assigning clinical priority a systematic methodology ray naden, ron paterson, paul hansen, alison...

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.

New Zealand

•4 Million people

•Universal State Funded Healthcare + Private

•Strong Social Security System

New Zealand 2083OECD 2550

Canada 3165

Relative Expenditure on Health – US$ Purchasing Power Parities

The ‘Gap’

• Not all healthcare needs can be met

• Decisions to give one patient priority over another are inevitable

How are priority decisions made?

Prioritisation in Elective Services

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

Prioritisation —what do patients want?

• Access to necessary care• Confidence in the publicly-

funded health system• Fair treatment• Good information about their

options

AccessThe 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

Waiting lists are political dynamite

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!

Lessons from dialysis rationing

Ethics: The practical realityA 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

Ethics: New Zealand’s choiceEthics: 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

Ethics: Basis of equitable Ethics: Basis of equitable prioritisation in New Zealandprioritisation in New Zealand

Degree of clinical needDesire to relieve the burdens of those worst off in health terms

Degree of expected benefitDesire to avoid waste and achieve the most good

Patient pathway: electives• Resource limitation • Inequities in electives pathway

• Patients’ rights • Health professional leadership

Patients’ rightsNew 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

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.

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.

New Zealand Government Policy

Fundamental Principles for Access to Publicly Funded Elective Services

•Clarity

•Timeliness

•Fairness

• To determine the order of treatment and deliver treatment equitably

• Delivery of treatment in accordance with the

priority assigned is intended to provide fairness in the decision-making as to which patients are offered access to treatments of limited availability.

Goals of Prioritisation Systems

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.

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

When creating a Points System for prioritisation,2 things are essential for it to be valid:

(1) The ‘right’ criteria (& levels within each) are included [Health Science]

(2) They have the ‘right’ point values (weights) [Decision Science]

e.g. Hip & Knee Replacement (abbrev.)

1000Minds (software for creating Points Systems) assists with both aspects… Algorithm (‘engine’) Overall process

(fully-integrated)

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.)

→ 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)

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)

In contrast, other common methods of determining a Points System’s points (weights) use introspection or scaling … Points???

↓

???

???

???

???

???

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)?”

Extremely urgentNot urgent

1000

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

Patient X3. Regular pain with weight-bearing activity4. Severe limitation to personal activities4. Severe limitation to social function2. Moderate improvement likely1. Unlikely to deteriorate

Patient Y2. Intermittent activity-related pain4. Severe limitation to personal activities5. Profound limitation to social function1. Small improvement likely 2. Likely to deteriorate

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)

How does the PAPRIKA work?(Potentially All Pairwise RanKings of All hypothetically-possible patients)

With 900 patient profiles, there are (9002 – 900)/2 = 404,550 pairwise 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

→ 126,907 pairwise comparisons to consider

1000Minds achieves this all in about 45 pairwise decisions (& 25 is sufficient for most applications) … by exploiting (logical) property of ‘transitivity’ ...

Patient profiles 1 2 3 4 5 6 7 8 9 10 . . . 900

1 ? ? ? ? ? ? ? ? ? ? ? ? ?

2 ? ? ? ? ? ? ? ? ? ? ? ?

3 ? ? ? ? ? ? ? ? ? ? ?

4 ? ? ? ? ? ? ? ? ? ?

5 ? ? ? ? ? ? ? ? ?

6 ? ? ? ? ? ? ? ?

7 ? ? ? ? ? ? ?

8 ? ? ? ? ? ?

9 ? ? ? ? ?

10 ? ? ? ?

. ? ? ?

. ? ?

. ?

900

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

Patient A3. Regular pain with weight-bearing activity4. Severe limitation to personal activities5. Profound limitation to social function 2. Moderate improvement likely2. Likely to deteriorate

Patient B2. Intermittent activity-related pain4. Severe limitation to personal activities4. Severe limitation to social function1. Small improvement likely 1. Unlikely to deteriorate

10s of thousands are automatically (incontrovertibly) ranked according to: Patient A (more highly ranked on all criteria)

> Patient B (more lowly ranked)

>

Transitivity property:

If Patient Profile A is ranked > B and B is ranked > C, A ranked > C

A Systematic Process for a Points Based Prioritisation System

Requires:

Defining:

» Criteria

» Categories

» Points

Priority CriteriaWhat 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

Priority Criteria

• Clinical Need


e.g: Vascular – Varicose Veins

Criterion Category

Extent of disease

LocalisedLong saphenous or

Short saphenousand

Few varicosities

IntermediateLong saphenous or

Short saphenousand

Extensive varicosities

ExtensiveLong saphenous

andShort saphenous

Priority Criteria

• Clinical NeedSeverity and extent of disease e.g: Cardiac – Coronary Artery Bypass Graft

Treadmill exercise/Perfusion imaging/Territory at Risk

• Negative/mildly positive or akinetic or small territory at risk

• Positive or moderate territory at risk

• Very positive or large territory at risk

• Markedly positive

Priority Criteria• Clinical Need



Personal Functional Limitation

due to

Orthopaedic Condition

1. No Limitation2. Minimal restriction to personal activities, eg trouble

reaching toes, occasional use of walking stick3. Moderate restriction to personal activities, e.g. requires

help with socks/shoes, or cutting toenails, regular use of walking stick.

