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Evidence-based Decision Making to Inform Resource Allocation:
Lessons from Western Canada
Craig Mitton and Howard Waldner
National Healthcare Leadership Conference
Saskatoon, Saskatchewan
June 3, 2008
Contact: [email protected]
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Background: priority setting
• Health organizations the world over are charged with allocating resources within a limited funding envelope
• Surveys in Canada (and elsewhere) have reported uncertainty amongst decision makers on how best to do this
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• What is to be done when there are not enough resources to meet all needs
• What is alternatives exist to historical and/ or political allocation processes?
• How can resources be shifted or re-allocated within existing budgets?
• How can evidence be drawn on to support a priority setting process?
Key questions
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Evolution of PBMA
• Economic framework to assist decision makers in making choices around limited resources
• Used in health care since 1970s
– 100+ organizations internationally
– Currently being used in health authorities in Alberta and British Columbia; also piloting in the LHINs
• Can be combined with ethical conditions in its application and is as evidence based as time and data allow for
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Practical Steps
• Determine aim and scope of activity
• Identify and map resource use
• Form an advisory panel
• Define and weight decision making criteria
• Identify options for investment and disinvestment
• Evaluate investments and disinvestments
• Validation and recommendations
• Communication, evaluation, revision
Peacock et al. BMJ 2006
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Expected Outcomes
• Primary benefit for PBMA
• Achieving real resource shifts that are consistent
with strategic decision-making objectives
• Secondary benefits for PBMA
• Evidence driven decisions
• Ownership of planning process
• Transparent and defensible decision making
• Clinician engagement and partnership
Gibson et al. JHSRP 2006Ruta et al. BMJ 2005
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Canadian examples
• Chinook Health Region (Alberta)– Surgery, chronic disease
• Headwaters Health Authority (Alberta)– Surgery, long term care
• Calgary Health Region (Alberta)– Macro, children’s services
• Vancouver Island Health Authority (BC)– Macro, within portfolios
• Interior Health Authority (BC)– Community care services
• Northern Health Authority (BC)– Home and community care
• BC Cancer Agency (BC)– Screening, select drug therapies
• North West, Central West and Champlain LHINs– Urgent priorities, Aging at Home, Alternative levels of care
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Vancouver Island Health Authority
• 750,000 population
• 17,000 employees
• All of Vancouver Island
• $1.5 billion operating budget (excluding Phys costs)
• 114 service delivery sites
• Strategic planning, commissioning and provider role
• Entire continuum of care - primary care to tertiary care
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PBMA implementation
• For the past two years, VIHA has used PBMA in collaboration with researchers from UBC
• Goals of PBMA in VIHA:
– Engage the organization, including physician leadership
– Transparent and evidence-based process
– Greater understanding of the need to make choices
– Achieve greater support for decisions
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VIHA’s 2007/08 Process
• Each portfolio presents their service growth and reduction opportunities using business case template; assessment against criteria
• Proposals scored by peers (senior management team)
• Ranking using formal benefit scoring tool
• Marginal analysis trade-off decisions on relative value of releases vs. investments
• Final list validated by the group
• Recommendations to Executive and/ or Board
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Patient/Client Safety Healthy Workplace
Access and FlowClient/Patient Focus
Health and Wellness
Net Revenue/ In-kind ResourcesEfficiency
Differential weighting across the criteria
Evaluation Criteriafor Proposals
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Decision-making Inputs
DeterminingOperational Priorities:
Identifying Marginsfor Change
DeterminingOperational Priorities:
Identifying Marginsfor Change
Population Needs
Population Needs
Provincial Requirements
/ Targets
Provincial Provincial Requirements Requirements
/ Targets/ Targets
Rating options against pre-defined criteria
Rating options against pre-defined criteria
Stakeholder InputThe CommunityStaff / Doctors
Board
Stakeholder InputThe CommunityStaff / Doctors
Board
Financial DataFinancial Data
Service UtilizationOutput / Outcomes
Data
Business Plan Priorities
Business Plan Priorities
Practice Guidelines &
Standards
Practice Guidelines &
Standards
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VIHA’s 2007/08 Process
• 18 service growth initiatives
• Total value of $72M
• 13 service reduction initiatives
• Total $9M in savings potential for 2007/08
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VIHA’s 2007/08 Process – sample
1. Close 30 Residential Care Beds ($1.6M)
2. Home Care Growth $6.0M
3. Acute Care Winter Capacity $3.4M
4. End of Life Plan $3.8M
5. Reduction of OR Slates at X ($1.2M)
6. Eliminate X Community Program ($1.5M)
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PBMA – A SHOCK TO THE SYSTEM?
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Key lessons
• Importance of strong leadership and Board endorsement
• Process alignment with organizational goals and strategies
• Need ‘data’ but still have to make decisions
• Well defined criteria and formal service proposal scoring tool
• Importance of transparency of process and decisions
• Physician engagement in criteria development and validation
• Credible commitment takes time- organizational trust
• Recognition of political overlay and expectation management
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Conclusions
• Health care environment is usually politically charged and always complex
– Need a pragmatic framework that can introduce evidence based decision making
– Leadership, leadership, leadership
• Lessons here likely relevant elsewhere as all health organizations faced with making difficult rationing decisions
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Questions/ comments
welcome!