Principles For Priority Setting Research Articles

Preparing popular views for inclusion in a reflective equilibrium: A case study on illness severity

Principles for priority setting in health care are typically forged by experts influenced by the normative literature on priority setting. Meanwhile, their implementation is subject to democratic deliberation, political pressures, and administrative bureaucracy. Sometimes expert proposals are democratically rejected. This points towards a problem: on the one hand, the fact that a majority shares a moral belief does not inherently validate this belief. On the other hand, when justifying a position to others, we cannot expect much success without engaging with their moral judgments. In this work we examine the possibility of including so-called popular views in a reflective equilibrium process. In reflective equilibrium processes, we are usually interested in considered judgments rather than mere intuitions. Popular views, arguably, often do not meet this standard. To mitigate this, we propose to bolster popular views by linking them with theoretical frameworks echoing similar moral perspectives. We use illness severity as a case study and show that a set of popular accounts can provide considered judgments that merit inclusion in a publicly informed reflective equilibrium process. This is plausibly a way forward in the search for priority setting principles that are both normatively sound and acceptable to the public. Our method provides a general framework for refining available data on popular views on moral questions, including when we cannot assess the consideredness of such views.

Guidelines and clinical priority setting during the COVID-19 pandemic – Norwegian doctors’ experiences

BackgroundIn the first phase of the COVID-19 pandemic, strong measures were taken to avoid anticipated pressure on health care, and this involved new priorities between patient groups and changing working conditions for clinical personnel. We studied how doctors experienced this situation. Our focus was their knowledge about and adherence to general and COVID-19 specific guidelines and regulations on priority setting, and whether actual priorities were considered acceptable.MethodsIn December 2020, 2 316 members of a representative panel of doctors practicing in Norway received a questionnaire. The questions were designed to consider a set of hypotheses about priority setting and guidelines. The focus was on the period between March and December 2020. Responses were analyzed with descriptive statistics and regression analyses.ResultsIn total, 1 617 (70%) responded. A majority were familiar with the priority criteria, though not the legislation on priority setting. A majority had not used guidelines for priority setting in the first period of the pandemic. 60.5% reported that some of their patients were deprioritized for treatment. Of these, 47.5% considered it medically indefensible to some/a large extent. Although general practitioners (GPs) and hospital doctors experienced deprioritizations equally often, more GPs considered it medically indefensible. More doctors in managerial positions were familiar with the guidelines.ConclusionsMost doctors did not use priority guidelines in this period. They experienced, however, that some of their patients were deprioritized, which was considered medically indefensible by many. This might be explained by a negative reaction to the externally imposed requirements for rationing, while observing that vulnerable patients were deprioritized. Another interpretation is that they judged the rationing to have gone too far, or that they found it hard to accept rationing of care in general. Priority guidelines can be useful measures for securing fair and reasonable priorities. However, if the priority setting in clinical practice is to proceed in accordance with priority-setting principles and guidelines, the guidelines must be translated into a clinically relevant context and doctors’ familiarity with them must improve.

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.

Abstract A020: Connection to Health for Smokers: A comprehensive smoking cessation program for community health centers

