Developing a multi-criteria approach for drug reimbursement decision making: an initial step forward.

BACKGROUND: Coverage decisions for a new drug revolve around the balance between perceived value and price. But what is the perceived value of a new drug? Traditionally, the assessment of such value has largely revolved around the estimation of cost-effectiveness. However, very few will argue that the cost-effectiveness ratio presents a fulsome picture of 'value'. Multi-criteria decision analysis (MCDA) has been advocated as an alternative to cost-effectiveness analysis and it has been argued that it better reflects real world decision-making. OBJECTIVE: The objective of this project was to address the issue of the lack of a satisfactory methodology to measure value for drugs by developing a framework to operationalize an MCDA approach incorporating societal values as they pertain to the value of drugs. METHODS: Two workshops were held, one in Toronto in conjunction with the CAPT annual conference, and one in Ottawa, as part of the annual CADTH Symposium. Notes were taken at both workshops and the data collected was analyzed using a grounded theory approach. The intent was to reflect, as accurately as possible, what was said at the workshops, without normative judgement. RESULTS: Results to date are a set of guiding principles and criteria. There are currently ten criteria: Comparative effectiveness, Adoption feasibility, Risks of adverse events, Patient autonomy, Societal benefit, Equity, Strength of evidence, Incidence/prevalence/severity of condition, Innovation, and Disease prevention/ health promotion. CONCLUSION: Much progress has been made and it is now time to share the results. Feedback will determine the final shape of the framework proposed.

Community dental clinics: providers' perspectives.

OBJECTIVES: Not-for-profit community dental clinics attempt to address the inequities of oral health care for disadvantaged communities, but there is little information about how they operate. The objective of this article is to explain from the perspective of senior staff how five community dental clinics in British Columbia, Canada, provide services. METHODS: The mixed-methods case study included the five not-for-profit dental clinics with full-time staff who provided a wide range of dental services. We conducted open-ended interviews to saturation with eight senior administrative staff selected purposefully because of their comprehensive knowledge of the development and operation of the clinics and supplemented their information with a year's aggregated data on patients, treatments, and operating costs. RESULTS: The interview participants described the benefits of integrating dentistry with other health and social services usually within community health centres, although they doubted the sustainability of the clinics without reliable financial support from public funds. Aggregated data showed that 75% of the patients had either publically funded or no coverage for dental services, while the others had employer-sponsored dental insurance. Financial subsidies from regional health authorities allowed two of the clinics to treat only patients who are economically vulnerable and provide all services at reduced costs. Clinics without government subsidies used the fees paid by some patients to subsidize treatment for others who could not afford treatment. CONCLUSIONS: Not-for-profit dental clinics provide dental services beyond pain relief for underserved communities. Dental services are integrated with other health and community services and located in accessible locations. However, all of the participants expressed concerns about the sustainability of the clinics without reliable public revenues.

Public participation in health care priority setting: A scoping review.

OBJECTIVE: While much literature has debated public engagement in health care decision-making, there is no consensus on when public engagement should be sought and how it should be obtained. We conducted a scoping review to examine public engagement in one specific area: priority setting and resource allocation. METHOD: The review drew upon a broad range of health and non-health literature in an attempt to elicit what is known and not known on this topic, and through this to outline any guidance to assist decision-makers and identify where efforts for future research should be directed. RESULTS: Governments appear to recognize benefits in consulting multiple publics using a range of methods, though more traditional approaches to engagement continue to predominate. There appears to be growing interest in deliberative approaches to public engagement, which are more commonly on-going rather than one-off and more apt to involve face-to-face contact. However, formal evaluation of public engagement efforts is rare. Also absent is any real effort to demonstrate how public views might be integrated with other decision inputs when allocating social resources. CONCLUSION: While some strands can be taken to inform current priority setting activity, this scoping review identified many gaps and highlights numerous areas for further research.

How to control the costs of health care services--an inventory of strategic options.

