadians value safe and efficacious drugs that have certainty of evidence. The values ranked in the top 5 by most of our subjects were potential effect on quality of life (65.4%), severity of the disease (62.6%), ability of drug to work (61.1%), safety (60.5%), and potential to extend life (49.4%). Values related to patient or disease characteristics such as rarity, socioeconomic status, and health and lifestyle choices held the lowest rankings and weights. CONCLUSIONS Canadians value, above all, treatment-related factors (eg, efficacy and safety) and disease-related factors (eg, severity and equity). Decision makers are currently using additional justifications to prioritize drugs for reimbursement, such as rarity and unmet need, which were not found to be highly valued by Canadians. Decision makers should integrate the public's values into a Canadian reimbursement framework for prioritization of drugs competing for limited funds.
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Affiliation(s)
- Shirin Rizzardo
- Pharmaceutical Services Division, British Columbia Ministry of Health, Victoria, BC, Canada
| | - Nick Bansback
- Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada; Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, BC, Canada
| | - Nick Dragojlovic
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Conor Douglas
- Department of Science and Technology Studies, York University, Toronto, ON, Canada
| | - Kathy H Li
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Craig Mitton
- Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Carlo Marra
- National School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Litsa Blanis
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Larry D Lynd
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, Vancouver, BC, Canada; Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada.
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Khowaja AR, Mitton C, Qureshi R, Bryan S, Magee LA, von Dadelszen P, Bhutta ZA. A comparison of maternal and newborn health services costs in Sindh Pakistan. PLoS One 2018; 13:e0208299. [PMID: 30521575 PMCID: PMC6283550 DOI: 10.1371/journal.pone.0208299] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 11/15/2018] [Indexed: 12/21/2022] Open
Abstract
Pakistani women suffer the highest rate of maternal mortality in South Asia. A lack of comprehensive knowledge about maternal and newborn health (MNH) services costs impedes policy decisions to maximize the benefit from existing, as well as emerging, MNH interventions in Pakistan. We compared MNH service costs at different levels of care. A cross-sectional survey was conducted during January to March 2016 as part of a large economic evaluation in Sindh, Pakistan. Health providers and facilities were selected from a sampling frame, inclusive of public and private sectors. This study utilized a broad perspective (i.e. costs to the health system and patients/families). The unit costs of MNH services were determined through a simultaneous allocation method in the public facilities; and patient billing department in the private facilities. Descriptive analysis was performed, and an analysis of variance (ANOVA) test was applied to compare overall mean costs both within and between health facilities. A total of 31 eligible health providers and facilities (n = 25 in private; n = 7 in public) were included in the final analysis. An ambulatory visit (AV) for routine antenatal care (ANC) costs $3.6 and $0.9 at secondary- and tertiary-level public facilities, respectively. In the private sector, the costs of an AV for ANC were slightly less ($2.8) at secondary-level and much higher ($6) at tertiary-level facilities compared to the public sector. Diagnostic test costs were much higher in private facilities. The average costs of inpatient admissions were $30.5 at general ward (GW), and $151 at the intensive care unit (ICU) in public facilities. In-patient admissions costs were lower such as $9.3 at GW and $36.5 at ICU in private facilities. Understanding cost is critical to guide decisions of resource allocation within the public sector; and risk mitigation for excessive OOP costs through third party payer for services in the private sector.
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Affiliation(s)
- Asif Raza Khowaja
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
- Centre for Clinical Epidemiology and Evaluation and School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation and School of Population and Public Health, University of British Columbia, Vancouver, Canada
- * E-mail:
| | - Rahat Qureshi
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
| | - Stirling Bryan
- Centre for Clinical Epidemiology and Evaluation and School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Laura A. Magee
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine King's College London, United Kingdom
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, Canada
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine King's College London, United Kingdom
| | - Zulfiqar A. Bhutta
- Division of Women & Child Health, Aga Khan University, Karachi, Pakistan
- Program for Global Pediatric Research, Hospital For Sick Children, Toronto, Canada
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Affiliation(s)
- William Hall
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada.
| | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada
| | - Adrian Levy
- Department of Community Health and Epidemiology, University of Dalhousie, Halifax, Nova Scotia, Canada
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Soril L, Mitton C, Seixas B, Bryan S, Clement F. Identifying and Prioritizing Low Value Care in British Columbia Using Three Administrative Health Data Assets. Int J Popul Data Sci 2018. [DOI: 10.23889/ijpds.v3i4.1010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
IntroductionClinical recommendations and/or lists of low value care (i.e., health technologies that provide little to clinical benefit for certain patient groups) have garnered attention internationally through campaigns such as Choosing Wisely. However, uptake of such recommendations at the healthcare system-level remains challenging in the absence of routine, data-driven processes.
