Centre for the Study of
Assessment and Prioritisation
in Health
History, Rationale, and
Work Programme
History of Prioritisation in NZ
Core Services Committee 1992
First national body anywhere to try to define ‘the core’
Considerable conceptual and methodological work
Criteria-based approach (e.g. effectiveness, equity)
Priority criteria project - booking system
In shadow of Oregon, which was getting bad press, CSC
tried to distance itself from that effort
History, cont.
•
Core Services Committee became National Health Committee 1996
Developed NZGG
•
Yielded prioritisation efforts to HFA 1997
•
Review of HFA’s prioritisation process 1999
•
Prioritising Health Services (background paper) Oct 2004;
•
Best Use of Available Resources: Dec 2004
•
Health technology assessment May 2005
This report led to creation of Service Planning and New Health
Initiative Assessment SPNIA
‘Best Use’ Recommendations
•
The National Health Committee recommends that The Ministry of Health, in
partnership with other health sector stakeholders, develop an integrated
information and support strategy to promote understanding of prioritisation
and further develop prioritisation capacity. Initiatives within this strategy
could include:
•
Developing and maintaining a central library where examples of
prioritisation analysis could be lodged.
•
Considering how best to provide specialised technical support for analysts
and analysis.
•
Maintaining an email list for sharing information, advice, and best practice
models amongst both those undertaking prioritisation analysis and other
interested parties.
•
Running annual symposia on best practice in prioritisation.
•
Developing workshops for analysts to provide training in prioritisation tools
and processes, and improving the availability of training in prioritisation
amongst health professionals at both undergraduate level and in continuing
professional development.
NHC says ‘no, not yet’
•
Media Release
1 April 2004
National Health Committee says “No, not yet” to prostate cancer screening
The National Health Committee (NHC) is recommending against the introduction of
prostate cancer screening in New Zealand.
In a report to the Minister of Health today, the NHC says the most commonly
available screening tests are not good enough. The NHC provides advice on the
kinds of health and disability services that should be publicly funded and their relative
priorities.
The NHC reached its recommendation following a comprehensive review of the issue
and says there is still no conclusive evidence to show that screening for prostate
cancer makes any difference to how long a man will live. Furthermore, the committee
says there is no conclusive evidence that early detection and treatment of prostate
cancer will result in improved quality of life for men.
“The prostate specific antigen, or PSA test, may detect the presence of prostate
cancer in a man, albeit with a significant error rate,” says Dr Api Talemaitoga, a
Christchurch general practitioner and a member of the National Health Committee.
“What it won’t do is tell us accurately enough which cancers are slow-growing and not
life-threatening and which are aggressive.”
...
History, cont.
• Pharmac (‘an international anomaly’) 1993
• Contractual approach to prioritisation
• Cost-utility main input
• Decision criteria (health needs of NZers, health needs of
Maori, effect on budget, effectiveness, etc.)
• Not clear how individual decisions linked to criteria
History, cont.
• HFA 1997 – 2000
• Continued CUA and criteria-based approaches
• Expanded work on horizontal prioritisation (across different
services)
• Substantial public and stakeholder consultation
• Method received qualified blessing from NHC
in 1999
• Disbanded in 2000 in wake of Labour victory
History, cont.
• DHBs 2000 – present
• Some good work in DHBs, ongoing – seeks to set
programme priorities via rating systems
• Not able to coordinate efforts
Not much overall progress, in part due to lack of financial
wiggle room for disinvestment
• So, not enough traction to spread and be used nationally
History, cont.
A national prioritisation renaissance?
Began with 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)
History, cont.
