Dionne, Francois

Donaldson, Cam

Mitton, Craig

Peacock, Stuart

English

Trade-offs abound in healthcare yet depending on where one stands relative to the stages of a pandemic, choice making may be more or less constrained. During the early stages of COVID-19 when there was much uncertainty, healthcare systems faced greater constraints and focused on the singular criterion of “flattening the curve.” As COVID-19 progressed and the first wave diminished (relatively speaking depending on the jurisdiction), more opportunities presented for making explicit choices between COVID and non-COVID patients. Then, as the second wave surged, again decision makers were more constrained even as more information and greater understanding developed. Moving out of the pandemic to recovery, choice making becomes paramount as there are no set rules to lean back into historical patterns of resource allocation. In fact, the opportunity at hand, when using explicit tools for priority setting based on economic and ethical principles, is significant.</p

ResearchOnline@GCU

Addressing prioritization in healthcare amidst a global pandemicMitton, Craig; Donaldson, Cam; Dionne, Francois; Peacock, StuartPublished in:Healthcare Management ForumDOI:10.1177/08404704211002539Publication date:2021Document VersionPublisher's PDF, also known as Version of recordLink to publication in ResearchOnlineCitation for published version (Harvard):Mitton, C, Donaldson, C, Dionne, F & Peacock, S 2021, 'Addressing prioritization in healthcare amidst a globalpandemic', Healthcare Management Forum, vol. 34, no. 5, pp. 252-255.https://doi.org/10.1177/08404704211002539General rightsCopyright and moral rights for the publications made accessible in the public portal are retained by the authors and/or other copyright ownersand it is a condition of accessing publications that users recognise and abide by the legal requirements associated with these rights.Take down policyIf you believe that this document breaches copyright please view our takedown policy at https://edshare.gcu.ac.uk/id/eprint/5179 for detailsof how to contact us.Download date: 13. Aug. 20232021, Vol. 34(5)  252 –255ORIGINAL ARTICLEAddressing prioritization in healthcareamidst a global pandemicCraig Mitton, PhD1,2 ; Cam Donaldson, PhD3; Francois Dionne, PhD2;and Stuart Peacock, DPhil4,5,6AbstractTrade-offs abound in healthcare yet depending on where one stands relative to the stages of a pandemic, choice making may bemore or less constrained. During the early stages of COVID-19 when there was much uncertainty, healthcare systems facedgreater constraints and focused on the singular criterion of “flattening the curve.” As COVID-19 progressed and the first wavediminished (relatively speaking depending on the jurisdiction), more opportunities presented for making explicit choices betweenCOVID and non-COVID patients. Then, as the second wave surged, again decision makers were more constrained even as moreinformation and greater understanding developed. Moving out of the pandemic to recovery, choice making becomes paramountas there are no set rules to lean back into historical patterns of resource allocation. In fact, the opportunity at hand, when usingexplicit tools for priority setting based on economic and ethical principles, is significant.IntroductionSetting priorities and allocating scarce resources is an activitythat healthcare decision makers have always had to address, bothin Canada and elsewhere.1 Limited or constrained budgets leadto the inevitability of choices having to be made, usually at themargin, about what to fund and what not to fund.2 The process ofmaking these choices is referred to as priority setting. On theback of examining choices and assessing relative value of bothclinical and non-clinical options, decision makers are chargedwith determining where resources are best placed.During a pandemic, such choices and allocation decisionsare under even greater scrutiny as the demand for urgentservices is significantly increased. Throughout COVID-19, ithas been very clear to the public that healthcare organizationsare making trade-offs with respect to which patients willreceive services and how quickly certain patients will betreated.3 There should be nothing surprising about this in andof itself. That is, as we have just stated, choice making is aglobal phenomenon in healthcare. One might suggest that thisis the raison d’etre of healthcare managers. The pandemic, andrecovery from it, simply highlight this fact.Having said that, we would be quick to acknowledge that, atcertain points during the COVID-19 pandemic, there has beenless flexibility in making choices because of limited knowledgeabout the virus, at first, and then, in the second wave, becauseof the rapid spread of the virus. But, looking beyond the currentpandemic to recovery, more attention may well be given to theprocess of decision making specifically around relative valueassessment and the trade-offs that ensue in part because of theneed for catching up on delayed interventions.The