Abstract Background: California’s 1200 community health centers (CHCs) provide primary care to 1 in 7 Californians, a disproportionate number of whom are tobacco smokers, low income, and medically vulnerable due to adverse social environments, other adverse health-related behaviors, and co-occurring health conditions. Thus, CHCs are an important setting for interventions to address tobacco-smoking disparities, despite their often-limited resources to do so. The goal of this research is to develop, implement, and evaluate the feasibility and acceptability of Connection to Health for Smokers (CTHS), a new theory- and evidence-based program supported by online tools, for use by CHC-based health educators to systematically engage CHC patients to quit smoking. Methods: We developed CTHS using a participatory approach in collaboration with smoking cessation experts, behavioral scientists, CHC primary care providers and health workers, and pilot tested the intervention with patients at three sites in Contra Costa County. Results: CTHS incorporates a novel theoretical framework that includes 1) the 5A’s (ask, advise, assess, assist, and arrange); 2) evidence-based principles of priority setting and action-planning; 3) direct support to patients for implementing tailored strategies to prepare for quitting and to prevent relapse; 4) indirect support for smoking cessation by managing other social and behavioral barriers (e.g., depression, housing instability or homelessness, substance use) either before or during the smoking cessation process, and (5) provide a structure and prompts for arranged follow-up and automated support between appointments. CTHS conducts an online patient assessment, guides health educators and patients to collaboratively develop a tailored action plan, and delivers automated text reminders to assist patients with action plan implementation. The program design accounts for CHC clinic flow, allowing enrollment through primary care referrals or outreach using clinic-based smoker registries. To date, CTHS has been implemented in three clinical sites by 10 health educators working with 44 smokers, aged 21 to 68 years, of whom 43% self-identified, 43% self-identified as male, and 82% reported being daily smokers. Using CTHS, 32 (73%) patients developed action plans to quit smoking, 10 (23%) developed plans to cut down, and 2 (4%) chose to work on other health issues in preparation for quitting smoking in the future. Conclusion: CTHS is a novel smoking cessation program for patients served by CHCs that is feasible and acceptable to clinic teams and their patients who smoke. Further evaluation of program efficacy through a randomized clinical trial is both warranted and ongoing. Trial registration: NCT03680599. Citation Format: Michael B Potter, Vicky Bowyer, Janice Y Tsoh, Jose Parra, Danielle Hessler. Connection to Health for Smokers: A comprehensive smoking cessation program for community health centers [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr A020.

Needs and cost-effectiveness in health care priority setting

How to balance the maximization of health and concerns for the worse off remains a challenge for health care decision makers when setting priorities. In regulatory guidelines these concerns are typically specified in terms of priority setting according to needs and priority setting according to cost-effectiveness. Still, it is often unclear when and why needs and cost-effectiveness diverge or overlap as guiding priority setting principles in practice. We conduct a comparative analysis of need and cost-effectiveness in the context of health care priority setting. Based on theories of distributive justice we specify three normative interpretations of need and explicate how these relate to the normative basis for cost-effectiveness analysis. Using priority-setting dilemmas we then move on to explicate when and why need and cost-effectiveness diverge as priority-setting principles. We find that: (i) although principles of need and cost-effectiveness may recommend the same allocation of resources the underlying reason for an allocation is different; (ii) while they both may give weight to patients who are worse off they do so in different ways and to different degree; and (iii) whereas cost-effectiveness clearly implies the aggregation of benefits across individuals principles of needs give no guidance with regard to if, and if so, how needs should be aggregated. Priority setting according to needs or cost-effectiveness does not necessarily recommend different allocations of resources. Thus, the normative conflict between them, often highlighted in practice, seems exaggerated. For health policy this is important knowledge because unclear conceptions may obstruct an informed public discussion. Moreover, if decision-makers are to properly account for both principles they need to recognize the inconsistencies as well as similarities between the two.

Physician behavior and conditional altruism: the effects of payment system and uncertain health benefit

This paper experimentally investigates the altruistic behavior of physicians and whether this behavior is affected by payment system and uncertainty in health outcome. Subjects in the experiment take on the role of physicians and decide on the provision of medical care for different types of patients, who are identical in all respects other than the degree to which a given level of medical treatment affects their health. We investigate physician altruism from the perspective of ethical principles, by categorizing physicians according to how well their treatment decisions align with different principles for priority setting. The experiment shows that many physicians are altruistic toward their patients but also that the degree of altruism varies across patients with different medical needs. We find a strong effect of payment system that is overall unaffected by the introduction of risk and ambiguity in patients’ health outcomes. There is, however, substantial heterogeneity across individuals, in particular under the capitation payment system where physicians’ responses to the introduction of uncertainty in patient health are modulated by their own generic risk and ambiguity preferences.

Balancing small against large burdens

AbstractCommon principles for resource allocation in health care can prioritise the alleviation of small health burdens over lifesaving treatment. I argue that there is some evidence that these principles are at odds with a sizable share of public opinion, which holds that saving a life should take priority over any number of cures for minor ailments. I propose two possible explanations for this opinion, one debunking and one vindicatory. I also outline how well-designed surveys and moral enquiry could help decide between them. Finally, I consider how priority-setting principles could be adjusted if the view that saving a life always trumps alleviating small burdens were vindicated.