This paper has two objectives: (1) to provide an inventory of popular strategies for cost reduction or cost containment in the health services research literature and (2) to propose a coherent framework to organize this inventory. The purpose of this framework is to inform decision-makers when grappling with the opposing forces they face in choosing a cost reduction strategy. The trade-off is clear: to access progressively more possible strategies, the decision-maker must be ready to expose the population and patients to more significant changes in services provided. On one hand, more choices are preferable because each strategy attacks the problem from a different angle and being restricted to fewer "angles" increases the likelihood that a specific "well" may have dried up. On the other hand, we know that change is often viewed, a priori, negatively in health care management, so there are pressures to limit the impact on services.

Decision maker views on priority setting in the Vancouver Island Health Authority.

BACKGROUND: Decisions regarding the allocation of available resources are a source of growing dissatisfaction for healthcare decision-makers. This dissatisfaction has led to increased interest in research on evidence-based resource allocation processes. An emerging area of interest has been the empirical analysis of the characteristics of existing and desired priority setting processes from the perspective of decision-makers. METHODS: We conducted in-depth, face-to-face interviews with 18 senior managers and medical directors with the Vancouver Island Health Authority, an integrated health care provider in British Columbia responsible for a population of approximately 730,000. Interviews were transcribed and content-analyzed, and major themes and sub-themes were identified and reported. RESULTS: Respondents identified nine key features of a desirable priority setting process: inclusion of baseline assessment, use of best evidence, clarity, consistency, clear and measurable criteria, dissemination of information, fair representation, alignment with the strategic direction and evaluation of results. Existing priority setting processes were found to be lacking on most of these desired features. In addition, respondents identified and explicated several factors that influence resource allocation, including political considerations and organizational culture and capacity. CONCLUSION: This study makes a contribution to a growing body of knowledge which provides the type of contextual evidence that is required if priority setting processes are to be used successfully by health care decision-makers.

Introducing priority setting and resource allocation in home and community care programs.

OBJECTIVE: To use evidence from research to identify and implement priority setting and resource allocation that incorporates both ethical practices and economic principles. METHOD: Program budgeting and marginal analysis (PBMA) is based on two key economic principles: opportunity cost (i.e. doing one thing instead of another) and the margin (i.e. resource allocation should result in maximum benefit for available resources). An ethical framework for priority setting and resource allocation known as Accountability for Reasonableness (A4R) focuses on making sure that resource allocations are based on a fair decision-making process. It includes the following four conditions: publicity; relevance; appeals; and enforcement. More recent literature on the topic suggests that a fifth condition, that of empowerment, should be added to the Framework. The 2007-08 operating budget for Home and Community Care, excluding the residential sector, was developed using PBMA and incorporating the A4R conditions. RESULTS: Recommendations developed using PBMA were forwarded to the Executive Committee, approved and implemented for the 2007-08 fiscal year operating budget. In addition there were two projects approved for approximately $200,000. CONCLUSION: PBMA is an improvement over previous practice. Managers of Home and Community Care are committed to using the process for the 2008-09 fiscal year operating budget and expanding its use to include mental health and addictions services. In addition, managers of public health prevention and promotion services are considering using the process.

Centralising drug review to improve coverage decisions: economic lessons from (and for) Canada.

Drug coverage decisions require information about clinically relevant benefits and risks, as well as economic information about direct and indirect costs, in comparison with relevant treatment alternatives. A recent Canadian initiative aims to improve the evidentiary basis for drug coverage decisions through centralised evaluation of the clinical and economic value of new drug products. Centralised review can make important, 'positive' contributions to decision making by raising the evidentiary basis for decisions. Even in the absence of a single-payer for medicines, such information can directly inform decisions focussed on matters of technical efficiency. Centralised review also provides necessary but not sufficient information for the many decisions in this sector that concern allocative efficiency and therefore have 'normative' implications. Thus, in addition to processes for collecting and critically assessing clinical and economic data, effective priority setting requires processes at a local level for engaging affected populations in the consideration of the trade-offs inherent in coverage decisions.

The Common Drug Review: a NICE start for Canada?

