Physicians’ Role in Healthcare PrioritisationDavid Hadorn, M.D., Ph.D.

Centre for Assessment and PrioritisationDept of Public Health

University of Otago, Wellington14 April 2011

“Shouldn’t 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 ‘Overs’

• Over-testing• Over-screening (esp. for cancer)• Over-diagnosis• Over-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 Good

From 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 effectivedelivery” of services will require . . . a transparent process for engagingclinicians in deciding the level at which services should be planned andfunded 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

it’s not likely to be cost-effective?• Can usually find reason not to treat (“probably

wouldn’t benefit anyway”)

Doctors as Healthcare ‘Attorneys’?

• Unequivocal advocate for patient• Requires externally applied limits on care• Diagnostic testing and treatment guidelines• Requires doctors to give up some power• Are they willing to do that?

Prioritising Health Care in NZ

• Core Services Committee 1992• Gave up task of defining ‘the core’ in 1996 --

too hard, too controversial (Oregon), lack of clarity around role definition

• HFA took over prioritisation efforts 1997-2000• Since then, little progress on national

systematic prioritisation – some DHB work• PHARMAC 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 Familieswith 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 Challenge”

• Ministerial 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 Criteria

• Algorithm

• Point count

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

• All aimed at defining medical necessity

Oregon’s MRI of Spine Guideline

DIAGNOSTIC 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.

Oregon’s Erythropoietin Guideline• GUIDELINE 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.

Pharmac’s Erythropoietin GuidelineErythropoietin

INITIAL APPLICATIONApplications only from a relevant specialist. Approvals valid for 2 years.Prerequisites Patient in chronic renal failure

andHaemoglobin: ......................................<= 100g/Land• patient is not diabetic

and• glomerular filtration rate: ....................<= 30ml/minor• patient is diabetic

and• glomerular filtration rate: ....................<= 45ml/minor• patient is on haemodialysis or peritoneal dialysis

Oregon’s 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 Guideline

Patients must have one of the following• A. Upper airway obstruction secondary to tonsillar

hyperplasia• B. Persistent dysphasia associated with large obstructing

tonsils• C. Chronic tonsillitis, clinically present for over thirty days• D. Recurrent tonsillitis with documentation of four episodes

in a 12 month period of time or six episodes in two consecutive years

• E. Suspected tonsil malignancy• F. Peritonsillar abscess

Colorado Hip Replacement Guideline

• Indications for total hip replacement• History 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 change• 2. Difficulty in putting shoe and/or stocking on affected lower limb• 3. Painful limp on affected lower limb• 4. Failure to respond to non-operative treatment• AND• Physical findings of both:• 1. Limitation of motion of hip joint• 2. Observation of limp and/or documented shortening of limb• AND• X-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 Criteria

Conditions requiring acute stabilization• Suicide attempt: serious attempt or gestures indicating a

danger to self• Homicidal threats or other assaultive behavior indicating a

danger to others• Gross dysfunction: self-care failure or threats to physical

health from life-threatening physical conditions resulting in inability to care for self

• Child exhibiting bizarre or psychotic behaviors that cannot be contained or treated in an outpatient setting

Pediatric Psychiatric IS Criteria

• Evaluation and adjustment of medication under close medical supervision

• Continuous secure setting with skilled observation and supervision

• Documented 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

Conclusion

Notice instances of:– the need to make allocation decisions– bedside rationing– where service costs may outweigh benefit– equity implications esp. of new $ drugs– overdiagnosis (e.g., false +ves)– overtreatment– where doctors can help develop coverage criteria