S9 - Resource Allocation + PROMs Flashcards
What is priority setting and rationing (in detail on other cards)
priority setting
Describes the decisions made about the allocation of resources between the completing claims of different services, patient groups or elements of care
rationing
Describes the effect of the decisions made about the allocation of resources on the individual patient (the extent to which patients receive less than the best possible treatment as a result)
☞ resources are scarce and could be used in many different ways
☞ ethically, need to be clear about aims of expenditure and who benefits the most
What are the two different types of rationing
Explicit based on defined rules of entitlement (systematic allocation of resources)
Implicit care is limited, but neither the decisions, nor the bases for those decisions are clearly expressed
What are the pros and cons of explicit rationing
pros
- Transparent + accountable
- Opportunity for debate
- More clearly evidence based
- More opportunities for equity in decision making
cons
- Very complex
- Heterogeneity of patients and illnesses
- Patient and professional hostility.
- Impact on clinical freedom
How do NICE work
- They are the decision makers of whether an intervention is approved for use
- They set the criteria for particular interventions (eg cochlear implantation)
- Look at cost effectiveness and the benefits
- Also looks at strength of evidence, effectiveness, patient acceptability, treatment alternatives and societal benefits
- NICE then provide guidance on whether treatments are recommended for NHS use in England
- If treatments are not approved, patients are denied access to them (except for individual requests)
- If approved, local NHS organisations must fund them, sometimes with adverse consequences for other priorities
- ‘people also have the right to be involved in making informed decisions about their care’ while still taking guidance into account
Basic concepts in health economics
- scarcity where need outstrips resources, and prioritisation is inevitable
- efficiency where getting the most out of limited resources
- equity the extent to which distribution of resources is fair
- effectiveness the extent to which an intervention produces desired outcomes
- utility the value an individual places on a health state
-
opportunity cost once resources have been used on one treatment, they can’t be used on another… cost is viewed as sacrifice rather than financial expenditure…
☞ 3 x IVF can fund 11 cataract removals, 150 MMR vaccine, 1/3 cochlear implantation etc
What is technical vs allocative efficiency
technical = the most efficient way of meeting a need (should antenatal care be community or hospital based)
allocative = choose between funding different treatments (fund antenatal or cardiology?)
How are costs measured
Sum of the costs of…
- the healthcare services
- the patient’s time
- costs associated with care-giving
- economic costs borne by the employers, other employees and the rest of society
How are benefits measured
More difficult to measure than costs…
- impact on health status
- savings in other healthcare resources
- improved productivity
what are the 4 main strategies of comparing costs and benefits? (more detail on sep cards)
- cost minimalization analysis
- cost effectiveness analysis
- cost benefit analysis
- cost utility analysis
Strategies of comparing costs and benefits: cost minimisation analysis
- outcomes assumed to be equivalent
- focus is on costs (ie only the inputs)
- not often relevant as outcomes are rarely equivalent
eg all prostheses for hip replacement equally… choose cheapest one
Strategies of comparing costs and benefits: cost effectiveness analysis
- used to compare drugs or interventions which have a common health outcome, eg reduction in blood pressure
- compared in terms of cost per unit outcome (eg cost per reduction of 5mm/Hg)
- if both costs and benefits are higher for one treatment, need to calculate how much extra benefit is gained for the extra cost
- ie is the extra benefit worth the cost?
Strategies of comparing costs and benefits: cost benefit analysis
- all inputs and outputs are viewed in monetary terms
- can allow comparison with interventions outside healthcare
- this has difficulties: eg putting monetary value on non-monetary benefits, such as lives saved
- ‘willingness to pay’ is often used but this is problematic
Strategies of comparing costs and benefits: cost utility analysis
- Particular type of cost effectiveness analysis
- Focusses on quality of health outcomes produced or foregone
- Most frequently used measure is quality adjusted life year (QALY)
- Interventions can be compared in cost per QALY terms
What are QALY (controversy on different card)
quality adjusted life year
- Adjust life expectancy for quality of life
- 1 year of perfect health = 1 QALY
- Assumes that 1 year of perfect health = 10 years of QoL of 0.10
- Takes both quality and quantity of life into account
- Useful measure of cost effectiveness and decision making for treatment
- However, many controversy with QALY (on different card)
*eg man is diagnosed with cancer, if he receives treatment he will live for 4 years but his QoL will be 0.2 of perfect health. Therefore (4 x 0.2) = 0.8 QALYs
QALY controversies
- About the values they embody: is one person’s life more valuable than another? Is QoL the same for everyone?
- Do not distribute resources according to need, but according to cost
- May disadvantage common conditions
- Technical problems with their calculations
- QALYs may not embrace all dimensions of benefit, and values expressed by experimental subjects may not be representative
- QALYs do not assess impact on carers or family
What is HRQoL
health related quality of life
☞ health is a state of complete physical, mental and social wellbeing
☞ QoL is a conscious cognitive judgement of satisfaction with one’s life
Therefore HRQoL are those aspects of self-perceived wellbeing that are related to or affected by the presence of disease or treatment. It is subjective and takes many health states into account…
- Mobility
- Self care
- Leisure
- Symptoms
- Psychosocial
What are patient-reported outcome measures (PROMs)
- Health outcome reported directly by the person who experienced it
- Measure health or HRQoL at a single point in time
- Collected using self-completed questionnaires
What are generic vs specific PROMs
generic
- Considers all aspects of HRQoL
- Therefore considers mobility, self-care, leisure, symptoms and psychosocial
- Comparable across conditions and systems
- But less clinical detail
specific
- Need different questionnaires for different populations, eg for Rheumatoid Arthritis, would need specific questionnaire
- more clinical detail for their defined application
- burdensome (if you wanted to ask everyone in society) + less comparable between different conditions
PROM scores can be used to…
- Calculate QALYs
- Monitor system interventions
- Inform individual healthcare
