a systematic methodolog - 1000Minds by chenmeixiu

VIEWS: 10 PAGES: 74

									          Assigning Clinical Priority
          A Systematic Methodology
            Ray Naden, Ron Paterson, Paul Hansen, Alison Barber

  Franz Ombler, Ralph Stewart, Justin Roake, Peter Haddad, Wayne Gillett,
                           Jean-Claude Theis

                      New Zealand Ministry of Health
                New Zealand Health & Disability Commission
                              1000Minds™ Ltd
                Cardiac Society of Australia and New Zealand
                       New Zealand Vascular Society
       Royal Australian and New Zealand College of Ophthalmology
Royal Australian and New Zealand College of Obstetricians and Gynaecologists
                   New Zealand Orthopaedic Association.
                    New Zealand




•4 Million people
•Universal State Funded Healthcare + Private
•Strong Social Security System
Relative Expenditure on Health – US$ Purchasing
                 Power Parities


    Canada 3165

                     OECD 2550
                                 New Zealand 2083
              The ‗Gap‘
• Not all healthcare needs can be met
• Decisions to give one patient priority
  over another are inevitable

   How are priority decisions made?
Prioritisation in Elective Services
        Clinical Prioritisation

For Elective surgical procedures:

The process by which Doctors decide,
from those patients who would benefit,
which individual should have priority for the
 available capacity of publicly funded
 services
         Prioritisation —
       what do patients want?
• Access to necessary care
• Confidence in the publicly-
  funded health system
• Fair treatment
• Good information about their
  options
                      Access
The public understands that resources exceed demand
and rationing is necessary
But people are rightly intolerant of —
    inequity of access
      (easier access to elective surgery based
      on geography / inconsistent approaches)
    short-sighted clinical decision making
      (delayed access leading to more costly interventions
      later)
    denial of life-saving treatment
 Waiting lists are
political dynamite
    Prioritisation and the law
•    No legal right to access health care in
     New Zealand
•    But the right to be free from unlawful
     discrimination
      (eg, by age or disability)
•    Procedural fairness matters!
Lessons from dialysis rationing
 Ethics: The practical reality
A and B are candidates for an elective
surgical procedure

The procedure has been judged not to be futile, and A & B have
made an informed choice for the elective surgical procedure

   i.e: the clinician has decided that both patients would
   benefit from the procedure AND both patients have
   agreed.

There are sufficient resources for only one of
them
Ethics: New Zealand’s choice
 NZ has chosen to ration elective surgery
 explicitly and equitably

 Aim to achieve fair inequality through
 prioritisation of A & B:
 i.e: Differentiate A from B in an ethically acceptable
 (equitable) and relevant way
  Ethics: Basis of equitable
prioritisation in New Zealand

Degree of clinical need
Desire to relieve the burdens of those worst off in health
terms

Degree of expected benefit
Desire to avoid waste and achieve the most good
      Patient pathway: electives
• Resource limitation   • Inequities in electives pathway




• Patients‘ rights          • Health professional leadership
                 Patients’ rights
  New Zealand‘s Code of Patients‘ Rights
  recognise that patients referred for specialist
  assessment or waiting for surgery are
  entitled to

• reasonable care in assessment/treatment

• reasonable information about their
  condition, whether and when they will be
  seen, and options
The Southland urology case (2006)

―Prioritisation systems should be fair,
systematic, evidence-based and transparent.‖

It is unfair and unlawful to prioritise 58% of urology
patients as ―urgent‖ and leave them to wait more than
one year for assessment.
    What do Patients Want?
• Patients want to know they will receive
  treatment.

• Patients want to know when they will
  receive treatment.

• Patients want to be treated equally.
New Zealand Government Policy



Fundamental Principles for Access to Publicly
        Funded Elective Services

                  •Clarity
                •Timeliness
                 •Fairness
 Goals of Prioritisation Systems

• To determine the order of treatment
  and deliver treatment equitably

    • Delivery of treatment in accordance with the
      priority assigned is intended to provide
      fairness in the decision-making as to which
      patients are offered access to treatments of
      limited availability.
  Goals of Prioritisation Systems


• Priority assignment becomes a
  predictor of the future delivery of
  treatment and enables clarity to be
  given to patients as to whether and
  when they might receive treatment.
      Critical Success Factors
• Participative
      • Clinically led, considers all relevant stakeholder
        points of view – fellow clinicians, consumers,
        government, ethics
• Clinician Based
      • Has face validity - Based on actual cases
• Flexible
      • Continuous Quality Improvement – evolves as new
        evidence emerges
• Systematic
      • Based on good principles of complex decision-
        making
        When creating a Points System for prioritisation,
           2 things are essential for it to be valid:
                                     e.g. Hip & Knee Replacement (abbrev.)


