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Biomedical subjects

Craig Mitton

Publications and source records attributed to Craig Mitton.

At least 19 recordsLinked to original sources
PubMed2006

A cluster randomized controlled trial comparing three methods of disseminating practice guidelines for children with croup [ISRCTN73394937].

BACKGROUND: The optimal management of croup--a common respiratory illness in young children--is well established. In particular, treatment with corticosteroids has been shown to significantly reduce the rate and duration of intubation, hospitalization, and return to care for on-going croup symptoms. Furthermore treatment with a single dose of corticosteroids does not appear to result in any significant adverse outcomes, and yields overall cost-savings for both families and the health care system. However, as has been shown with many other diseases, there is a significant gap between what we know and what we do. The overall aim of this study is to identify, from a societal perspective, the costs and associated benefits of three strategies for implementing a practice guideline that addresses the management of croup. METHODS/DESIGNS: We propose to use a matched pair cluster trial in 24 Alberta hospitals randomized into three intervention groups. We will use mixed methods to assess outcomes including linkage and analysis of administrative databases obtained from Alberta Health and Wellness, retrospective medical chart audit, and prospective telephone surveys of the parents of children diagnosed to have croup. The intervention strategies to be compared will be mailing of printed educational materials (low intensity intervention), mailing plus a combination of interactive educational meetings, educational outreach visits, and reminders (intermediate intensity intervention), and a combination of mailing, interactive sessions, outreach visits, reminders plus identification of local opinion leaders and establishment of local consensus processes (high intensity intervention). The primary objective is to determine which of the three intervention strategies are most effective at lowering the rate of hospital days per 1,000 disease episodes. Secondary objectives are to determine which of the three dissemination strategies are most effective at increasing the use of therapies of known benefit. An economic analysis will be conducted to determine which of the three intervention strategies will most effectively reduce total societal costs including all health care costs, costs borne by the family, and costs stemming from the strategies for disseminating guidelines.

Journal Article↗
PubMed2006

Using participatory action research to build a priority setting process in a Canadian Regional Health Authority.

Due to resource scarcity, every health system worldwide must decide what services to fund, and conversely, what services not to fund. In order to institute and refine a macro-level priority setting framework within a large, urban health authority in Alberta, Canada, researchers and decision makers together embarked on a participatory action research (PAR) project. The focus of this paper is the PAR process in this context, including reflections from PAR participants about the contribution of the research methodology to their own practice as health care managers and clinicians. The use of qualitative research in health economics--in this case, to refine the application of a macro-level priority setting model--is a relatively new advancement. PAR proved to be an appropriate and helpful approach to introducing a theoretically driven model of macro-level priority setting within a large, complex health organization. However, it is important that support for the change is sustained as long as necessary to embed the new practices into the organization.

Alberta↗
PubMed2006

Ethics and economics: does programme budgeting and marginal analysis contribute to fair priority setting?

OBJECTIVE: Limited resources mean that decision-makers must set priorities among competing opportunities. Programme budgeting and marginal analysis (PBMA) is an economic approach that focuses on optimizing benefits with available resources. Accountability for reasonableness (A4R) is an ethics approach that focuses on ensuring fair priority-setting processes. PBMA and A4R have been used separately to provide decision-makers with advice about how to set priorities within limited resources. The goals of this research were to use the A4R framework to evaluate the fairness of using PBMA for priority setting and to assess how A4R might make PBMA fairer. METHODS: Qualitative case studies to describe priority setting using PBMA in the Calgary Health Region (Alberta, Canada) evaluated using A4R as a conceptual framework. RESULTS: The use of PBMA for priority setting was fairer than previous priority setting because of its emphasis on explicit rational decision-making. However, there were opportunities to improve the process, particularly by collecting data related to the decision criteria, by developing a communication plan to engage internal and external stakeholders about priority-setting, and by providing a formal mechanism to review priority-setting decisions and resolve disputes. CONCLUSIONS: There is potential for combining A4R and PBMA in a more comprehensive approach to priority setting, which uses a fair priority-setting process to reach decisions aimed at achieving optimal benefits with available resources.

Alberta↗
PubMed2006

Centralising drug review to improve coverage decisions: economic lessons from (and for) Canada.

Drug coverage decisions require information about clinically relevant benefits and risks, as well as economic information about direct and indirect costs, in comparison with relevant treatment alternatives. A recent Canadian initiative aims to improve the evidentiary basis for drug coverage decisions through centralised evaluation of the clinical and economic value of new drug products. Centralised review can make important, 'positive' contributions to decision making by raising the evidentiary basis for decisions. Even in the absence of a single-payer for medicines, such information can directly inform decisions focussed on matters of technical efficiency. Centralised review also provides necessary but not sufficient information for the many decisions in this sector that concern allocative efficiency and therefore have 'normative' implications. Thus, in addition to processes for collecting and critically assessing clinical and economic data, effective priority setting requires processes at a local level for engaging affected populations in the consideration of the trade-offs inherent in coverage decisions.

Canada↗
PubMed2005

The Common Drug Review: a NICE start for Canada?