Objectives and ApproachThe objective of this work was to develop and implement a process, leveraging administrative health data assets and lists of ‘low value’ care, to identify and prioritize technologies at the healthcare system-level for reassessment and potential disinvestment. The British Columbia (BC) healthcare system was selected as the pilot site to test the process. Three provincial administrative health databases were used to examine the extent of low value care across the system: the discharge abstract database (DAD); the Medical Service Plan (MSP) physician claims database; and the MSP laboratory database.
ResultsOver 1300 recommendations of low value technologies (i.e., from the National Institute for Health and Care Excellence “do not do” recommendations, low value technologies in the Australian Medical Benefits Schedule, and Choosing Wisely “Top 5” lists) were identified. Using appropriate coding systems for BC’s administrative health data (e.g., International Classification of Diseases), low value technologies were queried to examine frequencies and costs of technology use between fiscal years 2010/11 and 2014/15. This information was used to rank technologies based high budgetary impact, defined as total in-hospital and claims expenditures exceeding $1M in any fiscal year examined. Clinical experts reviewed the ranked technologies prior to dissemination and stakeholder action. Pilot testing resulted in the prioritization of 9 candidate technologies for reassessment in the BC healthcare system.
Conclusion/ImplicationsThis work demonstrates the feasibility and strength of using administrative data to identify low value care at the healthcare system-level and prioritize candidates for reassessment. Faced with increasing pressure to control exorbitant costs, while maintaining quality of care, this process has been adopted and operationalized by the BC Ministry of Health.
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Seixas BV, Smith N, Mitton C. The Qualitative Descriptive Approach in International Comparative Studies: Using Online Qualitative Surveys. Int J Health Policy Manag 2018; 7:778-781. [PMID: 30316225 PMCID: PMC6186482 DOI: 10.15171/ijhpm.2017.142] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 12/12/2017] [Indexed: 11/17/2022] Open
Abstract
International comparative studies constitute a highly valuable contribution to public policy research. Analysing different policy designs offers not only a mean of knowing the phenomenon itself but also gives us insightful clues on how to improve existing practices. Although much of the work carried out in this realm relies on quantitative appraisal of the data contained in international databases or collected from institutional websites, countless topics may simply not be studied using this type of methodological design due to, for instance, the lack of reliable databases, sparse or diffuse sources of information, etc. Here then we discuss the use of the qualitative descriptive approach as a methodological tool to obtain data on how policies are structured. We propose the use of online qualitative surveys with key stakeholders from each relevant national context in order to retrieve the fundamental pieces of information on how a certain public policy is addressed there. Starting from Sandelowski’s seminal paper on qualitative descriptive studies, we conduct a theoretical reflection on the current methodological proposition. We argue that a researcher engaged in this endeavour acts like a composite-sketch artist collecting pieces of information from witnesses in order to draw a valid depiction of reality. Furthermore, we discuss the most relevant aspects involving sampling, data collection and data analysis in this context. Overall, this methodological design has a great potential for allowing researchers to expand the international analysis of public policies to topics hitherto little appraised from this perspective.