(1) The ‗right‘ criteria (& levels
    within each) are included
    [Health Science]

(2) They have the ‗right‘ point
    values (weights)
    [Decision Science]
1000Minds (software for
creating Points Systems)
assists with both aspects…
 Algorithm („engine‟)
 Overall process
        (fully-integrated)
                 1000Minds Algorithm – PAPRIKA method
     (Potentially All Pairwise RanKings of All hypothetically-possible patients)

• Based on decision makers‘ expert knowledge & preferences, seeks to rank potentially
  all hypothetically-possible patients representable by a given Points System (i.e. all
  combinations of the level on the criteria), except for medically impossible ones…
• From that overall ranking, derive (via Linear Programming) the point values for the
  Points System (that matches decision makers‘ expert knowledge & preferences)



• The overall ranking of all hypothetically-possible patients is arrived at by asking
  decision makers a series of simple questions involving tradeoffs between 2 criteria at a
  time… (The number of questions asked is as small as possible.)
→ for users, the simplest & least cognitively/psychometrically demanding of
all methods … Therefore greater validity & reliability.
“The advantage of choice-based methods is that choosing, unlike scaling, is
a natural human task at which we all have considerable experience, and
furthermore it is observable and verifiable.” (Drummond et al. Methods for
the Economic Evaluation of Health Care Programmes, 2005)
     In contrast, other common methods of determining a Points
       System‟s points (weights) use introspection or scaling …   Points???
                                                                      ↓
1. Introspective (Ad hoc) Methods
                                                                    ???

(A) “Off the top of your head, choose the
point values that you think represent the
relative importance of the criteria.”                               ???

e.g. Ham (1993), Priority setting in the NHS:
Reports from six districts. BMJ 307
                                                                    ???
(B) “Out of a „budget‟ of 100 points,
allocate them amongst the criteria,
which are interpreted as criterion                                  ???
weights.”
e.g. Oregon Health Services Commission
                                                                    ???
(1991)
         2. Rating scale-based conjoint (regression) analysis

        “On a scale of 0 to 100, how would you rate the
        urgency of these patients (and others)?”

                    Patient X                                      Patient Y
3. Regular pain with weight-bearing activity    2. Intermittent activity-related pain
4. Severe limitation to personal activities     4. Severe limitation to personal activities
4. Severe limitation to social function         5. Profound limitation to social function
2. Moderate improvement likely                  1. Small improvement likely
1. Unlikely to deteriorate                      2. Likely to deteriorate



              Not urgent                                Extremely urgent
                     0                                             100
e.g. Noseworthy, et al. (2003) Waiting for scheduled services in Canada:
     Development of priority-setting scoring systems. Journal of Evaluation in
     Clinical Practice 9
     MacCormick et al. (2003) Prioritizing patients for elective surgery: A systematic
     review. Australia & New Zealand Journal of Surgery 73
                            1000 Minds
Asks a series of simple questions (the simplest possible) involving tradeoffs
between 2 criteria at a time …

→ generates a ranking of potentially all hypothetically-possible patients
representable by a given Points System (i.e. all combinations of the level on
the criteria), except for medically impossible ones

→ ‗solve‘ for the corresponding point values (representing decision makers‘
preferences)
                         How does the PAPRIKA work?
          (Potentially All Pairwise RanKings of All hypothetically-possible patients)

       e.g. with 5 criteria, & 5, 4, 5, 3, 3 levels each
                         → 5 x 4 x 5 x 3 x 3 = 900 hypothetically-possible patient profiles

