Decision Making in Pathways Development

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Decision Making in Pathways Development

• Dr Andrew J Taylor
• Assistant Director Public Health Science Hull
  Teaching PCT

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s On Website

• http//www.hullpublichealth.org

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Decision Making in Pathways Development

• Objectives
• Describe an Economic view of Decision Making in
  Health Care
• Offer a potential approach
• Describe simple approach
• Pull together main recommendations

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Economists Perspective

• More Demands on resources than there are
  resources available
• A view not always accepted by participants in NHS
• Patients needs must come first!
• Which patients needs come first
• Cardiac Pathway
• Cancer Pathway

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Economists Perspective2 key economic principles

• Opportunity Cost
• Investing resources in one way or on one group of
  patients means that resources not available for
  another

• The Margin
• About changes to the resource mix
• If budget increases how to spend new resources
• If budget decreases where to reduce resources
• If budget stays constant how to reconfigure for
  improved service

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Marginal Analysis

• Aim to allocate resources to the point when no
  further change will result in a health gain
• Without explicit adherence to the two economic
  principles resources will be unlikely to be
  allocated in the best possible configuration.
• Opportunity Cost - The Margin

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Program Budgeting Marginal Analysis (PBMA)

• Approach used in UK Australia New Zealand and
  Canada
• Hull is participant in National PBMA Pilot with
  York Observatory - Diabetes
• Similar principles to economic evaluation but
  suggested to be more pragmatic and applicable to
  various levels through organisation
• Key is to ensure that opportunity cost and the
  margin are used in decision making process

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PBMA Steps

• Determine aim and scope of decision process
• Define budget (map current activity and spending)
• Form marginal analysis advisory panel
  (representative)
• Determine locally relevant decision criteria
• input from decision makers board public etc
• Advisory Panel identify
• Areas for service growth
• Areas for savings through using less resources
  for same service level
• Areas for resource release through scaling back /
  stopping services
• Advisory Panel make recommendations in terms of
• Funding growth areas from new resources
• Moving resources from 5b to 5a
• Trade off decisions to move resources from 5c to
  5a if considered to be an improvement
• Validity checks with stakeholders

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Determine Scope

• Aims need to be clearly stated
• Might be
• To determine optimum investment across all
  programs within Trust (PCT or Provider)
• Or
• To identify priorities for new technologies
• Both important for Pathways Development
• Map current activity and spending
• Starting point for decisions

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Advisory Panel (Pathways Group)

• Representative group but not too large
• Group dependent on question under consideration
  and scope of exercise
• Necessary to restate economic principles

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Decision Making Criteria

• Need to clearly state dependent criteria and make
  explicit (some examples)
• Cost-effectiveness/Clinical efficacy
• Deprivation/Equity
• Innovation
• Ethics
• Political Imperatives
• May be put into a decision making pro-forma to
  ensure fair consideration and avoid the loudest
  voice dominating
• Or use Qualitative (Delphi) methods

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Identify options for change

• Stage 5 in the PBMA process
• Prioritised list of service growth options
• Examine current expenditure to improve
  operational efficiency
• Identify options for service reductions or
  scaling back

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Rating Options for Change

• Part 6 in the PBMA process
• Each planning group member to explicitly rate
  each option from stage 5 according to the
  pre-defined criteria
• All decision matrix forms summed and total score
  averaged to give a score per option51121

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Ranking and Decisions

• If for example service growth items A B and C
  get scores of 900 800 and 700 and service
  reduction options X Y and Z get average scores
  of 850 750 and 650 respectively
• Ranking of options is then A X B Y C Z
• Service A should be financed from lowest ranked
  service reduction (Z) still getting funding
• Continue comparing growth and service reduction
  until no further gains can be had by switching
  resources between options

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Why and What Challenges

• Notion of freeing resources through improving
  operational efficiency commonplace in health
  organisations
• But Still
• Challenge to obtain resource releases through
  service reductions / disinvestments
• Need good information

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Information and PBMA

• Economic Evaluations
• Systematic Overviews
• Outcome studies
• Health technology assessments
• Quality reports
• DoH or other guidelines
• Local utilisation data
• Informal input
• Expert opinion
• Business cases
• Etc as relevant

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Other Challenges

• Data Requirements - Cost of Information
• Need to make decisions when there is little
  evidence (Bounded rationality)
• Identifying areas for resource release (sacred
  cows and protection of interests)
• Might be better approached by informal
  consultation with key personnel or by anonymous
  questionnaire
• How to incorporate patient views without
  distorting a rational or dispassionate view

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Barriers and Facilitators

• Barriers
• Lack of trust between facilitators
• Physicians not on board
• Advisory panel lacking in health economics and/or
  allocation experience
• Politics preventing program evolution
• Discontinuity of personnel
• Too many admin demands leaving priority setting
  as a low priority activity

• Facilitators
• Senior level managerial/clinical champions
• Strong leadership
• Culture to learn and change
• Integrated budgets
• Resources earmarked for PBMA process itself
• Built in incentives for appropriate and efficient
  spending

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Advantages of PBMA

• Explicit recognition of opportunity cost and the
  margin
• Transparent process
• Stakeholder consultation
• Enables public input
• Can be coupled with an ethical framework to
  examine the fairness of the process
• Improvement on common unstructured decision
  processes

