Search

Background: Cardiac catheterization (CATH) is key in the diagnosis and management of coronary artery disease. Increasing demand coupled with limited resources in a publicly funded system (e.g. Ontario, the largest province in Canada) resulted in a waitlist for this procedure. Our province has recommended maximum wait times (RMWT) for patients referred to CATH. The purpose of this study is to describe our experience over the past decade in attempting to meet RMWTs for patients needing CATH at our centre, and to discuss issues concerning capacity planning in providing timely service., Methods: We measured the proportion of patients undergoing a procedure within the RWMT, and calculated both the mean number of patients and mean length of time on the wait list for each year over a decade for those referred to CATH using prospectively collected registry data. We identified factors that increased referrals or improved capacity. Wait time was compared to community standard RMWTs in order to establish if and how RMWTs were achieved., Results: Despite a number of systematic and capacity improvements, RMWTs were not achieved until after the addition of a 4th laboratory., Interpretation: Improving access to CATH in our centre was reactive to the increasing need of the community rather than based on anticipation of need and continuity of service within RMWTs. Registry data can help monitor key indicators (e.g. RMWT). Prudent use of this information should help policy makers with future expansion in our region.

Unlabelled: The CHIPS randomized controlled trial (Control of Hypertension in Pregnancy Study) found no difference in the primary perinatal or secondary maternal outcomes between planned "less tight" (target diastolic 100 mm Hg) and "tight" (target diastolic 85 mm Hg) blood pressure management strategies among women with chronic or gestational hypertension. This study examined which of these management strategies is more or less costly from a third-party payer perspective. A total of 981 women with singleton pregnancies and nonsevere, nonproteinuric chronic or gestational hypertension were randomized at 14 to 33 weeks to less tight or tight control. Resources used were collected from 94 centers in 15 countries and costed as if the trial took place in each of 3 Canadian provinces as a cost-sensitivity analysis. Eleven hospital ward and 24 health service costs were obtained from a similar trial and provincial government health insurance schedules of medical benefits. The mean total cost per woman-infant dyad was higher in less tight versus tight control, but the difference in mean total cost (DM) was not statistically significant in any province: Ontario ($30 191.62 versus $24 469.06; DM $5723, 95% confidence interval, -$296 to $12 272; P=0.0725); British Columbia ($30 593.69 versus $24 776.51; DM $5817; 95% confidence interval, -$385 to $12 349; P=0.0725); or Alberta ($31 510.72 versus $25 510.49; DM $6000.23; 95% confidence interval, -$154 to $12 781; P=0.0637). Tight control may benefit women without increasing risk to neonates (as shown in the main CHIPS trial), without additional (and possibly lower) cost to the healthcare system.Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01192412. [ABSTRACT FROM AUTHOR]

The pan-Canadian Oncology Drug Review (pCODR) makes recommendations to Canada's provinces and territories (except Quebec) to guide their cancer drug funding decisions. The objective of this paper is to explore, using an economic perspective and the pCODR as an example, the challenges associated with striving to simultaneously achieve the goals of maximizing health benefits with available resources and improving access to a more consistent standard of care across Canada. The first challenge concerns how to interpret the goals in order to determine how resources should be allocated to achieve each goal. The second challenge relates to whether, if pursued simultaneously, both goals can be achieved to the same extent that each goal could have been achieved alone with the same available resources. Regarding the first challenge, we illustrate that, due to a lack of definitional clarity, it is difficult to determine exactly how resources should be allocated in order to achieve the goal of improving access to amore consistent standard of care across Canada. Regarding the second challenge, we illustrate that choosing to strive for both of the pCODR goals simultaneously will likely be associated with tradeoffs in the extent to which one or both goals can be achieved (relative to what could have been achieved for each goal alone with the same available resources). We suggest that, if the pCODR and the provincial drug plan decision-makers it supports want to strive for both goals simultaneously, they must prioritize the goals and explicitly identify the tradeoffs associated with the prioritization. This will ensure that the consequences of striving to simultaneously achieve both goals are explicit, transparent, and predictable for provincial drug plan decision-makers, physicians, patients, caregivers, and society as a whole. [ABSTRACT FROM AUTHOR]