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Affiliation(s)
- Brayan V Seixas
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - 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
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Soril LJJ, Seixas BV, Mitton C, Bryan S, Clement FM. Moving low value care lists into action: prioritizing candidate health technologies for reassessment using administrative data. BMC Health Serv Res 2018; 18:640. [PMID: 30111308 PMCID: PMC6094474 DOI: 10.1186/s12913-018-3459-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 08/09/2018] [Indexed: 11/25/2022] Open
Abstract
Background Active management of existing health technologies (e.g., devices, diagnostic, and/or medical procedures) to ensure the delivery of high value care is increasingly recognized around the world. A number of initiatives have raised awareness of technologies that may be overused, mis-used, or potentially harmful by compiling them into lists of low value care. However, despite the growing number of lists, changes to local healthcare practices remain challenging for many systems. The objective of this study was to develop and implement a process, leveraging existing initiatives and data assets, to produce a list of prioritized low value technologies for health technology reassessment (HTR). Methods An expert advisory committee comprised of clinical experts and health system decision-makers was convened to determine key process requirements. Once developed, the process was piloted to assess feasibility in the Canadian province of British Columbia (BC). Results The expert advisory committee identified five required attributes for the process: data-driven, routine and replicable, actionable, stakeholder collaboration, and high return on investment. Guided by these attributes, a 5-step process was developed. First, over 1300 published low value technologies (i.e., from the National Institute for Health and Care Excellence [NICE] “do not do” recommendations, low value technologies in the Australian Medical Benefits Schedule, and Choosing Wisely “Top 5” lists) were identified. Using appropriate coding systems for BC’s administrative health data (e.g., International Classification of Diseases [ICD]), the low value technologies were queried to examine frequencies and costs of technology use. This information was used to rank potential candidates for reassessment based on high annual budgetary impact. Lastly, clinical experts reviewed the ranked technologies prior to broad dissemination and stakeholder action. Pilot testing of the process in BC resulted in the prioritization of 9 initial candidate technologies for reassessment. Conclusions This is the first account of a systematic approach to move a collective body of low value technology recommendations into action in a healthcare setting. This work demonstrates the feasibility and strength of using administrative data to identify and prioritize low value technologies for HTR at a population-level. Electronic supplementary material The online version of this article (10.1186/s12913-018-3459-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lesley J J Soril
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Health Technology Assessment Unit, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Brayan V Seixas
- Centre for Clinical Epidemiology and 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
| | - Craig Mitton
- Centre for Clinical Epidemiology and 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
| | - Stirling Bryan
- Centre for Clinical Epidemiology and 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.,British Columbia SUPPORT Unit, Vancouver, BC, Canada
| | - Fiona M Clement
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada. .,Health Technology Assessment Unit, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada.
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Hall W, Williams I, Smith N, Gold M, Coast J, Kapiriri L, Danis M, Mitton C. Past, present and future challenges in health care priority setting. J Health Organ Manag 2018; 32:444-462. [PMID: 29771204 DOI: 10.1108/jhom-01-2018-0005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose Current conditions have intensified the need for health systems to engage in the difficult task of priority setting. As the search for a "magic bullet" is replaced by an appreciation for the interplay between evidence, interests, culture, and outcomes, progress in relation to these dimensions requires assessment of achievements to date and identification of areas where knowledge and practice require attention most urgently. The paper aims to discuss these issues. Design/methodology/approach An international survey was administered to experts in the area of priority setting. The survey consisted of open-ended questions focusing on notable achievements, policy and practice challenges, and areas for future research in the discipline of priority setting. It was administered online between February and March of 2015. Findings "Decision-making frameworks" and "Engagement" were the two most frequently mentioned notable achievements. "Priority setting in practice" and "Awareness and education" were the two most frequently mentioned policy and practical challenges. "Priority setting in practice" and "Engagement" were the two most frequently mentioned areas in need of future research. Research limitations/implications Sampling bias toward more developed countries. Future study could use findings to create a more concise version to distribute more broadly. Practical implications Globally, these findings could be used as a platform for discussion and decision making related to policy, practice, and research in this area. Originality/value Whilst this study reaffirmed the continued importance of many longstanding themes in the priority setting literature, it is possible to also discern clear shifts in emphasis as the discipline progresses in response to new challenges.
