BACKGROUND: In rationing decisions in health, many criteria like costs, effectiveness, equity and feasibility concerns play a role. These criteria stem from different disciplines that all aim to inform health care rationing decisions, but a single underlying concept that incorporates all criteria does not yet exist. Therefore, we aim to develop a conceptual mapping of criteria, based on the World Health Organization's Health Systems Performance and Health Systems Building Blocks frameworks. This map can be an aid to decision makers to identify the relevant criteria for priority setting in their specific context. METHODS: We made an inventory of all possible criteria for priority setting on the basis of literature review. We categorized the criteria according to both health system frameworks that spell out a country's health system goals and input. We reason that the criteria that decision makers use in priority setting exercises are a direct manifestation of this. RESULTS: Our map includes thirty-one criteria that are distributed among five categories that reflect the goals of a health system (i.e. to improve level of health, fair distribution of health, responsiveness, social & financial risk protection and efficiency) and one category that reflects feasibiliy based on the health system building blocks (i.e. service delivery, health care workforce , information, medical products, vaccines & technologies, financing and). CONCLUSIONS: This conceptual mapping of criteria, based on well-established health system frameworks, will further develop the field of priority setting by assisting decision makers in the identification of multiple criteria for selection of health interventions. Hide
Priority setting in primary health care: a framework for local catchments
Author:
Mcdonald, J. and Ollerenshaw, A.
Year:
2011 Source: Rural and remote health, Vol. 11, Issue 2
Managers and staff in primary health care partnerships in local catchments, particularly in regional areas, are periodically required to work collaboratively to set health priorities. Setting priorities involves making decisions about which health needs are most important and what programs will be funded to address them. There is no universally agreed set of decision-making rules for setting priorities. Dominant approaches prioritise health economics, and have favoured expert knowledge drawn from technical-rational methodologies rather than consumer involvement and community action. However, research reveals that setting priorities is a complex, value laden, contested process buffeted by competing objectives and political interests. As such, an interdisciplinary, collaborative approach is called for. Using reflective practice from a priority setting project for a primary care partnership in a local, regional catchment in Victoria, Australia, a conceptual framework for priority setting is presented that identifies 13 interconnected factors spanning economic, political, policy, epidemiological, moral, evidentiary and evaluative domains. This interdisciplinary framework extends current knowledge about the considerations and trade-offs in setting priorities among collaborating primary health care agencies. It offers a potentially valuable heuristic tool for healthcare decision-makers in rural areas. Hide
Identifying research priorities for health care priority setting: a collaborative effort between managers and researchers
Author:
Smith, N., Mitton, C., Peacock, S., Cornelissen, E. and Macleod, S.
BACKGROUND:To date there has been relatively little published about how research priorities are set, and even less about methods by which decision-makers can be engaged in defining a relevant and appropriate research agenda. We report on a recent effort in British Columbia to have researchers and decision-makers jointly establish an agenda for future research into questions of resource allocation. METHODS:The researchers enlisted decision-maker partners from each of British Columbia's six health authorities. Three forums were held, at which researchers and decision-makers from various levels in the health authorities considered possible research areas related to three key focus areas: (1) generation and use of decision criteria and measurement of 'benefit'against such criteria; (2) identification of so-called 'disinvestment'opportunities; and (3) evaluation of the effectiveness of priority setting procedures. Detailed notes were taken from each forum and synthesized into a set of qualitative themes. RESULTS:Forum participants suggested that future research into healthcare priority setting would benefit from studies that were longitudinal, comparative, and/or interdisciplinary. As well, participants identified two broad theme areas in which specific research projects were deemed desirable. First, future research might usefully consider how formal priority setting and resource allocation projects are situated within a larger organizational and political context. Second, additional research efforts should be devoted to better understanding and improving the actual implementation of priority setting frameworks, particularly with respect to issues of change management and the resolution of impediments to action on recommendations for resource allocation. CONCLUSIONS:We were able to validate the importance of initial areas posed to the group and observed emergence of additional concerns and directions of critical importance to these decision-makers at this time. It is likely that the results are broadly applicable to other healthcare contexts. The implementation of this research agenda in British Columbia will depend upon the ability of the researchers and decision-makers to develop particular projects that fit within the constraints of existing funding opportunities. The process of engagement itself had benefits in terms of connecting decision-makers with their peers and sparking increased interest in the use and refinement of priority setting frameworks. Hide
Methods for priority setting among clinical preventive services
Author:
Maciosek, M. V., Coffield, A. B., Mcginnis, J. M., Harris, J. R., Caldwell, M. B., Teutsch, S. M., Atkins, D., Richland, J. H. and Haddix, A.
