Resource withdrawal from medical services

Resource withdrawal from unnecessary medical services is an important issue as the cost of health care continues to rise. In many countries, resource withdrawal is primarily determined by government policies that remove, restrict, reduce, or limit the availability of publically insured medical services. Ideally, resource withdrawal is the result of a careful assessment of clinical and economic evidence regarding a service’s safety and effectiveness in order to ensure that it is the most efficient use of resources. Despite advocacy for a routinized and systematic approach to the withdrawal of resources from medical services, research has indicated that political and social factors often influence government, resulting in decisions that are neither consistent nor transparent. In this dissertation I seek to understand factors that may influence resource withdrawal decisions in an attempt to promote a more routinized and systematic approach. In order to understand the resource withdrawal landscape and provide greater conceptual clarity, the first study in this dissertation identifies and explores its characteristics (antecedents, attributes, and outcomes). Definitions of two prominent terms, disinvestment, and rationing are proposed. In the second study, a qualitative analysis of two examples of resource withdrawal reveals how the characteristics of problem frames affect the shape and timing of government resource withdrawal policies. Findings support the proposition that the complexity of the story told within the problem frame affects the shape of the policy; while visibility affects the timing. In the third study, I analyzed the perspectives of key informants about the Choosing Wisely Canada (CWC) campaign, which has the aim of reducing unnecessary services by encouraging a discussion between physician and patient. Findings reveal that CWC was designed to address pressures from government, patients, and the public. However, CWC was not designed in a way that is expected to address the underlying reasons unnecessary services are provided, including limited time in the clinical encounter, patient demands, uncertainty in the care pathway, and physician fear of litigation. Results from all three studies help establish a common language, identify influences on government led resource withdrawal and reasons why CWC is unlikely to reduce unnecessary services. Together this thesis provides insights into some of the factors affecting resource withdrawal from medical services, and findings may be used to help assess ways to improve the formulation of resource withdrawal policies.DissertationDoctor of Philosophy (PhD)Currently several governments pay for unnecessary medical services, leading to suboptimal patient health outcomes and a waste of public resources. Several researchers and organizations have proposed methods to identify and assess medical services to determine if they are unnecessary; however, governments have been slow to adopt such methods on a routine basis. It is clear that evidence is rarely sufficient to motivate governments to withdraw resources from unnecessary medical services. Instead, governments are often influenced by social and political factors when they make such decisions. Through a better understanding of these factors, we may be able to find ways to incorporate evidence into governments’ decisions to withdraw resources from medical services. Qualitative methods were used to investigate how resource withdrawal is defined, factors influencing government resource withdrawal decisions in Ontario, and the effectiveness of Choosing Wisely Canada, an initiative led by the medical community to reduce unnecessary services

Conceptualising characteristics of resources withdrawal from medical services : a systematic qualitative synthesis

Abstract: Background: Terms used to describe government-led resource withdrawal from ineffective and unsafe medical services, including ‘rationing’ and ‘disinvestment’, have tended to be used interchangeably, despite having distinct characteristics. This lack of descriptive precision for arguably distinct terms contributes to the obscurity that hinders effective communication and the achievement of evidence-based decision-making. The objectives of this study are to (1) identify the various terms used to describe resource withdrawal and (2) propose definitions for the key or foundational terms, which includes a clear description of the unique characteristics of each. Methods: This is a systematic qualitative synthesis of characteristics and terms found through a search of the academic and grey literature. This approach involved identifying commonly used resource withdrawal terms, extracting data about resource withdrawal characteristics associated with each term and conducting a comparative analysis by categorising elements as antecedents, attributes or outcomes. Results: Findings from an analysis of 106 documents demonstrated that terms used to describe resource withdrawal are inconsistently defined and applied. The characteristics associated with these terms, mainly antecedents and attributes, are used interchangeably by many authors but are differentiated by others. Our analysis resulted in the development of a framework that organises these characteristics to demonstrate the unique attributes associated with each term. To enhance precision, these terms were classified as either policy options or patient health outcomes and refined definitions for rationing and disinvestment were developed. Rationing was defined as resource withdrawal that denies, on average, patient health benefits. Disinvestment was defined as resource withdrawal that results in, on average, improved or no change in health benefits. Conclusion: Agreement on the definition of various resource withdrawal terms and their key characteristics is required for transparent government decision-making regarding medical service withdrawal. This systematic qualitative synthesis presents the proposed definitions of resource withdrawal terms that will promote consistency, benefit public policy dialogue and enhance the policy-making process for health systems