• Discussions with key people (e.g., Margaret Earle, Peter
Crampton, Matthew Brougham, Jackie Cumming, Wendy
Edgar, David Moore, Geoff Fougere) concerning best
way to re-invigorate prioritisation in NZ
• General agreement that some kind of impetus required,
preferably from academic arena
• Idea for new prioritisation centre based in DPH
conceived in discussions between Peter Crampton and
myself late Dec 2008
History, final
•
Steering group: Peter Crampton, Geoff Fougere, David Moore, Matthew
Brougham, Jackie Cumming, Ed Mares, myself
•
Series of 3 discussion papers written in support of idea of new academic
centre in UOW:
•
•
•
proposal for new centre;
proposed national prioritisation process, including role for new Centre; and
proposed work programme
•
Other important input from Helen Griffiths (MOH), George Laking (ADHB),
Stephen Munn (ADHB), and Tony Blakely (DPH)
•
Dept Public Health agreed to host new Centre 10 July 2009
“Meeting the Challenge”
• Ministerial Review Group (MRG) – Horn
Report
• Released 16 August 2009
• Has changed dynamic for health reform
• Several recommendations support CAP’s
mission
• Quoted throughout rest of this seminar
Rationale
Principal Objective:
To create a fit-for-purpose centre to serve
as an ‘academic anchor’ for governmental
efforts to assess and prioritise of
healthcare services in New Zealand, with
the goal of fair and efficient allocation of
these services
Rationale, cont.
Primary Aims:
•
To assist in developing a systematic, efficient, and fair process for
healthcare evaluation and systematic prioritisation
•
To facilitate and to help coordinate prioritisation efforts in NZ
•
To study healthcare assessment, including research design, health
measurement, and statistical inference
•
To study the ethical aspects of prioritisation in order to develop
recommendations for mitigating the ethical, cultural, and distributive pitfalls
inherent in rationing health services
•
To provide a world-class academic environment for students and scholars,
including research, teaching, and community service
Rationale, cont.
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 cost-effectiveness of new
services, and progressively reassessing existing services. p 5 [my
emphasis throughout]
[A] single national agency removed from both DHBs and the Ministry
[is needed]. The best approach would be to strengthen the NHC . . .
An essential component of this strengthening is to ensure the
agency has the capability to conduct evidence-based assessment of
the likely costs of new and existing procedures and interventions. 29
72
CAP’s Modus Operandi
• To seek out and invite clinicians and researchers who are doing (or
who would like to do) research in areas relevant to assessment and
prioritisation to work with us
• To build scholarly bridges and to develop networks to enable stateof-the-art research in key areas
• To assist in brainstorming, preparing funding proposals and
performance of projects
• To serve as a forum and platform upon which to build a programme
of research, teaching, and community service (e.g., sponsoring
‘town hall’ meetings to facilitate public discussion)
How Differs from Existing Centres?
• Purpose-built for study of prioritisation
• Healthcare assessment in this context
• For example, rare for current HTAs to identify indications that are
insufficiently effective (or cost-effective) to warrant public funding
• Focus on methodological work
• Formal philosophy connection for epistemology and ethical work
• Aspiring to be central academic connection point for prioritisation,
including for government
Governance Structure
Director David Hadorn Department of Public Health
Co-directors
•
Tony Blakely Professor, DPH
•
Peter Crampton, Professor DPH, UOW and Dean, UOW
•
Jackie Cumming, Director, Health Services Research Centre, VUW
•
Ed Mares Chair, Dept of Philosophy, VUW)
Advisory board
•
Matthew Brougham, CEO, Pharmac
•
David Moore, Managing Director, LECG (former CEO Pharmac and head of Personal
Health at HFA)
•
Deborah Roche, Deputy DG MOH
•
Norman Sharpe, Medical Director, National Health Foundation
•
Others TBI
Main roles are to:
(1) ensure CAP’s work remains relevant to real world and
(2) Guard against ‘capture’ by medical community (a worry for some)
Evolution of name
• Started with Centre for Healthcare Evaluation and Prioritisation
• Changed to Centre for Assessment and Prioritisation (CAP)
• Keep above as short name and acronym but expand full title to:
• Centre for the Study of Assessment and Prioritisation in Health
• Add ‘study of’ to emphasise academic, epistemological and
methodological focus
• Add ‘in health’ to clarify domain, which might not be obvious outside
medical environment
Academic Work Programme
•
Divided into three main sections: policy, epistemology, and ethics
Policy:
•
To analyse past efforts at reform, esp. the 1990s NZ reforms (paper and
conference)
•
To (help) develop a prioritisation process that can work in NZ
•
To assess the applicability or generalisability of Pharmac’s model outside
pharmaceuticals
•
To assess current clinical practices at the end of life (esp. in hospital)
•
To explore clinicians’ ability to help identify opportunities for disinvestment
Analyse past reforms
• The health reforms of the 1990s, in
particular, contains many lessons
• Most advanced effort at complete
purchaser/provider split and centralisation
of planning and funding
• Effectiveness and impact on equity?