Year:
2001 Source: American Journal of Preventive Medicine, Vol. 21, Issue 1, PP 41921
Methods used to compare the value of clinical preventive services based on two criteria-clinically preventable burden (CPB) and cost effectiveness (CE)-are described. A companion article provides rankings of clinical preventive services and discusses its uses for decision-makers; this article focuses on the methods, challenges faced, and solutions. The authors considered all types of data essential to measuring CPB and CE for services recommended by the U.S. Preventive Services Task Force and developed methods essential to ensuring valid comparisons of different services'relative value. Hide
Disinvestment of ineffective practices
Reducing ineffective practice: challenges in identifying low-value health care using Cochrane systematic reviews
Author:
Garner, S., Docherty, M., Somner, J., Sharma, T., Choudhury, M., Clarke, M. and Littlejohns, P.
Year:
2013 Source: Journal of health services research & policy, Vol. 18, Issue 1, PP 41802
OBJECTIVES: Despite international agreement that stopping low value practices will increase efficiency, identifying them is difficult and controversial. Opponents of centralized lists of low value practices stress that the actual problem is inappropriate low value use, and better targeting and implementation of treatment thresholds is needed. Our objective was to use Cochrane Reviews to identify low value practices to support local disinvestment decisions. METHODS: New or updated reviews were included if the authors concluded that the uncertain effectiveness of an intervention meant it should only be used in research, or that it was ineffective or harmful and should not be used. The reviews go through a production and quality assurance process, and are published as 'Cochrane Quality and Productivity topics'through the NHS Evidence website (http://www.library.nhs.uk/qipp/). RESULTS: Over a six-month period, 65 Cochrane reviews were processed by the National Institute for Health and Clinical Excellence (NICE). Of these, 28 identified potentially low value practices in the UK context. This was primarily due to a lack of randomized evidence of effectiveness, rather than robust evidence of a lack of effectiveness, or evidence of harm. CONCLUSIONS: Identifying low-value health care practices for local disinvestment (total or partial) is both practically and politically challenging, yet it is necessary to manage health budgets. This project identified that Cochrane Reviews can potentially identify low value health care practices. However, each review has to be reinterpreted for the UK context and additional analysis has to be undertaken to facilitate local implementation. Recommendations to improve the usability of systematic reviews are made. Hide
A novel research design can aid disinvestment from existing health technologies with uncertain effectiveness, cost-effectiveness, and/or safety
Author:
Haines, T., O'brien, L., Mcdermott, F., Markham, D., Mitchell, D., Watterson, D. and Skinner, E.
