Elsevier

Health Policy

Volume 80, Issue 3, March 2007, Pages 444-458
Health Policy

Priority setting and cardiac surgery: A qualitative case study

https://doi.org/10.1016/j.healthpol.2006.05.004Get rights and content

Abstract

Purpose

The purpose of this study is to describe priority setting in cardiac surgery and evaluate it using an ethical framework, “accountability for reasonableness”. Introduction: Cardiac surgery is an expensive part of hospital budgets. Priority setting decisions are made daily regarding ever increasing volumes of patients. While much attention has been paid to the management of cardiac surgery waiting lists, little empirical research exists into the way actual decision makers deliberate upon and resolve priority setting decisions on a daily basis. A key goal of priority setting, in cardiac surgical areas as well as others, is fairness. “Accountability for reasonableness” is a leading ethical framework for fair priority setting, and can be used to identify opportunities for improvement (i.e. make it fairer) and highlight good practices.

Methods

A case study was conducted to examine the process of priority setting processes at three University of Toronto affiliated cardiac surgery centres. Relevant documents were examined, weekly triage rounds were observed for 27 months, and interviews were carried out with 23 key participants including cardiac surgeons, cardiologists, and triage nurses. In data analysis, the conditions of “accountability for reasonableness” (relevance, publicity, appeals and enforcement) were used as an analytic lens.

Results

Relevance: While decisions may appear to be based strictly upon clinical criteria (e.g. coronary anatomy); non-clinical criteria also have an impact upon decision-making (e.g. patients’ lifestyle choices, type of surgical practice and departmental constraints on resource use). Participants stated that these factors influence their decision-making and can result in unfair and inconsistent decisions. Publicity: Non-clinical reasons are not publicly accessible, nor are they clearly acknowledged in discussions between cardiac clinicians. Appeals: There are mechanisms for challenging decisions however without access to the non-clinical reasons, this can be problematic. Enforcement: Participants cite little departmental or institutional support to engage in fairer priority setting.

Conclusions

To our knowledge, this is the first study to describe actual priority setting practices for cardiac surgery practices and evaluate them using an ethical framework, in this case, “accountability for reasonableness”. Priority setting decision making in cardiac surgery has been described and evaluated with lessons learned include specific findings regarding the contextual and dynamic nature of decision making in cardiac surgery. The approach of combining a descriptive case study with the ethical framework of “accountability for reasonableness” is a useful tool for identifying good practices and highlighting areas for improvement. The good practices (including surgeons strongly facilitating patients seeking second opinions and approaching patients from a holistic perspective in consideration for surgery) and areas for improvement (including lack of transparency and lack of institutional support for “fair” decision making) that we have identified in this case study can be used to reflect upon the present tool used in priority setting and improve the fairness and legitimacy of priority setting decision making in cardiac surgery.

Introduction

Cardiovascular surgery is an expensive part of hospital budgets [1]. Cardiac surgery is a fast paced and quickly growing specialization, incorporating some of the most expensive technologies of any surgical specialty. The capacity of cardiac surgery is also growing as more elderly and high risk patients are being accepted for surgery. While offering more patients significant options in revascularization is a positive step, the priority setting process has become more complex and complicated for decision makers as the average acuity of the cardiac patient increases and the available options for surgical intervention increase in number.

Currently, our understanding of how priority setting decisions are made in cardiac surgery is at a basic level. There are few clinicians focusing on priority setting specifically and even fewer focusing on priority setting within cardiac surgery. Most of the Canadian literature addresses specific issues in priority setting such as waiting list management and monitoring as well as patients’ outcomes [2], [3], [4], [5], [6], [7]. However, these studies focus on practical aspects of the process on an everyday basis and give little attention to any ethical issues within priority setting. While it is important to examine the outcomes and practical aspects of priority setting decisions, it is also important to examine the actual process of decision-making and the experience of those most involved in the process from an ethical lens.

Giacomini et al. examined guidelines for cardiac surgical decision making from 1989 [8]. They found that 69% of the guidelines mentioned psychosocial criteria as procedure indications or contraindications. Researchers in the United Kingdom demonstrated that evaluations of surgical candidates include issues of lifestyle habits and the deservedness of the patient alongside discussions of medical criteria. This study concluded that there were many non-specific terms such as attitude, substance abuse, compliance, psychosocial stability and the general medical, emotional and mental state used in the criteria for eligibility for cardiac surgery [9], [10]. Criteria such as lifestyle choices, occupations, smoking and alcohol intake, moral character, obesity and the patient's perceived will to make lifestyle changes were discussed both overtly and subtly in the case conferences. These criteria were used in the decision making process to “rule out” or less often, to “rule in” patients for cardiac surgery [9], [10].