• Pharmac and CSC/NHC remain strong
• A conference would be useful
Develop prioritisation process
• The second CAP background paper described a possible process
for setting health priorities in NZ
• On this model, a National Healthcare Prioritisation Board (NHPB)
would be created de novo
• NHC would continue as now, rather than be ‘revamped’
• NHPB would develop list of services for both new investments and
disinvestments based on advice from CAP and consultation
• Parliament would have to accept or reject the entire list of
investment and disinvestments, and could not make changes
Develop prioritisation process
From MRG report:
The MRG recommendations are for service prioritisation ‘at the
margin’, rather than the more comprehensive approach first
envisioned by the predecessor of the NHC and tried in some
jurisdictions offshore [Oregon and ? NICE].
The MRG considered the experience in New Zealand and overseas
with attempts to try and assess and prioritise all services and identify
those ‘core’ services that should be publicly funded. We concluded
that this was unlikely to succeed in the current environment. In any
event, our more modest approach would probably be a useful
prerequisite even if a more ambitious approach was to be
contemplated in the future. 31 78
Assess Generalisability of
Pharmac’s Business Model
From MRG report:
Outside pharmaceuticals, however, the current
mechanisms for assessing the effectiveness and relative
priority of health interventions are not as well developed.
Strengthening these mechanisms will help improve the
value and control the costs of improvements in health
technology. In particular, the MRG considers it both
possible and desirable to develop a Pharmac-like
process for assessing the cost-effectiveness of medical
devices and prioritising them for public funding. 27 68
Study End-of-Life Care
From MRG report
[On prevention vs. cure] On the question of cost, it is not clear that
living longer and generally healthier lives will necessarily reduce our
demand on health and disability services over our lifetime. Half of all
spending goes on the last year of life and the older we are the more
likely we are to suffer from multiple conditions. In addition, many of
us will live longer with long-term chronic conditions, like diabetes,
that are expensive to treat and increase the risk of multiple
conditions later in life. Information is needed on the impact of
preventative and public health interventions on lifetime health and
disability costs to guide future investment decisions in these areas.
50 114
End of Life Study
• Initial focus is on why people die in hospital,
rather than at home or hospice
• Who is pushing for continued aggressive or
curative treatment – patient, family, doctor?
• What were the decision points?
• Hypothesis: Communication of major importance
• Planned in conjunction with palliative care team
and Mary Potter Hospice researchers
Develop Disinvestment Strategies
From MRG report:
The NHC would also have to act within a defined budget for new
interventions that was determined by the Minister [ . . .] taking into
account likely savings from discontinuing existing interventions. 29
72
As part of its prioritisation process, the NHC should also be asked to
identify and assess a number of existing interventions that, in the
opinion of the NHC, the Minister or the Ministry appear to be low
priority (e.g., have uncertain or relatively little health benefit net
of the harm they cause). This should include existing health services
whose application may have been extended beyond the point where
significant net health benefits are demonstrable. 30 73
Role of GPs in Identifying
Disinvestment Opportunities
From MRG report:
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
Possible GP Reprioritisation Project
• GPs have ‘birds-eye view’ of health
system including long-term outcomes
• Can assess value of specialist treatment
better than specialists, incl long-term f/u
• Have no vested interest regarding value of
specific secondary tests and treatments
• Represent a potentially significant source
of information on relative value of services,
per MRG report
Epistemology
• Assist in ‘wiring the system for outcomes’,
including patient-report outcome measures
• Assess Oregon and NZ DHBs’ experience using
transparent, criteria-based prioritisation
• Compare efficiency of Google-based literature
searches with standard approaches
Wiring system
• Study feasibility of linking and expanding
existing e-heath data to enable information
about real-world effectiveness
• Device registry a possible starting point
• Address adequacy of control for possible
confounders given non-randomised
samples
Transparent Prioritisation
From MRG report:
The Minister would require the NHC to prioritise new interventions
on the basis of their cost-effectiveness and identify the process the
NHC must apply in making its decisions (such as any requirements
for
consultation, consideration of ethical reviews, publication of the
decision and its rationale, including the evidence on which the
decision was made). 30 74
Transparency has its virtues and its downsides
Ultimately however full transparency of process is probably necessary
for national prioritisation decisions
Programme Scoring Components
Score Maori Health Criteria
1
No targeting for Maori,
mainstream service
2
Little targeting to Maori (e.g.