OBJECTIVES: The aim of this study was to determine how evidence from systematic review (SR) is perceived and negotiated by expert stakeholders in considering a technology for potential disinvestment. METHODS: An evidence-informed stakeholder engagement examined results from a diagnostic accuracy SR of vitamin B12 and folate tests. Pathologists deliberated around the SR findings to generate an informed contribution to future policy for the funding of B12 and folate tests. Deliberations were transcribed and subject to qualitative analysis. RESULTS: Pathologists did not engage with findings from the SR in depth; rather they sought to contest the terms of the problem driving the review and attempted to reframe it. Pathologists questioned the usefulness of SR outcomes given the variable definitions of B12 deficiency and deferred addressing disinvestment options specifically pertaining to B12 testing. However, folate testing was proffered as a potential disinvestment candidate, based upon pathologists'definition of "appropriate" evidence beyond the bounds of the SR. CONCLUSIONS: The value of SR to informing disinvestment deliberations by expert stakeholders may be a function of timing as well as content. Engagement of stakeholders in co-produced evidence may be required at two levels: (i) Early in the synthesis phase to help shape the SR and harmonize expert views with the available evidence (including gaps); (ii) Collaboration in primary research to fill evidence-gaps thus supporting evidence-based disinvestment. Without this, information asymmetry between clinically engaged experts and decision makers may preclude the collaborative, informed, and technical discussions required to generate productive policy change. Hide
Disinvestment for re-allocation: a process to identify priorities in healthcare
Resource scarcity and increasing service demand lead health systems to cope with choices within constrained budgets. The aim of the paper is to describe the study carried out in the Tuscan Health System in Italy on how to set priorities in the disinvestment process for re-allocation. The analysis was based on 2007 data benchmarking of the Tuscan Health System with an impact on the level of resources used. For each indicator, the first step was to estimate the gap between the performance of each Health Authority (HA) and the best performance or the regional average. The second step was to measure this gap in terms of financial value. The results of the analysis demonstrated that, at the regional level, 2-7% of the healthcare budget can be re-allocated if all the institutions achieve the regional average or the best practice. The implications of this study can be useful for policy makers and the HA top management. In the context of resource scarcity, it allows managers to identify the areas where the institutions can achieve a higher level of efficiency without negative effects on quality of care and instead re-allocate resources toward services with more value for patients. Hide
Knowledge translation for decision making
Tracking and understanding the utility of Cochrane reviews for public health decision-making
Author:
Armstrong, R., Pettman, T., Burford, B., Doyle, J. and Waters, E.
Year:
2012 Source: Journal of public health, Vol. 34, Issue 2, PP 309-313
Cochrane reviews aim to support policy and practice decisions. Developing systematic strategies to understand the pathway from their production to actually making a difference in practice is difficult but extremely valuable. Such an exercise can help to determine meaningfulness of the reviews, identify their use in highlighting the spectrum of the primary evidence, flag opportunities to update and stimulate research gap analyses. This paper briefly describes our emerging approach to tracking and understanding the use, and usefulness, of published Cochrane Public Health Group (CPHG) reviews to date. Hide
A proposal to speed translation of healthcare research into practice: dramatic change is needed
Author:
Kessler, R. and Glasgow, R. E.
Year:
2011 Source: American Journal of Preventive Medicine, Vol. 40, Issue 6, PP 637-644
Efficacy trials have generated interventions to improve health behaviors and biomarkers. However, these efforts have had limited impact on practice and policy. It is suggested that key methodologic and contextual issues have contributed to this state of affairs. Current research paradigms generally have not provided the answers needed for more probable and more rapid translation. A major shift is proposed to produce research with more rapid clinical, public health, and policy impact. Hide
The case for knowledge translation: shortening the journey from evidence to effect
Author:
Davis, D., Evans, M., Jadad, A., Perrier, L., Rath, D., Ryan, D., Sibbald, G., Straus, S., Rappolt, S., Wowk, M. and Zwarenstein, M.
[First paragraph] A large gulf remains between what we know and what we practise. Eisenberg and Garzon point to widespread variation in the use of aspirin, calcium antagonists, ß blockers, and anti-ischaemic drugs in the United States, Europe, and Canada despite good evidence on their best use. Such variation is common not only internationally but within countries. Large gaps also exist between best evidence and practice in the implementation of guidelines. Failure to follow best evidence highlights issues of underuse, overuse, and misuse of drugs and has led to widespread interest in the safety of patients. Not surprisingly, many attempts have been made to reduce the gap between evidence and practice. These have included educational strategies to alter practitioners'behaviour and organisational and administrative interventions. We explore three constructs: continuing medical education (CME), continuing professional development (CPD), and (the newest of the three) knowledge translation (box). Knowledge translation both subsumes and broadens the concepts of CME and CPD and has the potential to improve understanding of, and overcome the barriers to, implementing evidence based practice. Hide
Global Health
Global health priorities and research funding
Author:
Catalá-López, F., Gènova-Maleras, R. and Peiró, S.
