Priority Setting In Health Care Research Articles

Production losses from morbidity and mortality by disease, age and sex in Norway.

The inclusion of production losses in health care priority setting is extensively debated. However, few studies allow for a comparison of these losses across relevant clinical and demographic categories. Our objective was to provide comprehensive estimates of Norwegian production losses from morbidity and mortality by age, sex and disease category. National registries, tax records, labour force surveys, household and population statistics and data from the Global Burden of Disease were combined to estimate production losses for 12 disease categories, 38 age and sex groups and four causes of production loss. The production losses were estimated via lost wages in accordance with a human capital approach for 2019. The main causes of production losses in 2019 were mental and substance use disorders, totalling NOK121.6bn (32.7% of total production losses). This was followed by musculoskeletal disorders, neurological disorders, injuries, and neoplasms, which accounted for 25.2%, 7.4%, 7.4% and 6.5% of total production losses, respectively. Production losses due to sick leave, disability insurance and work assessment allowance were higher for females than for males, whereas production losses due to premature mortality were higher for males. The latter was related to neoplasms, cardiovascular disease and injuries. Across age categories, non-fatal conditions with a high prevalence among working populations caused the largest production losses. The inclusion of production losses in health care priority debates in Norway could result in an emphasis on chronic diseases that occur among younger populations at the expense of fatal diseases among older age groups.

Comparison of Rare and Common Diseases in the Setting of Healthcare Priorities: Evidence of Social Preferences Based on a Systematic Review.

In light of the limited availability of healthcare resources, providing universal access to healthcare is a challenging task. As a result, prioritizing healthcare services has emerged as a crucial issue. This study aims to explore the preferences of the public regarding healthcare prioritization for rare and common diseases. By examining public attitudes, this study seeks to inform government decisions concerning resource allocation and distribution within healthcare. "Social preference" and "rare disease" were searched as MeSH terms in the electronic databases of Ovid Medline, Web of Science, Embase, and Econlit for articles published since their establishment, and the information on the characteristics of the articles and the results of social preferences for rare diseases were analyzed and summarized. The public held predominantly neutral views on the setting of healthcare priorities for rare and common diseases. The results of the included studies showed that with all else being equal, no social preference for rarity was found, but when the public considered the proportional advantage of rare diseases or when the respondents were young, a social preference for rarity existed. In addition, the public weighed attributes such as the health benefits of treatments, the effectiveness of treatment options, the safety of treatment, equity, unmet needs, and disease severity in the process of setting of treatment priorities for rare diseases. Furthermore, in consideration of equity, the public showed a willingness to pay for rare diseases in spite of the high medical costs. International studies on social preferences provide some evidence for the setting of healthcare priorities for rare diseases, and health policymakers should consider social preferences in an integrated manner in order to set healthcare priorities appropriately.

Factors influencing institutionalization of health technology assessment in Kenya

BackgroundThere is a global interest in institutionalizing health technology assessment (HTA) as an approach for explicit healthcare priority-setting. Institutionalization of HTA refers to the process of conducting and utilizing HTA as a normative practice for guiding resource allocation decisions within the health system. In this study, we aimed to examine the factors that were influencing institutionalization of HTA in Kenya.MethodsWe conducted a qualitative case study using document reviews and in-depth interviews with 30 participants involved in the HTA institutionalization process in Kenya. We used a thematic approach to analyze the data.ResultsWe found that institutionalization of HTA in Kenya was being supported by factors such as establishment of organizational structures for HTA; availability of legal frameworks and policies on HTA; increasing availability of awareness creation and capacity-building initiatives for HTA; policymakers’ interests in universal health coverage and optimal allocation of resources; technocrats’ interests in evidence-based processes; presence of international collaboration for HTA; and lastly, involvement of bilateral agencies. On the other hand, institutionalization of HTA was being undermined by limited availability of skilled human resources, financial resources, and information resources for HTA; lack of HTA guidelines and decision-making frameworks; limited HTA awareness among subnational stakeholders; and industries’ interests in safeguarding their revenue.ConclusionsKenya’s Ministry of Health can facilitate institutionalization of HTA by adopting a systemic approach that involves: - (a) introducing long-term capacity-building initiatives to strengthen human and technical capacity for HTA; (b) earmarking national health budgets to ensure adequate financial resources for HTA; (c) introducing a cost database and promoting timely data collection to ensure availability of data for HTA; (d) developing context specific HTA guidelines and decision-making frameworks to facilitate HTA processes; (e) conducting deeper advocacy to strengthen HTA awareness among subnational stakeholders; and (f) managing stakeholders’ interests to minimize opposition to institutionalization of HTA.

