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Peter Satterthwaite Senior Portfolio Manager Capital & Coast District Health Board Private Bag 7902 WELLINGTON To: C&C DHB BOARD Through: Margot Date: May Subject: Resource Allocation & Cardiovascular Resource Allocation EXECUTIVE SUMMARY In October 2002 the Board asked CPHAC (its Community and Public Health Advisory Committee) to begin a programme of work to provide greater clarity on how C&C DHB should determine resource allocation for the prevention and treatment of cardiovascular disease (CVD). CPHAC established a work programme, which included:
• A CPHAC paper in May 2003 which gave information on the spread of CVD, options for intervention and some indications on how to compare the relative benefits of those different intervention options,
• A community forum in June 2003 to discuss the above findings and options,
• The current report (from a working group of CPHAC called the Resource Allocation Working Group) which is being presented to the Board at this meeting, following discussion at the April CPHAC meeting. This report looks at the way in which resources have historically been allocated for CVD, the different options for resource allocation and their relative merits. Finally it makes recommendations on how resources should in future be allocated for the prevention and treatment of CVD. In making its recommendations the report seeks to find a model of resource allocation which not only addresses current needs, but also reduces the prevalence of CVD in 10 years time. The working group’s assessment is that the current approach does not meet both these aims, and that future resource allocation needs to invest more in measures which will modify the risk factors (factors which cause CVD) for both individuals and populations. This report recommends:
• Taking a strong advocacy role – and encouraging nationwide programmes that target risk factors such as high fat or salt content in foods, tobacco smoking and lack of exercise.
• Implementing the New Zealand Guidelines Group’s guidelines for modifying CVD risk factors.
• Favouring innovative models of care which are community based for funding – to reduce pressure/demand on hospitals, while building capacity (and prevention) in the community. G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc
• That the reallocation of resources should be phased in over several years (to avoid unnecessarily destabilising existing infrastructure for combating CVD). ORIGIN OF REQUEST The CPHAC resource allocation working group (RAWG) has completed a work programme proposed in the August 2003 CAPHAC meeting. A brief chronology of the original request and subsequent workstream follows:
1. The Board asked CPHAC (October 2002 item 947) to examine rules and principles of prioritisation that could reasonably be applied to cardiovascular disease. Background papers appeared in the September and October CPHAC agendas. 2. CPHAC report to Board (February 2003) 3. CPHAC information paper, May 2003, Decreasing the community Burden of Cardiovascular Disease 4. CPHAC forum June 2003; Resource Allocation: A Case Study – Cardiovascular Disease 5. RAWG Work Programme: October to November 2003 6. CPHAC informal meeting February 18th, 2004 to review RAWG Proposal for Discussion Other than to assert that Diabetes and Cardio Vascular Disease (CVD) are priorities for the district, the Board has not developed a written strategy for CVD. A specific Board decision has been made with respect to investing in a new Cardiac Electrophysiology Service. It is intended that this workstream will result in the development of a strategic approach to service investment, disinvestment, and development to reduce the burden of cardiovascular disease in the C&C District.
APPROACH: CARDIOVASCULAR DISEASE The May 2003 CPHAC paper provided the epidemiological background to CVD, options for intervention (DHB Toolkit) and identified some of the methodological issues involved in comparing relative benefit of interventions. The June 2003 CPHAC Community Forum shared some of the resource allocation options available to the Board and discussed and obtained feedback on some of the complex considerations that need to be taken into account by the Board in making CVD resource allocation decisions. The RAWG approach taken to addressing cardiovascular disease resource allocation was to adopt the general approach developed and presented in appendix one; and apply it to CVD. Some of the specific tasks undertaken by the RAWG included:
1. Identify and acknowledge DHB resource allocation flexibility 2. Determine the scope of interventions 3. Examine the evidence on the cost effectiveness of interventions G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc 4. Determine and acknowledge political risks and vested interests in changing the current mix of service funding 5. Acknowledge the historical drivers of current pattern of resource allocation, including role of medical endeavour 6. Specifically address mechanisms for addressing inequalities 7. Weigh up balance of evidence to determine appropriateness of current service funding for addressing future CVD incidence 8. Make recommendations on priorities for CVD funding The results of the RAWG work programme are summarized in the “Proposal for Discussion” in appendix one
VALUES AND CRITERIA The values that guide resource allocation decisions can be summarised as: 1. Parity 2. Integration 3. Independence 4. Sustainability 5. Quality These values were echoed in the themes that were discussed and presented at the June 2003 CPHAC Community Forum. The process of resource allocation for C&C DHB should therefore acknowledge and explicitly incorporate these values into decision making processes.
The scope of interventions for CVD are summarised in the Proposal for Discussion, and were covered in detail in the May 2003 CPHAC paper.
ASSESSMENT The following trends were noted: • The difficulty in evaluating very different service approaches such as health promotion and surgical intervention, which have dramatically different timeframes of effectiveness and collateral benefits;
• The successful development over the twentieth century of highly developed medical specialisation and a concentration of resources in high technology interventions in a hospital setting;
• The dramatic disparity in access to services and CVD health outcomes for Maori and Pacific peoples; and
• The current trend for increasing prevalence of major population risk factors, such as obesity. The key question for DHBs could be summarised as: “Is the current allocation of resources optimal to both address the needs of today, and impact on the prevalence of disease in 10 years time?” Given the historical pattern of resource allocation it is considered a safe conclusion that the investment in population and individual risk factor G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc modification is suboptimal. In summary, it is therefore considered that the answer to the above question is almost certainly: “No”, and that investment in population and individual risk factor modification should be preferred in future resource allocation decisions. initiatives.
RECOMMENDATIONS It is recommended that the Board: 1. Ask CPHAC to examine rules and principles of prioritisation that could be applied to cardiovascular disease. 2. Note that CPHAC was to assume constant real levels of funding for cardiovascular services. 3. Note that some services are aspects of integrated public and primary health systems and are not just specific to cardiovascular disease. 4. Agree that the following policy framework be used as a basis for completing a proposal for resource allocation: a) Constant real levels of funding for cardiovascular services will continue b) The balance of funding between community and hospital services be adjusted towards prevention and primary services. c) The relative expenditure between community and hospital services being adjusted gradually without sudden or large annual re-allocations. d) Agree to the extent that resources are limited, movement towards parity is best achieved on a population basis by prioritising (in order) Maori, Pacific people, and peoples living in areas classified as NZ Dep Deciles 9-10. e) Confirm developments of by Maori for Maori and by Pacific for Pacific services as a significant strategy to achieve parity, respond to user preferences and support Whanau and community development. f) Promote equitable level of access to services recognising there are significant disparities in access to services and health outcomes, particularly for Maori and Pacific people. g) The DAP and SOI priorities for contracting and resource allocation include from 2004/2005: • Implementing the NZGG National Guidelines for cardiovascular risk modification.
