Setting priorities explicitly (or not)

PRIORITISING HEALTH SERVICES OR MUDDLING THROUGH

A chapter of this book explains who does what in prioritisation (resource allocation and rationing).
I've found of interest this classification of rationing:

• Rationing by denial. Exclusion of specific services or treatments from the National Health System portfolio (often explicitly) or from one healthcare provider (near always implicitly) that believes that such treatment or service is inappropriate.
• Rationing by selection. Exclusion of some patients of some treatments because they do not meet certain eligibility criteria fixed by the regulator (often explicitly) or the provider (near always implicitly). 
• Rationing by delay. The demand that cannot be met by a rigid offer remains on hold (waiting list) and the wait acts as a barrier to access and, in many cases, as a de facto denial of care. 
• Rationing by deterrence. Barriers placed, either consciously or unconsciously, by the healthcare providers that make it difficult for patients to find out about, and book appointments with, some healthcare services. 
• Rationing by deflection. Patients being shunted off to another institution, agency or programme. 
• Rationing by dilution. Services continue being offered to patients, but with fewer resources, and the quality of care gets worse

 And the summary:

In conclusion, adequate priority setting is not about choosing either to muddle through implicit rationing or to be corseted by an exhaustive, rigid and explicit interventionist structure at the macro, meso and micro decision-making levels. This dichotomy fails to capture the complexity of priority setting in practice. We need more and better explicit priority setting, not to substitute but to improve implicit priority setting.

 

 Weegee by Weegee

Pasimonious medicine

PRÁCTICAS CLÍNICAS EVITABLES: EL COSTE DEL DESPILFARRO

Tilburg and Cassel wrote in JAMA

Parsimonious medicine is not rationing; it means delivering appropriate health care that fits the needs and circumstances of patients and that actively avoids wasteful care—care that does not benefit patients

And Austin Frakt answered in his blog:

Perhaps the consequences of what they support with good intention will include rationing. Perhaps it’s hard to achieve parsimony with out at least a touch of it. If that’s the case, how much rationing will we tolerate to achieve some additional efficiency? Keep in mind, today we have a high level of rationing by ability to pay and a low level of parsimony. (in USA)

Unfortunately we don't now the level of parsimony in our health system. But if you want to know the size of the waste  in spanish health system, these are some figures for primary care:

El estudio APEAS cifraba en 10,1 por 1000 visitas los eventos adversos en atención primaria de los que un 7,3% graves y un 70,2% evitables (40), mientras que el ENEAS los cifraba en 9,3% por cada 100 hospitalizados, con un 16% graves y 42,8% evitables (41). Mientras que ambos estudios tendían a minimizar el impacto de estas cifras, los 300 millones de visitas no urgentes anuales en atención primaria resultarían en 3 millones de efectos adversos anuales, de los que casi 300.000 graves y al menos 2 millones evitables. En el caso de la hospitalización, los 5,2 millones de hospitalizaciones del año en que se realizó el ENEAS ofrecerían cifras de 450.000 efectos adversos anuales, de los que 90.000 serían graves y unos 200.000 evitables. Estas cifras situarían los eventos adversos derivados de la atención sanitaria como la probable tercera causa de morbi-mortalidad en nuestro país, tras las enfermedades cardiovasculares y el cáncer.

And regarding hospitalizations,

Diversos estudios publicados en la década del 2000 cifran en torno al 10-15% la cuota de este tipo de ingresos hospitalarios sobre el total de hospitalizaciones producidas en España en los años estudiados (42-46). Este porcentaje sería aún mayor para los ingresos por hospitalizaciones evitables en enfermedades crónicas estudiados más recientemente por el grupo Atlas de Variaciones en la Práctica Médica

And the figures for inappropriateness and low value care are more diffiuclt to estimate, though:

En España se han realizado numerosos estudios sobre utilización inapropiada de la hospitalización con cifras que sitúan este problema alrededor del 10% de las admisiones y el 30% del total de estancias hospitalarias

And only one example regarding pharmaceuticals

Añadir lapatinib a capecitabina en el tratamiento en segunda línea del cáncer de mama permite ganar, en promedio, 0,3 meses (10 días) de supervivencia con respecto al tratamiento previo con solo capecitabina, con un coste adicional de 18.298 € (60.996 € por mes de vida adicional) (59). Estas cifras implicarían que socialmente estamos dispuestos a pagar unos 732.000 euros por cada año de vida adicional ganado y, si se tiene en cuenta la baja calidad de vida de estos días ganados en la fase final de los procesos oncológicos, probablemente estaríamos hablando de cifras superiores a los 2 millones de euros por año de vida ajustado por calidad (AVAC o QALY) ganado con la incorporación de este tratamiento a este precio a la cartera de servicios.

