Assigning Clinical Priority A Systematic Methodology

1. 0 Assigning Clinical PriorityA Systematic Methodology Ray Naden, Ron Paterson, Paul Hansen, Alison Barber Franz Ombler, Ralph Stewart, Justin Roake, Peter Haddad, Wayne Gillett, Jean-Claude Theis New Zealand Ministry of Health New Zealand Health & Disability Commission 1000Minds™ Ltd Cardiac Society of Australia and New Zealand New Zealand Vascular Society Royal Australian and New Zealand College of Ophthalmology Royal Australian and New Zealand College of Obstetricians and Gynaecologists New Zealand Orthopaedic Association.

2. 0 New Zealand • 4 Million people • Universal State Funded Healthcare + Private • Strong Social Security System

3. Relative Expenditure on Health – US$ Purchasing Power Parities 0 Canada 3165 OECD 2550 New Zealand 2083

4. 0 The ‘Gap’ • Not all healthcare needs can be met • Decisions to give one patient priority over another are inevitable How are priority decisions made?

5. 0 Prioritisation in Elective Services

6. 0 Clinical Prioritisation For Elective surgical procedures: The process by which Doctors decide, from those patients who would benefit, which individual should have priority for the available capacity of publicly funded services

7. 0 Prioritisation —what do patients want? • Access to necessary care • Confidence in the publicly-funded health system • Fair treatment • Good information about their options

8. 0 Access The public understands that resources exceed demand and rationing is necessary But people are rightly intolerant of — • inequity of access (easier access to elective surgery based on geography / inconsistent approaches) • short-sighted clinical decision making (delayed access leading to more costly interventions later) • denial of life-saving treatment

9. 0 Waiting lists are political dynamite

10. 0 Prioritisation and the law • No legal right to access health care in New Zealand • But the right to be free from unlawful discrimination (eg, by age or disability) • Procedural fairness matters!

11. 0 Lessons from dialysis rationing

12. Ethics: The practical reality 0 • A and B are candidates for an elective surgical procedure • The procedure has been judged not to be futile, and A & B have made an informed choice for the elective surgical procedure • i.e: the clinician has decided that both patients would benefit from the procedure AND both patients have agreed. • There are sufficient resources for only one of them

13. 0 Ethics: New Zealand’s choice NZ has chosen to ration elective surgery explicitly and equitably Aim to achieve fair inequality through prioritisation of A & B: i.e: Differentiate A from B in an ethically acceptable (equitable) and relevant way

14. 0 Ethics: Basis of equitable prioritisation in New Zealand Degree of clinical need Desire to relieve the burdens of those worst off in health terms Degree of expected benefit Desire to avoid waste and achieve the most good

15. Patient pathway: electives 0 • Resource limitation • Inequities in electives pathway • Health professional leadership • Patients’ rights

16. 0 Patients’ rights New Zealand’s Code of Patients’ Rights recognise that patients referred for specialist assessment or waiting for surgery are entitled to • reasonable care in assessment/treatment • reasonable information about their condition, whether and when they will be seen, and options

17. 0 The Southland urology case (2006) “Prioritisation systems should be fair, systematic, evidence-based and transparent.” It is unfair and unlawful to prioritise 58% of urology patients as “urgent” and leave them to wait more than one year for assessment.

18. 0 What do Patients Want? • Patients want to know they will receive treatment. • Patients want to know when they will receive treatment. • Patients want to be treated equally.

19. 0 New Zealand Government Policy Fundamental Principles for Access to Publicly Funded Elective Services Clarity Timeliness Fairness

20. 0 Goals of Prioritisation Systems • To determine the order of treatment and deliver treatment equitably • Delivery of treatment in accordance with the priority assigned is intended to providefairnessin the decision-making as to which patients are offered access to treatments of limited availability.

21. 0 Goals of Prioritisation Systems • Priority assignment becomes a predictor of the future delivery of treatment and enables clarity to be given to patients as to whether and when they might receive treatment.

