Physicians’ Role in Healthcare Prioritisation

1. Physicians’ Role in Healthcare Prioritisation David Hadorn, M.D., Ph.D. Centre for Assessment and Prioritisation Dept of Public Health University of Otago, Wellington 14 April 2011

2. “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

3. 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

4. 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;53Achieving 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

5. 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”)

6. 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?

7. 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

8. National Prioritisation Back on Agenda Renewed 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 2008Judy Kavanaugh, MOH. Prioritisation: why is it so hard? 21 August 2008Janet McDonald. Prioritisation: Change and Adaptation in Familieswith Young Carers. 11 September 2008David 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

9. “Meeting the Challenge” • Ministerial Review Group (MRG) – Horn Report • Released 16 August 2009 • Changed dynamic for health reform • Most key recommendations already taken up

10. MRG on prioritisation From 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

11. Coverage Criteria • Algorithm • Point count • Guidelines (Boolean combination of clinical/social variables predicting benefit) • All aimed at defining medical necessity

17. 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 caudaequinasyndrome (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.

18. 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.

19. Pharmac’s Erythropoietin Guideline Erythropoietin INITIAL APPLICATION Applications only from a relevant specialist. Approvals valid for 2 years. Prerequisites Patient in chronic renal failure and Haemoglobin: ......................................<= 100g/L and • patient is not diabetic and • glomerular filtration rate: ....................<= 30ml/min or • patient is diabetic and • glomerular filtration rate: ....................<= 45ml/min or • patient is on haemodialysis or peritoneal dialysis

20. Oregon’s Tonsillectomy Guideline GUIDELINE 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; • Peritonsillarabscess 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.

21. 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

22. 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

23. NZOA Hip and Knee Prioritisation Tool http://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 activity 2-3 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

24. 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

25. NZOA Hip and Knee Replacement Tool, cont. • Similar criteria for: • Social limitation • Potential to benefit from surgery • Consequence of delay > 6 mo

26. 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

27. 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

28. 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