aim of this short article is to highlight some of thechallenging issues around trade-offs and then to reviewrelevant tools for priority setting and resource allocation thatcan bepart ofmanaging the recovery in thewake of thepandemic.Trade-offs everywhereDuring the first wave of COVID in the Spring of 2020, therewas much uncertainty. It was not clear what the R value (thenumber of people, on average, that one infected person willpass the virus on to) was. Nor was there clarity on theunderlying biological mechanisms, the forms of transmission,how best to treat this disease or expected outcomes. In thisstate, decision makers fell back on the precautionaryprinciple and many jurisdictions went into lockdown. In thehealth system, capacity was freed up through the cancellationof hundreds of thousands of elective surgical procedures acrossCanada, initially for reasons of safety. As the first wavesubsided and more information became available, differentdecisions could be made on public health measures.Individual and community “choices” were emphasizedincluding physical distancing, minimizing travel, and maskwearing. From a health system perspective, there was also, attimes, room for greater choice making. For example, over theSummer and early Fall 2020, there could be less of a focus on“flattening the curve” and more on taking otherwise freed up1 School of Population and Public Health, University of British Columbia,Vancouver, British Columbia, Canada.2 Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal HealthResearch Institute, Vancouver, British Columbia, Canada.3 Glasgow Caledonian University, Glasgow, Scotland.4 Faculty of Health Sciences, Simon Fraser University, Vancouver, BritishColumbia, Canada.5 Canadian Centre for Applied Research in Cancer Control, BC Cancer,Vancouver, British Columbia, Canada.6 Cancer Control Research, BC Cancer, Vancouver, British Columbia, Canada.Corresponding author:Craig Mitton, Centre for Clinical Epidemiology and Evaluation, Vancouver,British Columbia, Canada.E-mail: craig.mitton@ubc.caHealthcare Management Forumª 2021 The Canadian College ofHealth Leaders. All rights reserved.Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/08404704211002539journals.sagepub.com/home/hmfMitton, Donaldson, Dionne and Peacock 253capacity and allocating resources back toward non-COVIDpatients.As the second wave hit and the health system facedincreasing pressure, once again capacity issues wereidentified and there was less ability for decision makers tomake choices. Having said that, during the second wave,there was more information at hand and as such, morenuanced and evidence-based decisions could be made whenapplying broad policy tools such as lockdowns. Also,vaccines were developed with varying, but for the most part,high levels of effectiveness at reducing symptoms (notinglonger term evidence of their impact on mitigatingtransmission is still required).4 This further enabled decisionmakers to address choice making directly and provided anopportunity to be explicit in determining how best limitedresources would be allocated. In this, one may also reflect,critically, on the unintended consequences at the differentphases of the pandemic as these can inform choice makinggoing forward. For example, increases in domestic violence,isolation leading to mental health challenges, higher rates ofoverdose due to illicit drug toxicity, and challenges of socialwell-being for children unable to see their friends, among otherthings, should all be assessed.From an economic perspective, the fundamental principle ofopportunity cost is at play in almost every decision made in thehealth system. As there are limited resources, funding of onegroup leads to some benefit lost in not funding another group.Despite the contention that healthcare managers have theability to make choices, in the early days of the pandemic,this was curtailed as economy and health went hand in handand non-COVID care was cut back.5 Systems with greatercapacity already built in seemed to do better, whereaselsewhere the needed capacity had to be gotten from“somewhere.”5 As our understanding of the disease increasedand effective vaccines were developed, health systems havebegun to prepare for recovery and future resilience. Movingforward, questions of trade-offs should be addressed explicitly.The good news is there are readily available priority settingtools that can be used to assist decision makers in these often-complex and politically charged waters.Priority setting toolsUse of a formal approach to priority setting and resourceallocation would typically involve the eight steps illustratedin Figure 1.6 There is room within this type of framework forthe application of high-quality evidence, including the formoften produced in health technology assessments, and further,there are multiple opportunities for substantive publicengagement.7 Program Budgeting and Marginal Analysis(PBMA) and Accountability for Reasonableness are twoFigure 1. Process for priority setting and resource allocation