Week 5 Flashcards
have an thorough understanding of rationing in LMIC
e.g.: recommendation on the introduction scenario’s for RV and HPV in 2022-2024 in addition to PCV introduction:
- develop it quickly or delayed?
apply knowledge about supply and demand side rationing to LMIC context
supply side: for introductie and vaccin (they look which one, and how, and the impact on the budget)
- CAPACITI tool
- basic benefit package design (cost-effectiveness ranking) –> priority setting.
Implementation depends on the available budget and potential options to improve the fiscal space..
demand side:
have a understanding of (the consequences of) rationing in times of the COVID-19 pandemic
High covid-19 infection rate –> fewer delivered invasive procedures/surgeries
Fewer delivered surgeries –> large health losses
Hoge covid-19 infectiegraad –> minder operaties.
Minder uitgevoerde operaties –> grote gezondheidsverliezen.
● Losses are the results of 305 thousand fewer elective surgeries
● Largest losses in:
Ophthalmology: cataract surgeries (eye surgerie: ‘in dutch: staar;)
Othopedics: knee and hip replacements
Conclusion: Delay of elective procedures not without consequences
● Urgency classification was meant to be a temporary tool. Not expected to be applied for 2
years or even longer.
● Delays of elective surgeries also have negative health consequences: 320 thousand QALYs
have not been delivered.
● This stresses the importance of continuing to deliver regular care as much as possible, even
in times of scarcity.
apply knowledge about supply and demand side rationing to the COVID-19 context
supplyside: bedden/equipments gingen naar mensen die met COVID-19 besmet waren, en niet naar ander patiënten
Current practice early in the pandemic:
National (not only surgeries)
* ‘Urgency list’ (Urgentielijst) (mostly cancer, cardiovascular)
* Developed by Gupta Strategists for ‘Landelijk Centrum Patiënt Spreiding’
* Checked by ‘Federatie Medisch Specialisten’
* ‘Validated’ by Zorginstituut Nederland
* On DBC level
Local (for surgeries):
* ‘Triage overleg’ team sits together twice a week to prioritize patients
Demandside:
Rationing in times of COVID
* Rationing more explicit momentum
* Ideally transparent
* Maximize the benefits / utilitarian perspective is defendable
model
* Stakeholders in general agree with this perspective
* Implementation (at different levels) obviously challenging
* Model individual patients
* Link to capacity
* Non-OR interventions
What is the CAPACITI decision-support proces?
Smal:
1: decision question
2: criteria for decision-making
3: evidence assessment
4: appraisal
5: recommendation
1: objectives (why is the recommendation being made?0
2: committee
3: criteria (how will the recommendation be made?)
4: evidence plan
5: evidence
6; trade offs (how does each option perform across the criteria?)
7: uncertainty: (how confident is the committee in the recommendation? is more data or consensus needed?
8: recommendation (what does the community recommend and why?)
9: communication. (which messaging will convey the rationale to the decision-maker)
10: evaluation: (how can the recommendation process be improved?)
Where is the CAPACITI decision-support tool used for?
purpose
- for prioritization among multiple immunization products, services or strategies
- incorporates input from multiple stakeholders, evidence across disciplines, operational and socio-ethical aspects, and data uncertainty
End user
- secretariat coordinating the recommendation/decision proces in LMIC’s
- may be used for policy or program question
Status
- developed in collaboration with 12 countries in Africa, Asia, and the Americas
- Recommended for country implementation by WHO immunization and vaccines related implementation research advisory committee (IVIR-AC)
Recommendation for rationing in times of scarcity like COVID-19
Health losses can be constrained in future pandemics by:
– aiming for high volumes: search for ways to continue as many surgeries as possible
› Coordination in/between regions, with independent treatment centers (ZBCs), and with
foreign hospitals
– aiming for health effects:
› Prioritize surgeries with the highest QALY gains
› Reassess possible prioritizations of elective surgeries
Gezondheidsverliezen kunnen bij toekomstige pandemieën worden beperkt door
- streven naar hoge volumes: zoeken naar manieren om zoveel mogelijk operaties door te laten gaan
‘ Coördinatie in/tussen regio’s, met onafhankelijke behandelcentra (ZBC’s) en met
buitenlandse ziekenhuizen
- streven naar gezondheidseffecten:
‘ Prioriteit geven aan operaties met de hoogste QALY-winst
Herbeoordeling van mogelijke prioritering van electieve operaties
WHatis the disadventage of prioritization on patients by expert opinion?
- Level of agreement on prioritization between experts is low (MacCormick
AD, Parry BR. Med Decis Making 2006) - Prioritization across disciplines is complicated by the high degree of specialization in modern medicine.
- Most importantly, this approach does not systematically optimize population health
- Not clear which values are considered not transparent
What is the ethical perspective while rationing?
Four criteria to allocate scarce resources:
1) Maximize the benefits produced by scare resources
2) Treat people equally
3) Promote and reward instrumental values
4) Give priority to the worst-off (the sickest).
In the context of a pandemic, maximizing the benefits is justifiable.
This is a utilitarian ethical perspective: Which entails that the right decision is the one that will produce the greatest good at the population level.
Wat voor triage tool voor OR planning is er gemaakt during COVID-19 pandemic door EMC?
metingen van pt EMC: surgeries en generalists
Ze hebben ook een interactive tool gemaakt: je kan de surgerie intypen die je wilt vergelijken. (urgency = DALY’s lost in a month delay). , endan krijg je een vergelijking, met delay per month, en de duur van de operatie.
How to use
Hospital level? people who do the planning can look at space and who to prioritized
National level? national shortage: the government / insurance companies can advise where to go