22. 0 Critical Success Factors • Participative • Clinically led, considers all relevant stakeholder points of view – fellow clinicians, consumers, government, ethics • Clinician Based • Has face validity - Based on actual cases • Flexible • Continuous Quality Improvement – evolves as new evidence emerges • Systematic • Based on good principles of complex decision-making

23. 0 When creating a Points System for prioritisation,2 things are essential for it to be valid: e.g. Hip & Knee Replacement (abbrev.) • The ‘right’ criteria (& levels within each) are included [Health Science] • They have the ‘right’ point values (weights) [Decision Science] • 1000Minds (software for creating Points Systems) assists with both aspects… • Algorithm (‘engine’) • Overall process (fully-integrated)

24. 0 1000Minds Algorithm – PAPRIKA method(Potentially All Pairwise RanKings of All hypothetically-possible patients) • Based on decision makers’ expert knowledge & preferences, seeks to rank potentially all hypothetically-possible patients representable by a given Points System (i.e. all combinations of the level on the criteria), except for medically impossible ones… • From that overall ranking, derive (via Linear Programming) the point values for the Points System (that matches decision makers’ expert knowledge & preferences) • The overall ranking of all hypothetically-possible patients is arrived at by asking decision makers a series of simple questions involving tradeoffs between 2 criteria at a time… (The number of questions asked is as small as possible.)

25. 0 → for users, the simplest & least cognitively/psychometrically demanding of all methods … Therefore greater validity & reliability. “The advantage of choice-based methods is that choosing, unlike scaling, is a natural human task at which we all have considerable experience, and furthermore it is observable and verifiable.” (Drummond et al. Methods for the Economic Evaluation of Health Care Programmes, 2005)

26. 0 In contrast, other common methods of determining a Points System’s points (weights) use introspection or scaling … Points??? ↓ 1. Introspective (Ad hoc) Methods (A) “Off the top of your head, choose the point values that you think represent the relative importance of the criteria.” e.g. Ham (1993), Priority setting in the NHS: Reports from six districts. BMJ 307 (B) “Out of a ‘budget’ of 100 points, allocate them amongst the criteria, which are interpreted as criterion weights.” e.g. Oregon Health Services Commission (1991) ??? ??? ??? ??? ???

27. Extremely urgent Not urgent 0 100 0 2. Rating scale-based conjoint (regression) analysis “On a scale of 0 to 100, how would you rate the urgency of these patients (and others)?” e.g. Noseworthy, et al. (2003) Waiting for scheduled services in Canada: Development of priority-setting scoring systems. Journal of Evaluation in Clinical Practice 9 MacCormick et al. (2003) Prioritizing patients for elective surgery: A systematic review. Australia & New Zealand Journal of Surgery 73

28. 0 1000 Minds Asks a series of simple questions (the simplest possible) involving tradeoffs between 2 criteria at a time … → generates a ranking of potentially all hypothetically-possible patients representable by a given Points System (i.e. all combinations of the level on the criteria), except for medically impossible ones → ‘solve’ for the corresponding point values (representing decision makers’ preferences)

29. 0 How does the PAPRIKA work?(Potentially All Pairwise RanKings of All hypothetically-possible patients) e.g. with 5 criteria, & 5, 4, 5, 3, 3 levels each → 5 x 4 x 5 x 3 x 3 = 900 hypothetically-possible patient profiles With 900 patient profiles, there are (9002 – 900)/2 = 404,550pairwise comparisons possible !!! 10s of thousands are automatically (incontrovertibly) ranked according to: Patient A (more highly ranked on all criteria) > Patient B (more lowly ranked) … And others are duplicates → 126,907pairwise comparisons to consider 1000Minds achieves this all in about 45 pairwise decisions (& 25 is sufficient for most applications) … by exploiting (logical) property of ‘transitivity’ ...

30. 0 Transitivity property: If Patient Profile A is ranked > B and B is ranked > C,  A ranked > C 10s of thousands are automatically (incontrovertibly) ranked according to: Patient A (more highly ranked on all criteria) > Patient B (more lowly ranked) >

31. 0 A Systematic Process for a Points Based Prioritisation System Requires: Defining: • Criteria • Categories • Points

32. 0 Priority Criteria What criteria should be used to determine priority for access? • Clinical Need • Severity and extent of disease • Impact of a condition on an individual’s life resulting from pain, disfigurement, disablement • Ability to Benefit from proposed treatment • Likelihood and duration of optimal outcome • Degree to which impact on life is reversible