in healthcare. A4R indicates Accountability for Reasonableness; MCDA,multi-criteria decision analysis; key areas for public involvement indicated by stick figures; PBMA, program budgeting and marginal analysis.254 Healthcare Management Forumframeworks that have been used in concert for many years toassist decision makers in determining how best to allocatescarce resources.8Within an explicit approach to priority setting, relative valueofoptions canbe assessedusingMulti-CriteriaDecisionAnalysisenabling decisionmakers to determine explicitly the benefit gainof competing alternatives for the limited resources.9 Clear andtransparent criteria, weighted to reflect their relative importance,are an effective means to reflect preferences from differentstakeholder groups with regards to healthcare management.Determination of those criteria can inform decisions on whogets the limited resources as well as the magnitude of costs andbenefits, thus providing a clear understanding of the trade-offsinvolved along with equity implications.10,11With routine use of a prioritization framework as presentedherein (see again Figure 1), decision makers are able todetermine not only what the quantifiable trade-offs are butalso how, on an ongoing basis, resources should best beallocated.7,12 There are no “set” results that come out of theapplication of these tools and indeed it is almost certain thatdifferent jurisdictions will come to different decisions,reflecting population make-up, resources availability, andsocietal preferences. There are many examples of this type ofapproach in the health policy and management literature, withour own work spanning over 100 organizations.One recent case study was in a large urban hospital inOntario, which sought to mitigate some financial pressure aswell as optimize existing spend through resource reallocation.This was done pre-pandemic, but the challenges faced thenwere the same as will be faced in pandemic recovery exceptthat in pandemic recovery the financial pressures will only begreater because of the new required spending. The PBMAprocess was applied as per the steps in Figure 1. Amultidisciplinary priority setting steering committee wasstruck, decision criteria (and their weights) were selected,proposals for both investment and disinvestment weredeveloped and rated, and decisions were made based onexplicit evaluation of the proposals against the criteria.Twelve criteria were identified for this process includingaccess, health gain, equity, client experience, and innovation,to name a few. In addition, a formal rating tool was utilized bythe steering committee in coming up with resource allocationrecommendations. In all, the process took about eight monthswith decisions incorporated into the annual budget process.In the wake of a pandemic, as health systems get “back ontheir feet,” it becomes critical to be explicit in the analysis ofopportunity costs because there will be significant reallocationof resources. Examples of reallocations across the health systeminclude the need to invest in ongoing public health vaccinationand track and trace programs; strengthening PPE supply chains;critical vaccine production capacity; and health human resourcesneeded to manage endemic COVID-19. These investments willneed to be balanced against potential disinvestments elsewherein the system, for example, longer elective surgery wait times.Each organization across the country will need to assess trade-offs and determine to what extent specific reallocations makesense. One particular area that was substantially rocked throughthe pandemic is long-term care. These organizations will need toassess trade-offs within their limited budgets. The type ofapproach described in this article can be applied to walk amanagement team through the steps for reallocation, balancingimportant criteria such as patient safety, caregiver safety, patientexperience and well-being, and access to care, to name just afew. Having such a framework in place can lead to greateraccountability in this sector.An important corollary is the degree of public involvementin healthcare priority setting. There is good evidence to showthat a broader set of constituents can be engaged in healthcaredecision making.13,14 In fact, it is plausible that, in the recoveryphase of a pandemic, public consultation is even moreparamount. In addition, building on this notion of publicengagement would be to determine values aroundpreparedness for future pandemics. How much should thepossibility of the next pandemic be considered relative toshort or even longer term non-pandemic goals? Along theselines, thinking on portfolio approaches to investment maywell help in determining how much to allocate in preparingfor future pandemics.15 The Canadian public has shownremarkable trust in the health system; it is vital that this trustis preserved through meaningful, ongoing, public engagement.One final point is warranted. Although the focus here is on theapplication of an evidence-informed process for priority settingwithin