Ageing, impairments and travel: Priority setting for an inclusive transport system

The ageing of the population in many countries suggests that transport systems will have to be adapted to the needs of an increasing number of persons experiencing travel-related impairments. This development underscores the importance of a more fundamental challenge for transport planning: providing all persons with accessibility to key destinations, irrespective of the features of a person's body. The challenge is to move beyond the notion of universally accessible transport systems towards an inclusive transport system. Where the former focuses on adapting existing transport systems to the needs of persons with the widest possible range of abilities, the latter refers to the goal to provide all persons with access to a range of key destinations. This challenge requires not only the adaption of existing transport systems, but also the extension of those systems to provide travel-impaired persons and others with access to destinations. The aim of the paper is to develop a basic framework that can be helpful to set priorities towards the development of such an inclusive transport system. The framework distinguishes two principles for priority setting, one derived from the principle of welfare maximization and one conceptualizing the notion of hardship. Based on these two principles of priority setting, three different categories of measures to enhance accessibility for persons experiencing travel-related impairments are distinguished: (1) measures that live up to the principle of efficiency or welfare maximization; (2) measures that reduce transport-related hardship through adaptation or extension of the mainstream transport system; and (3) measures that reduce transport-related hardship through dedicated services for persons with travel impairments. The proposed framework requires changes in the practice of cost-benefit analysis, as well as a clear delineation of a hardship threshold. The latter is considered essential to make the transport problems experienced by persons with travel impairments visible to the public eye.

Balancing Small against Large Burdens

Common principles for resource allocation in health care can prioritise the alleviation of small health burdens over lifesaving treatment. I argue that there is some evidence that these principles are at odds with a sizable share of public opinion, which holds that saving a life should take priority over any number of cures for minor ailments. I propose two possible explanations for this opinion, one debunking and one vindicatory. I also outline how well-designed surveys and moral enquiry could help decide between them. Finally, I consider how priority-setting principles could be adjusted if the view that saving a life always trumps alleviating small burdens were vindicated.

Indeterminacy and the principle of need

The principle of need—the idea that resources should be allocated according to need—is often invoked in priority setting in the health care sector. In this article, I argue that a reasonable principle of need must be indeterminate, and examine three different ways that this can be dealt with: appendicizing the principle with further principles, imposing determinacy, or empowering decision makers. I argue that need must be conceptualized as a composite property composed of at least two factors: health shortfall and capacity to benefit. When one examines how the different factors relate to each other, one discovers that this is sometimes indeterminate. I illustrate this indeterminacy in this article by applying the small improvement argument. If the relation between the factors are always determinate, the comparative relation changes by a small adjustment. Yet, if two needs are dissimilar but of seemingly equal magnitude, the comparative relation does not change by a small adjustment of one of the factors. I then outline arguments in favor of each of the three strategies for dealing with indeterminacy, but also point out that all strategies have significant shortcomings. More research is needed concerning how to deal with this indeterminacy, and the most promising path seems to be to scrutinize the position of the principle of need among a plurality of relevant principles for priority setting in the health care sector.

A comparative analysis of coverage decisions for outpatient pharmaceuticals: Evidence from Denmark, Norway and Sweden

This study analyses the reasons for differences and similarities in coverage recommendations for outpatient pharmaceuticals in Denmark, Norway and Sweden, following HTA appraisals. A comparative analysis of all outpatient drug appraisals carried out between January 2009 and December 2012, including an analysis of divergent coverage recommendations made by all three countries was performed. Agreement levels between HTA agencies were measured using kappa scores. Consultations with stakeholders in the three countries were carried out to complement the discussion on HTA processes and reimbursement outcomes. Nineteen outpatient drug-indication pairs appraised in each of the three countries were identified, of which 6 pairs (32%) had divergent coverage recommendations. An uneven distribution of coverage recommendations was observed, with the highest overlap in appraisals between Norway and Sweden (free-marginal kappa 0.89). Similarities were found in priority setting principles, mode of appraisal and reasoning for coverage recommendations. The study shows that health economic evaluation is less prominent or explicit in outpatient drug appraisals in Denmark than in Norway and Sweden, that all three countries could benefit from improved communication between appraisers and manufacturers, and that final coverage recommendations rely on factors other than safety, comparative efficacy or cost-effectiveness.