Should relational effects be considered in health care priority setting?

It is uncontroversial to claim that the extent to which health care interventions benefit patients is a relevant consideration for health care priority setting. However, when effects accrue to the individual patient, effects of a more indirect kind may accrue to other individuals as well, such as the patient's children, friends, or partner. If, and if so how, such relational effects should be considered relevant in priority setting is contentious. In this paper, we illustrate this question by using disease-modifying drugs for Alzheimer's disease as a case in point. The ethical analysis begins by sketching the so-called prima facie case for ascribing moral weight to relational effects and then moves on to consider a number of objections to it. We argue that, whereas one set of objections may be dismissed, there is another set of arguments that poses more serious challenges for including relational effects in priority setting.

Preventing pressure injury in open-heart surgical patients: A systematic review.

Cardiac surgical patients are highly prone to developing surgery-related Pressure injuries (PIs). Prevention of PIs is an important patient safety priority in healthcare settings and patients care. So the aim of this study is to detect the effectiveness of prevention strategies to decrease PIs prevalence and incidence in patients undergoing open heart surgery. We identified studies through Web of Science, Scopus, PubMed, Cochrane, and ProQuest databases from inception through September 2022 with restrictions on the English language. Cochrane RoB 2, JBI, and NIH checklist were carried out as critical appraisal Tools to investigate the studies risk of bias. Finally, 10 studies with a total sample No. 1348, which fulfilled eligibility criteria were included in final systematic review. Most common interventions investigated in included studies were addressing impairments skin care which included the use of multilayer silicone foam, Care bundle and multiple intervention programs, alternative head inflatable pads, pressure-reducing foam mattresses, and electric bed frames as the effective PIs Prevention (PIP) strategies. While repositioning is one of the important causes mentioned in most PIP protocols, there was not adequate evidence to recommend any special turning regimens for PIP. Given current evidence, multilayer silicone foam, Care bundle and multiple intervention programs, alternative inflatable head pads, pressure-reducing foam mattresses, and electric bed frames are effective strategies to prevent pressure ulcers. Further investigations are needed to specify the cost-effectiveness of mentioned strategies and RCTs to determine other PIP strategies such as repositioning and mobilization, nutritional supplementation, creams, and co-interventions effects.

Justification of principles for healthcare priority setting: the relevance and roles of empirical studies exploring public values

How should scarce healthcare resources be distributed? This is a contentious issue that became especially pressing during the pandemic. It is often emphasised that studies exploring public views about this...

OP28 Health Technology Assessment: A Situation Analysis Of Zimbabwe

IntroductionWith ever increasing burden of disease and limited resources, health technology assessment (HTA) is required for efficient resources allocation and priority setting in healthcare. The objective of this study was to establish the baseline HTA evidence generation and use in Zimbabwe.MethodsIn 2019, we convened a stakeholder workshop on HTA at the University of Zimbabwe. Presentations on HTA processes, current healthcare reimbursement model, priority setting in the Ministry of Health and selection of medicines into the treatment guidelines, were done by the experts. We adapted the Health Intervention and Technology Assessment Program questionnaire for situational analysis of HTA introduction at national level and administered it among the workshop participants. We report the baseline information on HTA situation, the need, demand and supply of HTA in Zimbabwe obtained from the presentations and responses from workshop participants.ResultsA total of 33 participants attended the workshop. Participants indicated that there is no formal HTA agency or process in Zimbabwe. The selection of medicines into treatment guideline is determined by disease burden, safety, efficacy and cost data, and it is done by a group of experts. The Association of Healthcare Funders of Zimbabwe (AFHOZ) reported that private healthcare funders use resource-based relative value scale system to determine tariffs and reimbursement levels. The regulator requires safety, efficacy and product quality data for the registration of medicines. Transparency in decision-making, registration of heath technology and formulation of essential medicines and treatment guidelines were reported as the major needs of HTA. The major users of HTA outputs were reported as medicines regulator, AFHOZ and Ministry of Health. Key suppliers of HTA evidence are academic and clinical research institutions and healthcare workers. Lack of training in health economics was cited as the major challenge to supply of HTA evidence.ConclusionsThere is a need to institute a formal, systematic and transparent processes of determining value of health technologies.

