Deciding Together? Best Interests and Shared Decision-Making in Paediatric Intensive Care

In the western healthcare, shared decision making has become the orthodox approach to making healthcare choices as a way of promoting patient autonomy. Despite the fact that the autonomy paradigm is poorly suited to paediatric decision making, such an approach is enshrined in English common law. When reaching moral decisions, for instance when it is unclear whether treatment or non-treatment will serve a child’s best interests, shared decision making is particularly questionable because agreement does not ensure moral validity. With reference to current common law and focusing on intensive care practice, this paper investigates what claims shared decision making may have to legitimacy in a paediatric intensive care setting. Drawing on key texts, I suggest these identify advantages to parents and clinicians but not to the child who is the subject of the decision. Without evidence that shared decision making increases the quality of the decision that is being made, it appears that a focus on the shared nature of a decision does not cohere with the principle that the best interests of the child should remain paramount. In the face of significant pressures toward the displacement of the child’s interests in a shared decision, advantages of a shared decision to decisional quality require elucidation. Although a number of arguments of this nature may have potential, should no such advantages be demonstrable we have cause to revise our commitment to either shared decision making or the paramountcy of the child in these circumstances.     

Consumer-driven and commercialised practice in dentistry: an ethical and professional problem?

The rise and persistence of a commercial model of healthcare and the potential shift towards the commodification of dental services, provided to consumers, should provoke thought about the nature and purpose of dentistry and whether this paradigm is cause for concern. Within this article, whether dentistry is a commodity and the legitimacy of dentistry as a business is explored and assessed. Dentistry is perceived to be a commodity, dependent upon the context of how services are to be provided and the interpretation of the patient–professional relationship. Commercially-focused practices threaten the fiduciary nature of the interaction between consumer and provider. The solution to managing commercial elements within dentistry is not through rejection of the new paradigm of the consumer of dental services, but in the rejection of competitive practices, coercive advertising and the erosion of professional values and duty. Consumerism may bring empowerment to those accessing dental services. However, if the patient–practitioner relationship is reduced to a mere transaction in the name of enhanced consumer participation, this empowerment is but a myth.     

Current and Future Use of HEOR Data in Healthcare Decision-Making in the United States and in Emerging Markets

Background

Health economics and outcomes research (HEOR) is a growing field that provides important information for making healthcare coverage and access decisions. However, there is no standard process for incorporating HEOR into the decision-making process, and the current use of HEOR by healthcare payers remains unknown.

Objectives

To examine how HEOR data are being used by healthcare payers, including managed care organizations today, and how the use of such data is expected to change in the future in relation to access and reimbursement decision-making.

Methods

The Managed Care Survey (MCS) and the Pharmacy & Therapeutics (P&T) Committee Survey (PTS) were distributed to decision makers in the United States. A total of 72 managed care decision makers responded to the MCS and 30 P&T Committee members responded to the PTS from US healthcare organizations that cover from tens of thousands to millions of lives. The goal of these surveys was to understand the current use of HEOR data, perceived barriers and limitations in the use of HEOR, and the expectations for future use, and how these and other factors affect formulary decisions. An international perspective was gained by modifying the MCS based on feedback received at a European conference, and a pilot version was given to individuals in emerging markets across Asia, Latin America, and the Middle East and Africa.

Results

The majority of US respondents to the MCS (74%; N = 53) and to the PTS (77%; N = 23) indicate that HEOR is currently being used in their decision-making process; but the majority of respondents to the MCS (66%; N = 48) also state that quality assessment is limited (quality assessment was not addressed in the PTS). In addition, the majority of respondents to the MCS (82%; N = 59) expect the use of HEOR to increase in the future. Safety and efficacy were reported in the PTS to be the most important factors in the P&T Committee decision-making process, followed by head-to-head comparisons, and cost. The current use of HEOR in Asia, Latin America, and the Middle East and Africa varied widely across respondents.