4. Severe restriction to personal activities, e.g. requires help with dressing/shower, consistently uses 2 crutches or wheelchair


Points Score

Little or No difficulty 0.00%Quite difficult but not impossible 11.10%Makes some things impossible 29.20%






Patient Impact on Life Questionnaire solved at Cataract patient focus group 18 Nov 2005

Safety for self - including reading medicine labels, judging distances to cross the road, pouring hot drinks

Ability to fulfil their responsibility to others - including caring for children or grandchildren, partner, doing community/charity work, doing work for clubs you belong to

Total score:

Ability to interact with the world around them including seeing bus numbers, filling out forms/cheques, using the phone/computers, reading street or shop signs, seeing the TV/Teletext

Leisure activities - including sporting activities (such as bowls, golf), handicrafts (such as cross-stitch), DIY maintenance/carpentry, reading books

Personal Care - includes maintaining health, preparing food, reading food labels, using appliances such as phones/microwaves

Social Interaction - including meeting friends, going to church, recognising faces, going shopping

Priority CriteriaWhat criteria should be used to determine

priority for access?

• Clinical Need



• Ability to Benefit from proposed treatment



Priority Criteria Ability to Benefit from proposed treatment


1. Life expectancy < 2 years,or age >85 with moderate co-morbidity, or age >80 with severe co-morbidity

2. Age >85 or age 80-85 with moderate co morbidity,or age <80 with severe co-morbidity

3. Age >80 with no co-morbidity,or age <72 with moderate co-morbidity

4. Age 72-80 with no co-morbidity, or age <72 with moderate co-morbidity

5. Age < 72 with no co-morbidity

Expected Duration of Benefit from Cardiac Surgery

Priority Criteria

Ability to Benefit from proposed treatment


1. Small improvement likely

2. Moderate improvement likely

3. Return to near normal likely

Potential to benefit from major joint replacement operation (for patient, dependents or community)

Priority Criteria

Defining Categories

Personal Functional Limitation

due to

Orthopaedic Condition

1. No Limitation

2. Minimal restriction to personal activities, e.g: trouble reaching toes, occasional use of walking stick

3. Moderate restriction to personal activities, e.g: requires help with socks/shoes, or cutting toenails, regular use of walking stick.

4. Severe restriction to personal activities, e.g: requires help with dressing/shower, consistently uses 2 crutches or wheelchair

Defining Categories

I.

II.

III.

IV.

V.

VI.

VII.

VIII.

Impact on Life - (Impact of gynaecology problem on ability to engage in and enjoy activities which are important to the individual patient)

No compromise of any important activities

No compromise of important activities because symptoms are controlled by other non-surgical management

Compromises some important activities for at least 2 days in the month

Compromises some important activities for at least 7 days in the month

Avoids some important activities for at least 2 days of the month

Compromises some important activities for the whole of the month

Avoids some important activities for at least 7 days of the month

Avoids some important activities for the whole of the month

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 compromised in spite of non-surgical management eg. made

more difficult/embarrassing or reduced or postponed Important activities are avoided or prevented eg. 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.


Requires:

Defining:

» Criteria

» Categories

» Points – 1000 Minds


also Requires:

» Engagement of Clinicians

» Development by Clinicians

» Endorsement by Clinicians


also Requires:

1. Engagement of Clinicians• Clinical Champion

• Support of President/Chair

• Mandate by Professional Body

• Credible Clinical Expertise

• Imperative for Change

Cataract Clinical Vignette Ranking

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A B C D E I QM N O

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F H J KG P R S T U W X Y

Cataract Clinical Vignette Ranking

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= Median

F H J KG P R S T U W X Y


also Requires:

2. Development by Clinicians• Scope• Criteria• Categories• Points• Validity• Reliability• Acceptability (Pilot)

Scope

What’s in and what’s not?

• Malignancy, Fertility – Gynaecology

• Acute Coronary Syndrome – Cardiac

• Revision – Major Joint Replacement

Criteria

• Evidence vs Expert Opinion

• Independence

• Defect

• Clinician Assessment vs Patient Assessment

Disability Impact on Life

Categorisation

Can Clinicians assign patients consistently to categories?