If we as a society, we are not able to solve the rationing puzzle, then we could start by a more parsimonious medicine. You'll find more details in the chapter by S. Peiró in this book (p.273).
After reading this chapter, you'll be more concerned than before.

Garry Winogrand

On rationing (ventilators)

Recomendaciones éticas para tomar decisiones en la situación excepcional de crisis por pandemia Covid-19 en las UCI

These are tough times for mankind. We are social animals and current instructions/recommendations are focused to behave exactly the opposite. Once the coronavirus hits someone, the result may be being hospitalised and one may need intensive care and mechanical ventilation. And if supply is not enough for the demand of ventilators, then starts the most difficult question: who gets the ventilator?. A professional answer is needed. Fortunately the scientific society  Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias has released a document that helps to provide specific recommendations in such situation.
This is exactly what we can expect from a modern society. Professional decisions need guidance and consensus. There is no role for politicians in this issue and in this moment, scientific societies have to coordinate such efforts. Therefore my congratulations for their recommendations.
Basically, the document highlights the criteria of maximizing capability of benefit, and in the current situation and in intensive care, this has to be applied in a general way, for covid-19 and non covid-19 disease requiring such services. And these criteria should be applied in an uniform way.
In this blog I've been supporting the role of professionalism in taking tough decisions. Today I've to say that these is a good example of rationing to keep in mind.

PS. If projects like this one succeed, then tough decisions could be avoided. Great initiative.

La deconstrucció del racionament clínic

Thinking about rationing

Quan la barrera del preu és inexistent, aleshores apareix d'alguna manera algun mecanisme de racionament. La forma que adopta és diversa i el document de la King's Fund ens ajuda a deconstruir el concepte. I com que el primer que signa és en Rudolf Klein, d'entrada ja cal llegir-lo. Destaco:

When population-based criteria for allocating resources (priority-setting) have to be translated into what the results mean for individual patients (rationing), that a new set of criteria or ethical principles comes into play. Here two principles compete. The first is that resources are allocated according to the capacity to benefit: the doctor’s attention or the scarce kidney goes to the patient with the best prospect of surviving longest. The other is the rule of rescue: the patient with the highest risk of death has first claim on the available care, no matter what the costs.

I més endavant fa referència a l' Accountability for Reasonableness Framework de Norman Daniels. Convé que tots aquells que es dediquen a l'avaluació econòmica, i aquells que els toca prendre decisions clíniques cada dia, li facin una ullada. Però també els gestors i els que es dediquen a la política sanitària. Molts volen passar de puntetes davant la realitat del racionament, una realitat tossuda que tenim davant els nostres ulls i sobre la que ens cal criteri fonamentat.

PS. Magnífic discurs d'en Puyal.  En una paraula, impressionant.

Foto de Cindy Sherman, no cal afegir res més

The pandemic in US

 Uncontrolled Spread. Why COVID-19 Crushed Us and How We Can Defeat the Next Pandemic

New book by Scott Gottlieb , former FDA comissioner

COVID revealed dangerous gaps in the US public health preparedness, medical infrastructure, and healthcare system. We lacked the public health capacity and resiliency we thought we had. In the most advanced healthcare system in the world, we ran out of medical masks. We had to retrofit anesthesia machines and turn them into respirators. We didn’t have enough swabs to collect samples from patients’ noses.

Our system was set up well to handle singular, technology-intensive, and complex problems like developing a novel vaccine or antibody drugs. We do this better than anyone. But it faltered when we were faced with more mundane problems like manufacturing those vaccines in bulk, deploying testing centers, or making nose swabs to collect respiratory samples. When we finally developed safe and effective therapeutics and vaccines that could treat or prevent infection, we couldn’t manufacture enough of them in time to supply the nation for the winter surge. We had to set up elaborate rationing schemes. Then, we were unable to establish an efficient distribution plan. Antibody drugs went unused because we couldn’t deliver them. 