Conclusion

This study provides an important benchmark of HEOR use in the United States before the implementation of healthcare reform. Between the years 2010 and 2011, HEOR data were used to varying extents across global regions, but their use in the future is likely to increase in relation to access and reimbursement decisions.With increasing access and utilization of healthcare, resources become more restricted, and prioritization in healthcare becomes unavoidable. Health economics and outcomes research (HEOR) is a discipline that is used to complement traditional clinical development information (ie, efficacy, safety, quality) to guide decision makers regarding patient access to specific drugs and services. HEOR has advanced considerably in methodology and in quantity over the past several decades. HEOR can provide data to help healthcare payers determine if treatments work in the populations they serve, and how much of the drug or treatment cost should be reimbursed by the healthcare system.As a key part of the request for comparative effectiveness evidence, the increased use of HEOR data can be expected in future decision-making processes.1,2 In addition, a greater emphasis has recently been placed on positioning the patient at the center of healthcare decisions. Outcomes research plays an increasingly important role in this, because it can provide data on specific populations and treatment combinations that are used. Understanding how these data are used in decision-making in the United States and globally can direct future efforts in this area.Currently, several global reimbursement agencies formally ask for HEOR information for their standard assessment process, including the National Institute for Health and Clinical Excellence in the United Kingdom, some of the Spanish health technology assessment (HTA) agencies, the Korean Health Insurance Review Agency, and the Health Intervention and Technology Assessment Program in Thailand.3–5 However, health-care payers in the United States do not currently have a standardized process for requesting or for using HEOR data. In the United States, HEOR data may come primarily from pharmaceutical companies via the Academy of Managed Care Pharmacy (AMCP) dossier format. Consequently, the pharmaceutical industry invests heavily in HEOR studies alongside clinical trials and continues to collect clinical, humanistic, and economic real-world data throughout the life cycle of a therapy.3 Discussions between healthcare payers and academic health economists suggest a need for this information by decision makers, but there is a lack of standardization regarding how such information is integrated into the current processes for drug (and other technology) evaluations.6,7Therefore, it remains unclear how healthcare payers in the United States currently use HEOR, and whether the use of such evidence will change in the future. The objective of this article is to describe the current and expected future use of HEOR data by healthcare payers, and to examine how pharmaceutical drug and manufacturer attributes are used in the decision-making process. This article summarizes the results of 2 surveys administered to individuals in formulary and reimbursement decision-making positions in the United States, as well as an adaptation of one of these surveys and workshops performed in other parts of the world.     

Managing stakeholder loyalty.

The authors question the utility of relying on the conventional wisdom in healthcare that satisfaction is the proper measure of strategic health. They offer four reasons why "stakeholder value" is the more appropriate measure. They present a case of a large midwestern HMO that has evolved to a stakeholder value approach. They demonstrate the linkages among the different components of the Stakeholder Value Information System, how stakeholder assessments of value drive loyalty and other key measures, and how that system can be used to inform strategic and operational decision making.     

Ethische Grundlagen der Priorisierung im Gesundheitswesen

The debate about priorities in healthcare has also started in Germany. Because of the special moral significance of health and healthcare, priority setting in healthcare also involves ethical issues. After clarifying the relationship between priority setting and rationing, I first discuss whether it is ethically acceptable or even mandated to set priorities in healthcare. If this first question is answered with “yes”, the following question is how the priorities can be determined in an ethically defensible way. I will try to show that it is impossible to justify priorities in healthcare within a liberal theory of justice that is neutral towards substantive conceptions of the good life. We rather need a deliberative decision process about how we want to live in the face of illness, suffering, and death. Only by reference to a substantial concept of a good life is it possible to define and justify healthcare priorities. A national priority-setting commission could play an important role in stimulating this deliberation and developing general recommendations according to which criteria and procedures priorities should be set in the German healthcare system. The application of this general framework requires the cooperation of medical scientific and physician organizations.     

Why Bayesian analysis hasn't caught on in healthcare decision making

The objective of this paper is to discuss why Bayesian statistics is not used more in healthcare decision making and what might be done to increase the use of Bayesian methods. First, a case is made for why Bayesian analysis should be used more widely. Serious weaknesses of commonly used frequentist methods are discussed and contrasted with advantages of Bayesian methods. Next, the question of why Bayesian methods are not used more widely is addressed, considering both philosophical differences and practical issues. Contrary to what some might think, the practical issues are more important in this regard. Finally, some steps to encourage increased use of Bayesian methods in healthcare decision making are presented and discussed. These ideas are straightforward but are by no means trivial to implement, largely because it is difficult to fight tradition and make major paradigm shifts quickly. The primary needs are improved Bayesian training at the basic level (which means textbooks and other materials as well as training of those who teach at the basic level), procedures to make Bayesian analysis easier to understand and use (better software and standard methods for displaying and communicating Bayesian outputs will help here), and the education of decision makers about the advantages of Bayesian methods in important healthcare decision-making problems.     