With 900 patient profiles, there are (9002 – Patient
900)/2 = 404,550 pairwise comparisons        profiles 1 2 3 4 5 6 7 8 9 10 . . . 900
possible !!!                                        1   ? ? ? ? ? ? ? ? ? ? ? ? ?
                                                  2        ? ? ? ?     ?   ?   ?   ?   ?   ?   ?   ?
10s of thousands are automatically                3          ? ? ?     ?   ?   ?   ?   ?   ?   ?   ?
(incontrovertibly) ranked according to:
                                                  4            ? ?     ?   ?   ?   ?   ?   ?   ?   ?
Patient A (more highly ranked on all
                                                  5              ?     ?   ?   ?   ?   ?   ?   ?   ?
criteria) > Patient B (more lowly ranked)
                                                  6                    ?   ?   ?   ?   ?   ?   ?   ?
… And others are duplicates                       7                        ?   ?   ?   ?   ?   ?   ?
                                                  8                            ?   ?   ?   ?   ?   ?
→ 126,907 pairwise comparisons to                 9                                ?   ?   ?   ?   ?
                  consider                       10                                    ?   ?   ?   ?
                                                  .                                        ?   ?   ?
1000Minds achieves this all in about              .                                            ?   ?
45 pairwise decisions (& 25 is                    .                                                ?
sufficient for most applications) … by          900
exploiting (logical) property of
„transitivity‟ ...
                        Transitivity property:

                        If Patient Profile A is ranked > B
                                     and B is ranked > C,
                                           A ranked > C



              10s of thousands are automatically (incontrovertibly) ranked
              according to: Patient A (more highly ranked on all criteria)
                         > Patient B (more lowly ranked)

                    Patient A                                           Patient B
3. Regular pain with weight-bearing activity         2. Intermittent activity-related pain
4. Severe limitation to personal activities
5. Profound limitation to social function
                                                 >   4. Severe limitation to personal activities
                                                     4. Severe limitation to social function
2. Moderate improvement likely                       1. Small improvement likely
2. Likely to deteriorate                             1. Unlikely to deteriorate
  A Systematic Process for a Points
    Based Prioritisation System
             Requires:

Defining:

            » Criteria

            » Categories

            » Points
                  Priority Criteria
     What criteria should be used to determine
                 priority for access?
• Clinical Need
     Severity and extent of disease
     Impact of a condition on an individual‟s life
     resulting from pain, disfigurement, disablement
• Ability to Benefit from proposed treatment
     Likelihood and duration of optimal outcome
     Degree to which impact on life is reversible
                       Priority Criteria
    • Clinical Need
            Severity and extent of disease
            e.g: Vascular – Varicose Veins

Criterion   Category
Extent of        Localised           Intermediate           Extensive
disease      Long saphenous or    Long saphenous or       Long saphenous
              Short saphenous      Short saphenous              and
                    and                   and             Short saphenous
              Few varicosities   Extensive varicosities
                    Priority Criteria
• Clinical Need
  Severity and extent of disease e.g: Cardiac – Coronary Artery
  Bypass Graft

 Treadmill                   • Negative/mildly positive
 exercise/Perfusion            or akinetic or small territory at risk
 imaging/Territory at Risk   • Positive
                               or moderate territory at risk
                             • Very positive
                               or large territory at risk
                             • Markedly positive
                      Priority Criteria
• Clinical Need
         Severity and extent of disease
         Impact of a condition on an individual‘s life
         resulting from pain, disfigurement, disablement
Personal         1.    No Limitation
   Functional    2.    Minimal restriction to personal activities, eg trouble
   Limitation          reaching toes, occasional use of walking stick
                 3.    Moderate restriction to personal activities, e.g. requires
due to                 help with socks/shoes, or cutting toenails, regular use of
                       walking stick.
Orthopaedic      4.    Severe restriction to personal activities, e.g. requires
   Condition           help with dressing/shower, consistently uses 2 crutches
                       or wheelchair
                    Impact of a condition on an individual‟s life
                    resulting from pain, disfigurement, disablement
                      Patient Impact on Life Questionnaire solved at Cataract patient focus group 18 Nov 2005
Personal Care - includes maintaining health, preparing food, reading food labels, using appliances such as
                                                                                                                                     Points            Score
phones/microwaves
                                                                    Little or No difficulty                                                0.00%
                                                                    Quite difficult but not impossible                                    11.10%
                                                                    Makes some things impossible                                          29.20%
Social Interaction - including meeting friends, going to church, recognising faces, going shopping
                                                                    Little or No difficulty                                                0.00%
                                                                    Quite difficult but not impossible                                     4.20%
                                                                    Makes some things impossible                                          11.10%
Safety for self - including reading medicine labels, judging distances to cross the road, pouring hot drinks
                                                                    Little or No difficulty                                                0.00%
                                                                    Quite difficult but not impossible                                    12.50%
                                                                    Makes some things impossible                                          29.20%
Ability to fulfil their responsibility to others - including caring for children or grandchildren, partner, doing community/charity work, doing work for clubs
you belong to
                                                                    Little or No difficulty                                                0.00%
                                                                    Quite difficult but not impossible                                    11.10%
                                                                    Makes some things impossible                                          16.70%
Ability to interact with the world around them including seeing bus numbers, filling out forms/cheques, using the phone/computers, reading street or shop
signs, seeing the TV/Teletext
                                                                    Little or No difficulty                                                0.00%
                                                                    Quite difficult but not impossible                                     5.60%
                                                                    Makes some things impossible                                          11.10%
Leisure activities - including sporting activities (such as bowls, golf), handicrafts (such as cross-stitch), DIY maintenance/carpentry, reading books
                                                                    Little or No difficulty                                                0.00%
                                                                    Quite difficult but not impossible                                     1.40%
                                                                    Makes some things impossible                                           2.80%