CIHR Health System Impact Fellows: Reflections on “Driving Change” Within the Health System

Learning health systems necessitate interdependence between health and academic sectors and are critical to address the present and future needs of our health systems. This concept is being supported through the new Canadian Institutes of Health Research (CIHR) Health System Impact (HSI) Fellowship, through which postdoctoral fellows are situated within a health system-related organization to help propel evidence-informed organizational transformation and change. A voluntary working group of fellows from the inaugural cohort representing diversity in geography, host setting and personal background, collectively organized a panel at the 2018 Canadian Association for Health Services and Policy Research Conference with the purpose of describing this shared scholarship experience. Here, we present a summary of this panel reflecting on our experiential learning in a practice environment and its ability for impact

Examining Why the Canadian Federal Government Placed an Orphan Drug Strategy on Their Decision Agenda Now

The Ministry of Health’s announcement of a National Orphan Drug Framework on 3 October 2012 was the first federal public acknowledgement of orphan drugs since the 1997 Drugs Directorate (DD) policy statement. The reform primarily announced an Orphan Drug Policy for Canada. This paper explains why the government decided to make this announcement now. Media and Parliamentary documents were analyzed for their use of symbols, numbers, and language in causal stories told by political actors. The initial story was that Canada’s population was too small and the cost too high for an orphan drug policy. Over the next fifteen years, a powerful interest group, the Canadian Organization for Rare Disorders (CORD), mobilized the rare disease community into a cooperative effort that generated collective action. They redefined the DD story from one of natural causes, to inadvertence, and finally to intentional causation. Their story invoked a federal response because it blamed the government directly for not acting on behalf of the 3 million Canadians with rare diseases, when patients in other countries were receiving better care. En annonçant le 3 octobre 2012 un Cadre National pour les Médicaments Orphelins, le Ministère de la Santé a mentionné pour la première fois publiquement les médicaments orphelins depuis l’énoncé de politique sur la Direction des Médicaments de 1997. La réforme a principalement consisté en l’annonce d’une Politique des Médicaments Orphelins pour le Canada. Cet article explique pourquoi le gouvernement a décidé de faire cette annonce aujourd’hui en analysant les symboles, chiffres et discours utilisés dans les représentations causales des acteurs politiques. La représentation causale de départ disait que la population du Canada était trop petite pour pouvoir s’offrir une politique de médicaments orphelins (cause naturelle). Au cours des quinze années suivantes, l’Organisation Canadienne pour les Maladies Rares (CORD en anglais, l’organisation n’existe apparemment pas en français), qui est un puissant groupe d’intérêts, a su fédérer la communauté d’individus intéressés par les maladies rares en un effort commun qui a débouché sur une action collective organisée. Cette action a transformé la représentation causale de la constitution de la Direction des Médicaments, l’histoire d’origine en termes de causes naturelles devenant une une histoire d’inadvertence, puis d’intentionalité. Leur récit a suscité une réponse fédérale car il mettait en cause de manière directe le gouvernement pour n’avoir pas su agir en faveur des trois millions de Canadiens souffrant d’une maladie rare alors que leurs équivalents à l’étranger recevaient des soins mieux adaptés.