BACKGROUND: Policymakers and stakeholders need immediate access to many types of research evidence to make informed decisions about the full range of questions that may arise regarding health systems. METHODS: We examined all types of research evidence about governance, financial and delivery arrangements, and implementation strategies within health systems contained in Health Systems Evidence (HSE) (www.healthsystemsevidence.org). The research evidence types include evidence briefs for policy, overviews of systematic reviews, systematic reviews of effects, systematic reviews addressing other questions, systematic reviews in progress, systematic reviews being planned, economic evaluations, and health reform and health system descriptions. Specifically, we describe their distribution across health system topics and domains, trends in their production over time, availability of supplemental content in various languages, and the extent to which they focus on low- and middle-income countries (LMICs), as well as (for systematic reviews) their methodological quality and the availability of user-friendly summaries. RESULTS: As of July 2013, HSE contained 2,629 systematic reviews of effects (of which 501 are Cochrane reviews), 614 systematic reviews addressing other questions, 283 systematic reviews in progress, 186 systematic reviews being planned, 140 review-derived products (evidence briefs and overviews of systematic reviews), 1,669 economic evaluations, 1,092 health reform descriptions, and 209 health system descriptions. Most systematic reviews address topics related to delivery arrangements (n = 2,663) or implementation strategies (n = 1,653) with far fewer addressing financial (n = 241) or governance arrangements (n = 231). In addition, 2,928 systematic reviews have been quality appraised with moderate AMSTAR ratings found for reviews addressing governance (5.6/11), financial (5.9/11), and delivery (6.3/11) arrangements and implementation strategies (6.5/11); 1,075 systematic reviews have no independently produced user-friendly summary and only 737 systematic reviews have an LMIC focus. Literature searches for half of the systematic reviews (n = 1,584, 49%) were conducted within the last five years. CONCLUSIONS: Greater effort needs to focus on assessing whether the current distribution of systematic reviews corresponds to policymakers'and stakeholders'priorities, updating systematic reviews, increasing the quality of systematic reviews, and focusing on LMICs. Hide
Priority setting for systematic review of health care interventions in Nigeria
Recommendations shaping policies, programs, and practices in global health should be based on the best available science, but how best to achieve this objective is less clear. We describe a new approach developed by the United Nations Development Programme/United Nations Population Fund/World Health Organization/World Bank Special Programme of Research, Development and Research Training in Human Reproduction within the World Health Organization Department of Reproductive Health and Research for addressing key challenges in global reproductive health. This approach leads to new recommendations for accelerating solutions to priority needs in the field and continued improvements in the science base-including the implementation science base-for meeting these needs. The key components of this new cycle for science-driven solutions include: 1) identifying priority needs of the field; 2) creating guidance that meets the needs of the field; 3) identifying research gaps and establishing and funding research priorities; 4) research synthesis and updating of the guidance in a timely fashion; and 5) supporting utilization in countries through systematic introduction of science-driven solutions. There is a synergistic effect when the contributions of the individual components of this cycle are linked. Strong institutional support is required for this collective effort, as is the creation of a team of researchers, practitioners, donors, and implementing agencies with shared responsibilities for its success. This new approach has already made important contributions toward addressing key challenges in family planning and maternal and perinatal health. We believe that it will help bridge the gap between knowledge and action for reproductive health and for global health more broadly. Hide
Establishing health systems financing research priorities in developing countries using a participatory methodology