Can reflective multicriteria be the new paradigm for healthcare decision-making? The EVIDEM journey

Background

Multiple technologies, procedures and programs call for fairly-based decisions for prioritization of healthcare interventions. There is a diversity of perspectives of what constitutes a legitimate decision, which depends on both the process and the reasoning applied. Current approaches focus on technical aspects while methods to support alignment of decisions with the compassionate impetus of healthcare systems is lacking.

Methods

The framework was developed based on an analysis of the foundations of healthcare systems, the reasoning underlying decisions and fair processes. The concept of reflective multicriteria was created: it assumes that decisionmakers guided by a generic interpretative frame rooted in the compassionate impetus of healthcare systems, can sharpen their reasoning, raise awareness of their motivation and increase legitimacy of decisions. The initial framework was made available through a not for profit organization (the EVIDEM Collaboration, 2006–2017) to stimulate its development with thought leaders and stakeholders in an open source philosophy. Development was tailored to the real-life needs of decisionmakers and drew on several domains of knowledge including healthcare ethics, evidenced-based medicine, health economics, health technology assessment and multicriteria approaches.

Results

The 10th edition framework builds on four dimensions: (1) the universal impetus of healthcare systems, (2) reasoning, values and ethics, (3) evidence and knowledge on interventions, and (4) a transformative process. Mathematical aspects of the framework are designed to help clarify, express and share individual reasoning; this non-conventional use of numbers requires a cultural change and needs to be phased in slowly. The framework includes four tools for easy adaptation and operationalization: (a) concepts and operationalization, (b) adapt and pilot, (c) evidence matrix, (d) mathematical representation of reasoning. Application is useful throughout all types of healthcare interventions, for all levels of decision, and across the globe.

Conclusion

By clarifying their reasoning while keeping decisionmakers aware of the impetus of healthcare systems, reflective multicriteria provides an effective approach to increase the legitimacy of decisions. Beyond a tool, reflective multicriteria pioneered by EVIDEM is geared to transform our vision of the value of healthcare interventions and how they might contribute to relevant, equitable and sustainable healthcare systems.

     

Three methods to monitor utilization of healthcare services by the poor

Background

Achieving equity by way of improving the condition of the economically poor or otherwise disadvantaged is among the core goals of contemporary development paradigm. This places importance on monitoring outcome indicators among the poor. National surveys allow disaggregation of outcomes by socioeconomic status at national level and do not have statistical adequacy to provide estimates for lower level administrative units. This limits the utility of these data for programme managers to know how well particular services are reaching the poor at the lowest level. Managers are thus left without a tool for monitoring results for the poor at lower levels. This paper demonstrates that with some extra efforts community and facility based data at the lower level can be used to monitor utilization of healthcare services by the poor.

Methods

Data used in this paper came from two sources- Chakaria Health and Demographic Surveillance System (HDSS) of ICDDR,B and from a special study conducted during 2006 among patients attending the public and private health facilities in Chakaria, Bangladesh. The outcome variables included use of skilled attendants for delivery and use of facilities. Rate-ratio, rate-difference, concentration index, benefit incidence ratio, sequential sampling, and Lot Quality Assurance Sampling were used to assess how pro-poor is the use of skilled attendants for delivery and healthcare facilities.

Findings

Poor are using skilled attendants for delivery far less than the better offs. Government health service facilities are used more than the private facilities by the poor. Benefit incidence analysis and sequential sampling techniques could assess the situation realistically which can be used for monitoring utilization of services by poor. The visual display of the findings makes both these methods attractive. LQAS, on the other hand, requires small fixed sample and always enables decision making.

Conclusion

With some extra efforts monitoring of the utilization of healthcare services by the poor at the facilities can be done reliably. If monitored, the findings can guide the programme and facility managers to act in a timely fashion to improve the effectiveness of the programme in reaching the poor.     

What health care services does the public want and who should decide? Ask them!