33. 0 Priority Criteria • Clinical Need • Severity and extent of disease e.g: Vascular – Varicose Veins

34. 0 Priority Criteria • Clinical Need • Severity and extent of disease e.g: Cardiac – Coronary Artery Bypass Graft

35. 0 Priority Criteria • Clinical Need • Severity and extent of disease • Impact of a condition on an individual’s life resulting from pain, disfigurement, disablement

36. Impact of a condition on an individual’s life resulting from pain, disfigurement, disablement 0

37. 0 Priority Criteria What criteria should be used to determine priority for access? • Clinical Need • Severity and extent of disease • Impact of a condition on an individual’s life resulting from pain, disfigurement, disablement • Ability to Benefit from proposed treatment • Likelihood and duration of optimal outcome • Degree to which impact on life is reversible

38. 0 Priority Criteria • Ability to Benefit from proposed treatment • Likelihood and duration of optimal outcome Expected Duration of Benefit from Cardiac Surgery • Life expectancy < 2 years,or age >85 with moderate co-morbidity, or age >80 with severe co-morbidity •  Age >85 or age 80-85 with moderate co morbidity,or age <80 with severe co-morbidity • Age >80 with no co-morbidity,or age <72 with moderate co-morbidity  • Age 72-80 with no co-morbidity, or age <72 with moderate co-morbidity  • Age < 72 with no co-morbidity

39. 0 Priority Criteria • Ability to Benefit from proposed treatment • Degree to which impact on life is reversible Potential to benefit from major joint replacement operation (for patient, dependents or community) • Small improvement likely • Moderate improvement likely • Return to near normal likely

40. 0 Priority Criteria Defining Categories

41. Defining Categories Impact on Life - (Impact of gynaecology problem on ability to engage in and enjoy activities which are important to the individual patient) I. No compromise of any important activities II. No compromise of important activities because symptoms are controlled by other non-surgical management III. Compromises some important activities for at least 2 days in the month IV. Compromises some important activities for at least 7 days in the month V. Avoids some important activities for at least 2 days of the month VI. Compromises some important activities for the whole of the month VII. Avoids some important activities for at least 7 days of the month VIII. Avoids some important activities for the whole of the month 0

42. 0 Defining CategoriesInterpretation Notes • The focus is to reflect on the impact of the symptoms on life rather than to specify the nature and degree of symptoms. In evaluating two separate symptoms, the symptom with the highest weighting should be taken. • There are 3 steps to assigning a category: • i)Determine how the predominant symptom is affecting the woman in her ability to participate in, or perform, activities important for her. • ·No significant compromise –symptom does not significantly affect the woman’s ability to participate in any activity important to her • ·No significant compromise because the symptoms are controlled with non – surgical management e.g. use of pads for incontinence or medication for pain management • ·Important activities are compromisedin spite of non-surgical management eg. made more difficult/embarrassing or reduced or postponed • ·Important activities are avoided or preventedeg. avoidance of or inability to engage in sexual, sport, social, work and home activities. • ii) Determine the duration of the impact on life using the separate categories (Avoids or Compromises activities for at least 2 days, at least 7 days or for the whole of the month) • iii) Assign one of eight categories.

43. 0 A Systematic Process for a Points Based Prioritisation System Requires: Defining: • Criteria • Categories • Points – 1000 Minds

44. 0 A Systematic Process for a Points Based Prioritisation System alsoRequires: • Engagement of Clinicians • Development by Clinicians • Endorsement by Clinicians

45. 0 A Systematic Process for a Points Based Prioritisation System alsoRequires: • Engagement of Clinicians • Clinical Champion • Support of President/Chair • Mandate by Professional Body • Credible Clinical Expertise • Imperative for Change

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48. 0 A Systematic Process for a Points Based Prioritisation System alsoRequires: • Development by Clinicians • Scope • Criteria • Categories • Points • Validity • Reliability • Acceptability (Pilot)

49. 0 Scope What’s in and what’s not? • Malignancy, Fertility – Gynaecology • Acute Coronary Syndrome – Cardiac • Revision – Major Joint Replacement

50. 0 Criteria • Evidence vs Expert Opinion • Independence • Defect • Clinician Assessment vs Patient Assessment Disability Impact on Life