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Highlight = Consensus

LOCALISED - Long saphenous OR Short saphenous AND Few varicosities 1 1 2 1 2 4 2 4 8INTERMEDIATE - Long saphenous OR Short saphenous AND Many varicosities 7 8 1 7 6 8 8 7 6 2 4 6 2 4EXTENSIVE - Long saphenous AND Short saphenous 7 6 6

Severity 2: Asymptomatic or occasional non-ulcer pain; Ankle oedema 8 1 5 4 3 1 1 3 1 1 8Severity 3: Frequent (daily) non-ulcer pain controllable by conservative measures; Leg oedema without cellulitis; Minor venotensive skin changes 4 1 4 5 6 6 6 1 5Severity 4: Frequent (daily) non ulcer pain not controlled by conservative measures; Oedema associated with cellulitis (single episode); Moderate OR extensive venotensive skin changes 3 2 8 1 1 1 2Severity 5: Oedema associated with recurrent cellulitis AND not responsive to thorough conservative management; Healed venous ulceration 5 8Severity 6: Recurrent venous ulceration (despite use of compression hosiery); Active venous ulceration (resistant to compression) 8 7

Disability 1:Able to carry out usual activities without compressive therapy 8 8 8 8 7 7 1 4 1 7 8

Disability 2:Able to carry out usual activities only with compression and/or limb elevation. Includes use of (or prescription for) compression hose for ulcer prophylaxis. 1 8 1 1 6 8 4 3 1Disability 3:Unable to carry out usual activities even with compression and/or limb elevation 8 7 1 4

Extent of Disease

Severity of Disease

Disability treatable by varicose vein surgery

Assigning Points

Individual Consensus

Validity

Individual Consensus

Ranking of Cases - Vignettes

“Best Practice” Ranking

Rank Order Comparison of Prioritisation System with “Best Practice” Ranking

CPS Validity

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K H S C I B A G F N D E J R L O M P

Clinical

CPAC

Clinical vs CPSClinical vs CPSComparison of Vignette Rankings

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Clinical Rank

CPAC Rank

Reliability Do Standardised Criteria reduce

Variability?Comparison of Ranking Methods

MEDIANSClinical CPS

Vignette SD SD A 3 2B 5 3C 6 2D 3 2E 5 4F 6 1G 2 3H 7 0I 4 3J 2 4K 3 1L 5 2M 7 1N 4 4O 1 5P 1 1

Mean SD 3.9 2.3

SD>3.5 7 4

Pilot Testing

• Purpose:– To test clinical usability and acceptability– Test whether proposed CPS improves

prioritisation consistency– Test correlation with treatment decisions


also Requires:

3. Endorsement by Clinicians• Presentation to Colleagues

• Formal Endorsement by Professional Body

• Progressive Adoption

Priority Assignment

Commitment to Treat

Decisionto Treat

Clarity Timeliness

Fairness

Summary

Priority Assignment

Commitment to Treat

Decisionto Treat

Clarity Timeliness

Fairness

•Systematic

•Transparent

•Evidence based

•Consistent with established principles

•Differentiates adequately

•Consistently applied

General Principles for Prioritisation Methods

Critical Success Factors

• Doctors

• Clinical Cases

• Criteria / Categories / Points

• Process


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QUALITY OF LIFE

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QUALITY OF LIFE

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QUALITY OF LIFE

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Disease Disability Impact on Life

Disease Disability Impact on Life

Doctors Patients

Clinical Prioritisation (micro-prioritisation) is important for

• Fairness and Equity

• Clarity for Patients

• Good quality resource-allocation decisions

Prioritisation Systems

•Clinical Judgement

•Broad Bands

•Scenario Systems

•Point Systems

Point Systems chosen because they ‘fit’ best with multiple criteria of varying degrees


QUESTION 1:Is the treatment in the best interests of the patient?

( net ability to benefit >0 )

QUESTION 2:Is the treatment available to this patient?Can everyone who needs it, have it? (no prioritisation

needed)If not,• Who can have it and who cannot?

Prioritisation based on net ability to benefit of one patient relative to another


Working Principles for Prioritisation Methods

•Based on relative ability to benefit

•Numerical (e.g. multi dimensional additive point systems)

•Iterative (Continual Quality Improvement)

•“Gold Standard” is consensus of judgement of a group of experts

assigning clinical priority a systematic methodology ray naden, ron paterson, paul hansen, alison...

Documents

treatment slide

good slide

options slide

integrated slide

elective services slide

relevant way slide

political dynamite slide

new evidence