The virus made clear that we’ll need to fundamentally alter the way we approach all of these risks. If we don’t, our society will remain excessively vulnerable. For starters, we’ll have to lean much more on our intelligence agencies, and in a different fashion. International agreements alone haven’t provided us with the information we need about emerging threats. There’s little reason to believe they’ll perform much better in the future. The devastation caused by the pandemic proved that these risks, and our preparedness for them, is a matter of national security on par with other threats. We’re going to have to build the capacity to seek out the information we need to protect ourselves. Sometimes that will demand that we avail ourselves of the tools and tradecraft of our clandestine services. The challenge will be to maintain collaboration and multilateral efforts even as we turn more heavily toward intelligence services to guard against the risk of new contagions. 

 

The value of life (2)

 What's Your Life Worth?: Health Care Rationing...Who Lives? Who Dies? Who Decides?

Pandemethics

The Ethics of Pandemics

From this timely book I'm specially interested in Chapter 4: Scarce Resource Allocation. The whole book offers an overview of some of the most pressing issues of our time. Outline of chapter 4:

4.1 Ezekiel J. Emanuel et al., Fair Allocation of Scarce Medical Resources in the Time of COVID-19

4.2 Angela Ballantyne, ICU Triage: How Many Lives or Whose Lives?

4.3 Jackie Leach Scully, Disablism in a Time of Pandemic

4.4 Joseph J. Fins, Disabusing the Disability Critique of the New York State Task Force Report on Ventilator Allocation

4.5 Franklin G. Miller, Why I Support Age-Related Rationing of Ventilators for COVID-19 Patients

4.6 Shai Held, The Staggering, Heartless Cruelty toward the Elderly: A Global Pandemic Doesn’t Give Us Cause to Treat the Aged Callously

Case Study: Ventilator Shortages: Who Should Live?

On rationing (ventilators) (2)

Fair Allocation of Scarce Medical Resources in the Time of Covid-19

The four fundamental values for allocating resources, according Ezequiel Emanuel and colleagues are those included in this article:

Maximizing the benefits produced by scarce resources, treating people equally, promoting and rewarding instrumental value, and giving priority to the worst off. Consensus exists that an individual person’s wealth should not determine who lives or dies.

And,

Maximization of benefits can be understood as saving the most individual lives or as saving the most life-years by giving priority to patients likely to survive longest after treatment. Treating people equally could be attempted by random selection, such as a lottery, or by a first-come, first-served allocation. Instrumental value could be promoted by giving priority to those who can save others, or rewarded by giving priority to those who have saved others in the past. And priority to the worst off could be understood as giving priority either to the sickest or to younger people who will have lived the shortest lives if they die untreated.

The proposals for allocation discussed above also recognize that all these ethical values and ways to operationalize them are compelling. No single value is sufficient alone to determine which patients should receive scarce resources.24-33 Hence, fair allocation requires a multivalue ethical framework that can be adapted, depending on the resource and context in question.

Here you'll find some reflections on how to put this into practice.

Eating in pandemic times

Book choice

The Rationing
A Novel

Book choice

Rationing and Resource Allocation in HealthcareEssential Readings

Who should get treatment?

Who should receive treatment? An empirical enquiry into the relationship between societal views and preferences concerning healthcare priority setting

The concern for an equitable and fair allocation of healthcare resources requires a prioritisation approach. Otherwise we are going to live in an arbitrary and opaque world.
An article from the Netherlands explains what people think about three perspectives:

The view “Equal right to healthcare” comprises an egalitarian view on health and healthcare. People with this view consider access to healthcare a basic human right. Everyone is equal, hence has an equal right to healthcare. According to people with this view, prioritisation should solely be based on the need for care and prioritisation based on patient, disease, and intervention characteristics, such as the effect of treatment, is opposed. What is considered to be “the right care” is a matter of personal concern for patients and, according to people with this view, patients should be supported in their treatment choices regardless of the costs.