• Reducing the use and funding of hospital services by developing models of care that include frequent attend or case coordination, hospital in the home services, and promoting the role of expert patient.
• Assessing the introduction of new health technologies in terms of contribution to the balance between community and hospital based services. h) Advocate strongly in encouraging national population based approaches to prevention of cardiovascular disease such as reducing salt levels in processed foods, promoting healthy fat use by commercial food retailers and population approaches to smoking cessation and exercise promotion. G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc i) Priorities for 2004/2005 service development, contracting and resource allocation will include advocacy and facilitation services to reduce barriers to access. 5. Agree that the above policy framework be used as a basis for completing a proposal for resource allocation inviting professional critique and for drafting the statement of intent for 2004/2005. 6. Ask that the Chief Executive report peer responses to the proposal of the July meetings of CPHAC and CPHAC to report to the Board in August. 7. Note that the recommendations in the policy and framework may imply a higher financially sustainable threshold for surgery. 8. Ask the Chief Executive to estimate the impact of this approach on access to surgery and consider the possibility of comparable demand management for medical services. 9. Ask the Chief Executive to: a) Identify equitable levels of access for Maori and Pacific peoples in order to achieve the national guidelines. b) Propose performance objectives for access and treatment based on those levels. c) Propose incentives for providers that implement current guidelines and achieve performance objectives. d) Consult with Maori and Pacific peoples on preferred options for advocacy and facilitation services to reduce barriers to access. 10. Note that the Committee agreed that action points for implementation should be prioritised that action points 11. Agree that a prioritisation process be put in place to implement this policy framework in accordance with the District Strategic Plan and available resources 12. Agree to review performance in 2006/2007 and consider the need to specifically fund services for populations with high needs. 13. Refer the proposal to the strategic communications committee for advice on communication and consultation with the relevant communities of interest. Approved for release: WIN BENNETT MARGOT MAINS Director Planning & Funding Chief Executive Officer Capital & Coast District Health Board Capital & Coast District Health Board G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc APPENDIX ONE PROPOSAL FOR DISCUSSION Prepared by Peter Satterthwaite on behalf of the Resource Allocation Working Group, a working group of the Community & Public Health Advisory Group of Capital & Coast DHB INTRODUCTION The CPHAC resource allocation working group (RAWG) has completed a work programme proposed in the August 2003 CAPHAC meeting. The first part of this paper discusses specific aspects of a resource allocation process and proposes a general approach that could be taken by a DHB to developing a robust resource allocation process. The second part of the paper addresses the specific Board request by applying the principles to cardiovascular disease.
PART ONE: RESOURCE ALLOCATION - DECISION MAKING AND EVALUATION 1. RESOURCE ALLOCATION: DHB FLEXIBILITY The DHB receives an allocation of funding which is directly related to the size and characteristics of its population. The quantum of this funding is fixed annually but is consistent with a government three year future funding track. A DHB does not have total flexibility in the allocation of resources; there are a number of constraints placed by the Minister and by a “clinical duty of care”. Firstly, there are ringfences that restrict the movement of funding between the so-called NDOCs, that is: Mental Health and Personal Health. There was formerly a ringfence around Disability Support funding, but this has been removed. Public Health funding has not been devolved to DHBs. Secondly, whilst the Statement of Service Coverage states that there are not entitlements for services, in reality there are some services to which all eligible residents are entitled and which the DHB is obliged to fund whatever is consumed. Examples of these include: immunisation benefits and pharmaceutical reimbursements. Thirdly, the DHB is required to fund and have provided a range of services, as laid out in the Statement of Service Coverage, and has a ‘clinical duty of care’ to ensure that there is a sufficient level of service provided to fulfill this duty of care. Examples of these include: Emergency Department access and acute surgical services. Fourthly, there is a current policy which prohibits reducing funding levels for elective services. The combined effect of the above four factors is to significantly curtail the quantum of funding available for redistribution by any DHB. G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc 2. SCOPE OF INTERVENTIONS In broad terms, the scope of interventions for addressing health problems can in most cases be grouped into four categories of intervention. These are shown below with some examples of characteristic interventions. Population Prevention by Targetting High Acute Treatment of Measures Risk Individuals Established Treatment of Established Aim is to identify individuals at high risk of developing disease. Aim is to treat acute This may lead to treatment of episodes of disease level of risk modifiable risk factors such as obesity, smoking, or blood Examples: impact of population pressure Hospital treatment disease or for acute illness reduce risk of recurrence developing Examples: Breast Screening Programme GP treatment of (secondary acute respiratory prevention) Example: Blood glucose screening for diabetes in high risk populations Example: Promotion, Effective management settings eg health food in school levels in For many health problems interventions will be available from all four categories. In these instances, opportunities will exist for funders to fund a comprehensive range of interventions to address the problems. However, the essence of resource allocation for DHBs is to determine the relative mix of interventions from the four categories, and the relative allocation within each category. A discussion of approaches that can be taken to this task are discussed in the next section.
3. COMPARISON OF BENEFITS OF DIFFERENT INTERVENTIONS The task of resource allocation involves assessing comparative benefits and making choices. There are numerous factors that make this an extraordinarily difficult task. Perhaps the most fundamental difficulty is obtaining clarity and agreement about what constitutes benefit. Whilst “health benefit” may seem self evident, even a cursory exploration of the concept reveals that it can be assessed in different ways. For example, benefit could be assessed as years of life gained, quality of life gained or reduction in inequalities gained. There have been varied approaches to addressing and simplifying this problem. These include a focus on either: G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc 1. Maximising efficiency through such techniques as cost utility analysis 2. Maximising equity: a social justice approach 3. A values based approach CUA, and in particular the use of the quality adjusted life years (QALYs), is a health economic approach to assessing any health intervention in terms of it’s cost in dollars for a standardised unit of benefit. A fuller discussion of this relatively high profile approach is in section four. The equity approach aims to specifically target services that help redress disparities in health access and outcome. Ham (1) states: “The pursuit of equity may result in resources being allocated to services for which the cost of achieving a certain quantum of benefit is greater than for alternatives. Trade-offs of this kind are made all the time in health policy and indicate the potential incompatibility of efficiency and equity objectives.” An example of this trade-off would be the ‘equity choice’ of providing outpatient services at three geographical locations with the volume of services correlated to local need; versus the ‘efficiency choice’ of providing all services from one central location to reduce infrastructural costs and lost productivity due to health staff traveling between locations. Ham (1) presented the contrasting views of proponents of efficiency and equity: “Williams maintained that effective priority setting required clarity about objectives, information about costs and outcomes, and the ability to measure performance. Klein responded the key task was less to refine the technical basis of decision-making than to construct a process that enabled a proper discussion to occur given that questions of rationing cannot be resolved by appeal to science.” The values approach is perhaps best demonstrated by the Swedish approach. This has involved the attempt to rank values; the highest priority attached to respect for human dignity, followed by solidarity or equity and then by efficiency.