Health care decision-makers are responsible for making the best use of available health care resources. Economic evaluation is concerned with ensuring that the value of what is gained by an activity outweighs the value of what is sacrificed and hence provides a scientific basis for determining whether a particular health care programme represents an efficient use of health care resources. We show how the application of economic evaluation in the field of health economics has strayed from the scientific basis of the economics approach. We analyse the implications of this divergence from science for health care systems and present an alternative approach aimed at restoring a scientific basis for health care decision-making. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Allocating resources on the basis of population need is a health care policy goal in many countries. Thus, resources must be allocated in accordance with need if stakeholders are to achieve policy goals. Small area methods have been presented as a means for revealing important information that can assist stakeholders in meeting policy goals. The purpose of this review is to examine the extent to which small area methods provide information relevant to meeting the goals of a needs-based health care policy. Methods We present a conceptual framework explaining the terms 'demand', 'need', 'use' and 'supply', as commonly used in the literature. We critically review the literature on small area methods through the lens of this framework. Results 'Use' cannot be used as a proxy or surrogate of 'need'. Thus, if the goal of health care policy is to provide equal access for equal need, then traditional small area methods are inadequate because they measure small area variations in use of services in different populations, independent of the levels of need in those populations. Conclusions Small area methods can be modified by incorporating direct measures of relative population need from population health surveys or by adjusting population size for levels of health risks in populations such as the prevalence of smoking and low birth weight. This might improve what can be learned from studies employing small area methods if they are to inform needs-based health care policies. [ABSTRACT FROM AUTHOR]

Background: Concern has been growing in the academic literature and popular media about the licensing, introduction and adoption of surgical devices before full effectiveness and safety evidence is available to inform clinical practice. Our research will seek empirical survey evidence about the roles, responsibilities, and information and policy needs of the key stakeholders in the introduction into clinical practice of new surgical devices for pelvic floor surgery, in terms of the underlying ethical principals involved in the economic decision-making process, using the example of pelvic floor procedures. Methods/Design: Our study involves three linked case studies using, as examples, selected pelvic floor surgery devices representing Health Canada device safety risk classes: low, medium and high risk. Data collection will focus on stakeholder roles and responsibilities, information and policy needs, and perceptions of those of other key stakeholders, in seeking and using evidence about new surgical devices when licensing and adopting them into practice. For each class of device, interviews will be used to seek the opinions of stakeholders. The following stakeholders and ethical and economic principles provide the theoretical framework for the study: Stakeholders - federal regulatory body, device manufacturers, clinicians, patients, health care institutions, provincial health departments, and professional societies. Clinical settings in two centres (in different provinces) will be included. Ethics - beneficence, non-maleficence, autonomy, justice. Economics - scarcity of resources, choices, opportunity costs. For each class of device, responses will be analysed to compare and contrast between stakeholders. Applied ethics and economic theory, analysis and critical interpretation will be used to further illuminate the case study material. Discussion: The significance of our research in this new area of ethics will lie in providing recommendations for regulatory bodies, device manufacturers, clinicians, health care institutions, policy makers and professional societies, to ensure surgical patients receive sufficient information before providing consent for pelvic floor surgery. In addition, we shall provide a wealth of information for future study in other areas of surgery and clinical management, and provide suggestions for changes to health policy. [ABSTRACT FROM AUTHOR]

It has been suggested that scepticism among decision-makers about using cost-effectiveness analysis (CEA) is caused in part by the low level of the cost-effectiveness 'thresholds' in the economic evaluation literature. This has led Ubel and colleagues to call for higher threshold values of US$200,000 or more per quality-adjusted life-year. We show that these arguments fail to identify the objective of CEA and hence do not consider whether or how the threshold relates to this objective. We show that incremental cost-effectiveness ratios (ICERs) cannot be used to identify an efficient use of resources – the 'biggest bang for the bucks' – allocated to health care. On the contrary, the practical consequence of using the ICER approach is shown to be an increase in health care expenditures, or 'bigger bucks for making a bang', without any evidence of the bang being bigger (i.e. that this leads to an increase in benefits to the population). We present an alternative approach that provides an unambiguous method of determining whether a new intervention leads to an increase in health gains from whatever resources are to be made available to health care decision-makers. [ABSTRACT FROM AUTHOR]