Prescription drugs are one of the fastest growing cost components of modern health care systems. Efforts to control escalating costs while simultaneously maximizing population health outcomes have led many countries to implement restrictive criteria on the funding of certain drugs. While drugs are licensed for sale based on evidence of safety and efficacy versus a placebo, many funders now require evidence of clinical- and cost-effectiveness compared to existing drugs as part of their reimbursement criteria. In some countries, concerns about duplication of drug assessment and administrative effort across different jurisdictions have led to experimentation with various forms of centralized drug review processes. Centralized drug reviews strive to standardize, inform, and improve drug reimbursement decisions through critical assessments of comparative clinical- and cost-effectiveness. The ultimate objective is to inform formulary listing decisions that both maximize health outcomes and achieve good "value for money". This paper describes the Common Drug Review (CDR), a uniquely Canadian version of a centralized drug review process, and compares it with the much-studied National Institute for Health and Clinical Excellence (NICE) in the United Kingdom. Through this analysis, which draws on prior critiques and experiences of NICE, we highlight several critical issues for pharmaceutical priority setting that must be considered in the operation and appraisal of centralized drug review processes. These include the selection of drugs for review, centralized versus decentralized decision-making, receptor capacity at local decision making levels, and public participation.

Quality and cost in healthcare: a relationship worth examining.

Debate over healthcare often focuses on two key issues: quality and cost. However, because of the unique characteristics of healthcare, this relationship is not as simple as it might seem. A recent Supreme Court of Canada judgement directly addressing aspects of quality of care, combined with related government policy, provides an impetus for a review of research on quality as it affects costs of care. Our premise is that quality problems may not be the result of financing constraints but rather quality issues are a significant contributor to funding pressures. Theoretical and empirical evidence is reviewed and the implications for decision makers are discussed. A managerial focus on cost minimisation strategies makes implementing priority setting processes challenging because it calls for behaviours that typically counter professional self-interest. We suggest that a focus on quality would ultimately provide an effective strategy to contain costs, not to mention having a positive impact on patient well-being.

Priority-setting in health authorities: moving beyond the barriers. The Calgary experience.

The objective of this study was to identify key issues relevant to the development and implementation of a macro-level priority-setting framework (i.e., across broad service areas) within the Calgary Health Region. We used rigorous qualitative methods, including focus groups, meeting observations and interviews to identify views of decision-makers. Key issues relevant to macro-level priority-setting included: application of evidence, incentives, physician involvement, public involvement and application of values. Detailed insight into each of these issues was derived, including how best to handle related barriers to priority-setting in health organizations and important lessons for framework development. These lessons learned should provide insight for similar activity in other jurisdictions.

Physician involvement in setting priorities for health regions.

Although many authors have emphasized the importance of including physicians in organizational activities, especially in integrated delivery systems, much of the literature has focused on physician involvement in governance or as managers. In this paper, program budgeting and marginal analysis (PBMA) is suggested as a mechanism to link physicians into organizational decision-making processes. This research included a wide range of examples that demonstrate the versatility of PBMA, and many ways to involve physicians.

The evolution of PBMA: towards a macro-level priority setting framework for health regions.

To date, relatively little work on priority setting has been carried out at a macro-level across major portfolios within integrated health care organizations. This paper describes a macro marginal analysis (MMA) process for setting priorities and allocating resources in health authorities, based on work carried out in a major urban health region in Alberta, Canada. MMA centers around an expert working group of managers and clinicians who are charged with identifying areas for resource re-allocation on an ongoing basis. Trade-offs between services are based on locally defined criteria and are informed by multiple inputs such as evidence from the literature and local expert opinion. The approach is put forth as a significant improvement on historical resource allocation patterns.

Making choices in healthcare: the reality of scarcity.

Processes are required to aid decision-makers in better managing existing resources in healthcare. To date, limited research has informed priority setting at the macro level, across broad service areas, within health organizations. As part of a participatory action research project, a macro-level resource allocation framework was developed and implemented in the Calgary Health Region (CHR). The approach relies on an expert panel of managers and clinicians who are charged with identifying, on the basis of evidence and local information, how resources might be reallocated to improve population well-being. The framework developed was seen as an improvement over historical allocation processes.