targeted to low income),
mainstream service
Score Effectiveness Criteria
1
No expert evidence
2
Conflicting evidence but
recommended by Service
Planning Groups
Some evidence or expert
consensus
3
Mainstream service
targeted to Maori
3
4
Maori service
4
5
Fully by Maori for Maori
service
15% Weighting
Good international evidence
or well designed controlled
trials
5
Good New Zealand
evidence or randomised
control trials
25% Weighting
Score Equity Criteria
1
Untargeted service
Untargeted service but with
relatively high proportions of
those with the poorest
health and highest need
3
Some targeting to those
with the poorest health and
highest need
4
Generally targeted to those
with the poorest health and
highest need
5
Targeted specifically to
those with the poorest
health and highest need
25% Weighting
Score Value-for-Money Criteria
2
Scored on 4 separate
dimensions below
35% Weighting
Value-for-Money dimensions
Score Cost per Person Criteria
Score Cost Savings Criteria
1
2
>$10,000 per person
$1,000-$10,000 per person
1
2
Little or no cost offsets
Small cost offsets
3
$100-$999 per person
3
Medium cost offsets
4
$10-$99 per person
4
Large offsets
5
$0-$9 per person
5
Very Large cost offsets
15% Weighting
5% Weighting
Score Effectiveness per Person
Criteria
1
Little, if any, direct gain
2
Some benefits, small
reduction in disability or
small increase increase in
quality of life
3
Medium benefits, moderate
reduction in disability and/or
some increase in quality of
life or life expectancy
4
Large benefits, good
reduction in disability and/or
increase in quality of life or
life expectancy
5
Huge
benefits, adding many
years of quality life
10% Weighting
Score Timing of Benefits Criteria
1
2
10+ years
6-9 Years
3
3-5 years
4
2 years
5
Within 1 year
5% Weighting
Ranked Table of Initiatives
Prioritisation Scoring Table - With Weightings
Plan
Diab/Card
Primary
Card
Child
Youth
Cancer
Chronic Dis
Child
Health Comm
Health Comm
Primary
Youth
Child
Health Comm
Oral
Primary
Youth
All
All
Diab
Disability
Maternity
Resp
Surgery
Youth
All
Health Comm
Child
Oral
Maternity
Youth
Child
Surgery
Health Comm
Proposal/Initiative
Diabetes Pilot prevention
PHO JV
Card rehab Prog
Kidznet
Youth School Health Clinics - targeted
Cancer mole removal subsidy
Chronic Dis Clinical Pathways in Primary care
Immunisation assertive outreach
Lifestyle - CHW via targetted PHO
Smoking Cessation
Primary care teams - Additional Nurses
YHS to older youth
Ear Caravan
Physical Activity - Market Green Scripts
Pilot Basic dental service
Primary care reduce copayments -Targeted
Youth School Health Clinics
Service Directory
Audits - additional
Increase Podiatry Service
Disability Advisor
Additional post natal support -special needs
Flu Vac assert recall
Increase Nurse clinics Card & ED
Peer support /educators
Workforce development fund
Ethnicity Collection
Workforce development - well child
Oral Health enrol adolescents w default prov
Maternity coordination mechanism
Youth Health Coordinator
Mental Health Moderate needs pilot
Surgery Diagnostics - Radiology
Workforce Study
15%
25%
25%
Score
78
68
68
64
65
74
65
72
66
69
62
61
68
62
69
66
53
46
67
66
52
63
65
53
50
62
68
47
60
55
37
44
41
37
Maori
9
9
9
9
6
3
9
9
9
6
6
9
9
3
9
12
6
6
9
9
3
6
3
3
6
9
12
6
9
6
3
6
3
6
Effective
ness
20
15
20
10
15
25
15
15
10
20
15
15
15
20
10
10
15
5
20
20
10
15
20
15
10
15
15
10
10
15
5
10
10
5
Equity
25
15
15
20
20
20
20