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Affiliation(s)
- William Hall
- Department of Medicine, University of British Columbia , Vancouver, Canada.,Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | | | - Neale Smith
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - Marthe Gold
- The City College of New York, New York, New York, USA
| | | | - Lydia Kapiriri
- Department of Medicine, McMaster University , Hamilton, Canada
| | - M Danis
- Howard Hughes Medical Institute, University of Chicago , Chicago, Illinois, USA
| | - Craig Mitton
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada.,School of Population and Public Health, University of British Columbia , Vancouver, Canada
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Hall W, Smith N, Mitton C, Urquhart B, Bryan S. Assessing and Improving Performance: A Longitudinal Evaluation of Priority Setting and Resource Allocation in a Canadian Health Region. Int J Health Policy Manag 2018; 7:328-335. [PMID: 29626400 PMCID: PMC5949223 DOI: 10.15171/ijhpm.2017.98] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 08/09/2015] [Indexed: 11/16/2022] Open
Abstract
Background: In order to meet the challenges presented by increasing demand and scarcity of resources, healthcare organizations are faced with difficult decisions related to resource allocation. Tools to facilitate evaluation and improvement of these processes could enable greater transparency and more optimal distribution of resources.
Methods: The Resource Allocation Performance Assessment Tool (RAPAT) was implemented in a healthcare organization in British Columbia, Canada. Recommendations for improvement were delivered, and a follow up evaluation exercise was conducted to assess the trajectory of the organization’s priority setting and resource allocation (PSRA) process 2 years post the original evaluation.
Results: Implementation of RAPAT in the pilot organization identified strengths and weaknesses of the organization’s PSRA process at the time of the original evaluation. Strengths included the use of criteria and evidence, an ability to reallocate resources, and the involvement of frontline staff in the process. Weaknesses included training, communication, and lack of program budgeting. Although the follow up revealed a regression from a more formal PSRA process, a legacy of explicit resource allocation was reported to be providing ongoing benefit for the organization.
Conclusion: While past studies have taken a cross-sectional approach, this paper introduces the first longitudinal evaluation of PSRA in a healthcare organization. By including the strengths, weaknesses, and evolution of one organization’s journey, the authors’ intend that this paper will assist other healthcare leaders in meeting the challenges of allocating scarce resources.
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Affiliation(s)
- William Hall
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Neale Smith
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Craig Mitton
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
| | - Bonnie Urquhart
- Planning and Performance Improvement, Northern Health Authority, Prince George, BC, Canada
| | - Stirling Bryan
- Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada.,School of Population and Public Health, The University of British Columbia (UBC), Vancouver, BC, Canada
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Seixas BV, Mitton C, Danis M, Williams I, Gold M, Baltussen R. Should Priority Setting Also Be Concerned About Profound Socio-Economic Transformations? A Response to Recent Commentary. Int J Health Policy Manag 2017; 6:733-734. [PMID: 29172383 PMCID: PMC5726326 DOI: 10.15171/ijhpm.2017.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Accepted: 07/11/2017] [Indexed: 11/09/2022] Open
Affiliation(s)
- Brayan V. Seixas
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
- Correspondence to: Brayan V. Seixas
| | - Craig Mitton
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Marion Danis
- National Institutes of Health, Bethesda, MD, USA
| | | | - Marthe Gold
- New York Academy of Medicine, New York City, NY, USA
- City College, New York City, NY, USA
| | - Rob Baltussen
- Radboud University Medical Center, Nijmegen, The Netherlands
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Affiliation(s)
- Jugpal S Arneja
- Division of Plastic Surgery, British Columbia Children's Hospital and University of British Columbia
| | - Craig Mitton
- Centre for Healthcare Management, Vancouver, British Columbia
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Polisena J, Burgess M, Mitton C, Lynd LD. Engaging the Canadian public on reimbursement decision-making for drugs for rare diseases: a national online survey. BMC Health Serv Res 2017; 17:372. [PMID: 28549479 PMCID: PMC5446683 DOI: 10.1186/s12913-017-2310-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 05/16/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Funding of drugs for rare diseases (DRDs) requires decisions that balance fairness for all individuals within the healthcare system with compassion for affected individuals. Our study objective was to conduct a national online survey to determine the Canadian public's perspective, including regional variations, associated with DRD decision-making. METHODS The survey collected responses from 1631 Canadians. Respondents were asked to rank at least three and up to five DRD decision-making priorities, out of a total of eight priorities presented. They were also asked to compare and rate their agreement level on a 5-point Likert scale with four funding scenarios described. The frequency of each priority, independent of where it was ranked in relation to the other priorities, was calculated. Regression analyses were conducted to measure the association between respondents' demographics and selected priorities with their agreement level for each funding scenario. RESULTS Among the survey respondents, Improved Quality of Life and Effective Health Care were most frequently selected as top priorities. Also, 79.2% of respondents agreed with equal access to DRDs across Canada, and 73.0% agreed with DRD funding if additional expenses are justified in the DRD's cost-effectiveness. Approximately half agreed to pay for DRDs independent of their effectiveness. There were no geographic differences in priorities. Selecting Effective Health Care in the top priorities was positively associated with both prioritizing other programs over programs for rare diseases and DRD funding only if deemed as cost-effective. Respondents, who selected National Access as one of the top priorities, were less likely to agree to fund DRDs only if deemed as cost-effective and were more likely to agree with the scenario to provide national access to DRDs. CONCLUSIONS The survey results suggest the level of public support for funding decisions and programs that incorporate assessment of the effectiveness of drugs for improving quality of life, and to promote similar access across Canada. The responses anticipate public responses to different policy scenarios and the priorities that underlie them. Decision-makers may find it useful to consider whether and how to incorporate these results into policy decisions and their justification to citizens and patients.