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Decision Tree Approach
Square Decision Node Circle Chance Node with
probability
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Decision Trees1 Year Timescale in this case for
simplicity
Die
A
Live
Decision
Die
B
Live
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Decision Trees ProbabilitiesMust Sum to 1
Die
0.05
A
Live
0.95
Decision
Die
0.1
B
Live
0.9
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Decision Trees OutcomesMeasured using HUI SF36
Euroqol etc
Die
0
0.05
A
Live
0.85
0.95
Decision
Die
0
0.1
B
Live
0.80
0.9
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Decision Trees CostImportant in every Pathway
Die
0
0.05
A
Live
0.85
0.95
1000
Decision
Die
0
0.1
100
B
Live
0.80
0.9
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Decision Trees OutcomesMeasured using HUI SF36
Euroqol etc
Die
0
0.05
Outcome 0.81
A
Live
0.85
0.95
1000
new treatment
Decision
Die
0
Existing treatment
0.1
100
B
Live
0.80
Outcome 0.72
0.9
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Decision Trees OutcomesMeasured using HUI SF36
Euroqol etc
Die
0
0.05
Outcome 0.81
A
Live
0.85
0.95
1000
Expensive Treatment
Decision
Cheap Treatment
Die
0
0.1
100
B
Live
0.80
Outcome 0.72
0.9
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Decision Trees OutcomesMeasured using HUI SF36
Euroqol etc
Die
0
0.05
Outcome 0.81
A
Live
0.85
0.95
1000
Expensive Treatment
1 Patient Or 1000
Decision
Die
0
Cheap Treatment
0.1
100
B
Live
0.80
Outcome 0.72
0.9
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What Next

• Difference in Health Related Quality of Life
  Outcome 0.09 on scale (between 0 death and 1 full
  health
• Cost difference 900
• Cost per QALY
• 900 for 0.09 improvement in Quality of life
• 9999 cost per QALY
• NIHCE Boundary 30000 per QALY
• 9999.9999999

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What Next Whats important

• PBMA - Allows consideration and input of
  pathway for all members of group avoid dominance
  by any group
• Finite Resources Probably shrinking in real
  terms due to increases in costs
• Evidence Based From Studies and Measured Local
  Outcomes
• Costed Essential but not always considered but
  relatively easy
• Gold Standard Silver Standard or Bronze -
  Based on Maximisation of benefit to patients

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What Next Whats important

• Cost of Information Not always possible to meet
  all the important points but should attempt to
  find ways where we can
• Innovation and Change Can it be accommodated
  in a tariff based system
• Others

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• References
• Farrar S Ryan M Ross D Ludbrook A Using
  discrete choice modelling in priority setting an
  application to clinical service
  developments.Social
• Science and Medicine 2000 5063-75.
• Lomas J Woods J Veenstra G Devolving authority
  for health care in Canadas provinces 1. An
  introduction to the issues.Canadian Medical
  Association Journal 1997 156(3)371-377.
• Mitton C Donaldson C Setting priorities in
  Canadian regional health authorities a survey of
  key decision makers.Health Policy 2002
  60(1)39-58.
• Birch S Chambers S To each according to need a
  community-based approach to allocating health
  care resources.Canadian Medical Association
  Journal 1993 149607-612.
•  Donaldson C Mitton C Currie G Managing
  Medicare the pre-requisite to spending or
  reform.The Health Papers No. 157. Toronto CD
  Howe Institute 2002.  
• Mitton C Donaldson C Tools of the trade a
  comparative analysis of approaches to priority
  setting in health care.Health Services
  Management Research 2003 1696-105.
•  Mooney G Gerard K Donaldson C Farrar S
  Priority Setting in Purchasing Some Practical
  Guidelines.(Research paper number 6) Scotland
  National Association of Health Authorities and
  Trusts 1992.
• Cohen D Marginal analysis in practice an
  alternative to needs assessment for contracting
  health care.British Medical Journal 1994
  309781-785.
• Shackley P Ryan M Involving consumers in health
  care decision making.Health Care Analysis 1995
  3(3)196-204.
• Mabin V King G Menzies M Joyce K Public
  sector priority setting using decision support
  tools.Australian Journal of Public
  Administration 2001 60(2)44-59.  
•  

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• References
• Astley J Wake-Dyster W Evidence-based priority
  setting.
• Australian Health Review 2001 24(2)32-39.
• Peacock S An Evaluation of Program Budgeting and
  Marginal Analysis Applied in South Australian
  Hospitals.Melbourne Center for Health Program
  Evaluation Monash University 1998.
• Daniels N Accountability for reasonableness.Brit
  ish Medical Journal 2000 321(7272)1300-1.
• Singer P Martin D Giacomini M Purdy L
  Priority setting for new technologies in
  medicine qualitative case study.British Medical
  Journal 2000 3211316-1318.
• Ruta DA Donaldson C Gilray I Economics public
  health and health care purchasing the Tayside
  experience of programme budgeting and marginal
  analysis.
• J Health Serv Res Policy 1996 1(4)185-193.
  Donaldson C Mooney G Needs assessment priority
  setting and contracts for health care an
  economic view.British Medical Journal 1991
  3031529-1530.
• McIver S Baines D Ham C McLeod H Setting
  Priorities and managing demand in the
  NHS.Birmingham Health Services Management
  Centre 2001.
•  Ratcliffe J Donaldson C Macphee S Programme
  budgeting and marginal analysis a case study of
  maternity services.Journal of Public Health
  medicine 1996 18(2)175-182.  
•  Litva A Coast J Donovan J Eyles J Shepherd
  M Tacchi J Abelson J Morgan K The public is
  too subjective public involvement at different
  levels of health-care decision making.Social
  Science and Medicine 2002 541825-37.
•  Mitton C Donaldson C Setting priorities and
  allocating resources in health regions lessons
  from a project evaluating program budgeting and
  marginal analysis (PBMA).Health Policy 2003
  64335-348.