4. CONCERNS WITH COST UTILITY ANALYSIS How does one compare the relative benefits of fluoridation of a water supply with a coronary bypass operation. On the face of it, this would seem an impossible task. Health economists have responded by developing, in the QALY, a standard metric for comparing such vastly different interventions. QALYs have a seductive appeal because they appear to simplify the very complex. However, there have been many criticisms of the QALY, mainly to the effect that in their simplicity they fail to account for important considerations. These issues are not just academic. QALYs are the most straightforward means of assessing the relative value of services. The DHB owned Pharmac organization uses QALYs as one of its eight inputs in benchmarking the value G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc of all pharmaceutical agents it assesses. A high cost per QALY is a major adverse factor in Pharmac’s assessment. A selection of the questions raised about the validity of QALYs is presented below: Extrapolation from personal to allocative preferences Although the techniques used in CUA, such as the “standard gamble” and the “time tradeoff”, give an idea of what individuals would want for themselves, they do not reveal what people would prefer as a principle for allocation. For example, in assessing the quality of life gained from an intervention, researchers ask individuals what percentage of their remaining life they would forgo to obtain the benefit from the intervention. McGregor (2) quotes the QALY evidence for Viagra, an erectile dysfunction remedy, where men questioned were prepared to give up 26% of their remaining years for the benefits of the drug (Their wives when asked would give up only 2%). The resulting cost per QALY is less than renal dialysis. In this example, the men were asked about the perceived value as an individual of a single intervention, not the relative value to society of a range of interventions. It is clear that the extrapolation from individual to allocative preferences may not be valid. “Rule of Rescue” Society does not consider a unit of health gained by a severely ill individual to be of equal value to a unit of health gained by an individual who is less severely ill. Concerns for fairness and equity are also important to the public in distributional decisions. There is a generally held view that society has a duty of care to those who are acutely and severely ill. This will not be reflected in QALY calculations as shown in the Viagra example above. Several studies have shown that the public is prepared to sacrifice overall health gain to some extent in order to help the most severely ill. Age and Disability Discrimination It has been claimed that QALYs are ageist because the intrinsic calculation (QALY = quality factor times number of years of benefit) would appear to disadvantage those who have less years of life expectancy in which to benefit. Several economic and ethical formulations have been developed to assess whether and how to incorporate age as a criterion for resource allocation. One of the main underlying rationales is the equalization of life health, the so called ‘fair innings’. The basic idea here is that all persons are entitled some equal life-span and those having already lived these years of life should be given less priority. Schwappach (3) notes that a moderate or even strong preference for giving priority to the young has been observed. There is much less support for negative discrimination against the elderly. A similar argument has been made that QALYs discriminate against the disabled or those with chronic conditions because in theory, these people have less potential to benefit because they have a reduced quality of life as a starting point. There is empirical evidence, however, that the public prefers to give equal priority to those with and without disabilities in the allocation of life saving technologies. Two other observations from Schwappach (3) provide useful context: “In general there seems to be reluctance to allocate resources on treatments that leave patients in comparatively poor health.”
G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc “When explicit trade-offs between health gains achieved by curative or preventive treatments are involved, there seems to be a slight trend to prioritise preventive healthcare.”
5. MACRO / MESO / MICRO APPROACHES TO PRIORITISATION Prioritisation can occur at a number of levels in the health system and can vary in its explicitness. ‘Macro’ attempts at resource allocation have involved attempts to define services which are and aren’t available under public funding. They are therefore inherently explicit. Two of the most notable examples worldwide are the Oregon prioritization process in the early 1990s and the New Zealand attempt through the NZ Core Services Committee to define a core of publicly funded services. ‘Meso’ level approaches have the prioritisation decisions being made by funding organisations, where decisions are made about the type and mix of services funded for a community. ‘Micro’ level approaches are decisions made at the service or individual clinician level; for example using guidelines as a tool to determine service access. It is notable that the NZ Core Services Committee retreated from the macro view to a meso/micro view that priority setting was best approached not by limiting service coverage but by determining how services could be targeted on those patients most likely to benefit. The major mechanism for implementing this was ‘guidelines’. Rationing by guidelines rather than exclusions leaves ultimate responsibility for deciding who should get access to health care resources to agencies such health authorities at the meso level and to physicians at the micro level. Ham (1) is rather derogatory of “muddling through” approaches which avoid explicit decision making in order to avoid political risk. However he notes that: “The political cost of explicitness may outweigh the benefits and this could result in a return to previous decision making processes” Schwappach (3) notes too that the public is generally against allocative decisions that are too extreme, there is an underlying preference for moderation: “There seems to be general reluctance against extreme final distributions. The public wishes to maintain hope and the chance for treatment for all patients.”
6. CONSULTATION The Health and Disability Act (2001) describes a legal obligation on DHBs to consult on their District Strategic Plans. The minimum level of consultation permitted is defined as the consultation process described in the Local Government Act (1954). Engaging the community in meaningful deliberation about health service resourcing choices is difficult to do well. One of the concerns of the community, in engaging with public agencies, is at which stage of the decision making process they engage; and therefore what is the potential for the consultation to influence decision making. G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc Beierle, quoted in Abelson et al (4), described four factors that need to be addressed in any consultation design or evaluation: 1. Representation 2. The structure of the process or procedures 3. The information used in the process 4. The outcome and decisions arising from the process The question of representation concerns the extent to which those in the community who are consulted with truly represent the views of the wider community. There is often an inherent tension between the breadth of consultation in terms of the range and representativeness of the consulted, versus the depth of consultation. Many health resourcing issues require the sharing of a significant amount of information to the consulted to put them in a position to develop an opinion. For this reason, Abelson et al (4) assert that: “Surveys are limited in their ability to communicate and obtain in-depth views about complex issues.” The choice of information shared with the consulted has the potential to undermine the usefulness of the process, Abelson et al (4) state: “A double edged sword built into the deliberative paradigm is the naïve assumption about the role of information as a tool for informing dialogue which ignores the reality of information as a source of power.” Other consequences of the asymmetry of information and power between public agencies and the consulted include (4): “The vast majority of the public will defer to the experts when it comes to these decisions because they may not have the expertise required to critically appraise the information presented.” ”‘Once exposed to the complexities of the system, participants become sympathetic to the challenges faced by decision makers who deal with these types of issues on a daily basis.” The numerous and potentially competing goals for public participation processes and consequently the trade-offs inherent in designing public participation processes may often result in a situation where, in emphasising a particular goal they may sacrifice another. Positive benefits can be gained from effective consultation in the formative stages of planning. These would include a smoother implementation of policy. It was suggested that broad and open consultation, that is open dialogue that asks questions rather than provides options, was more likely to engage the community and provide useful feedback on the real issues perceived by the community. In this context the process of consultation and the models of presentation were seen to be critical to the outcomes achieved from consultation. Quite different engagement and outcomes could be expected from pre-packaged versus open-ended consultation. This could represent the difference between community tolerance or support. Given that there are different levels of resource allocation occurring in the DHB it was considered that it was appropriate to develop different levels of consultation and have a gradient of methods based upon the importance, risk, or community relevance of the decision.