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Affiliation(s)
- Julie Polisena
- Canadian Agency for Drugs and Technologies in Health, 600-865 Carling Ave, Ottawa, K1S 5S8, ON, Canada.
| | - Michael Burgess
- W. Maurice Young Centre for Applied Ethics, School of Population and Public Health, University of British Columbia, Kelowna, BC, Canada
| | - Craig Mitton
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.,Centre for Clinical Epidemiology and Evaluation, Vancouver, BC, Canada
| | - Larry D Lynd
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada.,Centre for Health Evaluation and Outcomes Sciences, Providence Health Research Institute, Vancouver, BC, Canada
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Laba TL, Mitton C. A priority-setting framework is needed to understand the value of investing in a universal drug plan. CMAJ 2017; 189:E704. [PMID: 28507093 DOI: 10.1503/cmaj.732990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Tracey-Lea Laba
- Research Fellow, Centre for Clinical Epidemiology and Evaluation, and School of Population and Public Health, The University of British Columbia, Vancouver, BC; Menzies Centre for Health Policy, University of Sydney, Sydney, Australia
| | - Craig Mitton
- Professor, Centre for Clinical Epidemiology and Evaluation, and School of Population and Public Health, The University of British Columbia, Vancouver, BC
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Baltussen R, Mitton C, Danis M, Williams I, Gold M. Global Developments in Priority Setting in Health. Int J Health Policy Manag 2017; 6:127-128. [PMID: 28812791 PMCID: PMC5337249 DOI: 10.15171/ijhpm.2017.10] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Accepted: 01/21/2017] [Indexed: 01/26/2023] Open
Abstract
Countries around the world are experiencing an ever-increasing need to make choices in investments in health and healthcare. This makes it incumbent upon them to have formal processes in place to optimize the legitimacy of eventual decisions. There is now growing experience among countries of the implementation of stakeholder participation, and a developing convergence of methods to support decision-makers within health authorities in making tough decisions when faced with the stark reality of limited resources. We call for further interaction among health authorities, and the research community to develop best practices in order to confront the difficult choices that need to be made.
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Affiliation(s)
- Rob Baltussen
- Radboud University Medical Center, Nijmegen, The Netherlands
| | - Craig Mitton
- University of British Columbia, Vancouver, BC, Canada
| | - Marion Danis
- National Institutes of Health, Bethesda, MD, USA
| | | | - Marthe Gold
- New York Academy of Medicine, New York City, NY, USA
- City College, New York City, NY, USA
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Khowaja AR, Mitton C, Qureshi R, Bryan S, Magee LA, von Dadelszen P, Bhutta ZA. SOCIETAL PERSPECTIVE ON COST DRIVERS FOR HEALTH TECHNOLOGY ASSESSMENT IN SINDH, PAKISTAN. Int J Technol Assess Health Care 2017; 33:192-198. [PMID: 28587686 PMCID: PMC5934709 DOI: 10.1017/s0266462317000320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Understanding cost-drivers and estimating societal costs are important challenges for economic evaluation of health technologies in low- and middle-income countries (LMICs). This study assessed community experiences of health resource usage and perceived cost-drivers from a societal perspective to inform the design of an economic model for the Community Level Interventions for Pre-eclampsia (CLIP) trials. METHODS Qualitative research was undertaken alongside the CLIP trial in two districts of Sindh province, Pakistan. Nine focus groups were conducted with a wide range of stakeholders, including pregnant women, mothers-in-law, husbands, fathers-in-law, healthcare providers at community and health facility-levels, and health decision/policy makers at district-level. The societal perspective included out-of-pocket (OOP), health system, and program implementation costs related to CLIP. Thematic analysis was performed using NVivo software. RESULTS Most pregnant women and male decision makers reported a large burden of OOP costs for in- and out-patient care, informal care from traditional healers, self-medication, childbirth, newborn care, transport to health facility, and missed wages by caretakers. Many healthcare providers identified health system costs associated with human resources for hypertension risk assessment, transport, and communication about patient referrals. Health decision/policy makers recognized program implementation costs (such as the mobile health infrastructure, staff training, and monitoring/supervision) as major investments for the health system. CONCLUSIONS Our investigation of care-seeking practices revealed financial implications for families of pregnant women, and program implementation costs for the health system. The societal perspective provided comprehensive knowledge of cost drivers to guide an economic appraisal of the CLIP trial in Sindh, Pakistan.