Comparing an in-person workshop and a postal Delphisurvey for involving health service users in health care and health research prioritization.

To involve health service users in health care and health research priority setting, different methods exist. Which method is most suitable under which circumstances is unknown. We compared a postal Delphi survey and an in-person workshop to involve health service users in priority settings for rehabilitative care and research in Germany. One hundred and eighty-four former rehabilitants were randomly assigned to a postal Delphi survey (n = 152) or an in-person workshop (n = 32). Two hundred and seventy-sixemployees in rehabilitation were also invited to the Delphi Survey. The methodological comparison refers only to the sample of rehabilitants. Within each method, the participants agreed on the top 10 priorities for practice improvement and research in rehabilitative care. The priorities were compared descriptively. Participants' satisfaction was measured with the Public and Patient Engagement Evaluation Tool. The usability of both methods was compared based on the effort, time and material costs required for implementation. Seventy-five formerrehabilitants and 41 employees in rehabilitation completed both Delphi survey rounds. Eleven former rehabilitants participated in the in-person workshop. Priorities for practice improvement showed a high degree of overlap between both methods whereas research priorities differed greatly. Participants of the in-person workshop felt significantly better prepared, more listened to and more likely to feel that different views on the topics were discussed. Participants of the Delphi survey expressed difficulties in understanding all survey questions. The Delphi survey was more elaborate in preparation and implementation but caused lower material costs. The differences in research priorities between the two methods could be due to the different samples, differences in the individual interests of participants or differences in the prioritization process. In-person workshops seem to be more appropriate for complex topics, where clarifications of questions and deeper discussions are needed. Delphi surveys seem to be more suitable for easily understandable topics, larger sample sizes and when fewer financial resources are available. The different study phases were supported by employees in rehabilitation and former rehabilitants (e.g., developing study documents, and interpreting results).

The prominence effect in health-care priority setting

AbstractPeople often choose the option that is better on the most subjectively prominent attribute — the prominence effect. We studied the effect of prominence in health care priority setting and hypothesized that values related to health would trump values related to costs in treatment choices, even when individuals themselves evaluated different treatment options as equally good. We conducted pre-registered experiments with a diverse Swedish sample and a sample of international experts on priority setting in health care (n = 1348). Participants, acting in the role of policy makers, revealed their valuation for different medical treatments in hypothetical scenarios. Participants were systematically inconsistent between preferences expressed through evaluation in a matching task and preferences expressed through choice. In line with our hypothesis, a large proportion of participants (General population: 92%, Experts 84% of all choices) chose treatment options that were better on the health dimension (lower health risk) despite having previously expressed indifference between those options and others that were better on the cost dimension. Thus, we find strong evidence of a prominence effect in health-care priority setting. Our findings provide a psychological explanation for why opportunity costs (i.e., the value of choices not exercised) are neglected in health care priority setting.

Challenges and Opportunities for Deliberative Processes for Healthcare Decision-Making Comment on "Evidence-Informed Deliberative Processes for Health Benefit Package Design - Part II: A Practical Guide".

