Session 2.4 – Priority Setting in the Clinical Setting
Wednesday October 29 15:30-17:00
Micro-Level Priority Setting in the intensive Care Unit: An Ethical Algorithm
(Abstract 0070)Georg Marckmann
University of Tuebingen, Germany
In many health care systems around the world, prospective payments systems lead to implicit rationing on the micro level. Physicians usually receive no guidance how to resolve the resulting conflict between their competing obligations to the individual patient and to society. These conflicts are especially prevalent in the intensive care unit (ICU) with many high-cost procedures and resource-intensive patients: Physicians have to set priorities at the bedside: But how can they decide whether the benefits of an intervention to their patient are worth the costs to society?
We will present an ethically justified step-by-step algorithm for priority setting in the ICU which we have developed together with the ICU physicians.
If there is a high-cost intervention with a low or unlikely benefit the physician should work through several questions: (1) Is the intervention in the best interest of the patient? (2) Does a local standard exist for the intervention that includes cost-effectiveness considerations? (3) Is the use of the intervention supported by a clinical guideline? (4) How strong is the external (literature) and internal evidence that the patient will benefit from the intervention? (5) Is there a more cost-effective alternative? If there is only week evidence and a more cost-effective alternative, it is ethically justified to withhold the intervention.
The algorithm might help ICU-physicians to set priorities on the micro level in a medically sound, efficient and ethically justified way, taking into consideration both obligations to the individual patient and society.
Priority Setting for Elderly with Multimorbidity in an Acute Cardiovascular Context: What are the Views of Swedish Cardiologists?
(Abstract 0076)Niklas Ekerstad1, Rurik Löfmark2, Per Carlsson1
1IMH, Sweden, 2Karolinska Institute, Sweden
Background: In Sweden the growing gap between available resources and greater potential for medical treatment has brought evidence-based guidelines for priority setting into focus. However, there are problems in areas where the evidence base is weak. Elderly patients with heart disease and multiple comorbidities illustrate these problems.
Objective: Our aim is to evaluate the views of Swedish cardiologists on priority setting for elderly patients with acute coronary syndrome without ST-elevation (ACS-NS) and multimorbidity.
Methods: A confidential questionnaire study was conducted to assess the views of cardiologists (N=370) on decision-making and priority setting for elderly patients with ACS-NS and multimorbidity. Response rate 69 per cent.
Results: 81 per cent of the cardiologists reported using national guidelines for care of heart disease in their clinical decision-making to a high extent. However, when making decisions for multiple-diseased elderly patients, cardiologists' individual experience and patient views were used to a significantly higher extent than national guidelines. Of the respondents, approximately 50 per cent estimated that they treat multiple-diseased elderly patients with ACS-NS every day. Most preferred measures, among cardiologists, in order to improve priority setting were: a) carrying out treatment studies including these patients, and b) preparing specific national guidelines, considering comorbid conditions, for multiple-diseased elderly patients.
Policy Implications: National guidelines for heart disease enjoy high confidence among Swedish cardiologists. However, regarding elderly patients with heart disease and multiple comorbidities, guidelines ought to be adapted in order to be usable for these patients.
Guidelines for Carrying out Legal Regulations for Priority Setting in Norway
(Abstract 0080)Elizabeth Nygaard, Vidar Kårikstad
Norwegian Directorate of Health, Norway
In Norway legal regulations states that each patient shall be judged individually according to the severity of the patient’s health, the expected benefit and the cost-effectiveness of treatment.
However, evidence shows politically unacceptable variations in the priority setting: Similar patients face different legal rights.
The Ministry of Health mandated the Norwegian Directorate of Health to cooperate with the regional health authorities in developing national guidelines to ensure that prioritisation comply with legal provisions. Regional representatives from 30 specialities together with general practitioners and user representatives worked in groups, one for each speciality, to develop the guidelines. The project was divided in three rounds of 5 month’s work, each round having three workshops of two days.
Each speciality described and evaluated the most common medical conditions within their speciality according to dimensions of criteria for priority setting using a structured questionnaire and listed references in support of their views. After a month with reflections and peer discussions, they concluded whether a “typical” patient within each condition group should be recommended prioritised health care, and if so, a maximum waiting time was given. To ensure individual judgement of each patient, the groups supplemented the descriptions of the “typical” patient with additional characteristics of relevance. These have to be taken into consideration before concluding on the legal rights of the individual patient.
An expert group has reviewed the work. The first version of the guidelines is on a national consulting round and will be implemented in the end of 2008.
Priority Setting of HIV Care and Treatment in a High Prevalent Rural Region in Tanzania
(Abstract 0148)Kjell Arne Johansson1, Hamisi Kigwangalla2, Ingrid Miljeteig1, Ole Frithjof Norheim1
1University of Bergen, Norway, 2Tanzania National Institute of Medical Research, Tanzania, United Republic of
Background: Tanzania has scarce health resources and 1.8 million people living with HIV and a national goal of treating all HIV patients in need of antiretroviral treatment (ART).
Objectives: To describe forms or strategies of rationing for HIV treatment that takes place at a regional and district level in Tanzania.
Methods: Qualitative study based on semi-structured individual and focus group interviews, field-observations and document analysis. Setting was a high prevalent region with few established ART clinics.
Results: Seven forms of rationing are described: 1) Denial: Severity of disease, asymptomatic with CD4 count < 350, many adherence barriers, treatment failure or severe opportunistic infections lead to denial of treatment. 2) Selection: According to a clinical guideline and an adherence form. 3) Deflection: Patients had to buy some in private pharmacies and no patients were referred to tertiary care. 4) Deterrence: Major barriers were poverty, stigma, poor availability of health facilities, lack of information and bribe. 5) Delay: There was a1-2 month delay from patients were diagnosed with HIV until they were started on ART due to slow patient flow, structural barriers and poor infrastructure. Long waiting time was present. 6) Dilution: Late start of ART, few available diagnostic techniques, few health workers with not optimal quality. 7) Termination: Rarely, but severe side effects and poor adherence could lead to termination.
Policy implications: Knowledge of how priorities are actually made in clinical settings is needed in informing policy recommendation regarding fair resource allocation for HIV patients.