G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc Abelson et al (4) concisely summarised the key challenges to effective consultation:
• How to mitigate strong vested interests
• How to mitigate potential biases introduced by witness and information selection
• How to achieve representativeness when citizens do not want to participate
• How to ensure accountability of the participants for its outcome when the deliberative process is only one input in the decision-making process
• How to build an infrastructure of civic deliberation 7. ADDRESSING INEQUALITIES FOR MAORI There is strong and consistent evidence that Maori and Pacific peoples have a higher rate of hospitalization for acute cardiac events, and yet lower (40% and 64% respectively for Maori and Pacific men) rates of coronary bypass [Tukuitonga (5) and Westbrook (6)]. This experience mirrors the situation of black Americans in the United States. There are a number of potential reasons for this phenomenon including: patients’ health seeking behaviour, preferences for cardiac procedures or medical treatment, physician practice styles and patient doctor interaction. Discrimination against ethnic minorities has been suggested as a possible reason for ethnic disparities in the use of these procedures in the USA. There is a lack of information on the real causes for the reduced access to interventions for Maori and Pacific People. RAWG discussion focused mainly on Maori, but the issues were acknowledged to be similar for Pacific peoples. It was considered likely that from community through to tertiary care there could be inequalities in Maori:
• ability to access services
• assessment by mainstream services
• expectations of services
• ability and willingness to advocate on their own behalf It was considered that ideally the “system” should be modified to be responsive to the needs of Maori and provide equitable levels of service and outcome. This is unlikely in the short term due to the immense effort required to modify a system of such size and established patterns of practice. Four potential mechanisms were discussed that could be used, in the shorter term, to help overcome the inequitable service access and outcome experiences for Maori. Quotas or targets set for access levels for Maori to mainstream services Analysis of the known pattern of morbidity for Maori could be used to develop the expected level of mainstream services that would be expected to be accessed. These service levels could be incorporated as service targets for Maori. For example, if Maori were known to have twice the rate of cardiac disease, the service expectation would be that Maori would access cardiology assessments at twice the rate their proportion of the population would indicate. That is 22% of consultations (11% of C&C population).
G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc The Ministry of Health in their Maori Health Advice to incoming Minister (2002) suggested that the next ten years may see direct devolution of social service funding to iwi and major urban groups. Options already being explored include: 1. One government agency acting on behalf of other to streamline contracting with iwi for a range of social services 2. A full devolution model where iwi would purchase services on their own It follows from this that, if there was a failure to meet service targets, a stronger approach could be to allocate a proportion of service funding for Maori patients: quotas or ring-fencing of funding for Maori in selected services. By Maori for Maori Service development By Maori for Maori Service development is already a strategic priority. It remains an important mechanism in developing a health system responsive to Maori needs. “Advocacy” for Maori of their needs and to ensure Maori access the system effectively Advocacy services could be developed to assist Maori in overcoming system hurdles. These may be as simple as arranging transport to clinics or as complex as assisting people to weigh up the pros and cons of major surgery. There is some anecdotal local experience that advocacy services could be a transitional step; for the services would help Maori develop confidence and experience in advocating themselves for equitable access. Provider incentives for clinical guidelines implementation for Maori In clinical areas where there are clear guidelines and targets to Maori access and treatment, incentives could be developed to reward providers who address inequalities and meet clinical targets. Incentives should be tailored to each provider to recognise the specific access difficulties of populations.
8. INCORPORATING INNOVATION There is a progressive trend towards an increased burden of degenerative diseases in an aging population, who are alive but are frailer and with greater associated disability. This trend is likely to continue and intensify because of the aging population and the development of life extending health technologies. In this context, the Health System needs to be able to adapt to the changing demography, morbidity and consumerism. Around the western world innovative approaches to care delivery are developing in response to these trends. To a large extent these are driven by financial imperatives and overburdened hospitals. It is postulated that nearly one million unplanned hospitalisations in the US for congestive heart failure each year may be prevented by improvements in patient evaluation and management strategies. Other studies, quoted by Davidson et al (7), have suggested that 50-75% of readmissions may have been preventable by augmenting strategies to promote G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc treatment compliance and development of mechanisms of outpatient support and optimisation of medical therapy. Some of the key concepts in these innovative approaches to care are: 1. Integrating services around the patient to avoid care fragmentation or duplication 2. Stratification of patient groups: core patient group, hard to reach, and hard to treat groups (recidivist populations), as opposed to “one size fits all” 3. Development of specific services for these subpopulations of patients. For example case management approaches to people with complex conditions and high needs 4. Promotion of the expert patient concept where patients become the experts in their own condition and health professionals become consultants or advisors to them 5. Substitution of hospitalisation with community based alternatives such as: hospital in the home, intermediate care, ‘GP hospitals’ Frequent Attenders: a small group of people with multiple health problems who use large quantities of Capital and Coast District hospital services were discussed as an example of current patterns of care. There is often a fragmented approach to care management of complex patients. Integrated care aims to coordinate the health providers’ responses around the patient. The implication of these trends for the allocation of resources is that resource allocation is not a static process that allocates existing resources into a particular (possibly different) mix. Resource allocation must consider and incorporate changing paradigms of practice. This may mean investment in new types of services and consequent disinvestment in existing services.
9. INTERPRETATION Resource allocation is a process that involves comparing and evaluating different interventions in order to decide the nature and volume of services that will be funded. As described in section two, the choices that can be made are constrained by policy settings, and by a need to meet service coverage expectations. New funding is very limited. Over the next four years, for C&C there will be no growth in funding to reflect population growth; as the Ministry of Health reduces funding to the Population Based Funding Formula allocation. To achieve a different mix of funding within the categories outlined in section two will require a combination of investment and disinvestment in existing services. This will involve difficult choices between investments in prevention, and treatment of acute and chronic treatment services; and will require choices about which services to fund less of.
Factors that influence Deciding the choice of interventions and quanta of funding needs to choices of incorporate a number of different considerations that need to be Alternativ weighed up solutions simultaneously . The implications of resource allocation options needs to be including: evaluated. This train of logic is sh scenarios own below: effectiveness Populatio Impact of n at Risk: Determine: addressin Utilise: opportunity Evaluate decisions costs, equity problems on health benefits, allocation alignment G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc with strategic plan, innovation, and G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc The diagram below attempts to summarise the process graphically. Improved Access to New models Consultation Models of Disabilit Ad dressin Services Comparison inequalitie of Benefits Capacity Current & Potential Maori Health Prioritising Interventions Allocation Evaluation of Impact The scope of available interventions is wide and varied. The quanta exceed available resources. Inherent in this is that for any funding opportunity there are other alternative uses for resources and other benefits to be foregone. A process is required that makes a comparison of the relative benefits, considers the current and potential future capacity (and the impacts on this capacity of changes in resources), determines the explicit benefit for Maori Health, incorporates opportunities from changes to the model of care, and incorporates an agreed process of consultation. The cogs represent the need to mesh these factors into a composite process. An important feature of this diagram is that the prioritisation process is not a sequential series of steps addressing each of these factors, but a composite process. Whilst this makes it inherently more complex, and thus difficult to manage, it ensures that all aspects are considered alongside one another. A sequential process is more likely to make decisions on single or few criteria because of the ordering of the steps or failure to finish the sequence. In addition, without making the whole problem insolubly complex, the relative importance of the particular problem should also to be evaluated and compared to other problems, for example cancer, child health, cardiovascular disease etc.