The second edition of the practical guide for evidence-informed deliberative processes (EDPs) is an important addition to the growing guidance on deliberative processes supporting priority setting in healthcare. While the practical guide draws on an extensive amount of information collected on established and developing processes within a range of countries, EDPs present health technology assessment (HTA) bodies with several challenges. (1) Basing recommendations on current processes that have not been well-evaluated and that have changed over time may lead to weaker legitimacy than desired. (2) The requirement for social learning among stakeholders may require increased resourcing and blur the boundary between moral deliberation and political negotiation. (3) Robust evaluation should be based on an explicit theory of change, and some process outcomes may be poor guides to overall improvement of EDPs. This comment clarifies and reinforces the recommendations provided in the practical guide.

Integrating Citizens Juries and Discrete Choice Experiments: Methodological issues in the measurement of public values in healthcare priority setting

All health systems struggle with unlimited needs for healthcare, yet limited resources with which to address them. Under national health insurance systems, policymakers must make explicit and potentially contested decisions around resource allocation. Policymakers have recognized the need to include public values in decisions regarding the distribution of resources across competing health priorities. Given the complex nature of these decisions, however, research into how to effectively measure public preferences is underdeveloped. Measuring community values poses special challenges since they involve normative judgments that can be interpreted differently across individuals and communities. Researchers have previously proposed integrating two methods that are currently used for measuring public preferences around healthcare services: i) an individual survey instrument, the Discrete Choice Experiment (DCE) and ii) a group-based model that incorporates informed opinions and deliberative dialogue, Citizen Juries (CJs). This current paper proposes a framework for implementing that integration and assesses methodological issues in the integration of DCEs and CJs, including issues of generalizability and validity. CJs and DCEs have conflicting epistemological and methodological foundations, which impact how researchers might analyze results of the integrated method. Researchers and policymakers interested in measuring social values should determine the philosophical orientation of their research question prior to study design, which will assist in choosing an appropriate research method. Further research is needed to investigate the empirical validity of the integrated method and how it may be implemented to maximize public acceptance. Advancing these methods can provide an improved instrument for capturing public preferences for policymakers tasked with priority setting in diverse contexts.

Setting Health-Care Priorities: A Reply to Piotr Lichacz

I discuss the comments from Professor Piotr Lichacz on my book, Setting Health-Care Priorities. What Ethical Theories Tell Us (New York: OUP, 2019). The idea that our reluctance to let go of life and abstain from marginal life extension is irrational is defended against his criticism. The methodology used in the book—urging us to rely in our testing on ethical theories on the content of our considered moral intuitions—is explained at length and the notion of cognitive psychotherapy involved in it is defended.

Tricky Intuitions

This article is a critical discussion of the book Setting Health-Care Priorities by Torbjörn Tännsjö. This critique targets mainly Tännsjö’s method, but also several unjustified conclusions and some implicit assumptions.

The sociology of rationing: Towards increased interdisciplinary dialogue ‐ A critical interpretive literature review

Since the 1990s, the sociology of rationing has developed in explicit opposition to health economic and bioethical approaches to healthcare rationing. This implies a limited engagement with other disciplines and a limited impact on political debates. To bring the sociology of rationing into an interdisciplinary dialogue, it is important to understand the disciplines' analytical differences and similarities. Based on a critical interpretive literature synthesis, this article examines four disciplinary perspectives on healthcare rationing and priority setting: (1) Health economics, which seeks to develop decision models to provide for more rational resource allocation; (2) Bioethics, which seeks to develop normative principles and procedures to facilitate a just allocation of resources; (3) Health policy studies, which focus on issues of legitimacy and implementation of decision models; and lastly (4) Sociology, which analyses the uncertainty of rationing and the resulting value conflicts and negotiations. The article provides an analytical overview and suggestions on how to advance the impact of sociological arguments in future rationing debates: Firstly, we discuss how to develop the concepts and assumptions of the sociology of rationing. Secondly, we identify specific themes relevant for sociological inquiry, including the recurring problem of how to translate administrative priority setting decisions into clinical practice.

