Physicians Role in Healthcare PrioritisationDavid Hadorn, M.D., Ph.D.Centre for Assessment and PrioritisationDept of Public HealthUniversity of Otago, Wellington14 April 2011

Shouldnt 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 OversOver-testingOver-screening (esp. for cancer)Over-diagnosisOver-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 GoodFrom 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 its not likely to be cost-effective?Can usually find reason not to treat (probably wouldnt benefit anyway)

Doctors as Healthcare Attorneys?Unequivocal advocate for patientRequires externally applied limits on careDiagnostic testing and treatment guidelinesRequires doctors to give up some powerAre they willing to do that?

Prioritising Health Care in NZ Core Services Committee 1992Gave up task of defining the core in 1996 -- too hard, too controversial (Oregon), lack of clarity around role definition HFA took over prioritisation efforts 1997-2000Since then, little progress on national systematic prioritisation some DHB workPHARMAC has kept going strong

National Prioritisation Back on AgendaRenewed 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 ChallengeMinisterial Review Group (MRG) Horn Report

Released 16 August 2009

Changed dynamic for health reform

Most key recommendations already taken up

MRG on prioritisationFrom 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 [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 CriteriaAlgorithm

Point count

Guidelines (Boolean combination of clinical/social variables predicting benefit)

All aimed at defining medical necessity

Oregons MRI of Spine GuidelineDIAGNOSTIC 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.

Oregons Erythropoietin GuidelineGUIDELINE 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.

Pharmacs Erythropoietin GuidelineErythropoietinINITIAL APPLICATIONApplications only from a relevant specialist. Approvals valid for 2 years.Prerequisites Patient in chronic renal failureandHaemoglobin: ......................................

Oregons Tonsillectomy GuidelineGUIDELINE 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 GuidelinePatients must have one of the followingA. Upper airway obstruction secondary to tonsillar hyperplasiaB. Persistent dysphasia associated with large obstructing tonsilsC. Chronic tonsillitis, clinically present for over thirty daysD. Recurrent tonsillitis with documentation of four episodes in a 12 month period of time or six episodes in two consecutive yearsE. Suspected tonsil malignancyF. Peritonsillar abscess

Colorado Hip Replacement GuidelineIndications for total hip replacementHistory 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 change2. Difficulty in putting shoe and/or stocking on affected lower limb3. Painful limp on affected lower limb4. Failure to respond to non-operative treatmentANDPhysical findings of both:1. Limitation of motion of hip joint2. Observation of limp and/or documented shortening of limbANDX-ray evidence of significant hip joint narrowing and/or destruction

NZOA Hip and Knee Prioritisation Toolhttp://www.nzoa.org.nz/content/CPAC_Prioritisation_Guidelines.pdf

1. Pain

No Pain 0 points

Episodic activity-related pain; may use occasional analgesics 4 points

Daily pain with weight-bearing activity2-3 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 CriteriaConditions requiring acute stabilizationSuicide attempt: serious attempt or gestures indicating a danger to selfHomicidal threats or other assaultive behavior indicating a danger to othersGross dysfunction: self-care failure or threats to physical health from life-threatening physical conditions resulting in inability to care for selfChild exhibiting bizarre or psychotic behaviors that cannot be contained or treated in an outpatient setting

Pediatric Psychiatric IS CriteriaEvaluation and adjustment of medication under close medical supervisionContinuous secure setting with skilled observation and supervisionDocumented 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

ConclusionNotice instances of:the need to make allocation decisionsbedside rationingwhere service costs may outweigh benefitequity implications esp. of new $ drugsoverdiagnosis (e.g., false +ves)overtreatmentwhere doctors can help develop coverage criteria

*Prioritisation = rationing = saying noVery difficult to say no and esp. hard to remove established servicesAlmost like closing a hospital on a smaller scaleRule of Rescue*I think its pretty clear that only clinicians and doctors in particular -- must not only be brought into the disinvestment debate, but must lead it. In addition to the quotes shown here, the MRG cited the Medical Councils edict that doctors must also act on behalf of the greater community, not just for their own patients individual good. Moreover, their involvement must occur, according to the MRG, in a transparent context. *Prioritisation has been off the national agenda for almost a decade. Since the Health Funding Authority was disbanded in 2000, very little has happened on this front. The recently dismantled Service Planning and New Health Initiative Assessment (SPNIA) process did not deal with disinvestments and had no leverage over DHBs funding decisions. DHBs have done their own thing regarding prioritisation, with uneven results.*A new era of NZ prioritisation began last year when two Treasury officials gave a seminar at a WHEG meeting that addressed the need to make difficult choices about what to provide in the public health system and what to leave out. Two more WHEG seminars followed on similar topics over the next few months, signaling a trend. Judy Kavanaugh, in her last days at Ministry of Health, described how two screening programmes of dubious benefit (glue ear and lazy eye amblyopia) could not be discontinued despite evidence of insignificant net benefit because of the controversy engendered by advocates of continued screening. Ultimately Cabinet was called upon to make the final decision (to discontinue funding). This action set a precedent insofar as Cabinet can now be seen as the final arbiter of controversial disinvestment decisions. Obviously some better method must be found to underpin these decisions. My colleague Martin Hefford and I then jumped on the bandwagon and we gave a seminar on prioritisation at the same venue, describing work by NZ DHBs, Oregon, and NICE in the UK. We repeated the seminar at Jackie Cummings graduate health policy class and again at Treasury. Sensing that the time was right, the Centre for Assessment and Prioritisation was formed at the U of Otago medical school in Wellington in July 2009. (See Powerpoint presentation at http://www.uow.otago.ac.nz/academic/dph/research/cap/about.html)*This turned out to be good timing because the very next month a discussion paper was released by the Ministerial Review Group, led by Murray Horn. Called Meeting the Challenge, the paper was an echo of Simon Uptons Green and White paper of 1991, which led to the 1990s NZ health reforms. The recommendations of the MRG or Horn report also advocate a significant restructuring of the health system (though not nearly as radical, including support for increased activities around prioritisation.*In particular, MRG recommended that the National Health Committee be reinvigorated so as to be able to resume its original role as arbiter of what should be inside the core of publicly funded health services. An alternative approach would be to create a new board or agency designed for this purpose, but MRG wanted to minimise the number of new entitities. *Like Oregon, both Pharmac and NICE also use coverage guidelinesQualitative approaches much easier to developCan specify clinical circumstances under which treatment is coveredCost of treatment considered informally as one factor of many*Need for threshold management as in Oregon\Pretty good example of saying no (though its really not until your condition gets more urgent)