Most of the parties involved in healthcare decisions – governments, politicians, healthcare professionals, pharmaceutical companies, special interest groups – actively work to make their desires known. In Israel the public is part of the decision committee; in Germany health care decision are made more or less without the public being involved. In a recently published IJHPR article, Giora Kaplan and Orna Baron-Epel raise the question of how well acquainted senior decision makers in the Israeli health system are with the public’s priorities regarding the services being considered for inclusion in the public funding list. This commentary speculates about the reasons for the discrepancies found in that article between the decision makers’ and the public’s view. Furthermore, it reports on survey results from Germany about who should be part of the decision making committee and briefly touches upon the situation in other OECD countries. While public opinion may not be the determining factor, all authors advocate a strengthening of the public’s contribution to the health care decision making process, including steps to make decision makers aware of public priorities on an ongoing basis.     

用“公共卫生路径”的思路控制公共卫生质量和成本

目前状况下的农村卫生工作是极具中国特色、极富挑战的研究内容，理清卫生工作理论和实践两方面的线索是当前亟需解决的重要问题。由于公共卫生成本需求不能完全与高成本需枣的医疗服务相比，因此，不能简单地以公共卫生费用占卫生事业费份额作为标准来对公共卫生投入是否适宜进行评价。公共卫生服务工作亟需健全标准化、完整的、规范化、量化的，以服务的绩效质量为标准的计划、实施、评估体系。     

The Value of Disease Management

Recent years have seen the beginning of an industrial revolution in healthcare delivery. Healthcare is being transformed from a cottage industry, in which each provider sets individual standards, to a quality-controlled enterprise with common, evidence-based standards of care. Disease management is fundamental to this transformation; it is based on the application of the industrial engineering principle of ‘total quality management’ to healthcare as ‘continuous quality improvement’.As little evidence has been published in the peer-reviewed literature regarding the cost effectiveness of disease management, specific disease management programmes should be judged by the extent to which its design adheres to the principles of continuous quality improvement. Disease management should, furthermore, be integrated into the overall activities of the healthcare system rather than being a carve-out offering.The true value of disease management is as a paradigm by which the healthcare system can re-engineer how it goes about its business — with clear goals, recognised standards and ongoing monitoring. The adoption of evidence-based best practice guidelines and the attendant reduction in practice variation will inevitably benefit millions of patients.     

Medical advice-seeking behaviors based on transaction cost theory

Background

Given the global trend of aging societies, medical expenditure has hit record highs in many countries. Because medical advice-seeking behaviors can affect the health of whole societies, how members of a society make medical-related decisions with limited available resources is worthy of investigation. Although transaction cost theory has been extensively applied in commercial research, it is yet to be applied in studies on medical advice-seeking behaviors.

Method and results

This study conducted in-depth interviews with 15 participants and verified that transaction cost theory is applicable for analyzing people’s medical advice-seeking behaviors.

Conclusion

This study verified that transaction cost theory influenced the participants’ choices of physicians and treatment methods, which implies that improved transparency of medical information could considerably reduce transaction costs in relation to medical behaviors and enhance people’s well-being.

     

The patient as citizen. A common-good approach to medical treatment decisions balances the emphasis on patient desires

Individualism plays too strong a role in the arena of treatment decision making, frequently to the exclusion of any other consideration. Using a common-good or community-based ethic as a framework for treatment decision making may provide appropriate balance to the emphasis on patient desires. Self-determination is a good that must be balanced with other goods. When it is not, to quote Daniel Callahan, "Self-determination runs amok." For example, in the state of New Jersey, individuals are permitted to choose the criteria to be used in determining that their own death has occurred. Some of the principles that may lead to a reasonable understanding of the patient's rights in a "patient-as-citizen" ethical perspective are: Everyone has a legitimate claim to a basic level of healthcare. Everyone has a legitimate claim to respect for his or her refusal of recommended treatment. No one has a legitimate claim to nonbeneficial or futile treatment. No one has a legitimate claim to treatment that is being withheld as part of a just rationing system. No one has a legitimate claim to the ability to determine the medical criteria to be used for the diagnosis of his or her death. A just healthcare system is one in which individual desires for medical treatment beyond the basic level are accommodated whenever possible but not when they undermine the primary purpose of medicine to meet the basic healthcare needs of all persons.     