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Affiliation(s)
- Asif Raza Khowaja
- Department of Obstetrics and Gynaecology,and British Columbia Children's Hospital,University of British Columbia,Centre for Clinical Epidemiology and Evaluation,Vancouver Coastal Health Research Institute,Division of Women & Child Health,Aga Khan University
| | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation,Vancouver Coastal Health Research Institute,School of Population and Public Health,University of British Columbia,
| | - Rahat Qureshi
- Division of Women & Child Health,Aga Khan University
| | - Stirling Bryan
- Centre for Clinical Epidemiology and Evaluation,Vancouver Coastal Health Research Institute,School of Population and Public Health,University of British Columbia
| | - Laura A Magee
- Molecular and Clinical Sciences Research Institute,St George's,University of London,Department of Obstetrics and Gynaecology,St George's University Hospitals NHS Foundation Trust
| | - Peter von Dadelszen
- Molecular and Clinical Sciences Research Institute,St George's,University of London,Department of Obstetrics and Gynaecology,St George's University Hospitals NHS Foundation Trust
| | - Zulfiqar A Bhutta
- Division of Women & Child Health,Aga Khan University,Program for Global Pediatric Research,Hospital For Sick Children,Toronto
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Conte T, Mitton C, Erdelyi S, Chavoshi N, Siden H. Pediatric Palliative Care Program versus Usual Care and Healthcare Resource Utilization in British Columbia: A Matched-Pairs Cohort Study. J Palliat Med 2016; 19:1218-1223. [DOI: 10.1089/jpm.2016.0177] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tania Conte
- Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Shannon Erdelyi
- Centre for Clinical Epidemiology and Evaluation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Negar Chavoshi
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
- Canuck Place Children's Hospital
| | - Harold Siden
- Canuck Place Children's Hospital
- Child and Family Research Institute
- Division of General Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
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Smith N, Mitton C, Hiltz MA, Campbell M, Dowling L, Magee JF, Gujar SA. A Qualitative Evaluation of Program Budgeting and Marginal Analysis in a Canadian Pediatric Tertiary Care Institution. Appl Health Econ Health Policy 2016; 14:559-568. [PMID: 27289589 DOI: 10.1007/s40258-016-0250-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Hospitals in Canada are being asked by governments to improve efficiency and do more with fewer resources. Healthcare decision makers are thus driven to find better ways to manage budgets and deliver on their mission. Formal processes of priority setting and resource allocation (PSRA) are one means to this end. OBJECTIVE This paper reports an evaluation of one such approach, Program Budgeting and Marginal Analysis (PBMA), as applied at a children and women's tertiary care facility in Nova Scotia, Canada. A brief evaluation conducted immediately after the conclusion of the PBMA process was supplemented with a larger retrospective evaluation. METHODS The retrospective evaluation included 26 face-to-face individual interviews with senior and middle managers who took part in PBMA. Interview transcripts were analyzed against a template consisting of 19 elements of structure, process, attitudes, and outcomes associated with high performance in PSRA. RESULTS Respondents had a good experience with the implementation of PBMA, and considered it an improvement over past practice. Success was attributed to effective leadership, and substantial efforts to engage staff members. Understanding of economic and ethical principles of decision making was reportedly increased. Areas for improvement included ensuring that everyone participated in good faith, better communication of final results, and stronger follow-through to determine if anticipated changes and benefits in fact occurred. CONCLUSION The evaluation framework employed here proved useful in assessing the quality of this resource allocation exercise. The results are directly useful to local decision makers, and the identified strengths and weaknesses are broadly consistent with those reported in studies of other organizations.