Donor funding for health systems financing (HSF) research is inadequate and often poorly aligned with national priorities. This study aimed to generate consensus about a core set of research issues that urgently require attention in order to facilitate policy development. There were three key inputs into the priority setting process: key-informant interviews with health policy makers, researchers, community and civil society representatives across twenty-four low- and middle-income countries in four regions; an overview of relevant reviews to identify research completed to date; and inputs from 12 key informants (largely researchers) at a consultative workshop. Nineteen priority research questions emerged from key-informant interviews. The overview of reviews was instructive in showing which health financing topics have had comparatively little written about them, despite being identified as important by key informants. The questions ranked as most important at the consultative workshop were: It is hoped that this work on HSF research priorities will complement calls for increased health systems research and evaluation by providing specific suggestions as to where new and existing research resources can best be invested. The list of high priority HSF research questions is being communicated to research funders and researchers in order to seek to influence global patterns of HSF research funding and activity. A "bottom up" approach to setting global research priorities such as that employed here should ensure that priorities are more sensitive to user needs. Hide
Evidence-based priority setting for health care and research: tools to support policy in maternal, neonatal, and child health in Africa
Author:
Rudan, I., Kapiriri, L., Tomlinson, M., Balliet, M., Cohen, B. and Chopra, M.
As part of a series on maternal, neonatal, and child health in sub-Saharan Africa, Igor Rudan and colleagues discuss various priority-setting tools for health care and research that can help develop evidence-based policy. Hide
Priority setting in health care: Lessons from the experiences of eight countries
Author:
Sabik, L. M. and Lie, R. K.
Year:
2008 Source: International Journal for Equity in Health, Vol. 7
All health care systems face problems of justice and efficiency related to setting priorities for allocating a limited pool of resources to a population. Because many of the central issues are the same in all systems, the United States and other countries can learn from the successes and failures of countries that have explicitly addressed the question of health care priorities.We review explicit priority setting efforts in Norway, Sweden, Israel, the Netherlands, Denmark, New Zealand, the United Kingdom and the state of Oregon in the US. The approaches used can be divided into those centered on outlining principles versus those that define practices. In order to establish the main lessons from their experiences we consider (1) the process each country used, (2) criteria to judge the success of these efforts, (3) which approaches seem to have met these criteria, and (4) using their successes and failures as a guide, how to proceed in setting priorities. We demonstrate that there is little evidence that establishment of a values framework for priority setting has had any effect on health policy, nor is there evidence that priority setting exercises have led to the envisaged ideal of an open and participatory public involvement in decision making. Hide
Priority setting of public spending in developing countries: do not try to do everything for everybody
Author:
Baltussen, R.
Year:
2006 Source: Health Policy, Vol. 78, Issue 41673, PP 149-156
BACKGROUND: Public spending on health care in many developing countries falls short to provide a comprehensive set of essential health services, which indicates the need to target and prioritize resources. However, governments often attempt to provide free services to the whole population, and often spend resources on low-impact services. This results in an inequitable and inefficient use of resources. METHODS: This paper presents a rational approach to targeting and prioritization of public spending, with an application to Ghana. First, interventions were tested against the economic justification for public funding, to define to whom spending should be targeted. Second, resulting interventions were prioritized on the basis of medical and non-medical criteria. RESULTS: The step-wise approach led to a rank ordering of interventions with a specification whether public spending should be targeted at the whole population or the poor only. Disease control priorities are prevention of mother-to-child HIV/AIDS transmission and oral rehydration therapy to treat diarrhea in childhood, and public funding of these interventions is warranted for the whole population. Case-management of pneumonia in childhood is also a priority but public funding should be targeted at the poor only. Low priorities for public funding are certain interventions to control blood pressure, tobacco and alcohol abuse, be it for the whole population or the poor only. CONCLUSION: Governments should not try to provide everything for everybody. This may help health systems to move towards a more equitable and efficient use of resources Hide