20
25
20
15
15
20
10
25
20
10
10
15
15
15
20
15
10
10
15
20
10
20
10
5
10
5
5
63
64
45
50
55
41
36
6
6
6
3
9
6
3
20
20
10
15
10
10
5
15
15
10
15
15
10
5
0%
0%
15%
Consist w Acceptabi Cost per
NZHS
lity
person
0
0
9
0
0
15
0
0
9
0
0
15
0
0
12
0
0
9
0
0
9
0
0
12
0
0
9
0
0
6
0
0
15
0
0
12
0
0
12
0
0
15
0
0
12
0
0
12
0
0
12
0
0
15
0
0
15
0
0
9
0
0
15
0
0
9
0
0
12
0
0
12
0
0
12
0
0
15
0
0
15
0
0
15
0
0
12
0
0
15
0
0
15
0
0
9
0
0
12
0
0
15
5%
Cost
offsets
4
3
4
3
2
4
3
4
3
5
2
2
3
3
2
2
2
1
1
3
1
2
4
3
2
1
1
1
1
1
1
1
2
1
10%
5%
Time to
effectiven
Outcomes
ess
8
3
6
5
6
5
4
3
6
4
8
5
6
3
8
4
8
2
10
2
6
3
4
4
6
3
8
3
6
5
6
4
4
4
4
5
4
3
6
4
4
4
6
5
6
5
6
4
6
4
4
3
2
3
2
3
4
4
4
4
4
4
4
4
4
5
2
3
Mental Health
Mental Health
Mental Health
Mental Health
Mental Health
Mental Health
Mental Health
Mental Health
Psychological therapies
MH Quality & Outcomes program devel
Youth crisis respite services
MH Aged Care
Workforce development - MH Scholarships
Primary Mental Health long term stable
Outsource MH link Newsletter
0
0
0
0
0
0
0
0
0
0
0
0
0
0
9
15
6
6
15
6
15
3
1
2
1
1
1
1
6
4
6
6
2
4
2
4
3
5
4
3
4
5
Compare Methods of Literature
Review
• Most contemporary lit reviews still done using very large
and expensive searches of multiple databases
• More efficient process required, given scope of
prioritisation analyses required
• Google and Google Scholar have not penetrated into
health technology assessment
• Comparison of efficiency and effectiveness long overdue
• Compare results on about three substantial literature
reviews using both methods
Ethics
• Assess public acceptability of differential access to lifeprolonging treatments, e.g., expensive new cancer drugs
• Assess willingness of elderly to consider possible age
limits on publicly funded high-tech and end-of-life care
(perhaps in exchange for better comfort care and
hospice service?)
• Consider how to incorporate equity considerations in
prioritisation
• Study implications of incorporating anxiety and unrelated
future health care costs into CUAs
Public Acceptability of Differential
Access to Life-Prolonging Care
• Would NZ public accept (or prefer)
Canadian-style limits on care not available
to all?
• This would require those desiring nonavailable services to leave the country
• When Canadians travel to the US to
receive private care, a certain stigma is
attached, a sense of social solidarity
violated – how would NZers feel?
Age Limits on Public Funding?
• Assess willingness of elderly to accept
limits on publicly funded expensive care
based on age
• Possibly in exchange for enhanced
comfort care and hospice?
• Very sensitive topic
• Must be seen as originating from elderly
community
• Separate from end-of-life project
Incorporating Equity into
Prioritisation
• Remains an important unresolved issue
• NZ has made strides by adding points for
Maori-relevant to health services and even
health research grant funding
• Also possible to adjust QALY or DALY
based on which population experiencing
gain/loss, amongst other approaches
Anxiety and Unrelated Future
Costs in CUAs
• Recall MRG quote on expenses incurred
due to longer lives – huge implications
• Anxiety and related emotional and social
factors are a real and important outcome
of many tests and treatments
• These are rarely captured in CUAs
• Pharmac found it made 100-fold difference
in est. $/QALY depending on anxiety
• Anxiety due to false-positive screens