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Affiliation(s)
- Neale Smith
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, 7th floor, 828 W 10th Avenue, Vancouver, BC, V5Z1M9, Canada.
| | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, 7th floor, 828 W 10th Avenue, Vancouver, BC, V5Z1M9, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, BC, V5Z1M9, Canada
| | - Mary-Ann Hiltz
- Quality and System Performance, IWK Health Centre, Halifax, NS, B3K6R8, Canada
| | - Matthew Campbell
- Quality and System Performance, IWK Health Centre, Halifax, NS, B3K6R8, Canada
| | - Laura Dowling
- Nova Scotia Health Authority, Halifax, NS, B3H1V7, Canada
| | - J Fergall Magee
- Pathology and Laboratory Medicine, University of Saskatchewan and Saskatoon Health Region, 103 Hospital Dr, Saskatoon, Sk, SK S7N0W8, Canada
| | - Shashi Ashok Gujar
- Quality and System Performance, IWK Health Centre, Halifax, NS, B3K6R8, Canada
- Faculty of Medicine, Dalhousie University, Halifax, NS, B3H1X5, Canada
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Schneeberg A, Ishikawa T, Kruse S, Zallen E, Mitton C, Bettinger JA, Brussoni M. A longitudinal study on quality of life after injury in children. Health Qual Life Outcomes 2016; 14:120. [PMID: 27561258 PMCID: PMC5000468 DOI: 10.1186/s12955-016-0523-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 08/18/2016] [Indexed: 12/04/2022] Open
Abstract
Background In high income countries, injuries account for 40 % of all child deaths, representing the leading cause of child mortality and a major source of morbidity. The need for studies across age groups, and use of health related quality of life measures that assess functional limitations in multiple health domains, with sampling at specific post-injury time points has been identified. The objective of this study was to describe the impact of childhood injury and recovery on health related quality of life (HRQoL) for the 12 months after injury. Methods In this prospective cohort study parents of children 0-16 years old attending British Columbia Children’s Hospital for an injury were surveyed over 12 months post-injury. Surveys assessed HRQoL at four points: baseline (pre-injury), one month, four to six months and 12 months post injury. Generalized estimating equation models identified factors associated with changes in HRQoL over time. Results A total of 256 baseline surveys were completed. Response rates for follow-ups at one, four and twelve months were 74 % (186), 67 % (169) and 64 % (161), respectively. The mean age of participants was 7.9 years and 30 % were admitted to the hospital. At baseline, a retrospective measure of pre-injury health, the mean HRQoL score was 90.7. Mean HRQoL ratings at one, four and 12 months post injury were 77.8, 90.3 and 91.3, respectively. Both being older and being hospitalized were associated with a steeper slope to recovery. Conclusions Although injuries are prevalent, the long term impacts of most childhood injuries are limited. Regardless of injury severity, most injured children recuperated quickly, and had regained total baseline status by four month post-injury. However, although hospitalization did not appear to impact long term psychosocial recovery, at four and 12 months post injury a greater proportion of hospitalized children continued to have depressed physical HRQoL scores. Both older and hospitalized children reported greater impact to HRQoL at one month post injury, and both had a steeper slope to recovery and were on par with their peers by four month.
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Affiliation(s)
- Amy Schneeberg
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada.,British Columbia Injury Research & Prevention Unit, F508 - 4480 Oak Street, Vancouver, BC, V6H 3 V4, Canada.,British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Takuro Ishikawa
- British Columbia Injury Research & Prevention Unit, F508 - 4480 Oak Street, Vancouver, BC, V6H 3 V4, Canada.,British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Sami Kruse
- British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Erica Zallen
- British Columbia Children's Hospital, Vancouver, BC, Canada
| | - Craig Mitton
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Julie A Bettinger
- British Columbia Children's Hospital, Vancouver, BC, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,Vaccine Evaluation Center, BC Children's Hospital, Vancouver, Canada
| | - Mariana Brussoni
- School of Population & Public Health, University of British Columbia, Vancouver, BC, Canada. .,British Columbia Injury Research & Prevention Unit, F508 - 4480 Oak Street, Vancouver, BC, V6H 3 V4, Canada. .,British Columbia Children's Hospital, Vancouver, BC, Canada. .,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.