Total score:
                  Priority Criteria
     What criteria should be used to determine
                 priority for access?
• Clinical Need
     Severity and extent of disease
     Impact of a condition on an individual‟s life
     resulting from pain, disfigurement, disablement
• Ability to Benefit from proposed treatment
     Likelihood and duration of optimal outcome
     Degree to which impact on life is reversible
                   Priority Criteria
 Ability to Benefit from proposed treatment
       Likelihood and duration of optimal outcome
Expected Duration of Benefit from Cardiac Surgery
1. Life expectancy < 2 years,or age >85 with moderate co-
   morbidity, or age >80 with severe co-morbidity
2.   Age >85 or age 80-85 with moderate co morbidity,or age <80
     with severe co-morbidity
3. Age >80 with no co-morbidity,or age <72 with moderate co-
   morbidity
4. Age 72-80 with no co-morbidity, or age <72 with moderate co-
   morbidity
5. Age < 72 with no co-morbidity
                  Priority Criteria

 Ability to Benefit from proposed treatment
      Degree to which impact on life is reversible

Potential to benefit from major joint replacement operation
(for patient, dependents or community)
1. Small improvement likely
2. Moderate improvement likely
3. Return to near normal likely
               Priority Criteria
Defining Categories
Personal      1. No Limitation
Functional
Limitation    2. Minimal restriction to personal activities,
due to           e.g: trouble reaching toes, occasional use of
                 walking stick
Orthopaedic
Condition     3. Moderate restriction to personal activities,
                 e.g: requires help with socks/shoes, or cutting
                 toenails, regular use of walking stick.
              4. Severe restriction to personal activities,
                 e.g: requires help with dressing/shower,
                 consistently uses 2 crutches or wheelchair
                       Defining Categories
Impact on Life - (Impact of gynaecology problem on ability to engage in and enjoy activities
which are important to the individual patient)

       I.
             No compromise of any important activities

       II.   No compromise of important activities because symptoms are controlled by other non-
             surgical management

      III.
             Compromises some important activities for at least 2 days in the month

     IV.
             Compromises some important activities for at least 7 days in the month

      V.
             Avoids some important activities for at least 2 days of the month

     VI.
             Compromises some important activities for the whole of the month

    VII.
             Avoids some important activities for at least 7 days of the month

    VIII.
             Avoids some important activities for the whole of the month
                        Defining Categories
                        Interpretation Notes
•   The focus is to reflect on the impact of the symptoms on life rather than to specify the nature
    and degree of symptoms. In evaluating two separate symptoms, the symptom with the highest
    weighting should be taken.

•   There are 3 steps to assigning a category:

•   i) Determine how the predominant symptom is affecting the woman in her ability to
    participate in, or perform, activities important for her.
         No significant compromise –symptom does not significantly affect the woman‘s ability
    to participate in any activity important to her
         No significant compromise because the symptoms are controlled with non – surgical
    management e.g. use of pads for incontinence or medication for pain management
         Important activities are compromised in spite of non-surgical management eg. made
    more difficult/embarrassing or reduced or postponed
         Important activities are avoided or prevented eg. avoidance of or inability to engage in
    sexual, sport, social, work and home activities.