Eisenberg, in his work on medical decision-making, theorized that clinical decision-making occurs in the context of sociologic influences such as a patient's age, gender, race and social class as well as physician specific influences such as the practice setting, the degree of specialization of practice and the physician's background [11]. Clark et al., revisiting Eisenberg's work, state that there are few research studies that incorporate the important and inevitable social context of clinical decision-making [12]. Additionally, the decision-making models created out of this research are limited in scope and described as “models of biomedical rationality” [12]. Many research investigations of clinical decision making assume that physicians make clinical decisions in ‘socially insular clinical settings’ and fail to acknowledge the sociological research on the patient–physician relationship and the highly contextual nature of modern medical practice [12].

Factors other than biomedical criteria about patients are used in surgeons’ decision making when priority setting [3], [4], [5], [6], [8], [9], [10]. It is stated that both the patients and the processes are complex, occur within specific contexts and involve much more than simply an assessment of the biomedical facts about an individual patient. These studies do not take these observations further by talking to surgeons and other decision makers about their actual decision making practices. There is no thorough descriptive account of the process by which cardiac surgeons make priority setting decisions on a daily basis in their practice nor are there studies discussing the fairness of the process. The actual and perceived fairness of a priority setting process is an important concern for all, patients and families, the general public, surgeons, nurses, other health care professionals and policy makers.

Although this study focuses on cardiac surgery priority setting decisions, the descriptions and subsequent lessons learned are applicable to other contexts at the micro level. Clinicians make priority setting decisions on a daily basis in many different contexts, from emergency rooms to operating rooms to walk in clinics. Additionally, clinicians in all contexts and areas at the micro level aim to make fair and legitimate decisions. The challenges, constraints and factors that have an impact upon the clinicians’ abilities to make fair and legitimate decisions described by the participants in this study are not unique to cardiac surgery departments and can be appreciated by those working in other areas of health care in Canada at a micro level.

The purpose of this study is to describe how priority setting decisions are made within several programs of cardiac surgery, and to evaluate this decision-making process in regards to its fairness and legitimacy using an ethical framework, ‘accountability for reasonableness’ (A4R) [13]. By evaluating the process using an ethical framework developed through actual priority setting experiences and grounded in theories of democratic deliberation, we can make comments about the fairness of the process. It is only after we describe the process using the perspectives of those most involved and evaluate it using a relevant framework, that we can make recommendations regarding areas for improvement or comment on best practices.

Why is there a need for an ethical framework for priority setting processes? There are two key reasons. First, there is a need for an ethical framework that emphasizes process because we can never have agreement on what decisions to make [14]. Additionally, as a pluralistic society, we will never reach agreement on what outcomes are correct or preferable in priority setting dilemmas [14], [15].

Most traditional methods of approaching priority setting problems in health care are limited in their focus and scope as well as their applicability in the real world. Philosophical approaches to distributive justice such as utilitarianism or egalitarianism are highly abstract and are based on different values and lead to different decision outcomes, none of which is clearly correct. Economical approaches such as the cost-effectiveness analysis or the use of quality- or disability-adjusted life years (QALYs and DALYs) are limited as they do not address contextual, individualistic and humanistic aspects of actual patients and priority setting decision making [14], [16], [17]. Other approaches, such as legal and organizational ethics approaches are also limited in their scope, their ability to address contexts of decision-making and the possibility of application [14]. While they offer specific strategies for application, they do not address how to set priorities in a practical way [14].

Holm describes the last two decades of approaches to priority setting in health care systems as occurring in two phases [18]. The first phase included articulating specific criteria, factors or principles for priority setting. Two examples of this kind of approach are the Oregon experiment and the New Zealand Priority Criteria Project [19], [20]. These approaches were limited in their application and their ability to provide answers in cases of dispute or conflicting values [21].

The most recent approaches to priority setting problems, as cited by Holm, has grown out of two realizations [18]. First, there was a realization that more than simply rules or outcomes needed to be articulated. The process by which priority setting occurred also required examination, and this realization has driven the use of this ethical framework as well as the development of institutions like the National Institute of Clinical Excellence (NICE) in the United Kingdom, with its focus on establishing clear processes in priority setting [21].

The second realization was that we may never reach agreement on the specific criteria, factors or principles that are important in priority setting decisions. These criteria, factors and principles are based on values and aiming for agreement or consensus on moral issues or issues involving values in a diverse society is unreasonable and impossible [13], [16], [21], [22]. Daniels states that, “In pluralist societies, we are likely to find reasonable disagreement about principles that should govern priority setting” (p. 1300) [21]. So, instead of focusing on trying to reach agreement on what decisions should be made, the focus should shift to opening up discussion on how priority setting decisions are made [14]. Instead of consensus, Daniels states, we must focus on a fair process [21].