Use of big data for drug development and for public and personal health and care

The use of data analytics across the entire healthcare value chain, from drug discovery and development through epidemiology to informed clinical decision for patients or policy making for public health, has seen an explosion in the recent years. The increase in quantity and variety of data available together with the improvement of storing capabilities and analytical tools offer numerous possibilities to all stakeholders (manufacturers, regulators, payers, healthcare providers, decision makers, researchers) but most importantly, it has the potential to improve general health outcomes if we learn how to exploit it in the right way. This article looks at the different sources of data and the importance of unstructured data. It goes on to summarize current and potential future uses in drug discovery, development, and monitoring as well as in public and personal healthcare; including examples of good practice and recent developments. Finally, we discuss the main practical and ethical challenges to unravel the full potential of big data in healthcare and conclude that all stakeholders need to work together towards the common goal of making sense of the available data for the common good.     

Back on the chopping block

Just as hospitals were trying to figure out how they'd adapt to the new healthcare reform law, the cochairmen of the federal deficit reduction commission delivered a proposal with a new raft of cuts targeting healthcare that some say would be devastating. "Let's study it and not dismantle the public infrastructure that is holding pieces together," says David Lopez, left, of Harris County Hospital District.     

Assessing the context for partnerships between communities and the National Health Service in England

The debates surrounding public involvement in healthcare decision making have centred around how and in what capacity the public should be engaged. There is evidence that the public is reluctant to participate in setting priorities. More fundamentally, there is the question of whether the public sector can assess the capacity of communities to achieve a shared perspective on healthcare delivery. The notion of social capital addresses this question by examining the level of social cohesion and mutual trust within communities, thus providing an understanding on the one hand of the capacity of communities to develop a perspective on the 'common good' and on the other their willingness to connect with public sector organizations. It is important to gauge community capacity before developing strategies and methods for public involvement in healthcare decision making.     

Research paradigms in medical education research

Medical Education 2010: 44 : 358–366 Context The growing popularity of less familiar methodologies in medical education research, and the use of related data collection methods, has made it timely to revisit some basic assumptions regarding knowledge and evidence. Methods This paper outlines four major research paradigms and examines the methodological questions that underpin the development of knowledge through medical education research. Discussion This paper explores the rationale behind different research designs, and shows how the underlying research philosophy of a study can directly influence what is captured and reported. It also explores the interpretivist perspective in some depth to show how less familiar paradigm perspectives can provide useful insights to the complex questions generated by modern healthcare practice. Conclusions This paper concludes that the quality of research is defined by the integrity and transparency of the research philosophy and methods, rather than the superiority of any one paradigm. By demonstrating that different methodological approaches deliberately include and exclude different types of data, this paper highlights how competing knowledge philosophies have practical implications for the findings of a study.     

Re-engineering healthcare pipelnes: why trajectory selection is as important as process selection in enabling effective transfer of best practice

PURPOSE: To demonstrate that effective re-engineering of healthcare pipelines requires selecting both the "best" process (how we shall do it in the future) and the best trajectory for change (how we get from here to there). DESIGN/METHODOLOGY/APPROACH: Exploitation of Braess' Paradox to identify strategic factors necessary to enable change in the re-engineering of NHS healthcare pipelines. FINDINGS: Route to maximising the chance of achieving effective change is displayed via a Johari Window. Each cell is then related to no change (despite significant investment); failure; or successful implementation. RESEARCH LIMITATIONS/IMPLICATIONS: The demonstrator pipeline is an NHS cataract repair supply chain. However, via the "Power of Analogy" concept the NHS scenario is readily related to a substantial number of industrial case studies. PRACTICAL IMPLICATIONS: The need to understand both process and trajectory is the key to effective re-engineering of pipelines. All "actors" in re-engineering programmes should acquire this knowledge and benefit from the new way of doing things. ORIGINALITY/VALUE: Formalises the strategic route to enabling healthcare delivery "best practice".     

Access to capital--a growing concern

Access to capital over the next ten years will be one of the biggest challenges healthcare organizations will face as they strive to remain competitive and serve their communities. Meeting the growing needs for capital will require a disciplined and honest assessment of the capital sources that will be available and the best ways of positioning an organization to maximize their uses. It is incumbent on chief executive officers and other senior leaders to create a disciplined process for allocating capital and conveying how that process will be linked to the organization's strategic plan. All of the credit constituencies "buying" healthcare need to fully understand how the organization is positioning itself for future growth and success, and detailed bond marketing plans need to be implemented well before the actual sale of a new bond issue. Large and small healthcare providers will have sufficient access to capital in the future if investors believe that senior hospital executives have a credible plan and are disciplined enough to execute it.