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Global Cardiovascular Strategies
PRIORITIZATION IN CARDIOLOGY. IMPACT ON GUIDELINES
Nina Rehnqvist, MD, Sweden
National Board of Health and Welfare, Stockholm, Sweden
Proceedings on 14th International Congress
THE "NEW FRONTIERS" OF ARRHYTHMIAS 2000
Major Issue - Healthcare Resources versus Demands
Progress has been enormous in cardiology. New techniques have been developed and introduced. CABG is now common practice in octogenarians and older. New methods for treatment of arrhythmias apart from alleviating symptoms also actually produces cure. Pharmacologic treatment of heart failure is not only cost effective but has even been regarded as cost saving. The demand and also needs for such procedures is thus continuously increasing. At the same time resources spent on health care has been constant or in some countries declining. The situation is independent on whether the health care system is insurance based or based on taxes. In both instances there is a third party payer who has to deal with the demands from the customers, patients, and the professionals. Profession and patients are here on the same side and allies sometimes often in opposition to the provider of the means.The methods for handling the increasing gap between resources and demand have so far been rather imprecise and incomplete. The most common way is to produce waiting lists in order to somehow ration the treatment or diagnostic procedures. However the waiting list differs from a queue. In most cases where further resources have been allocated in order to shorten the waiting list the effect has most often been an actual lengthening of the list due to usually appropriate shifts in indication. The other way of handling the situation is open prioritization.
Prioritization in Healthcare
Prioritization is something that is being dealt with in most countries. Only the state Oregon in the USA has operationalized their priorities in regular itemized lists with ranking orders. In other countries prioritizations are effectuated in the form of practice guidelines to which reimbursement programmes are attached. i.e HMOs in the USA. The legitimity of such guidelines have often been questioned but hearings on the matter have not offered better solutions. The trick to obtain success in the form of implementation and adherence is probably depending on how and by whom the guidelines actually are produced1.The principles for considering prioritization have been expressed in different ways but some aspects are common. In Sweden a parliamentary group formulated the hierarchy of principles upon which prioritization should take place. This was ratified by the parliament. The first principle deals with equal rights between people irrespective of birth, age, race, sex, economic status, ethnicity, etc. There are seldom problems with this principle. Only when age is used in itself and not as constituting an increased risk have problems appeared. The second principle is called the need – solidarity principle. This means that those with the greatest need are put in front of those with less need and their needs are to be fulfilled to a greater extent than for those with lesser. Those with lesser are requested to show solidarity in prioritizing the others. This is where a conglomerate of political, ethical, scientific and professional aspects are to be taken into consideration and this area is probably the one where the legitimity of operationalizations made will be continuosly questioned.
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