G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc 10. DRAFT RECOMMENDATIONS Resource allocation is a complex and multi-factoral activity that is at the heart of a DHB’s functions. It is inherently a developmental and iterative process. The RAWG has considered a number of the aspects of resource allocation that should be considered in developing a robust and transparent process. Key principles that have emerged during the discussions include: • DHB funding is limited which means that trade-offs and comparison of relative benefit are essential
• There is no single, simple approach to resource allocation
• Cost effectiveness information is not a sufficient sole basis for allocative decision making
• Consultation is difficult to do well, and must balance representation, complexity (or depth), and timing
• Incorporating innovation needs to be considered at a system level and not at a marginal level
• Specific weighting needs to be given to addressing inequalities and specific mechanisms deployed In further development of C&C’s resource allocation process, the key concepts and ideas discussed above should be evaluated and incorporated into the prioritisation and planning process. It is specifically recommended that: 1. C&C DHB adopt the principles described in this paper as a general approach to resource allocation 2. C&C DHB apply these principles to the major components of the Board’s work programme (And explicitly include the Statement of Intent) 3. The principles and approach to resource allocation be used to assist C&C DHB’s high level decision making processes With respect to addressing inequalities it is specifically recommended that: 1. The concept of negotiating targets for access levels for Maori to mainstream services should be adopted where there are identified inequities of access. If, after three years, targets fail to address inequities: quotas or ring-fencing of funding for Maori could be considered. 2. By Maori for Maori Service development remains an important mechanism in developing a health system responsive to Maori needs. 3. Advocacy services could be developed to assist Maori in overcoming system hurdles 4. Introduction of provider incentives for implementing clinical guidelines for 5. Similar approaches should be used for Pacific peoples who have, in many instances, similar epidemiology and service needs. 11. REFERENCES 1. Ham C, Coulter A Explicit and implicit rationing: taking responsibility and avoiding blame for health care choices J Health Serv Res Policy. 2001 Jul;6(3):163-9 2. McGregor M Cost-utility analysis: use QALYs only with great caution CMAJ. 2003 Feb 18;168(4):433-4
G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc 3. Schwappach DL Resource allocation, social values and the QALY: a review of the debate and empirical evidence. Health Expect. 2002 Sep;5(3):210-22 4. Abelson J, Forest PG, Eyles J, Smith P, Martin E, Gauvin FP Deliberations about deliberative methods: issues in the design and evaluation of public participation processes. Soc Sci Med. 2003 Jul;57(2):239-51 5. Tukuitonga, C. and A. Bindman (2002). NZMJ 115(26 April): 179-82 Ethnic and gender differences in the use of coronary artery revascularisation procedures in New Zealand 6. Westbrook, I., J. Baxter, et al. (2001) Are Maori under-served for cardiac interventions? NZMJ 114: 484-7 7. Davidson P et al Addressing the burden of heart failure in Australia: the scope for home based interventions J Cardiovasc Nurs 2001: 16 (1) 56-68
G:\EO\COMMS\Maria\wwwroot\Meetings\CPHACpapers\2006_08_10\CardiovascularResourceAllocationMay04 .doc PART TWO: RESOURCE ALLOCATION - CARDIOVASCULAR DISEASE 1. INTRODUCTION Cardiovascular disease (CVD) is the leading cause of death in New Zealand, accounting for 41 percent of all deaths in 1997. An estimated $22.8m of funding was allocated in the Capital & Coast District in 2002/03 for the prevention or treatment of CVD. This paper applies the generic approach discussed in Part One to the prevention and treatment of CVD. For: Determine: Utilise: Evaluate Alternativ Factors that Impact of influence allocation decisions scenarios choices of on health Populatio solutions n at Risk: addressin including: effectiveness problems , costs, opportunity costs, equity benefits, alignment with strategic plan, innovation, and The wide range of approaches that can be used to prevent and treat CVD were summarised in a May CPHAC paper, and are grouped into four categories in this approach. The degree of funding flexibility the DHB has with respect to CVD is assessed. RAWG has reviewed some of the scientific literature that attempts to compare the relative effectiveness of these different interventions.
