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Ethically acceptable prioritisation of childless couples and treatment rationing: "accountability for reasonableness"
Gyn-Obst. Unit, Skellefteå Hospital, Sweden.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Public Health Sciences.
2008 (English)In: European Journal of Obstetrics, Gynecology, and Reproductive Biology, ISSN 0301-2115, E-ISSN 1872-7654, Vol. 139, no 2, 176-186 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: With in vitro fertilisation serving as a specific case, an intervention was aimed at investigating the potential for applying prioritisation theories and methods in a real-life situation to form an evidence-based proposal that met the standards of the "Accountability for Reasonableness" Model. In turn, this case would serve as a basis for public decision on rationalisation, prioritisation and rationing, whereby given resources are allocated with respect to the ethical template of the Swedish Parliament's decision on priorities in health care. STUDY DESIGN: Management representatives of the overall county council as well as the gynaecologic-obstetric department levels, infertility treatment professionals and a patients' organisation representative worked together to create guidelines building on the ethical principles of human dignity, needs/solidarity and cost-effectiveness, on evidence of treatment effect, epidemiology and economic resources availability. Also quality improvement techniques were used. RESULTS: Due to new guidelines for priority setting, it is expected that more childless couples in the studied health care region will get publicly financed IVF treatment. IVF treatment outcome is expected to be more cost-effective in terms of pregnancies for a given amount of resources. A balance between needs - as defined by the guidelines' criteria - and resources is expected and thus waiting lists are expected to vanish. The patients' organisations representative accepted the guidelines. They were also accepted by all obstetric clinics and formally agreed upon by the political boards of all county councils in the region. CONCLUSION: Use of a deliberative decisions model, structured quality improvement methodology and an accepted model for prioritisation helped create a system for legitimate prioritisation of couples and rationing of treatment regarding a group of patients where differentiation has been considered difficult.

Place, publisher, year, edition, pages
2008. Vol. 139, no 2, 176-186 p.
Keyword [en]
In vitro fertilisation, Health priorities, Rationing, Accountability for reasonableness, Structured quality improvement, Total quality management
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
URN: urn:nbn:se:umu:diva-22233DOI: 10.1016/j.ejogrb.2008.02.018PubMedID: 18417271OAI: diva2:213839
Available from: 2009-04-29 Created: 2009-04-29 Last updated: 2010-10-04Bibliographically approved
In thesis
1. Creating organisational capacity for priority setting in health care: using a bottom-up approach to implement a top-down policy decision
Open this publication in new window or tab >>Creating organisational capacity for priority setting in health care: using a bottom-up approach to implement a top-down policy decision
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

In this thesis, priority setting to the form of the Swedish parliamental decision on priority setting, 1997, is considered an innovation for implementation in health care. The features of this innovation are investigated. The practical implications of implementation are identified by investigating the user organisation, ie, Swedish health care organisations and management systems.

Also, a case of a three-stage process for macro-level priority setting that engaged the entire organisation in the Västerbotten County Council (VCC) is presented. This is done against a background of preceding implementation efforts in the VCC.

Four specific research efforts and papers are presented.

In Paper I, priority setting is operationalised into a multi-dimensional resource allocation task. On that basis, with the help of interviews (1998) and surveys (2002 and 2005) primarily of VCC health care managers, the impact of implementation is measured by prioritisation structures, processes and decisions. Survey response rates were low. Results were used as qualitative data, internally compared, and interpreted as: a) responses reflected mainly “early adopters’” opinions; b) priority setting is an ambiguous concept; c) indicating limited overall implementation; d) reinterpretation of the prioritisation task occurred over time among respondents; and, e) this group took increasingly personal responsibility as stakeholders in priority setting.

Paper II reports a case study intervention of explicit, departmental level priority setting with the aim of improving cost-effectiveness in in vitro fertilization resource use and a rationing of services perceived legitimate by all stakeholders. The intervention combined priority setting and structured quality improvement techniques. Results were: a) improved operational efficiency of diagnostic procedures that allowed resources to be reallocated to treatment; and b) patients were prioritized and treatment resources were rationed based on evidence of treatment effect among subgroups. Evaluation showed that the procedure met stated criteria for legitimacy.

In Paper III, a full-format test of the macro level prioritisation process is described and evaluated by participants with the help of surveys after each completed stage. Participants report the need for improvement of elements in the overall process and of procedural specifics. However, overall there was a strong commitment to the initiative and satisfaction with the process and the resulting decisions.

In Paper IV, procedural specifics of the prioritisation process are evaluated. They are also compared to the Program Budgeting and Marginal Analysis (PBMA) framework when used for macro level purposes. Procedures provided intended results such as vertical and horizontal priority setting and a consistent process. However, economic targets were not fully achieved in any of the stages.

Conclusions include that health care management systems are not prepared for priority setting and need profound restructuring and that the prioritisation process described in Papers III and IV was successful because: a) the process satisfied politicians’ directives; b) participants were satisfied with the procedures and perceived the subsequent reallocation decisions as legitimate; and, c) methods resulted in the intended outcome.

Factors suggested as the basis of success include: long-term overall preparations; broad and deep participation; a readiness for change among participants; a stage for horizontal priority setting that added to the quality, feasibility and perceived validity of the knowledge base; a strong process leadership; and politicians determined to protect the process from opportunistic disturbances.

Place, publisher, year, edition, pages
Umeå: Umeå university, 2010. 107 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1368
Health care; priority setting; implementation; management systems
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public health
urn:nbn:se:umu:diva-36316 (URN)978-91-7459-059-3 (ISBN)
Public defence
2010-10-22, Bergasalen, Byggnad 27, Norrlands universitetssjukhus, Umeå, 13:00 (Swedish)
Available from: 2010-10-01 Created: 2010-09-28 Last updated: 2010-10-04Bibliographically approved

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