Predictors of Compliance to Hand Hygiene among Health Care Workers in Rwanda

BackgroundHand hygiene is critical to the prevention of Healthcare Acquired Infections. Compliance of health care workers to hand hygiene in developing countries is reportedly low.ObjectiveThe aim of this study was to assess predictors of hand hygiene compliance among healthcare workers in RwandaMethodsThis cross-sectional study was conducted in 26 selected hospitals. Trained hospital IPC focal points anonymously observed 1380 hand hygiene opportunities from 341 healthcare workers. Logistic regression analysis was used to identify predictors of compliance to hand hygiene among health care workers using Stata.ResultsThe overall compliance to HH was 72.4%. It was respectively 70%, 77% and 60% less likely in labor (AOR=0.30, 95% CI: 0.19-0.49), maternity (AOR= 0.27, 95% CI: 0.17-0.43), and neonatology (AOR= 0.40 95% CI: 0.25-0.65) departments than in theater. Other clinical staff than nurses/midwives were 35% less likely to comply than did medical doctors. The availability of water source and soap at hand washing station was associated with 2.5 times higher odds of compliance (AOR=2.46, 95% CI: 1.27-4.77).ConclusionThe compliance to HH is associated with the availability of hand hygiene facilities. Well-maintained water sources and soap at hand washing stations should be a priority in health care settings.
 Rwanda J Med Health Sci 2022;5(2):170-179

Public Attitudes Toward Priority Setting Principles in Health Care During COVID-19.

What role should cost-effectiveness play in health care priority setting? We assess the level of acceptance toward different priority setting principles in health care during COVID-19 and in general, thereby exploring public support for principles presented at different levels of abstraction. An online survey was distributed to a diverse sample of the Swedish population (n = 1 553). The results show that respondents were generally more supportive of priority setting principles when expressed in general abstract terms than when expressed in more case specific concrete terms. However, prioritization based on cost-effectiveness was deemed as more acceptable when expressed in concrete terms related to health maximization rather than as an abstract principle. Respondents had a general inclination in support of physicians and other health care professionals the primary responsibility for the allocation of scarce resources in the healthcare during COVID-19, while being less supportive of health economists and politicians being involved in these decisions.

Public participation: healthcare rationing in the newspaper media

BackgroundIt is impossible to meet all healthcare demands, but an open and fair rationing process may improve the public acceptability of priority setting in healthcare. Decision-making is subject to scrutiny by newspaper media, an important public institution and information source for discussions about rationing. In Norway, healthcare rationing has been subject to public debate both before and after the establishment of “The National System for Managed Introduction of New Health Technologies within the Specialist Health Service” (New Methods) in 2013.AimTo describe and assess the development of the public debate on Norwegian healthcare rationing through three cases in print media.MethodsWe purposively sampled Norwegian newspaper articles between 2012 and 2018 concerning three reimbursement decisions in the Norwegian system. The reimbursement decisions were ipilimumab (Yervoy, n = 45) against metastatic melanoma, nivolumab (Opdivo, n = 23) against non-small cell lung cancer, and nusinersen (Spinraza, n = 68) against spinal muscular atrophy. Cases were analysed separately using the qualitative method of systematic text condensation.ResultsOur analysis highlighted four common themes—money, rationales, patient stories, and process—and a unique theme for each case. Ipilimumab was uniquely themed by rationing rejection, nivolumab by healthcare two-tiering, and Spinraza by patients’ rights. We found wide media deliberation among a multitude of stakeholders in all cases. Perceptions of rationing were found to be chiefly aligned with previous empirical research. We found that the media reported more frequently on opposition to rationing compared to findings from previous studies on Norwegian healthcare decision-making attitudes. We think this was influenced by our selection of cases receiving extraordinary media attention, and from media sources being subject to political communication from special interest groups.ConclusionWe observed that the introduction of New Methods institutionalised Norwegian healthcare rationing and isolated the public debate into conversations between stakeholders and decision makers outside the political sphere. The findings from these three extraordinary debates are not generalisable and should be seen as a stakeholder learning opportunity regarding media coverage and engagement with expensive specialist healthcare decision-making in Norway.