Page 20 of 1 2. THE SCOPE OF INTERVENTIONS The range of interventions that are available for CVD were grouped into four categories to simplify analysis. These categories are shown graphically below: Population Prevention by Targetting High Acute Treatment of Measures Risk Individuals Established Treatment of Established Examples: Examples: Examples: Examples: Legislation NZ Guidelines recommend screening target groups, eg Hospital treatment Guidelines Maori males over 35 years, for for heart attack Heart failure absolute risk of a cardiac event treatment Salt or Fat in the next 5 years. Hospital treatment for heart failure Processed Treatment of modifiable risk factors for those at high risk eg Secondary cholesterol, weight, smoking, Prevention blood pressure reduces Revascularisation individual risk Examples:
Examples: Marketing Coronary bypass rehabilitation Examples: Angioplasty smoking TV
3. RESOURCE ALLOCATION: DHB FLEXIBILITY The funding of CVD interventions was presented in the May 2003 CPHAC paper and is summarised below: Regional Public Health Community laboratory Primary care Providers:GMS etc Community pharmaceuticals (cardiovascular and lipid lowering 2002) $6,720k Secondary Cardiology Inpatient Care (excluding interdistrict flows) $6,414k Secondary Cardiology Outpatient Care Community Referred Cardiology Testing Cardiac Education and Management Page 21 of 1 Secondary Cardiothoracic Inpatient Care (excluding interdistrict flows) $5,306k Secondary Cardiothoracic Outpatient Care Estimated District Expenditure on Cardiovascular Services Secondary Cardiothoracic Regional Public Health Outpatient Care Secondary Cardiothoracic Community laboratory Inpatient Care (excluding interdistrict flows) Primary Care GMS etc Cardiac Education and Management Community Referred Cardiology Testing Community pharmaceutic (cardiovascular and lipid lowering 2002) Secondary Cardiology Outpatient Care Secondary Cardiology Inpatient Care (excluding interdistrict flows) The overall allocation is approximately $10m to Primary and Public Health interventions and $12.8m to hospital based services. Unfortunately it is not possible to accurately allocate the expenditure above across the four categories described in section two because it is not known the relative proportions of, for example laboratory tests, which are used for screening, acute management or chronic management. In terms of the DHB’s flexibility in altering funding levels for each category: Regional Public Health This funding for health promotion relating to CVD is from the Ministry of Health to the Regional Public Health Service. C&C DHB do not influence this funding level. The level of this funding cannot be reduced, but C&C DHB could allocate its own funding for additional Public Health activity. Community laboratory Community laboratory funding is reimbursement for referred tests from public and private sector medical practitioners and midwives. The level of funding Page 22 of 1 cannot be directly influenced by C&C DHB, but can be indirectly influenced by support for initiatives that promote clinical best practice and implementation of clinical guidelines. Primary care Providers Primary care providers are paid by a combination of fee for service and capitation formulae. Ultimately, it is expected that most funding will be through PHO capitation. Because capitation formulae are nationally determined, C&C DHB has no ability to decrease this level of funding but has discretion to increase funding through additional funding initiatives outside of capitation formulae. Community pharmaceuticals As with community laboratory, funding is reimbursement for prescribed pharmaceuticals by public and private sector medical practitioners, dentists and midwives. The level of funding cannot be directly influenced by C&C DHB, but can be indirectly influenced by support for initiatives that promote clinical best practice and implementation of clinical guidelines. Secondary Cardiology Inpatient Care Allocation of funding for Hospital and Health Services (HHS) is negotiated between Planning and Funding (P&F) and the HHS annually. The service is a combination of acute presentations and elective procedures (such as angioplasty). Decreases in service access could be effected by new models of care and by changes to access criteria for elective services. Increases in funding could be effected by reallocating from other services into cardiology. Secondary Cardiology Outpatient Care Allocation of funding for the HHS is negotiated between P&F and the HHS annually. The service is an elective service receiving referrals from medical practitioners from the lower half of the North Island and Nelson Marlborough. Decreases in service access could be effected by new models of care and by changes to access criteria for elective services. Increases in funding could be effected by reallocating from other services into cardiology. Community Referred Cardiology Testing Allocation of funding for the HHS is negotiated between P&F and the HHS annually. The service provides a specialist diagnostic service upon referral from a medical practitioner. Decreases in service access could be effected by new models of care and by changes to access criteria for elective services. Increases in funding could be effected by reallocating from other services into cardiothoracic. Cardiac Education and Management Allocation of funding for the HHS is negotiated between P&F and the HHS annually. The service contributes to patient education and cardiac rehabilitation following a cardiac event. Decreases in service access could be effected by new models of care and by changes to access criteria for elective services. Increases in funding could be effected by reallocating from other services into cardiothoracic. Secondary Cardiothoracic Inpatient Care Allocation of funding for the HHS is negotiated between P&F and the HHS annually. The service is a combination of acute presentations and elective procedures (such as coronary bypass surgery). Decreases in service access Page 23 of 1 could be effected by new technologies and by changes to access criteria for elective services. Increases in funding could be effected by reallocating from other services into cardiothoracic. Secondary Cardiothoracic Outpatient Care Allocation of funding for the HHS is negotiated between P&F and the HHS annually. The service is an elective service receiving referrals from medical practitioners in the lower half of the North Island and Nelson Marlborough. Decreases in service access could be effected by new models of care and by changes to access criteria for elective services. Increases in funding could be effected by reallocating from other services into cardiothoracic.
4. COMPARISON OF BENEFITS OF DIFFERENT INTERVENTIONS Risk Factors and Thresholds It is only in the last ten years that the contribution of risk factors to adverse outcomes has become well understood. It is now clear that hypertension and hypercholesterolemia, terms that imply that there is a level at which the level of blood pressure or cholesterol becomes ‘high’ and below which is normal and ‘safe’, are false concepts. In Western societies blood pressure, cholesterol and weight typically increase as people age. This rise does not occur in hunter-gatherer communities, the levels remain at low risk levels throughout life. The implication from this is that it is aspects of the Western lifestyle, such as physical inactivity, high animal fat diet, and smoking that directly contribute to the rise through life in these risk factors. There is a log linear relationship between risk factor levels and adverse CVD outcomes. This means that there is a constant proportional increase in adverse events with increasing levels of risk factors. The lower the risk factor, the lower is the risk of disease, down to levels well below average Western values. Some of the startling conclusions that can be drawn from this are: 1. Treat anyone at high risk! Blood pressure lowering drugs should not be limited to people with high blood pressure, nor cholesterol lowering agents to people with high cholesterol concentrations 2. The constant proportional relationship means that there is value in modifying risk factors in people with high risk, whatever the reason for the high risk and regardless of the level of risk factor 3. The conclusion is clear: anyone with existing disease (a previous myocardial infarction or stroke for example) should be treated irrespective of the level of the risk factors one seeks to modify 4. Because there is substantial benefit from lowering these physiological variables from any starting value at persons at high risk, all the reversible risk factors should be changed, not just those judged “abnormal” The practical implication of this information is that the development of cardiovascular disease in people with a high susceptibility can be prevented or delayed. To do this requires that people at high risk are identified and treated with a range of interventions encompassing both lifestyle and pharmaceutical. Page 24 of 1 Population Measures Population measures are actions taken at a community or national level to change the level of a risk factor in the whole population. Three examples of how this might be achieved are through: 1. industry agreement, or legislation to progressively lower the added salt in processed foods 2. industry agreement, or legislation to progressively move to healthier cooking oils for commercially prepared foods 3. mass media smoking cessation and increasing exercise messages Unfortunately limited information is available on the costs and benefits of community wide intervention programs that have aimed to modify multiple risk factors in the population. Whilst there have been a few large scale programmes, their evaluation has not been particularly robust, and therefore the cost effectiveness is hard to ascertain. Those studies that have targeted specific risk factors, rather than multiple, have shown that non personal health interventions to reduce blood pressure and cholesterol are very cost effective (Murray et al ).