Crisis Management and Public Health: Ethical Principles for Priority Setting at a Regional Level in Sweden

In this article I analyse and discuss guidelines for priority setting in crisis management at a regional level in Sweden. The guidelines concern three types of crises: pandemics, large losses of electric power and interruptions in water supply. Pandemics are typical public health issues. Large losses of electric power and interruptions in water supply are in themselves not, but may have serious public health consequences. These guidelines are compared with guidelines for priority setting in health care. This is done because of the central position of health care in the management of many different types of crises. The comparison shows clear differences. In the analysis, I use a distinction between substantive principles of priority setting and process-oriented principles. Regarding substantive principles, I have found that the guidelines point in different directions. This seems acceptable, however, since they focus on different problems. Moreover, it seems possible to integrate the various context-dependent principles by relating them to higher order principles. Regarding process-oriented principles, I have found that how and to what extent these principles are applied in the guidelines vary. If we want to apply these principles in a more satisfying way, this would require a more systematic approach.

Remote Monitoring or Close Encounters? Ethical Considerations in Priority Setting Regarding Telecare

The proportion of elderly in society is growing rapidly, leading to increasing health care costs. New remote monitoring technologies are expected to lower these costs by reducing the number of close encounters with health care professionals, for example the number of visits to health care centres. In this paper, I discuss issues of priority setting raised by this expectation. As a starting-point, I analyse the recent debate on principles for priority setting in Sweden. The Swedish debate illustrates that developing an approach to priority setting is an ongoing process. On the basis of this analysis, I conclude that several different ethical principles, and specifications of these principles, can be appealed to for giving priority--over close encounters--to a large-scale introduction of remote monitoring technologies in health care services to elderly people, but also that many specifications can be appealed to against giving such priority. I propose that given the different views on principles, it is necessary to develop fair procedures of deliberation on these principles and their application, in particular in order to reach agreement on exactly how much resources should be allocated to remote monitoring and how much to close encounters. I also present a few points to consider in a large-scale introduction of remote monitoring.

Gender in health technology assessment: Pilot study on agency approaches

Gender as a social construct is a recognized health determinant. Because best practice in reporting health technology assessment (HTA) clearly specifies the need to appraise a technology's social impact within the target population, the extent to which gender issues are taken into account in HTA production is of interest, not only in light of equitable practices but also for reasons of effectiveness. The aim of this study is to provide a first assessment of the degree of gender sensitivity shown by HTA agencies around the world today. The Web sites of sixty HTA agencies were analyzed. The consideration of gender aspects was specifically looked for in each agency's general mission statement, its priority setting process, and its methodological approach. Additionally, specific gender-oriented initiatives not belonging to any of the aforementioned categories were identified. Of the sixty agencies, less than half mention a commitment to addressing the social implication of health technologies. Only fifteen institutions make information on their priority setting principles available on their Web sites and gender was an issue in two of those cases. Data on methodology were obtainable online from 18 agencies, two of which mentioned gender issues explicitly. Finally, gender-oriented initiatives were identified by thirteen agencies. A gender-sensitive approach is apparently rarely adopted in current HTA production. Exceptional practices and relevant tools do exist and could serve as examples to be promoted by international collaborative networks.

The Development and Implementation of a User-Friendly Priority Setting Tool for HIV Care and Treatment Services in New York City

The Ryan White Human Immunodeficiency Virus (HIV) Program is the largest federal program designed to provide medical and social support services for HIV infected persons who are uninsured or underinsured. In 2008, the Ryan White budget was $2.2 billion, of which over $100 million went to the New York City (NYC) eligible metropolitan area (EMA), which receives the largest Ryan White allocation targeted to any EMA. The NYC Department of Health and Mental Hygiene (DOHMH) is the grantee for the EMA. To implement HIV care and treatment programs funded by this grant, the DOHMH works closely with the NYC Ryan White Planning Council, a local community planning body that assesses needs, plans for service delivery and sets priorities for funds. This article describes priority setting principles, practices, findings and lessons learned. It also outlines how the legislatively mandated community planning body has developed and implemented a user-friendly priority setting process and tool.