Examining Why the Canadian Federal Government Placed an Orphan Drug Strategy on Their Decision Agenda Now

The Ministry of Health’s announcement of a National Orphan Drug Framework on 3 October 2012 was the first federal public acknowledgement of orphan drugs since the 1997 Drugs Directorate (DD) policy statement. The reform primarily announced an Orphan Drug Policy for Canada. This paper explains why the government decided to make this announcement now. Media and Parliamentary documents were analyzed for their use of symbols, numbers, and language in causal stories told by political actors. The initial story was that Canada’s population was too small and the cost too high for an orphan drug policy. Over the next fifteen years, a powerful interest group, the Canadian Organization for Rare Disorders (CORD), mobilized the rare disease community into a cooperative effort that generated collective action. They redefined the DD story from one of natural causes, to inadvertence, and finally to intentional causation. Their story invoked a federal response because it blamed the government directly for not acting on behalf of the 3 million Canadians with rare diseases, when patients in other countries were receiving better care

Physician perspectives on Choosing Wisely Canada as an approach to reduce unnecessary medical care: a qualitative study

Abstract Background Reducing monies spent on unnecessary medical care is one possible target to improve value in healthcare systems. Regional variation in the provision of medical care suggests physician behaviour and patient demands influence the provision of unnecessary medical care. Recently, Choosing Wisely campaigns began using ‘top 5 do-not-do’ lists to target unnecessary medical care by encouraging greater physician and patient dialogue at the point of care. The present study aims to examine the rationale for Choosing Wisely Canada’s (CWC) design and to analyse physician perceptions regarding the features of CWC aimed to reduce unnecessary medical care. Methods The study involved semi-structured interviews with 19 key informant physicians with CWC experience and the application of procedures of grounded theory to analyse interview transcripts and develop explanations addressing the objectives. Results Participants reported that the CWC was the medical community’s response to three pressures, namely (1) demand for unnecessary medical care from patients during the clinical encounter; (2) public perception that physicians do not always prioritise patients’ needs; and (3) ‘blunt’ government tools aimed to reduce costs rather than improving patient care. Respondents stated that involving the patient in decision-making would help alleviate these pressures by promoting the clinical encounter as the paramount decision-point in achieving necessary care. However, CWC does not address several of the key reasons, from a physician perspective, for providing unnecessary medical care, including time pressures in the clinical encounter, uncertainty about the optimal care pathway and fear of litigation. Conclusion This study contributes to our understanding of the perceptions of physicians regarding the CWC campaign. Specifically, physicians believe that CWC does little to address the clinical reasons for unnecessary medical care. Ultimately, because CWC has limited impact on physician behaviour or patient expectations, it is unlikely to have a major influence on unnecessary medical care

‘Gearing Up’ to improve interprofessional collaboration in primary care: a systematic review and conceptual framework

Abstract Background Interprofessional Primary Care Teams (IPCTs) have been shown to benefit health systems and patients, particularly those patients with complex care needs. The literature suggests a wide range of factors that may influence collaboration in IPCTs, however the evidence base is unclear for many of these factors. To target improvement efforts, we identify studies that demonstrate an association between suggested factors and collaborative processes in IPCTs. Methods A systematic review of 25 years of peer-review literature was conducted to identify studies that test associations between policy, organizational, care team and individual factors, and collaboration in IPCTs. We searched Medline, ProQuest subject, ProQuest abstract, CINAHL, HealthSTAR, and Embase electronic databases between January 1990 to June 2015 and hand-searched reference lists of identified articles. Results The electronic searches identified 1421 articles, nine of which met inclusion criteria. Eighteen factors were significantly associated with collaboration in at least one article. We present the findings within a proposed conceptual model of interrelated ‘gears’. The model offers a taxonomy of factors that policy makers (macro gear), organizational managers (meso gear), care teams (micro gear) and health professionals (individual gear) can adjust to improve interprofessional collaboration in IPC teams. Thirteen of the eighteen identified factors were within the micro gear, or team level of decision-making. These pertained to formal processes such as quality audits and group problem-solving; social processes such as open communication and supportive colleagues; team attitudes such as feeling part of the team; and team structure such as team size and having a collaboration champion or facilitator. Fewer policy (eg governance), organizational (eg information systems, organizational culture) or individual (eg belief in interprofessional collaboration care and personal flexibility) level factors were identified. Conclusions The findings suggest that individual IPCTs have opportunities to improve collaboration regardless of the organizational or policy context within which they operate. Evidence supports the importance of having a team vision and shared goals, formal quality processes, information systems, and professionals feeling part of the team. Few studies assessed associations between collaboration and macro and meso factors, or between factors across levels, which are priorities for future research