Prevention by Targeting High Risk Individuals Most studies relating to CVD prevention have appraised interventions aimed at modifying the three most important risk factors for CHD: smoking, hypertension and hypercholesterolemia. Fewer studies have focused on the costs and benefits of exercise and weight-loss programmes. Crowley at al (2) summarise the evidence and state that hypertension treatment does not pay for itself in healthcare savings from strokes or coronary heart disease (CHD) prevented. It was estimated that only 22 per cent of the treatment costs of moderate hypertension (DBP of 105 mmHg or higher) and 15 per cent of the costs of treating mild hypertension (DBP of 90 to 104 mm Hg) were likely to be recovered. The epidemiological evidence for the effectiveness of exercise, weight reduction and stress management on hypertension is less conclusive. Costs per QALY gained consistently place GP based smoking cessation programs near the top of QALY league tables, thus supporting the evidence that smoking cessation programs are clearly among the most cost-effective of healthcare interventions. The NZ Guidelines Group CVD Guidelines (December 2003) make recommendations on which groups to target, how to assess risk, and how to treat. The guideline recommends comprehensive cardiovascular screening of men age 45 years or over and women aged 55 years or over without known cardiovascular disease, known smokers and Maori people are to be screened 10 years earlier and diabetics are to be screened at diagnosis. In New Zealand, absolute CVD risk is usually calculated from the Heart Foundation risk assessment charts or electronic decision support tools based on the Framingham Heart Study. The standard risks in the Heart Foundation risk charts are: 1. A personal history of CVD 2. Age Page 25 of 1 3. Sex 4. Smoking 5. Lipids 6. Blood Pressure 7. Diabetes It is notable that ethnicity, socioeconomic status, obesity and physical inactivity do not contribute to the risk assessment. A cost effectiveness analysis has been performed for the national implementation of the guidelines for people with an absolute risk of 10% and 15%. Compared with no systematic screening and lipid-lowering programme, the recommended ‘screen and treat’ strategy (at a treatment threshold of 15% absolute risk) would prevent 6716 incident cardiovascular events and 1885 premature deaths. Over the lifetime of the cohort this provides 17,205 life years and 21,317 QALYs. The net 5-year cost of the strategy is $70million including pharmaceuticals, GP consultations, and laboratory tests. Hospital costs avoided over 5 years (including incident and recurrent medical and surgical cardiovascular admissions, AT&R and rural admissions) offset about two- thirds of the net cost of pharmaceuticals. The NZ Population (2001) = 3,737,277; the C&C Population (2001) = 245,560 (6.6%). The estimated net cost of fully implementing the Ministry strategy in the C&C District would be approximately $4.62m. Net Five year implementation costs for C&C Maori are estimated at $456k. The cost effectiveness ratios of $4083 per life year gained and $3295 per QALY gained are well within the range of those that have been accepted in reimbursing novel drug therapies in New Zealand. Enlarging the pool of individuals who are eligible for statin treatment by reducing the treatment threshold from 15% to 10% absolute risk increases the QALY benefits by about one-third but doubles the total cost of the strategy. Murray et al summarise that overall Personal health service strategies have a much greater potential to reduce the burden of disease – even though they are less cost effective than the population-wide strategies.
Hospital Based Treatments for Established Disease Health promotion and secondary prevention programs are not necessarily more cost effective than high technology surgical or drug treatments. Cost effectiveness analysis of cardiac interventions such as percutaneous cardiac angioplasty (PTCA) and coronary bypass (CABG) has generally shown these measures to be at least moderately cost effective. However, the changing costs and rapidly changing technology make analyses of limited application because they become out of date. Crowley at al (2) in a 1995 literature review concluded that CABG was more cost effective than treatment for either hypertension or high serum cholesterol as single risk factors.
Page 26 of 1 Chronic Treatments of Established Disease The scientific literature on the cost effectiveness of cardiac rehabilitation is limited. There is a suggestion that it is moderately cost effective but the most comprehensive review of the subject by Oldridge (3) ends with the following conclusion: We still do not have an answer to the following two critical questions: …….what is the incremental value of exercise when added to other cost effective secondary prevention interventions such as smoking cessation and management of hyperlipidemia? Does cardiac rehabilitation in fact reduce costs and save scarce healthcare resources?
Key Points There is no analysis comparing the cost effectiveness of the full range of CVD interventions. Methodological issues have been raised as major criticisms of QALY league tables and also make comparisons between studies difficult: 1. Wide variation in the specification and measurement of cost categories 2. Different epidemiological assumptions 3. Benefits mostly judged on disease specific effects 4. Average rather than marginal benefits 5. Different durations of study 6. Different discount rates
For reasons stated above relating to the difficulty in comparing different QALY studies, there is unlikely to be in the near future. In such a situation the balance of prevention versus intervention is probably the major strategic decision for funders rather than the relative mix within interventions, or prevention approaches. Murray et al summarise: “From the perspective of how best to achieve the best population health for the available resources, the optimum overall strategy is a combination of the population-wide and individual based interventions.” Schulpher et al (4), reviewing cardiac interventions take a similar approach: “For purchasers the evidence could imply that blanket decisions to provide only one form of intervention to patients should not be made. The various main forms of treatment for stable angina should be available and patients should be informed of the therapeutic options rather than offered a single therapy based upon provider preferences.”
5. MACRO / MESO / MICRO APPROACHES TO PRIORITISATION In the context of CVD, macro approaches to prioritisation could include national policies towards the funding of new technologies. A “macro” decision could be made by the Ministry of Health, or DHBNZ, that certain new technologies would, or would not be funded by all DHBs. There is a precedent for the Ministry taking this position with oncology drugs. Explicit funding by a DHB of clinical guidelines for CVD could be seen as a meso approach, particularly if funding was specifically linked to the application of the guideline or achievement of service targets.
Page 27 of 1 Micro level allocation decisions could be decisions by individual medical practitioners on whether or not they agreed with clinical guidelines and intended to incorporate them into their clinical practice.
6. ADDRESSING INEQUALITIES FOR MAORI In a NZ study of heart failure outcomes for Maori and non-Maori over a ten year period, mortality from heart failure was more than 8.8 times higher among Maori men aged 45-64 years and 3.5 times higher among Maori aged 65 years and over. Pacific peoples have the highest hospitalisation rate for rheumatic fever, over nine times that of others (19 per 100,000, 45 cases, compared to 2 per 100,000). The Maori hospitalisation rate is just over five times that of non- Maori (9 per 100,000, 54 cases) (Ministry of Health 2001). And yet a study by Tukuitonga et al (5) showed that coronary bypass rates were lower in Pacific and Maori men compared with other NZ men (ratios 0.64 and 0.40). Angioplasty rate ratios were 0.25 in Pacific and 0.29 in Maori men compared with other men and 0.21 in Pacific and 0.43 in Maori women compared with other NZ women. The working group and guest participants were agreed that ideally the mainstream system, that provides nearly all CVD services, should be modified to be responsive to the needs of Maori and provide equitable levels of service and outcome. This is unlikely in the short term due to the immense effort required to modify a system of such size and established patterns of practice. In the shorter term the generic options for addressing these inequalities, as discussed and presented in the part one, could be applied to CVD. These actions aim to compensate for the system rather than transform it. Specific actions could include: 1. Determination of the expected level of mainstream services that would be expected to be accessed to set service targets for Maori. Consider funding quotas if performance does not move towards targets. 2. Continue by Maori for Maori Service development 3. Develop advocacy services to assist Maori in overcoming system hurdles. Consult with Maori to identify preferred options 4. Implement performance incentives for meeting service targets for guidelines implementation for Maori access and treatment. Incentives should be tailored to each provider to recognise the specific access difficulties of populations. The Ministry of Health CVD Guidelines recommend that: “Practitioners should be aware of the need to focus on population groups that have a high burden of cardiovascular disease. These groups should be specifically targeted to ensure they are able to benefit from risk screening and subsequent management”
7. INCORPORATING INNOVATION Innovative approaches to providing specialised services to people with established disease were reviewed. Worldwide there have been many initiatives to develop approaches to keeping people with CVD well, rather than acute hospital management.
