Physicians’ Role in Healthcare
Prioritisation
David Hadorn, M.D., Ph.D.
Centre for Assessment and Prioritisation
Dept of Public Health
University of Otago, Wellington
14 April 2011
“Shouldn’t
somebody at some level
be in a position to say ‘no’?”
A frustrated US Senator (John Danforth R-Mo.) at a health care hearing
in the USA, 1993
Epidemic of ‘Overs’
•
•
•
•
Over-testing
Over-screening (esp. for cancer)
Over-diagnosis
Over-treatment (esp. meds and surgery and at
EOL)
• ‘Overing’ is a leading cause of death and
disability and of need for rationing
Role of Doctors in Balancing Patient
and Societal Good
From Ministerial Review Group report (2009):
The Medical Council of New Zealand is clear that “ . .. doctors have
a responsibility to the community at large to foster the proper use of
resources and must balance their duty of care to each patient with they
duty of care to the population.” The challenges we face require
collective leadership . . . 19;53
Achieving the “. . . optimum arrangement for the most effective
delivery” of services will require . . . a transparent process for engaging
clinicians in deciding the level at which services should be planned and
funded and how that should change over time. 33 81
Bedside Rationing?
• Is it OK for doctors to be ‘double agents’?
• Can doctors self-restrain testing/ treatment?
• Is it OK not to mention a test or treatment if
it’s not likely to be cost-effective?
• Can usually find reason not to treat (“probably
wouldn’t benefit anyway”)
Doctors as Healthcare ‘Attorneys’?
•
•
•
•
•
Unequivocal advocate for patient
Requires externally applied limits on care
Diagnostic testing and treatment guidelines
Requires doctors to give up some power
Are they willing to do that?
Prioritising Health Care in NZ
• Core Services Committee 1992
• Gave up task of defining ‘the core’ in 1996 -too hard, too controversial (Oregon), lack of
clarity around role definition
• HFA took over prioritisation efforts 1997-2000
• Since then, little progress on national
systematic prioritisation – some DHB work
• PHARMAC has kept going strong
National Prioritisation Back on Agenda
Renewed government interest in prioritisation signaled through series of
Wellington Health Economist Group seminars:
Gerald Minnee, Ruth Isaac, NZ Treasury. Health system sustainability in the
long term: Why we need to act today. 22 May 2008
Judy Kavanaugh, MOH. Prioritisation: why is it so hard? 21 August 2008
Janet McDonald. Prioritisation: Change and Adaptation in Families
with Young Carers. 11 September 2008
David Hadorn and Martin Hefford. Saying ‘no’ in three countries:
alternative methods of healthcare prioritisation. 16 October 2008
(repeated at VUW and Treasury)
Creation of Centre for Assessment and Prioritisation July 2009
“Meeting the Challenge”
• Ministerial Review Group (MRG) – Horn
Report
• Released 16 August 2009
• Changed dynamic for health reform
• Most key recommendations already taken up
MRG on prioritisation
From MRG report:
[We recommend] revamping and strengthening the National
Health Committee, so that it is better able to perform its
original role of assessing the appropriateness and costeffectiveness of new services, and progressively reassessing
existing services. p 5
[A] single national agency removed from both DHBs and the
Ministry [is needed]. The best approach would be to
strengthen the NHC. p29 sec72
Coverage Criteria
• Algorithm
• Point count
• Guidelines (Boolean combination of
clinical/social variables predicting benefit)
• All aimed at defining medical necessity
Oregon’s MRI of Spine Guideline
DIAGNOSTIC GUIDELINE D4, MRI OF THE SPINE
MRI of the spine is covered in the following situations:
• Major or progressive neurologic deficit (objective
evidence of reflex loss, dermatomal muscle weakness,
dermatomal sensory loss, EMG or NCV evidence of
nerve root impingement), suspected cauda equina
syndrome (loss of bowel or bladder control or saddle
anesthesia), or suspected central spinal canal stenosis
in patients who are potential candidates for surgery;
• Clinical or radiological suspicion of neoplasm; or,
• Clinical or radiological suspicion of infection.
Oregon’s Erythropoietin Guideline
• GUIDELINE NOTE 7, ERYTHROPOIETIN GUIDELINES
• A) Indicated for anemia (Hgb < 10gm/dl or Hct < 30%) induced by cancer
chemotherapy, in the setting of myelodysplasia or in chronic renal failure,
with or without dialysis.
• 1) Reassessment should be made after 8 weeks of treatment. If no
response, treatment should be discontinued. If response is demonstrated,
EPO should be titrated to maintain a level between 10 and 12.
• B) Indicated for anemia (Hgb < 10gm/dl or HCT < 30%) associated with
HIV/AIDS.
• 1) An endogenous erythropoietin level < 500 IU/L is required for
treatment, and patient may not be receiving zidovudine (AZT) > 4200
mg/week.