•   ii) Determine the duration of the impact on life using the separate categories (Avoids or
    Compromises activities for at least 2 days, at least 7 days or for the whole of the month)

•   iii) Assign one of eight categories.
  A Systematic Process for a Points
    Based Prioritisation System
             Requires:

Defining:

            » Criteria

            » Categories

            » Points – 1000 Minds
A Systematic Process for a Points
  Based Prioritisation System
        also Requires:

       » Engagement of Clinicians

       » Development by Clinicians

       » Endorsement by Clinicians
A Systematic Process for a Points
  Based Prioritisation System
        also Requires:
1. Engagement of Clinicians
    •   Clinical Champion
    •   Support of President/Chair
    •   Mandate by Professional Body
    •   Credible Clinical Expertise
    •   Imperative for Change
                                                       Cataract Clinical Vignette Ranking

                                                                                                                    = Median
              24

              23
              22

              21
              20

              19
              18
              17                                                                                                               Clinician A

              16

              15                                                                                                               Clinician B

              14
Ra nk Order




              13                                                                                                               Clinician C

              12

              11
                                                                                                                               Clinician D
              10
              9
                                                                                                                               Clinician E
              8

              7
                                                                                                                               Clinician F
              6

              5
                                                                                                                               Clinician G
              4
              3

              2
              1

              0
                   A   B   C   D   E   F   G       I   J   K   M      N       O   P   Q     R   S   T   U   W
                                               H                                                                X   Y
                                                                   Vignette
                                                      Cataract Clinical Vignette Ranking

                                                                                                                   = Median
             24
             23
             22

             21
             20

             19

             18
             17                                                                                                               Clinician A

             16

             15                                                                                                               Clinician B

             14
Rank Order




             13                                                                                                               Clinician C

             12
             11
                                                                                                                              Clinician D
             10

             9
                                                                                                                              Clinician E
             8

             7
                                                                                                                              Clinician F
             6

             5
                                                                                                                              Clinician G
             4

             3

             2
             1
             0
                  A   B   C   D   E   F   G       I   J   K   M      N       O   P   Q     R   S   T   U   W
                                              H                                                                X   Y
                                                                  Vignette
A Systematic Process for a Points
  Based Prioritisation System
        also Requires:
2. Development by Clinicians
       • Scope
       • Criteria
       • Categories
       • Points
       • Validity
       • Reliability
       • Acceptability (Pilot)
                 Scope
         What‘s in and what‘s not?

• Malignancy, Fertility – Gynaecology
• Acute Coronary Syndrome – Cardiac
• Revision – Major Joint Replacement
                   Criteria

•   Evidence vs Expert Opinion
•   Independence
•   Defect         Disability       Impact on Life
•   Clinician Assessment vs Patient Assessment
   Categorisation



Can Clinicians assign patients
 consistently to categories?
                                                                                     Ganymede




                                                                                                                                                 Amalthea
                                                                                                                   Pasiphae




                                                                                                                                                                       Adrastea
                                                                                                                                                            Lysithea
                                                                                                                                        Europa
                                                                                                        Callisto
                                                                            Sinope




                                                                                                                              Himalia




                                                                                                                                                                                                         Thebe
                                                                                                                                                                                  Carme


                                                                                                                                                                                          Leda
                                                                                                Elara




                                                                                                                                                                                                 Metis
                                                                       Io
                                                     Highlight = Consensus
Extent of Disease
       LOCALISED - Long saphenous OR Short saphenous AND
       Few varicosities                                         1                               1        2                              1         2                     4         2              4       8
       INTERMEDIATE - Long saphenous OR Short saphenous
       AND Many varicosities                                    7      8              1         7        6          8          8        7         6          2          4         6       2      4
       EXTENSIVE - Long saphenous AND Short saphenous                                 7                                                                      6                            6

Severity of Disease
       Severity 2: Asymptomatic or occasional non-ulcer pain;
       Ankle oedema                                                    8    1         5         4                   3          1        1                    3                    1              1       8
       Severity 3: Frequent (daily) non-ulcer pain controllable by
       conservative measures; Leg oedema without cellulitis; Minor
       venotensive skin changes                                             4         1         4                   5          6        6                                         6       1      5
       Severity 4: Frequent (daily) non ulcer pain not controlled by
       conservative measures; Oedema associated with cellulitis
       (single episode); Moderate OR extensive venotensive skin
       changes                                                              3         2                  8                     1        1                                         1              2
       Severity 5: Oedema associated with recurrent cellulitis AND
       not responsive to thorough conservative management;
       Healed venous ulceration                                                                                                                              5          8
       Severity 6: Recurrent venous ulceration (despite use of
       compression hosiery); Active venous ulceration (resistant to
       compression)                                                                                                                               8                                       7

Disability treatable by varicose vein surgery
        Disability 1:Able to carry out usual activities without
        compressive therapy                                            8    8         8         8                   7                   7                    1                    4       1      7       8