The view “Limits to healthcare” comprises a view with a strong concern for providing “the right care” for patients. People with this view consider health-related quality of life to be an important outcome of treatment. According to people with this view, providing the right care may imply refraining from (life prolonging) treatment. People with this view do not consider cost-effectiveness to be an important criterion for priority setting, although they do consider it important to make good use of money. Hence, providing treatments that generate minimal benefits should be avoided. Priority setting based on patient characteristics is rejected, with an exception made for lifestyle. According to people with this view, patients who are culpable of their own disease should receive lower priority and prevention should receive higher priority in allocation decisions.

The view “Effective and efficient healthcare” comprises a utilitarian view on health and healthcare. People with this view consider it important to generate as much health for society as possible given the budget constraint, and consider a patient’s capacity to benefit from treatment important when setting priorities. Although people with this view focus on the cost-effectiveness of treatments, they do believe it is not possible to “put a [fixed] price on life”. The value of health benefits depends on circumstances and patient characteristics, such as age and culpability, and hence these should be taken into account in priority setting.

 And the result is:

 The majority of respondents was matched to the view “Equal right to healthcare” (64.5%), followed by “Limits to healthcare” (22.5%), and “Effective and efficient healthcare” (7.1%). A minority of respondents (5.9%) could not be matched

My impression is that we change such criteria according to the exact setting we are in a precise moment. That's why beyond societal criteria we do need professional criteria. Sounds too easy to solve the prioritisation exercise according to three principles.

PS. Still waiting for the book:Rationing and Resource Allocation in Healthcare: Essential Readings

 Juan Genovés exhibition at Marlborough gallery

How universal is universal coverage?

An analysis of perceived access to health care in Europe:How universal is universal coverage?

Two different realities are intertwined: healthcare access right and needs-based access. The first is widely acknowledged in European countries, the second depends on the specific measurement of geographic (and financial) barriers to healthcare providers.
An article in Health Policy sheds some light on the issue. And its results are compelling:

Despite clear commitments to move towards universal health coverage in Europe, our results suggest that there remains significant heterogeneity among individuals in terms of their perceptions of access to care across and within countries. Overall, we find that the poorest groups are still the most likely to feel they will be unable to accesscare if they need it. In some countries however, differences in the probabilities of perceiving access barriers between low and high-income individuals are relatively small. This insinuates that rationing mechanisms that affect all income groups, such as low quality care and long waiting times may serve as important barriers.

PS. There is no clear pattern between out of pocket expenditure as a percentage of total health expenditure, and the predicted probability of perceived inability to access care:

The price of life

A documentary about the rationing of high cost cancer drugs by the National Institute for Health and Clinical Excellence.

A primer on health economics and policy

Social values in health and social care

In just 38 pages Tony Culyer explains  the basics of health policy. It is not a review, these are a collection of key insights that basically come from his book. This is the outline:

• Introduction
• Liberalism versus libertarianism
• The market versus the state
• Public versus private insurance
• Equity versus equality
• Inequalities of health versus inequalities of health care
• Equity versus efficiency
• Needs versus wants
• Prices versus rationing
• Financial protection versus quality of life
• Public versus private
• Agents versus principals
• Universality versus selectivity
• Comprehensiveness versus limited benefit bundles
• Centralisation versus decentralisation
• Competition versus collaboration
• Experts versus citizens
• Mixing values and other things
• Key messages 

Take this sentence, as an exemple:

Cost is also a value and no mere matter of accountancy. If we introduce a new
health care procedure, the cost will have to come out of expenditure elsewhere
in the NHS –unless there is a concurrent increase in the NHS budget. But less
expenditure elsewhere will normally imply reduction of service elsewhere and
a consequential health loss. The true cost of getting more care (and hence
health) in one area of activity is therefore the minimum necessary loss of care
(and loss of health) elsewhere. This is the important notion of opportunity cost.

Many politicians don't want to hear such messages. I stronlgy suggest you to read this booklet from Kings' Fund.
.

El cost sanitari de la longevitat

Health Care Expenditures and Longevity: Is there a Eubie Blake Effect?

Eubie Blake va dir quan suposadament va fer 100 anys:

If I’d known I was going to live this long, I would have taken better care of myself.