• 2) Reassessment should be made after 8 weeks. If no response, treatment
should be discontinued. If response is demonstrated, EPO should be
titrated to maintain a level between 10 and 12.
Pharmac’s Erythropoietin Guideline
Erythropoietin
INITIAL APPLICATION
Applications only from a relevant specialist. Approvals valid for 2 years.
Prerequisites
Patient in chronic renal failure
and
Haemoglobin: ......................................<= 100g/L
and
• patient is not diabetic
and
• glomerular filtration rate: ....................<= 30ml/min
or
• patient is diabetic
and
• glomerular filtration rate: ....................<= 45ml/min
or
• patient is on haemodialysis or peritoneal dialysis
Oregon’s Tonsillectomy Guideline
GUIDELINE NOTE 36, TONSILLECTOMY
Tonsillectomy is an appropriate treatment in a case with:
• Five documented attacks of strep tonsillitis in a year or 3 documented
attacks of strep tonsillitis in each of two consecutive years where an
attack is considered a positive culture/screen and where an appropriate
course of antibiotic therapy has been completed;
• Peritonsillar abscess requiring surgical drainage;
• Moderate or severe obstructive sleep apnea (OSA) in children 18 and
younger, or mild OSA in children with daytime symptoms and/or other
indications for surgery.
Colorado Tonsillectomy Guideline
Patients must have one of the following
• A. Upper airway obstruction secondary to tonsillar hyperplasia
• B. Persistent dysphasia associated with large obstructing
tonsils
• C. Chronic tonsillitis, clinically present for over thirty days
• D. Recurrent tonsillitis with documentation of four episodes in
a 12 month period of time or six episodes in two consecutive
years
• E. Suspected tonsil malignancy
• F. Peritonsillar abscess
Colorado Hip Replacement Guideline
• Indications for total hip replacement
• History of (3 out of 4 of the following)
• 1. Pain in groin and/or anterior thigh and/or knee on hip motion, worse on
initiation of motion and/or on weather change
• 2. Difficulty in putting shoe and/or stocking on affected lower limb
• 3. Painful limp on affected lower limb
• 4. Failure to respond to non-operative treatment
• AND
• Physical findings of both:
• 1. Limitation of motion of hip joint
• 2. Observation of limp and/or documented shortening of limb
• AND
• X-ray evidence of significant hip joint narrowing and/or destruction
NZOA Hip and Knee Prioritisation Tool
http://www.nzoa.org.nz/content/CPAC_Priori
tisation_Guidelines.pdf
1. Pain
No Pain
0 points
Episodic activity-related pain; may use
occasional analgesics
4 points
Daily pain with weight-bearing activity
2-3 times/week; use of simple
analgesics/NSAIDs as needed 10 points
Pain which cannot be ignored with activity and
at rest; sleep disturbance 2-3 times/week due
to pain; daily analgesics/NSAIDs 19 points
Dominates life and interferes with sleep every
night; pain poorly controlled by analgesics
27 points
NZOA Hip and Knee Replacement Tool,
cont.
2. Personal Functional Limitation
No limitation
0 points
Minimal restriction, e.g., trouble reaching
toes; walking stick used for longer walks
3 points
Moderate restriction, e.g., requires help
with socks and shoes; requires help
cutting toenails; use of walking stick
indoors and outdoors
9 points
Severe restriction, e.g. requires help with
dressing or showering; consistently uses
2 crutches or wheelchair
18 points
NZOA Hip and Knee Replacement
Tool, cont.
Similar criteria for:
•Social limitation
•Potential to benefit from surgery
•Consequence of delay > 6 mo
Pediatric Psychiatric SI Criteria
Conditions requiring acute stabilization
• Suicide attempt: serious attempt or gestures indicating a
danger to self
• Homicidal threats or other assaultive behavior indicating a
danger to others
• Gross dysfunction: self-care failure or threats to physical
health from life-threatening physical conditions resulting in
inability to care for self
• Child exhibiting bizarre or psychotic behaviors that cannot be
contained or treated in an outpatient setting
Pediatric Psychiatric IS Criteria
• Evaluation and adjustment of medication under close medical
supervision
• Continuous secure setting with skilled observation and
supervision
• Documented failure of ambulatory programs with continued
deterioration of emotional and/or physical condition
(Documentation of extreme agitation, not eating, physical
complaints, self-care failure)
• Inpatient diagnostic evaluation required to indentify
treatment needs, i.e., the formulation of a diagnosis
Conclusion
Notice instances of:
– the need to make allocation decisions
– bedside rationing
– where service costs may outweigh benefit
– equity implications esp. of new $ drugs
– overdiagnosis (e.g., false +ves)
– overtreatment
– where doctors can help develop coverage criteria