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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 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.
The third principle is that of cost-effectiveness. In this respect the health economist
Alan Williams set the stage2-6. He introduced the term cost per life year saved (LYS)
or quality adjusted life year (QUALY). Although the term QUALY is imprecise and
immature and in need of improvement both these endpoints have been very useful
in comparing different treatment methods. Alan Williams also introduced a “rule of
the thumb” by stating that treatments costing less than 10000 dollars per LYS or
QUALY are to be considered as cost effective and worth their value for improvement
of quality of life or postponement of death. On the other hand measures costing
more than 100 000 dollars will not be considered worth while at any stage.
Hemodialysis is at the upper end of the grey zone in between. Clopidogrel for the
prophylactic treatment of patients with unspecified atherosclerotic disease will in
this context not be considered cost- effective in comparison to ASA as one extra life
year has been estimated to cost 150 000 dollars.
The prioritization hierarchy can be used both when priortizations are to be made
“horizontally” i.e between different areas, (cardiac disorders versus kidney disease,
arrhythmia-patients as a group vs angina pectoris-patients) or “vertically” i.e within
an area (prophylaxis of death due to VF).Allocation of resources in the form of
personnel, equipment and availability will perhaps be dealt with in a little more
rational way if these considerations are made in advance and professionals
working on the floor may feel a little less frustrated if such discussions are made in
advance and in a democratic way. On the other hand much research and
epidemiological work needs to be done to define needs in relation to demands and
current supply.
Much time and effort are presently spent on the production of clinical guidelines.
When after much work finally produced they are not are always adhered to. The
reasons for this has been dealt with in the EHJ7. Impact and implementation of
guidelines is mainly due to the level of legitimity of the guidelines. This in itself is
dependant not only on the contents and statements but also on how the production
of the guideline has been processed, the composition of the working group and
whether the guidelines actually have a bearing on reality and not an expression
either of wishful thinking by patients and profession or on the other hand only
cost-containment. Guidelines often contain decision trees and recommendations
regarding methods for diagnosing and treatment. In these instances priorities are
to be made. When considering diagnostics Baye´s theorem is an expression of need
or rather probability. The test chosen should of course first of all be based on the
pre- test probability, then on the sensitivity and specificity of the test complemented
with cost effectiveness evaluations. When dealing with treatments cost effectiveness
may be calculated as above, but before that, when it comes to horizontal prioritization,
the second principle, that of the relative need must be taken into account.
In Sweden we are now in the process of trying to operationalise these considerations
both in the production of guidelines for ischemic heart disease and in making a survey
of the resources spent within different areas of cardiology in three regions. Cardiology
is chosen since the proportion of measures that are actually evidence based is higher
in cardiology than in any other speciality although the total level does not exceed 50%.
Some groups of patients have been identified as belonging to the highest priority group.
To this group belongs life threatening conditions as acute myocardial infarction.
Rehabilitation after myocardial infarction and secondary or primary prevention are being
considered to belong to group 2 less severe disorders but still considered appropriate
to be covered by public means. In both these examples the next step in the
prio-process is to look at cost-effectiveness and chose according to that. This means
that pressure has to be put both on providers of health care and the health care
industry to openly declare both clinical effectiveness as well as cost-effectiveness and
of the profession and public to ask for this information both from a safety point of view
and from prioritisational aspects. Epidemiologic research is the basis for defining needs
but political and ethical aspects are also important. Cardiac disorders belonging to
group 3, less severe and not unquestionally to be provided by public means are more
difficult to exemplify but perhaps treatment of lower grade of obesity with some
increased cardiac risk may belong to this group. Unquestionally all these
considerations are until now very immature but a thorough discussion on these
matters are to my mind absolutely necessary in order to avoid wrong allocation of
resources. In these discussions patients, the public, politicians, both as the public
voice and meansproviders at least in systems where taxes are involved need to
participate along with the various professions in cardiology. Nurses, physiotherapists,
physicians, surgeons technicians, dieticians etc, all need to take part in the discussion.
All of these professional groups need to in the future to have records of what they
may provide to what effect and what cost.
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