Era el 1983, i just 5 dies abans de morir, però potser no en feia 100. Tant és. En Breyer et al. aprofiten la cita per construir un article suggerent amb l'objectiu de:

to demonstrate that percapita health care expenditures are significantly influenced by the age composition of the population, by mortality rates and by the development of longevity, as measured by the age-specific 5-year survival rates. We believe that this effect mirrors the medical profession’s willingness to perform expensive treatments on elderly patients if the patients can be expected to live long enough to enjoy the effects of the treatment.
The results of the simulations based on the regression coefficients show that if past trends continue, per-capita health care expenditures would rise by between 1.5 and 2 per cent per year even without demographic change.

El seu resultat és interessant perquè s'afegeix a la polémica de si la longevitat augmenta els costos sanitaris (resultat del cost sanitari que augmenta amb l'edat) o si ens trobem davant costos incrementals del darrer any de vida (esforç terapèutic desmesurat) o si tindrem una compressió de la morbiditat i els costos disminuiran. De tot plegat, pensen que potser els costos del darrer any de vida tendeixen a disminuir en la mesura que l'edat augmenta. I diuen:

We suggest that physicians, e.g. when implanting an artificial hip into a patient, will make a conjecture how long the patient will benefit from this treatment, and this depends upon his expected longevity. In that respect, the physician (and maybe the patient, too) will behave in a way described in the famous quotation by Eubie Blake. This effect will lead to a similar physician behaviour as “age-based rationing” of health care services when the notion of a “normal life span” (Callahan (1987), Daniels (1985)) shifts over time with rising longevity.

Bé, no sé si aquesta hipòtesi són capaços de demostrar-la completament, més aviat diria que és una intuició difícil de comprovar. En qualsevol cas, quan apliquen els seus resultats a Alemanya, per al conjunt de factors troben que si, que la despesa sanitària augmentarà amb el canvi demogràfic, a una taxa de creixement d'un 0,5 a un 0,9%. Qüestió a tenir en compte també per aquí aprop i que algú s'hauria de mirar amb atenció.

PS. Al Congrés Europeu d'Economia de la Salut presenten aquest paper.

PS. Lectura necessària d'avui: en Martin Wolf a FT i Roubini sobre com els guanys s'han privatitzat i les pèrdues s'han socialitzat.

Desmesura

Que a aquestes alçades en Kaplan i en Porter diguin que la forma de resoldre la creixent escalada de despesa sanitària sigui mitjançant una millor mesura dels costos i dels resultats és una novetat sorprenent. A més a més això ho publiquen a la portada de HBR com "la gran idea" i alhora l'editorial va sobre el tema tot dient:

The problem, Kaplan and Porter demonstrate, is that we simply don’t measure the right things. Few providers track actual patient outcomes or the costs incurred to attain them. As the axiom holds, if you don’t measure something, you can’t manage or improve it. In the current environment this means that effective and efficient providers often go unrewarded, while inefficient ones have little or no incentive to improve.
The authors argue that the key is to make patients and their conditions—rather than organizational divisions or diagnostic treatments—the fundamental unit of analysis for measuring costs and outcomes. That would foster a system focused on improving the quality of care while reducing overall costs: an impressive win-win in an era when cost control is often equated with rationing care.

Podeu evitar de llegir-lo i estalviareu temps i diners. Entre d'altres motius pel desconeixement que mostra al conjunt de treballs que precisament fan això des de fa temps. I no seré jo qui digui que no és important mesurar costos i resultats. Ara bé que això sigui una gran idea i la solució del creixement de la despesa sanitària és com a mínim una visió naïf. Obliden que la pregunta prèvia és quins incentius hi ha per a mesurar i que es pot fer per canviar-ho.
Donaré només una pista als autors, es tracta del treball que acabem de publicar a EJHE el mes passat amb el títol: Estimates of patient costs related with population morbidity: can indirect costs affect the results? (en versió prèvia online ho trobareu aquí)

PS. La liquidació del regulador dels medicaments mostra un cash-flow de 30 milions el 2010, i de 43 milions el 2009. El fet que no ha gastat gairebé el 20% del pressupost públic de 2010 (que és de 53 milions d'euros anuals) té a veure amb tres opcions possibles: un problema pressupostari, un problema de gestió, o les dues coses anteriors alhora. Em trobo que la provisió per riscos de devolució de taxes és de 32 milions d'euros(!) i no dic res més (el 60% del pressupost d'un any).

