Transcript No Slide Title

Priority Setting:
Beyond Evidence-based Medicine
and Cost-effectiveness Analysis
Douglas K. Martin, PhD
Director, Collaborative Program in Bioethics,
Assistant Professor, Department of Health Policy, Management and Evaluation,
and the Joint Centre for Bioethics, University of Toronto
Career Scientist, Ontario Ministry of Health and Long-Term Care
Outline
 Where
we have been – the 1980s & 1990s
 Where we are going – 2000 to 2010
 Improving priority setting
Where we have been
 PS:

Distribution of goods and services
among competing needs
PS occurs at all levels of system
government, RHAs, disease management
organizations, research agencies, PBM,
hospitals, clinical programs
 rationing
resource allocation
priority setting
sustainability
Evidence-based Medicine &
Cost-effectiveness Analysis
Dominant tradition;
 Technical problems

HTA = TAH
– Levels of evidence; types of benefits; availability
– WB “The Economics of Priority Setting for Health Care”
(2003): problems with economic evaluations; incorporating
equity; practical constraints

PaussJensen, Singer, Detsky. Ontario’s Formulary
Committee How Recommendations are Made.
Pharmacoeconomics (2003).
– “Complex economic analyses played a limited role.”

Helpful but limited; necessary but not sufficient
Let’s be clear: PS decisions are . . .
VALUE-BASED
DECISIONS
NOT information-based decisions
Compassion for the Vulnerable
Rule-of-Rescue
Evidence
Equity
Risk
Equality
Solidarity
Access
Benefit
Individual Responsibility
Democratic deliberation
Efficiency
Need
AND THESE VALUES OFTEN CONFLICT
Gaps in knowledge


Goodbye to simple solutions (Holm, BMJ 2000)
Normative approaches (e.g. philosophy, health economics)
 help identify values
 but conflict, no consensus, too abstract

Empirical approaches
 what is done \ what can be done
 but not what should be done

International experience shows difficulty
agreement on what decision
made (Ham, Coulter, JHSRP 2001)
Martin, Singer 2000
reaching
should be
Can agree on how : Fair process
But,
what is fair?
‘Accountability for reasonableness’

Relevance: based on reasons
upon which stakeholders can
agree in the circumstances

Publicity: reasons publicly
accessible

Revision/Appeals: mechanism
for challenging/revising reasons

Enforcement: to ensure 3
conditions met
Daniels & Sabin, 1997
Where we are going

“Simple solutions” on one hand
and “muddling through” on the
other, or substantive versus
procedural criteria, represent
dialectically opposite extremes. A
synthesized conceptual model or
framework, grounded in real
experience and taking account of
various discipline-specific
perspectives, represents
the next phase of priority setting.
Martin, Singer, 2000
Criteria & Process:
Parameters of Success
Competing goals and multiple stakeholder
relationships
 Efficiency considerations or technical solutions limited
influence, not sufficient
 An evaluation of the normative 'rightness' [of ps
criteria] depends on the specific institutional
circumstances, the stakeholders who are affected,
and the strategic goals that are being pursued.
 Underscores the importance of procedural fairness to
secure socially acceptable priority setting decisions
and to ensure public accountability.

Gibson, Martin, Singer. BMCHS, 2004
Informal Networks of Deliberation
Beyond formal institutional structures
 Emphasizes ‘public good’ over ‘private interests’
 Context where claims must be justified; actions
shaped by requirements of justification [Chaves, 1974]
 Provides more information about
others’ preferences
 Engages inherent human ability to
assess different reasons [Manin, 1987]
 Renders decision legitimate in the
eyes of participants;
 Groups can pool their experience
and creativity
 Enhances ‘buy-in’

Improving Priority Setting
Describe
 Case study methods
 What groups actually do
Evaluate
 ‘Accountability for reasonableness’
 What groups should do
 Correspondence: good practices
 Gaps: opportunities for improvement
 Improve
 Implement strategies to close gaps
Martin, Singer, Health Care Analysis
2003
Benefits of
describe/evaluate/improve
 Institution:




quality improvement
political involvement
learning organization
leadership
 Other
health care organizations:
 share good practices
Example #1:
PS and Hospital Strategic Planning

Relevance
 ensure info captures impact on academic
programs and hospital’s community
 optimize inclusivity / exclusivity
 revise agreement mechanism

Publicity
 comprehensive communication plan
 clarify op and strategic plan

Appeals
 develop appeals grounds / process

Enforcement
 start data consultation & data collection earlier
 describe, evaluate, and improve again!
Martin, Shulman, Santiago-Sorrel,
Singer, JHSRP 2003
Other examples
 Health System
 Martin, Singer “Canada” in Ham & Roberts (eds) Reasonable
Rationing. 2003
 Provincial Drug Formulary
 PaussJensen, Detsky, Singer Pharmacoeconomics 2002
 Hospital Drug Formulary
 Martin, Hollenberg, MacRae, Madden, Singer Health Policy 2003
 Cancer Drugs
 Martin, Pater, Singer Lancet 2001
 ICU
 Mielke, Martin, Singer Critical Care Medicine 2003
 Martin, Bernstein, Singer J Neur, Neurosurg, Psych 2003
Database of Learning
Relevance
Health system
MoH
PBM
Disease Manag.
Orgs
RHAs
Hosp Strat Plan
Hosp Oper Plan
Hosp drug
formulary
Clinical Programs
Publicity
Appeals
Enforce
Social Policy Learning
 Make
‘private’ decisions public
 Educative function
 Body of ‘case law’;
institutional reflective
equilibrium
 Iterative - improves
over time
Beyond and Forward

Synthesis: Criteria & Process
– Value-based decisions about which
there is much conflict
– EBM & CEA necessary but insufficient
– Fair process enhances legitimacy &
accountability

Informal networks of deliberation
– creates climate of ‘public good’, assessment
of reasons; enhanced
problem-solving;
increased ‘buy-in’
Describe-evaluate-improve approach
 Ongoing process of social policy learning

Acknowledgements

The JCB PS Research Team:
 Mark Bernstein, Scott Berry, Jennifer
Gibson, Heather Gordon, Lydia Kapiriri,
Shannon Madden, David Reeleder,
Zahava Rosenberg-Yunger, Peter A.
Singer, Ross Upshur, Nancy Walton

Norman Daniels has contributed
enormously to our understanding
Funded by grants from CIHR
 www.canadianprioritysetting.ca