Equity, justice, and social values in priority setting: a qualitative study of resource allocation criteria for global donor organizations working in low-income countries

BackgroundThere is increasing acceptance of the importance of social values such as equity and fairness in health care priority setting (PS). However, equity is difficult to define: the term means different things to different people, and the ways it is understood in theory often may not align with how it is operationalized. There is limited literature on how development assistance partner organizations (DAP) conceptualize and operationalize equity in their health care prioritization decisions that affect low-income countries (LIC). This paper explores whether and how equity is a consideration in DAP priority setting processes.MethodsThis was a qualitative study involving 38 in-depth interviews with DAPs involved in health-system PS for LICs and a review of their respective webpages.ResultsWhile several PS criteria were identified, direct articulation of equity as an explicit criterion was lacking. However, the criterion was implied in some of the responses in terms of prioritizing vulnerable populations. Where mentioned, respondents discussed the difficulties of operationalizing equity as a PS criterion since vulnerability is associated with several varying and competing factors including gender, age, geography, and income. Some respondents also suggested that equity could be operationalized in terms of an organization not supporting the pre-existing inequities.Although several organizations’ webpages identify addressing inequities as a guiding principle, there were variations in how they spoke about its operationalization. While intersectionalities in vulnerabilities complicate its operationalization, if organizations explicitly articulate their equity focus the other organizations who also have equity as a guiding principle may, instead of focusing on the same aspect, concentrate on other dimensions of vulnerability. That way, all organizations will contribute to achieving equity in all the relevant dimensions.ConclusionsSince most development organizations support some form of equity, this paper highlights a need for an internationally recognized framework that recognizes the intersectionalities of vulnerability, for mainstreaming and operationalizing equity in DAP priority setting and resource allocation. Such a framework will support consistency in the conceptualization of and operationalization of equity in global health programs. There is a need for studies which to assess the degree to which equity is actually integrated in these programs.

Differences between expert reported and patient reported burden of disease rankings

Many attempted to develop burden of disease rankings for the purpose of resource allocation, priority setting, cost-effectiveness evaluation, and service development in healthcare. As this proved difficult the World Health Organization commissioned expert panels to develop internally consistent burden of disease rankings. Although these rankings provide valuable insight in the biomedical burden of different diseases, they do not yet provide insight in the psychological burden of different diseases experienced and reported by patients on a daily basis. Since expert reported and patient reported burden of disease could differ, deviations between expert reported and patient reported burden of disease rankings are likely. To explore how these rankings differ, it is important to develop patient reported burden of disease rankings and compare these to expert reported burden of disease rankings. In this study patient reported burden of disease rankings were developed by ranking the subjective health experience of patients. To measure subjective health experience an online questionnaire was administered to a large panel of Dutch citizens. The final sample consisted of 58,490 panel members. This final sample contained 36 diseases and was largely representative of the Dutch population. The data were analysed by using reliability tests, descriptive statistics and Spearman rank-order correlation coefficients. This study shows that expert reported and patient reported burden of disease rankings could differ. Burden of cardiovascular diseases ranks low on patient reported burden of disease rankings, while it ranks higher on expert reported burden of disease rankings. Burden of psychiatric diseases and gastrointestinal diseases ranks high on patient reported burden of disease rankings, while it ranks lower on expert reported burden of disease rankings. Burden of pain diseases ranks high on patient reported burden of disease rankings, while it is still overlooked in expert reported burden of disease rankings. This study suggests that it can be beneficial to develop and utilize patient reported burden of disease rankings in addition to the already existing expert reported burden of disease rankings in order to establish a more comprehensive perspective on burden of disease. This could improve decision-making on resource allocation, priority setting, cost-effectiveness evaluation, and service development in healthcare.

Setting Health-Care Priorities: A Reply to Massimo Reichlin

This is a short reply to Professor Reichlin’s comment on my book Setting Health-Care Priorities. What Ethical Theories Tell Us. The version of prioritarianism I rely on in the book is defended as the most plausible one. The general claim that there is convergence between all plausible theories on distributive justice is also defended with regard to assisted reproduction, disability, and enhancement.