Raonable i necessari

Aquesta vegada el Journal of Economic Perspectives ve carregat de valent. Molts temes d'interès relacionats amb la salut.
Avui em referiré a l'article d'en Chandra, Jena i Skinner sobre efectivitat comparada. El text s'ha de llegir sencer i destacaria l'elevada expectativa que dispositen en l'avaluació de l'efectivitat comparada malgrat no hi hagi cost-efectivitat. Comparteixo totalment la seva perspectiva.
Aquesta és la seva posició:

We argue that comparative effectiveness research still holds promise. First, it sidesteps one problem facing cost-effectiveness analysis—the widespread political resistance to the idea of using prices in health care. Such resistance is not just from political interest groups, but also from voters, who even in lab settings often dislike rationing based on cost effectiveness (Nord, Richardson, Street, Kuhse, and Singer, 1995). Second, there is little or no evidence on comparative effectiveness for a vast array of treatments: for example, we don’t know whether proton-beam therapy, a very expensive treatment for prostate cancer (which requires building a cyclotron and a facility the size of a football fifi eld) offers any advantage over conventional approaches. Most drug studies compare new drugs to placebos, rather than “headto- head” with other drugs on the market, leaving a vacuum as to which drug works best (Nathan, 2010). Simply knowing what works and what doesn’t will improve productive effifi ciency by shedding medical practices that are unsafe at any price.

Aquí no tenim ni això encara que la llei tímidament demana avaluar utilitat terapèutica i ningú es preocupa per ara d'aplicar-la. Cal trobar un patró per mesurar aquelles prestacions que són raonables i necessàries.

Cartilla de Racionament

The Real Meaning of Rationing

La capacitat de sorpresa ha desaparegut definitivament. Si algú hagués dit que el pressupost públic de l'any que ve seria inferior a l'any anterior aleshores hauria invocat als factors inevitables: demografia i tecnologia per a justificar la necessitat de creixement. Doncs bé, resulta que ja no passa res, sembla que l'any 2011 no hi haurà més envelliment ni més tecnologia. Les comunitats autònomes estan reduint el pressupost sanitari. I en realitat el que hi ha són sous més baixos, perquè els factors inevitables (?) són un anclatge per al discurs (Evans dixit).
Ara bé, sabem que més enllà de la reducció salarial, el que convé és explicitar com cal complir la restricció pressupostària. El pressupost ens imposa una racionament, ens assenyala que la bota de Sant Ferriol només existeix a la llegenda. I si no volem viure en una llegenda convé començar a fer explícit quins són els criteris de racionament. En Detsky i Meltzer en parlen al JAMA aquesta setmana, però jo em vaig quedar amb les idees d'Emmanuel el "Complete Lives Systems"(remake de Williams, "Fair Innings"), - recomano llegir l'article sencer i no només aquestes cites per tal de situar les afirmacions en el context-:

We recommend an alternative system--the complete lives system--which prioritises younger people who have not yet live a complete life and also incorporates prognosis, save the most lives, lottery, and instrumental value principles.

Unlike allocation by sex or race, allocation by age is not invidious discrimination; every person lives through different states rather than being a single age. Even if 25-year-olds receive priority over 65-year-olds, everyone who is 65 years now was previously 25 years.

Consideration of the importance of complete lives also supports modifying the youngest-first principle by prioritising adolescents and young adults over infants. Adolescents have received substantial education and parental care, investments that will be wasted without a complete life. Infants by contrast, have not yet received these investments. Similarly, adolescence brings with it a developed personality capable of forming and valuing long-term plans whose fulfillment requires a complete life.

Tema massa controvertit per a resoldre en una entrada del blog. En algun moment caldrà fer explícits els criteris per a prioritzar, ara que el pressupost es redueix hi ha més motiu encara. Algú creu que aixó serà per poc temps, però tampoc ningú no pensava que durés tant la cartilla de racionament.

Per cert no busqueu el pressupost de Catalunya per al 2011. No n'hi ha (per ara).