Page 28 of 1 Two of the key themes are case management by specialised nurses of high needs patients and patient self management: the development of ‘expert patients’ who actively participate in the management of their condition. Evidence from overseas suggests that the improvements in patient care provided by these approaches result in significant reductions in the need for hospital based services. A service providing case coordination for people with heart failure has commenced in Porirua during 2003. This is an example of an integrated care service targeting ‘hard to treat’ and ‘hard to reach’ people and improve the management of their conditions. There has been little explicit funding of specific self management initiatives, as yet, in the C&C District. Given the potential for different models of care to improve care and save on hospitalisation costs, incorporating the funding of such service innovations needs to be factored into resource allocation decisions.
8. INTERPRETATION The review of resource allocation for service options for cardiovascular disease by RAWG has confirmed that there is a substantial body of knowledge about the causes, prevention and treatment of CVD. There is much less clarity about the relative value of different options compared with one another. A general assumption in this discussion is that the overall quantum of funding for CVD will remain similar in real terms, and the key decisions to be made concern the mix of services among the four service categories. It is clear that services are required in all of the service categories presented in section two. There is almost certainly unmet need in the C&C District in all of the four service categories, for example: additional benefit could be obtained from more population health, risk modification, cardiac surgery and cardiac rehabilitation. Much of the information reviewed on the relative effectiveness of interventions was from international sources. The working group has assumed that the conclusions from this information can be generalised to the New Zealand context. C&C DHB has little new Ministry of Health revenue over the next few years as adjustments in funding levels to meet Population Based Funding are implemented. Within the current funding categories there is a variable degree of ability to increase and decrease funding levels. Given the relatively static total revenue, changes in funding for different categories of intervention will need to be offset by changes in other categories. In terms of the four categories of intervention: Population measures: Population measures can be very cost effective, and should be part of the interventions supported. Some of these measures would require national initiatives. A DHB could play an advocacy, catalyst or supportive role in the development of such measures. Population measures could also be directed at target groups such as social marketing approaches for Maori.
Page 29 of 1 Prevention by Targetting High Risk Individuals: The NZ Guidelines Group recommendations strongly recommend systematic, targeted risk reduction to reduce the incidence of CVD. There is almost certainly significant current expenditure on investigation of CVD which would not be recommended practice and offers a potential saving if resource were directed as per the guidelines. For example, pharmaceutical treatment of moderate hypertension in individuals with low absolute CVD risk is common practice but no longer recommended. Acute and Chronic Treatment of Established Disease: There is mounting evidence that the investment in hospital based services could be modified by implementation of innovative community based models of care including case management and ‘the expert patient” self-management. Specific strategies need to be employed to address low rates of access to services for Maori and Pacific peoples. The relative mix of resourcing is currently weighted towards treatment of established disease. There have been strong historical drivers for the accumulation of resource and expertise in high technology, medical, facility- based, interventions. The key question for DHBs could be summarised as: “Is the current allocation of resources optimal to both address the needs of today, and impact on the prevalence of disease in 10 years time?” Given the historical pattern of resource allocation it is considered a safe conclusion that the investment in population and individual risk factor modification is suboptimal. In summary, it is therefore considered that the answer to the above question is almost certainly: “No”, and that investment in population and individual risk factor modification should be preferred in future resource allocation decisions.
9. DRAFT RECOMMENDATIONS After reviewing the range of prevention and treatment options for CVD, the RAWG makes the following recommendations: 1. Sudden, large funding reallocations should be avoided 2. C&C DHB should take a strong advocacy role in encouraging national population-based approaches to prevention of CVD such as reducing salt levels in processed foods, promoting ‘healthy’ fat use by commercial food retailers, and social marketing approaches to smoking cessation and exercise promotion. C&C should consider allocating Personal Health funding to augment currently Public Health funded initiatives. 3. C&C DHB should treat as a resource allocation priority the implementation of the NZGG guidelines for CVD risk factor modification. The priority population groups for implementation should be Maori and Pacific Peoples if limited funding is available. 4. Innovative models of care, such as frequent attender case coordination, hospital in the home, and promotion of the “expert patient”, should be Page 30 of 1 favoured for funding to reduce the utilisation of hospital based services and alter the balance of community / hospital service funding more towards prevention and community services 5. New health technology for CVD interventions should be considered carefully within the context of the balance of community / hospital service funding. With respect to addressing inequalities, it is specifically recommended that C&C DHB: 1. Determine an equitable level of access to mainstream services in order to negotiate service targets for Maori. Consider funding quotas if performance does not move towards targets after three years 2. Continue by Maori for Maori Service development 3. Develop advocacy services to assist Maori in overcoming system hurdles. Consult with Maori to identify preferred options 4. Implement performance incentives for meeting service targets for guidelines implementation for Maori access and treatment 5. Similar approaches should be used for Pacific peoples who have a similar epidemiology and service needs 10. REFERENCES 1. Murray CJL et al Effectiveness and costs of interventions to lower systolic blood pressure and cholesterol: a global and regional analysis on reduction of cardiovascular- disease risk Lancet 2003: 361: 717-25
2. Crowley S, Dunt D, Day N Cost-effectiveness of alternative interventions for the prevention of coronary heart disease, Aust J Public Health, 1995, 19: 336-46 3. Oldridge NB Comprehensive cardiac rehabilitation: is it cost-effective? Eur Heart J (1998) 19 (Supplement O) O42-O49 4. Sculpher, MJ et al Resource allocation for chronic stable angina: a systematic review of effectiveness of alternative interventions Health Technology Assessment 1998; Vol 2 No 10 (exec summary) 5. Tukuitonga, C. and A. Bindman (2002) Ethnic and gender differences in the use of coronary artery revascularisation procedures in New Zealand NZMJ 115(26 April): 179-82
Brief Overview of Common Psychotropic Medications: A Practical Guide from a Clinical Viewpoint Paula Bank, M.D., Ph.D. Dept. of Psychiatry University of Michigan MEDICATIONS FOR MOOD DISORDERS SSRI Antidepressants - Use; Depressive and anxious disorders including Dysthymia, Major Depression, Panic Disorder, Generalized Anxiety Disorder, Obsessive Compulsive Disorder, Posttraumatic Stres
A L E X A N D E R C A L A N L E A V I T T www.alexleavitt.com • www.doalchemy.org • (781) 526.6483 • firstname.lastname@example.org E D U C A T I O N Boston University College of Arts & Sciences , Boston, MA Bachelor of Arts in English Language & Literature; minor concentration in Japanese Kyoto Consortium for Japanese Studies, Kyoto University , Kyoto, Japan R E S E A R C H P O S