Attitudes towards priority-setting and rationing in healthcare — an exploratory survey of Swedish medical students

Healthcare priority-setting is inextricably linked to the challenge of providing publicly funded healthcare within a limited budget, which may result in difficult and potentially controversial rationing decisions. Despite priority-setting's increasing prominence in policy and academic discussion, it is still unclear what the level of understanding and acceptance of priority-setting is at different levels of health care. The aim of this study is threefold. First we wish to explore the level of familiarity with different aspects of priority-setting among graduating medical students. Secondly, to gauge their acceptance of both established and proposed Swedish priority-setting principles. Finally to elucidate their attitudes towards healthcare rationing and the role of different actors in decision making, with a particular interest in comparing the attitudes of medical students with data from the literature examining the attitudes among primary care patients in Sweden. A cross-sectional survey containing 14 multiple choice items about priority-setting in healthcare was distributed to the graduating medical class at Linkoöping University. The response rate was 92% (43/47). Less than half of respondents have encountered the notion of open priority-setting, and the majority believed it to be somewhat or very unclear. There is a high degree of awareness and agreement with the established ethical principles for priority-setting in Swedish health care; however respondents are inconsistent in their application of the cost-effectiveness principle. A larger proportion of respondents were more favourable to physicians and other health personnel being responsible for rationing decisions as opposed to politicians. Future discussion about priority-setting in medical education should be contextualized within an explicit and open process. There is a need to adequately clarify the role of the cost-effectiveness principle in priority-setting. Medical students seem to acknowledge the need for rationing in healthcare to a greater extent when compared with previous results from Swedish primary care patients.

The many meanings of deinsuring a health service: the case of in vitro fertilization in Ontario

There is currently much international interest in principles and processes for determining which services should qualify for health insurance packages. However, there has yet been little analysis of the implications of actual deinsurance decisions made by such priority-setting exercises. This paper reports experience from the case of in vitro fertilization (IVF) deinsurance in Ontario, Canada. The analysis addresses some of the more social aspects of financial incentives by characterizing funding structures as means of communicating complex policy objectives, rather than mechanistic reward-penalty systems. Deinsuring IVF was intended to support several policy goals, including: controlling public expenditures, restricting public coverage to ‘medically necessary’ services, applying evidence of effectiveness as a criterion for medical necessity and implementing part of a policy program to control new reproductive technologies. It may seem a modest step to remove one dubious service from public insurance coverage. Nevertheless, as interpreted by stakeholders, deinsurance of IVF may inadvertently promote the opposite of what policy makers intended. This case suggests that priority-setting decisions based on incomplete information, inconsistently applied principles and too little attention to health system dynamics (perhaps the norm in ‘real-world’ priority-setting) can have the perverse effect of undermining progress toward health reform goals of improved health, reduced expenditures and more rigorously evaluated services. The case of IVF in Ontario offers several lessons for other jurisdictions engaged in priority-setting and service deinsurance: (1) individual services interact with the rest of the system and cannot be removed without systemic effects, (2) inconsistent use of coverage principles can undermine legitimacy of both priority-setting principles and processes and (3) ‘evidence-based’ decisions can founder on differing stakeholder ideas about appropriate evidence and on the inconsistent message given by commercializing ineffective or unproven care.

Priority setting in Austria

Priority setting and rationing are not yet matters of public debate in Austria. Before a discussion on rationing is undertaken, the incentive system concerning the financing of health care services needs to be reformed, especially in relation to the reimbursement of hospitals and physicians. This is necessary if a waste of scarce resources is to be avoided. Although methods and principles of priority setting and rationing are not openly discussed, several rationing techniques are already performed as organisational tools. A Eurobarometer survey of the population regarding their satisfaction with the health care system confirms the presumption that Austrians are not aware of the fact that rationing methods already exist.

Principles for priority setting in mental health services and their implications for the least well off.

Funding for mental health services has declined in recent years, posing the difficult challenge of setting program and individual client service priorities with reduced resources. The author reviews seven principles for resource allocation and their potential impact on people with severe and persistent mental illness. These principles address issues of the autonomy of individual health care needs; the need for client, stakeholder, and provider input into goal setting; cost-effectiveness; equity and fairness; client responsibility for making effective use of services; the impact of private industry on the development and marketing of new treatments; and the importance of considering local skill availability and population needs in setting program priorities. Because none of these principles take precedence over the others, their joint application does not necessarily yield consistent program priorities. However, they provide a frame of reference for approaching the task of priority setting and for understanding why priorities may vary from different perspectives.