        Disability 2:Able to carry out usual activities only with
        compression and/or limb elevation. Includes use of (or
        prescription for) compression hose for ulcer prophylaxis.                                                   1          8        1         1          6          8         4       3      1
        Disability 3:Unable to carry out usual activities even with
        compression and/or limb elevation                                                                8                                        7          1                            4
  Assigning Points



Individual   Consensus
                  Validity

Ranking of Cases - Vignettes


Individual             Consensus
―Best Practice‖ Ranking


Rank Order Comparison of Prioritisation System
with ―Best Practice‖ Ranking
             CPS Validity
20
18
16
14
12
                                           Clinical
10
                                           CPAC
 8
 6
 4
 2
 0
     K H S C I B A G F N D E J R L O M P
                                              Vignette Rank
  A
   m




                   1
                   2
                   3
                   4
                   5
                   6
                   7
                   8
                   9
                  10
                  11
                  12
                  13
                  14
                  15
       al
          th
            ea
      Le
           d
  Ly a
     sit
         he
  A          a
   dr
      as
          te
             a
   Ca
      lli
G         s
 an to
    ym
         ed
             e
   H
     im
         al
             ia
   Si
      no
           pe
      El
         ar
             a
     M
        et
            is
   Eu
       ro
           pa
    Ca
                                                              Comparison of Vignette Rankings




        rm
             e
    Th
                                                                                                Clinical vs CPS




         eb
  Pa e
    sip
         ha
             e

           Io
                  CPAC Rank
                              Clinical Rank
             Reliability
Do Standardised Criteria reduce
         Variability?
      Comparison of Ranking Methods

      MEDIANS
                  Clinical    CPS
       Vignette        SD             SD
          A              3             2
          B              5             3
          C              6             2
          D              3             2
          E              5             4
          F              6             1
          G              2             3
          H              7             0
           I             4             3
           J             2             4
          K              3             1
          L              5             2
          M              7             1
          N              4             4
          O              1             5
          P              1             1
      Mean SD           3.9           2.3

        SD>3.5          7              4
                Pilot Testing
• Purpose:
  – To test clinical usability and acceptability
  – Test whether proposed CPS improves
    prioritisation consistency
  – Test correlation with treatment decisions
A Systematic Process for a Points
  Based Prioritisation System
        also Requires:
3. Endorsement by Clinicians
      • Presentation to Colleagues
      • Formal Endorsement by
        Professional Body
      • Progressive Adoption
Summary
               Commitment
                 to Treat

     Clarity                Timeliness



  Priority                    Decision
 Assignment                   to Treat
                 Fairness
              Commitment
                to Treat

    Clarity                Timeliness



 Priority                    Decision
Assignment                   to Treat
                Fairness
General Principles for Prioritisation Methods



         •Systematic
         •Transparent
         •Evidence based
         •Consistent with established principles
         •Differentiates adequately
         •Consistently applied
Critical Success Factors


  •   Doctors
  •   Clinical Cases
  •   Criteria / Categories / Points
  •   Process
          Prioritisation in Elective Services

     100


QUALITY
OF LIFE

     50       A     A




                          A     A
     0
          Prioritisation in Elective Services

     100


QUALITY           B
OF LIFE
                          B

     50       A       A




                              A   A

     0
          Prioritisation in Elective Services

     100


QUALITY           B
OF LIFE
                          B

     50       A       A



                                  B       B

                              A       A
     0
Disease   Disability   Impact on Life
Disease        Disability       Impact on Life


     Doctors                Patients
Prioritisation in Elective Services
Clinical Prioritisation (micro-prioritisation)
               is important for

  • Fairness and Equity
  • Clarity for Patients
  • Good quality resource-allocation decisions
    Prioritisation Systems

                •Clinical Judgement
                •Broad Bands
                •Scenario Systems
                •Point Systems

Point Systems chosen because they ‗fit‘ best with multiple criteria of
varying degrees
     Prioritisation in Elective Services
QUESTION 1:
Is the treatment in the best interests of the patient?
             ( net ability to benefit >0 )


QUESTION 2:
Is the treatment available to this patient?
Can everyone who needs it, have it? (no prioritisation
    needed)
If not,
• Who can have it and who cannot?

 Prioritisation based on net ability to benefit
 of one patient relative to another
          Prioritisation in Elective Services


Working Principles for Prioritisation Methods


•Based on relative ability to benefit

•Numerical (e.g. multi dimensional additive point systems)

•Iterative (Continual Quality Improvement)

•“Gold Standard” is consensus of judgement of a group of experts

								
To top