Ministry of Health, New Zealand, 2004 - present
Goal: Prioritize patients for access to ‘elective’ (non-urgent) health services
- Inconsistent prioritization of patients
- Need to convince decision-makers there’s a problem to fix
- Need for consensus
- Geographical spread of decision-makers
- Need to iteratively improve the tool with minimal reworking
Outcome: Points systems for prioritizing patients for various types of elective services
In public health systems in New Zealand and worldwide there is insufficient capacity to be able to treat all patients for elective health services immediately. Prioritizing patients, usually via waiting lists, is therefore inevitable.
Before NZ’s waiting lists were overhauled in 1998, they were criticised for being “a diverse mix of patient cases – placed and kept on the list for a number of different reasons, and with no agreed criteria for admission to the list.” (Fraser, Alley & Morris 1993).
According to one cardiologist: “Manipulation by referring doctors, friends in high places, MP letters, or just persistent nagging, and just slight exaggeration of symptoms, is rampant, and the poor benign patient simply sits on the list and is leap frogged.” (Hadorn & Holmes 1997).
To remedy these problems, ‘Clinical Priority Assessment Criteria’ (CPAC), usually implemented as points systems (i.e. explicit criteria and weights), were introduced nationwide in 1998. Not long afterwards, however, these initial points systems were criticised for being largely arbitrary and resulting in significant numbers of patients being mistakenly denied treatment (sometimes with fatal consequences).
New points systems
Since 2004, using 1000minds software, NZ’s Ministry of Health has led projects to create and validate new points systems for elective services – with the ultimate goal of more equitable access and better patient outcomes overall.
The first points systems (CPACs) created using 1000minds were for coronary artery bypass graft (CABG) surgery. They were developed in a Ministry of Health-led collaboration with the NZ Region of the Cardiac Society of Australia & NZ (CSANZ) and with advice from the National Ethics Advisory Committee, the Medical Council, the Health & Disability Commission, the Human Rights Commission and Māori representatives.
A group of cardiologists and cardiac surgeons in different locations throughout NZ used 1000minds via the Internet and teleconferences to create points systems for prioritizing patients for CABG surgery. The CABG points systems have been formally accepted by CSANZ and are in use throughout NZ.
Other points systems have been successively created (and clinically endorsed) via collaborations with the relevant clinical professional organizations for the following specialities. Other points systems are currently underway or planned for the future.
Measures of success
The validity of the new points systems have been established by examining the face validity of the relative importance of the criteria implied by the point values and by comparing the ranking of patient case descriptions (‘vignettes’) from the points systems with clinicians’ consensus intuitive rankings (in effect, the ‘gold standard’).
Surveys of the participating clinicians revealed high levels of ‘user’ satisfaction with the 1000minds method/software.
Based on this body of work, 1000minds received several national and international innovation awards, and the process has been written up (Hansen et al 2012) so that it is possible for readers to appreciate how they might use 1000minds to create points systems for their own patient-prioritization applications.
National Prioritization Web Service
NZ’s National Prioritization Web Service is used to assign a booking status and clinically appropriate timeframe for patients waiting for elective treatment. The Service is accessed by the Ministry of Health’s Electives team, District Health Boards (DHBs), clinical directors and clinicians. The Service is also accessed as a web service by other clinical information systems, which provide their own user interface to the service.
Various charts and data for the Ministry, clinical directors and clinicians to review their use of the tools compared with DHB and national averages are provided. A learning module also lets a clinician score a hypothetical patient vignette and compare their rating of the patient with that of an expert reference group’s rating of the same vignette.
Canada and the UK
Inspired by NZ’s success, since 2008 the same process supported by 1000minds has been used in the public health systems of Canada’s western provinces (e.g. Fitzgerald et al 2011), and for prioritizing social services, including health care, for ‘people in need’ in the UK.
Other health applications
Other health sector uses of 1000minds include:
- Health technology prioritization: Prioritization of spending on pharmaceuticals, medical devices, equipment, procedures, etc (e.g. Golan & Hansen 2012)
- Disease classification and diagnosis: Identification of criteria for classifying and diagnosing diseases
- Disease R&D prioritization: Prioritizing diseases for Research and Development spending
- Clinical guidelines: Identification and prioritization of treatment guidelines
- Health-related quality of life: 1000minds supports the EuroQol Group’s EQ-5D-5L and EQ-5D-3L
- Measuring medical research outcomes (e.g. Dobson et al 2013),
- Planning for disasters and pandemics (allocating Tamiflu)
- Assessing students for admission to medical schools and health professionals for jobs (e.g. junior doctors for hospitals)
- Allocating research funds, etc.
F Dobson, R Hinman, E Roos et al (2013), “OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis”, Osteoarthritis & Cartilage 21, 1042-52.
A Fitzgerald, C De Coster, S McMillan et al. (2011), “Relative urgency for referral from primary care to rheumatologists: The priority referral score”, Arthritis Care & Research 63, 231-39.
G Fraser, P Alley & R Morris (1993), Waiting Lists & Waiting Times: Their Nature & Management, National Advisory Committee on Core Health & Disability Support Services.
O Golan & P Hansen (2012), “Which health technologies should be funded? A prioritization framework based explicitly on value for money”, Israel Journal of Health Policy Research 1, 44.
D Hadorn & A Holmes (1997), “The New Zealand priority criteria project. Part 2: Coronary artery bypass graft surgery, British Medical Journal 314, 135-8.
P Hansen, A Hendry, R Naden, F Ombler & R Stewart (2012), “A new process for creating points systems for prioritizing patients for elective health services”, Clinical Governance: An International Journal 17, 200-209.