Craig Mitton

Setting priorities in Canadian regional health authorities: a survey of key decision makers

INTRODUCTION The aims of this study were, within three Canadian health regions, to identify existing resource management techniques, to elicit ways in which the current process of setting priorities could be improved and to determine if an economic framework, used internationally, would have merit in Canada. METHODS Structured, face-to-face interviews were conducted with 62 of 73 key decision makers. This sample included all senior executives and medical directors involved in setting priorities. Descriptive statistics and content analysis were utilised. RESULTS Key decision makers reported that a clear process of setting priorities does not exist. Allocation of resources generally occurs on the basis of historical trends; only 22% of participants stated that the process works well. Respondents were critical of the lack of transparency and a lack of meaningful inclusion of physicians in the priority setting process. Overall, 92% of respondents indicated that program budgeting and marginal analysis (PBMA) would be an appropriate and useful priority setting framework. CONCLUSIONS Given the political and historical influence in the process of priority setting and resource allocation, an evidence-based approach, like PBMA which explicitly attempts to identify ways of maximising health benefit within a limited budget, should have merit in the new regional structure in Canada.

Setting priorities and allocating resources in health regions: lessons from a project evaluating program budgeting and marginal analysis (PBMA)

BACKGROUND Program budgeting and marginal analysis (PBMA) is a framework for setting priorities in health care, used internationally over the last 25 years in Britain, Australia and New Zealand. However, the framework has undergone limited evaluation, and insight into how such evaluation should even take place is not found in the literature. METHODS Seven PBMA case studies were conducted in three Canadian health regions to examine the feasibility of applying the PBMA framework. Structured follow-up surveys with the users of the framework were carried out following the priority setting exercises. RESULTS The PBMA framework was feasibly implemented in three regionalized contexts and was generally viewed favorably by managers and clinicians who participated in the case studies. Numerous methodological lessons were learned and it was found that successful implementation hinges on organizational context. An empirically derived model describing PBMA is outlined and put forth as an evaluation framework for future exercises. CONCLUSIONS Comparisons to the health care management literature indicate that the derived PBMA model is a novel addition to this broader literature. Overall, managers in health organizations internationally would be well-served to consider PBMA to aid regional decision-making processes, but should do so with explicit consideration of the context in which such activity is to occur.

Priority setting in health authorities: a novel approach to a historical activity

As resources in health care are scarce, health authorities and other health organizations are charged with determining how best to spend limited resources. While a number of formal approaches to priority setting within health authorities have been used internationally, there has been limited success with such activity, particularly across major service portfolios. This participatory action research project instituted a novel priority setting framework, coined macro-marginal analysis (MMA), in a fully integrated urban health region in Alberta, Canada. The focus of MMA is on identifying areas for service growth and areas for resource release, then determining, based on pre-defined, locally generated criteria, if actual shifts or re-allocation of resources should occur. For fiscal year 2002/03, the Calgary Health Region identified over 40 M dollars in resource releases (approximately 3% of the total budget), which were made available for servicing the deficit, and more importantly for our purposes, re-investing in service growth areas. The MMA framework is pragmatic in nature and has the ability to incorporate relevant evidence directly into the decision-making process. This work constitutes a significant advancement in health economics, and responds where previous priority setting approaches have failed in that it allows decision-makers to achieve genuine re-allocation of resources with the aim of improving population health or better meeting other important criteria.

Health economic evaluation

A glossary is presented on terms of health economic evaluation. Definitions are suggested for the more common concepts and terms.

Resource Allocation in Health Care: Health Economics and Beyond

As resources in health care are scarce, managers and clinicians must make difficult choices about what to fund and what not to fund. At the level of a regional health authority, limited approaches to aid decision makers in shifting resources across major service portfolios exist. A participatory action research project was conducted in the Calgary Health Region. Through five phases of action, including observation of senior management meetings, as well as two sets of one-on-one interviews and two focus groups, an approach to priority setting at the macro level within the health region was developed and implemented. The resulting macro level approach builds on the program budgeting and marginal analysis (PBMA) framework. Using a multi-disciplinary expert panel, about

Program Budgeting and Marginal Analysis: A Priority-Setting Framework for Canadian Regional Health Authorities

45M (CAN) was released for the 2002/03 fiscal year and made available for re-allocation to service growth areas and the deficit. Important qualitative themes from the managers and clinicians informed both process development and refinement. The approach developed here not only facilitated re-allocation of resources, but also drew in both clinicians and managers to work together on this challenging task. The approach is pragmatic, transparent and evidence based, and should have application elsewhere.

Cost-utility analysis of pacemakers for the treatment of vasovagal syncope

Health regions in Canada are responsible for meeting the needs of local populations with limited resources. However, relatively little attention has been given to this within-region resource allocation problem. An economic approach to needs assessment, namely program budgeting and marginal analysis, may be of benefit. Its potential for use in Canada is examined, in particular with examples from two Alberta health regions, the Calgary Regional Health Authority and the Chinook Health Region.

Economic evaluation in obstetrics and gynaecology: principles and practice.

Dual-chamber pacing is a promising treatment for patients with very frequent vasovagal syncope, but its cost utility is unknown. We report that the incremental cost per quality-adjusted life-year gained is

Priority Setting in a Canadian Long-Term Care Setting: A Case Study Using Program Budgeting and Marginal Analysis

13,159 Canadian dollars (about

Twenty-five years of programme budgeting and marginal analysis in the health sector, 1974-1999

8,600 US dollars), and therefore this pacemaker therapy for vasovagal syncope has a favorable cost-utility ratio.