healthcare, of course, the implications of public policyincluding restrictions placed on individuals and communities gowell beyond healthcare and enter “whole of government.” Themost obvious of these implications is the economic impact as theGross Domestic Product has dropped in Canada as well aselsewhere since the start of the COVID-19 pandemic. Otherexamples of economic trade-offs include income support forworkers who have been laid off due to COVID-19 restrictions;funding for sick leave for individuals who have to self-isolate;and, child care costs for parents during school closures. As such,we would suggest that the type of thinking behind the approachto priority setting put forward here is also highly applicable indetermining the cross-sectoral impacts. Recent work from theUnited Kingdom and Canada indicates how this type of thinkingcan inform decision making.16ConclusionIn summary, we are strong proponents for the use of explicit,evidence-informed tools for setting priorities and allocatingresources in healthcare. This sentiment has recently beenechoed by others in the healthcare management space incalling for more transparency in decision making.17 Althoughsuch tools are always relevant, their application can be severelylimited during a pandemic due to extreme constraints on choicemaking. But, as we move into pandemic recovery, such toolsbecome highly relevant because the range of possible choices isbroader and there is no requirement to go back to the sameresource allocation patterns. We would implore governmentagencies to look seriously at these tools as they can assist inMitton, Donaldson, Dionne and Peacock 255determining the relative value of trade-offs and optimizing useof the limited resources at a time when there will be importantchoices to be made.ORCID iDCraig Mitton https://orcid.org/0000-0001-7871-8977Stuart Peacock https://orcid.org/0000-0002-8243-8721References1. Kapiriri L, Razavi D. How have systematic priority settingapproaches influenced policy making? A synthesis of thecurrent literature. Health Policy. 2017;121(9):837-946.2. Mitton C, Donaldson C. Priority Setting Toolkit: A Guide to the Useof Economics in Health Care Decision Making. BMJ Books; 2004.3. CBC article. Accessed March 22, 2021. 2021. Available at:https://www.cbc.ca/news/canada/british-columbia/surgery-waitlist-bc-backlog-ministry-of-health-1.58633884. The Lancet Respiratory Medicine (editorial). Realising thepotential of SARS-VoV-2 vaccines—a long shot? Lancet RespirMed. 2021;9(2):117. doi:10.1016/S2213-2600(21)00045-X5. Donaldson C, Mitton C.Coronavirus: where has all the healtheconomics gone? Int J Health Policy Manag. 2020;9(11):466-468.6. Peacock S, Ruta D, Mitton C, Donaldson C, Bate A, Murtagh M.Using economics for pragmatic and ethical priority setting: twochecklists for doctors and managers. Br Med J. 2006;332(7539):482-485.7. Mitton C, Dionne F, Donaldson C. Managing healthcare budgetsin times of austerity: the role of program budgeting and marginalanalysis. Appl Health Econ Health Policy. 2014;12(2):95-102.8. Gibson JL, Mitton C, Martin DK, Donaldson C, Singer PA. Ethics& economics: does program budgeting and marginal analysiscontribute to fair priority setting? J Health Serv Res Policy.2006;11(1):32-37.9. Baltussen R, Marsh K, Thokala P, et al. Multicriteria decisionanalysis to support health technology assessment agencies:benefits, limitations and the way forward. Value Health. 2019;22(11):1283-1288.10. Frolic A, Kata A, Kraus P. Development of a critical care triageprotocol for pandemic influenza: integrating ethics, evidence andeffectiveness. Healthc Q. 2009;12(4):56-64.11. Williams I, Essue B, Nouvet E, et al. Priority setting during theCOVID-19 pandemic: going beyond vaccines. BMJ Glob Health.2021;6(1):e004686.12. Smith N, Mitton C, Hall W, et al. High performance in healthcarepriority setting and resource allocation: a literature and case studybased framework in the Canadian context. Soc Sci Med. 2016;162:185-192.13. McKie J, Shrimpton B, Hurworth R, Bell C, Richardson J. Whoshould be involved in healthcare decision making? A qualitativestudy. Health Care Anal. 2008;16(2):114-126.14. Litva A, Coast J, Donovan J, Eyles J, et al. ‘The public is toosubjective’: public involvement at different levels of healthcaredecision making. Soc Sci Med. 2002;54(12):1825-1837.15. Shiell A, Hawe P, Perry R, Matthias S. How health managersthink about risk and the implications for portfolio theory inhealth systems. Health Risk Soc. 2009;11:71-85.16. Donaldson C, Mitton C. Health economics and emergence fromVOCID-19 lockdown: the great big marginal analysis. HealthEcon Policy Law. 2020;1-5.17. Menon D. Health Care Management Forum official blog.Accessed March 22, 2021. 2020. Available at: https://healthcaremanagementforum.wordpress.com/page/2/

Addressing prioritization in healthcare amidst a global pandemic

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Addressing prioritization in healthcare amidst a global pandemic

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