Health care policy in Canada is based on providing public funding for medically necessary physician and hospital-based services free at the point of delivery ("first-dollar public funding"). Studies consistently show that the introduction of public funding to support the provision of health care services free at the point of delivery is associated with increases in the proportionate share of services used by the poor and in population distributions of services that are independent of income. Claims about the success of Canada's health care policy tend to be based on these findings, without reference to medical necessity. This article adopts a needs-based perspective to reviewing the distribution of health care services. Despite the removal of user prices, significant barriers remain to services being distributed in accordance with need--the objective of needs-based access to services remains elusive. The increased fiscal pressures imposed on health care in the 1990s, together with the failure of health care policy to encompass the changing nature of health care delivery, seem to represent further departures from policy objectives. In addition, there is evidence of increasing public dissatisfaction with the performance of the system. A return to modest increases in public funding in the new millennium has not been sufficient to arrest these trends. Widespread support for first-dollar public funding needs to be accompanied by greater attention to the scope of the legislation and the adoption of a needs-based focus among health care policymakers. [ABSTRACT FROM AUTHOR]

In the last 10 years, there has been a major growth in the development of treatment decision aids. Multiple goals have been identified for these tools. However, the rationale for and meaning of these goals at the conceptual level, the mechanisms through which decision aids are intended to achieve these goals, and value assumptions underlying the design of aids and associated values clarification exercises have often not been made explicit.In this paper, we present ideas to help inform the future development and evaluation of decision aids.We suggest, (i) that the appropriateness of using any decision aid be assessed within the context of the wider decision-making encounter within which it is embedded; (ii) that goal setting activities drive measurement activities and not the other way round; (iii) that the rationale for and meaning of goals at the conceptual level, and mechanisms through which they are intended to have an impact be clearly thought through and made explicit; (iv) that value assumptions underlying both decision aids and associated values clarification exercises be communicated to patients; (v) that taxonomies developed and used to classify various types of decision aids include a section on value assumptions underlying each tool; (vi) that further debate and discussion take place on the role of explicit values clarification exercises as a component of or adjunct to treatment decision aids and the feasibility of implementing valid measures.Further debate and discussion is needed on the above issues. [ABSTRACT FROM AUTHOR]

The National Institute for Clinical Excellence (NICE) responds to requests by the Department of Health for guidance on the use of selected new and established technologies in the National Health Service (NHS) in England and Wales. This paper asks whether the NICE methodological guidelines help NHS decision makers meet the objectives of maximum health improvements from NHS resources and an equitable availability of technologies. The analytical basis of the guidelines is a comparison of the costs and consequences of new and existing methods of dealing with particular conditions using the incremental cost-effectiveness ratio. We explain why information on the costs and consequences of a particular technology in isolation is insufficient to address issues of efficiency of resource use. We argue that to increase efficiency, decision makers need information on opportunity costs. We show that in the absence of such information decision makers cannot identify the efficient use of resources. Finally we argue that economics provides valid methods for identifying the maximisation of health improvements for a given allocation of resources and we describe an alternative practical approach to this problem. Drawing on the experience of Ontario, Canada where an approach similar to that proposed by NICE has been in use for almost a decade, and recent reports about the consequences of NICE decisions to date, we conclude that instead of increasing the efficiency or equity of the use of NHS resources, NICE methodological guidelines may lead to: uncontrolled increases in NHS expenditures without evidence of any increase in total health improvements; increased inequities in the availability of services; and concerns about the sustainability of public funding for new technologies. [ABSTRACT FROM AUTHOR]

Summary: The issues concerning treatment decision-making are that often options for treatment lead to uncertain outcomes (benefits and risks) at the individual patient level and that both patients and physicians might value these outcomes differently. There are three main approaches commonly used to describe treatment decision-making including paternalistic, shared and informed decision-making. The challenge and responsibility of physicians is to effectively communicate to patients that they should feel welcome to participate in decision-making through whichever approach seems suitable to them. Changes in laws governing the ethics of medical practice mandate a more comprehensive decision-making tactic requiring a two-way flow of information between patient and physician. The key to information exchange lies in evoking patient preferences by informing the patient of the benefits and risks associated with each treatment option. Decision aids have been developed in a variety of forms to facilitate this transfer of information about available treatment alternatives in as unbiased fashion as possible. We believe that treatment options presented should include not only those available by the particular physicians at that institution but also those available at outside institutions and within other healthcare systems. We discuss barriers for physicians who wish to encourage patient participation such as the power differential that exists between patients and physicians, factors related to health policy, and those unique to surgery. We believe that investigation is necessary to understand how the differences between types of medical practices, or even within a medical field, will influence the importance that patients attach to having their values and preferences considered during treatment decision-making and to evaluate how this importance changes as the severity of adverse events associated with treatment outcomes changes. We feel that it is important for physicians and surgeons to begin to think about these issues and how they might investigate potential resolutions for incorporating patient values and sharing their own preferences for treatment options with their patients during the orthopaedic encounter. [Copyright &y& Elsevier]