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Smith N, Mitton C, Kershaw P. The reallocation challenge: Containing Canadian medical care spending to invest in the social determinants of health. Can J Public Health 2016; 107:e130-e132. [PMID: 27348100 DOI: 10.17269/cjph.107.5184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 01/20/2016] [Accepted: 11/06/2015] [Indexed: 11/17/2022]
Abstract
We argue that Canadian provincial governments should contain medical care spending in order to invest more in the social determinants of health (SDH). Others have said this, many times. Doing it has not proven easy. We therefore emphasize the potential contribution of the priority-setting and resource allocation literature. This literature identifies formal tools and approaches that have built cultures of support for resource shifts, while providing pragmatic means for advancing efficiency and equity. Although reallocation towards SDH from other areas of the health care system is financially viable and supported by existing research, it will require new emphasis on the design of population health interventions that make reallocation politically expedient.
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Affiliation(s)
- Neale Smith
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, 7th Floor, 828 W 10th Avenue, Vancouver, BC, V5Z 1M9, Canada. .,School of Public Health, University of Alberta, Edmonton, AB, Canada.
| | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, 7th Floor, 828 W 10th Avenue, Vancouver, BC, V5Z 1M9, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
| | - Paul Kershaw
- School of Population and Public Health, University of British Columbia, Human Early Learning Partnership, Canada.,Founder, Generation Squeeze, Vancouver, BC, Canada
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Abstract
Objectives: Resource scarcity dictates the need for health organisations to set priorities. Although such activity should be based, at least in part, on evidence, there are limited examples in the literature of decision-makers reflecting on their use of evidence in priority-setting. Methods: A participatory action-research project was conducted in a single health authority in Alberta. It included in-depth interviews and focus groups with senior decision-makers both before and after development and implementation of a macro-level priority-setting framework (programme budgeting and marginal analysis, PBMA). Data were thematically coded and information on the use of evidence in priority-setting is reported. Results: Barriers to the use of evidence in priority-setting identified by decision-makers included crisis-orientated management, time constraints and a lack of skills. Decision-makers suggested using a mix of 'soft' and 'hard' forms of evidence in priority-setting. Following PBMA implementation, decision-makers wanted better information on capacity to benefit, but preferred to do this pragmatically from multiple sources of information rather than using a single metric. Conclusion: In examining the perspectives of decision-makers in using evidence to support priority-setting, valuable information was derived which should provide insight for such processes in other jurisdictions. The main finding of a desire for pragmatic assessment of benefit is informative for those involved in both decision-making and research.
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Affiliation(s)
- Craig Mitton
- Centre for Healthcare Innovation and Improvement, University of British Columbia, Canada
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Abstract
Due to resource scarcity, health organizations worldwide must decide what services to fund and, conversely, what services not to fund. One approach to priority setting, which has been widely used in Britain, Australia, New Zealand and Canada, is programme budgeting and marginal analysis (PBMA). To date, such activity has primarily been based at a micro level, within programmes of care. In order to institute and refine the PBMA framework at a macro level across major service areas within a single health authority, researchers and decision-makers in Alberta embarked on a participatory action research project together. This paper identifies key issues of importance to decision-makers in a real-world priority-setting context. Themes discussed include making comparisons across disparate patient groups, dealing with political factors, using relevant forms of evidence, recognizing innovations and involving the public. The in-depth insight gained through this qualitative analysis will enable future refinement of PBMA at a macro level in the health authority under study, and should also serve to inform priority-setting activity in regionalized contexts elsewhere. In identifying aspects of priority setting that are important to decision-makers, researchers can also be better informed with respect to realworld processes.
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Affiliation(s)
- San Patten
- Centre for Health and Policy Studies, University of Calgary, Calgary, Canada
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