A fair process, according to Daniels and Sabin involves important elements of transparency regarding reasons behind decisions, the use of reasons or rationales for decision making that are deemed relevant by all to meeting health care needs, and procedures of revising decisions in light of new evidence or challenges [13], [23]. These key elements are drawn out of theories of justice and democratic deliberation, specifically in the work of John Rawls [13], [24], [25]. They ensure ‘accountability for reasonableness’ [13]. Fair procedures must also be sustainable and acknowledge the contexts and varied goals of all involved in the kinds of institutions where priority setting decisions are made [13].

Daniels and Sabin developed an ethical framework for examining priority setting processes according to their fairness and legitimacy. A key goal of priority setting, in cardiac surgical areas as well as others, is fairness, which remains an illusive concept for which consensus is difficult. Accountability for reasonableness is a leading ethical framework for fair priority setting, and can be used to identify opportunities for improvement (i.e. make it fairer) and highlight best practices. It encompasses values of democratic deliberation, which outlines elements of a fair process. The focus on the process instead of solely the outcomes is a more comprehensive way to approach exploration into priority setting problems. It can also help to illuminate the criteria used in decision making, from a different perspective than one concerned solely with outcomes. To date, this ethical framework stands alone as one focused on the processes of decision-making and grounded in theories of justice and democratic deliberation.

Although priority setting decisions may be framed as medical or clinical decisions, they rest on value judgments. Reasonable people may certainly disagree on the factors and values involved in these decisions. They may disagree on the fairness of the decision and the legitimacy of the decision makers. There may never have agreement on what values or factors are relevant or about principles of fairness or legitimacy. Instead we must rely on a fair process.

According to Daniels and Sabin, a decision making process is deemed to be fair according to the degree to which it meeting four conditions: relevance, publicity, appeals and enforcement. These four conditions of accountability for reasonableness are outlined in Table 1.

There are two goals achieved in meeting these conditions. First, the decision making process is made essentially broader, by making public deliberation and examination part of the process. In other words, there is more involvement of the key stakeholders, the public, in decisions around the use of limited resources in their health care system. Second, achieving these conditions contributes to of social learning, making the public more knowledgeable about the health care system, limits and ways of reasoning about those limits [24].

Section snippets

Design

This research involved a qualitative case study. Case studies are valuable where “broad complex questions have to be addressed in complex circumstances” [26] and are ideal when the goal is to study complex social phenomena in their natural settings and contexts [27]. Schramm, when defining the case study, states that “the essence of a case study, the central tendency among all types of case study, is that it tries to illuminate a decisions or set of decisions, why they were taken how they were

Results

In this section we present the results according to the four conditions of accountability for reasonableness; relevance, publicity, appeals/revision and enforcement. Supporting verbatim quotes from interviews with participants have been included to emphasize key points.

Discussion

Previous research has described issues of priority setting in cardiac surgery in Canada [2], [3], [4], [5], [6], [7]. Priority setting in cardiac surgery is seen as simply a problem of how to manage waiting lists and the use of decision-making tools, such as the URS. There is little attention in the literature to other types of priority setting decisions, such as the initial decision to accept or refuse a patient for surgery. In addition, the URS is advocated as a useful decision-making tool,

Limitations

The results of this study have limited generalizability. This case study was carried out in three complex urban teaching hospitals in Toronto with a small cohort of surgeons, nurses and cardiologists. The findings and implications arising out of them might not be the same in smaller cardiac surgery centres, or those without a teaching hospital focus. Clinicians in cardiac surgery centres serving a greater rural population may have different issues of concern than those stated here. The

Conclusions

This study has described the process of priority setting decision-making in cardiac surgery and evaluated it using the ethical framework ‘accountability for reasonableness’. Accountability for reasonableness is an effective evaluative tool for evaluating priority setting decisions in clinical programs, leading to the identification of best practices and areas for improvement [59]. The best practices and areas for improvement that we have identified in this case study can be used to reflect upon

Acknowledgments

This research was supported by an operating grant from the Canadian Institutes of Health Research. Dr. Walton was supported by a Canadian Institutes of Health Research/Canadian Health Services Research Foundation/Canadian Nurses Foundation Doctoral Fellowship, and for part of the research was also supported by a Lupina Foundation Program in Comparative Health and Society Doctoral Fellowship and a Faculty of Medicine Fellowship, both at the University of Toronto. Dr. Martin is supported by an

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