Prescription drugs are one of the fastest growing cost components of modern health care systems. Efforts to control escalating costs while simultaneously maximizing population health outcomes have led many countries to implement restrictive criteria on the funding of certain drugs. While drugs are licensed for sale based on evidence of safety and efficacy versus a placebo, many funders now require evidence of clinical- and cost-effectiveness compared to existing drugs as part of their reimbursement criteria. In some countries, concerns about duplication of drug assessment and administrative effort across different jurisdictions have led to experimentation with various forms of centralized drug review processes. Centralized drug reviews strive to standardize, inform, and improve drug reimbursement decisions through critical assessments of comparative clinical- and cost-effectiveness. The ultimate objective is to inform formulary listing decisions that both maximize health outcomes and achieve good "value for money". This paper describes the Common Drug Review (CDR), a uniquely Canadian version of a centralized drug review process, and compares it with the much-studied National Institute for Health and Clinical Excellence (NICE) in the United Kingdom. Through this analysis, which draws on prior critiques and experiences of NICE, we highlight several critical issues for pharmaceutical priority setting that must be considered in the operation and appraisal of centralized drug review processes. These include the selection of drugs for review, centralized versus decentralized decision-making, receptor capacity at local decision making levels, and public participation.

Canada↗
PubMed2005

From the trenches: views from decision-makers on health services priority setting.

Due to resource scarcity, health organizations worldwide must decide what services to fund and, conversely, what services not to fund. One approach to priority setting, which has been widely used in Britain, Australia, New Zealand and Canada, is programme budgeting and marginal analysis (PBMA). To date, such activity has primarily been based at a micro level, within programmes of care. In order to institute and refine the PBMA framework at a macro level across major service areas within a single health authority, researchers and decision-makers in Alberta embarked on a participatory action research project together. This paper identifies key issues of importance to decision-makers in a real-world priority-setting context. Themes discussed include making comparisons across disparate patient groups, dealing with political factors, using relevant forms of evidence, recognizing innovations and involving the public. The in-depth insight gained through this qualitative analysis will enable future refinement of PBMA at a macro level in the health authority under study, and should also serve to inform priority-setting activity in regionalized contexts elsewhere. In identifying aspects of priority setting that are important to decision-makers, researchers can also be better informed with respect to real-world processes.

Alberta↗
PubMed2005

Priority-setting in health authorities: moving beyond the barriers. The Calgary experience.

The objective of this study was to identify key issues relevant to the development and implementation of a macro-level priority-setting framework (i.e., across broad service areas) within the Calgary Health Region. We used rigorous qualitative methods, including focus groups, meeting observations and interviews to identify views of decision-makers. Key issues relevant to macro-level priority-setting included: application of evidence, incentives, physician involvement, public involvement and application of values. Detailed insight into each of these issues was derived, including how best to handle related barriers to priority-setting in health organizations and important lessons for framework development. These lessons learned should provide insight for similar activity in other jurisdictions.

Alberta↗
PubMed2005

Can tissue transglutaminase antibody titers replace small-bowel biopsy to diagnose celiac disease in select pediatric populations?

OBJECTIVES: The use of screening tests for celiac disease has increased the number of patients referred for evaluation. We proposed that the subgroup of patients with very high tissue transglutaminase antibody (TTG) titers is positive for celiac disease and a small-bowel biopsy is not necessary to make the diagnosis. A gluten-free diet should be attempted and, if the patient's symptoms do not improve, then a biopsy should be performed to confirm the diagnosis. METHODS: A chart review of data for 103 patients who underwent both TTG testing and a small-bowel biopsy was performed. We examined the impact of using TTG values of >100 U and <20 U as cutoff values and suggested performing biopsies for patients with TTG values of 20 to 100 U, as is current practice. RESULTS: Fifty-eight of 103 patients demonstrated positive biopsy results. Forty-nine of 103 patients had TTG levels of >100 U, with 48 of 49 exhibiting positive biopsy results. Only 7 of 16 patients with TTG values of 20 to 100 U exhibited positive biopsy results. Three patients with TTG levels of <20 U had positive biopsies; 2 were IgA negative and 1 had a duodenal ulcer. With the cutoff values of >100 U and <20 U with known IgA status, the sensitivity was 0.980 (48 of 49 cases) and the specificity was 0.972 (35 of 36 cases). An incremental cost analysis found that this proposal could potentially decrease the costs of investigation and diagnosis by almost 30%. CONCLUSIONS: When the cutoff values were changed to >100 and <20 U and IgA levels were verified, the sensitivity and specificity were very high. Patients with mid-range TTG values (20-100 U) or values of <20 U with negative IgA status should continue to undergo biopsies for diagnosis of celiac disease.

Autoantibodies↗
PubMed2004

Setting priorities in the south west of Western Australia: where are we now?

Due to resource scarcity, health care decision makers must make choices about what services to fund. In exploring the potential for developing a formal approach to priority setting in the South West Area Health Service (SWAHS) in Western Australia, we carried out a qualitative survey of senior decision makers. Respondents indicated that resources were primarily allocated on the basis of historical patterns. Suggested improvements for priority setting include development of a transparent approach to priority setting, better intra-organisational communication, public input in the form of identifying social determinants of health, and having an organisational 'credible commitment' in planning processes.

Decision Making, Organizational↗
PubMed2004

A randomized trial of a single dose of oral dexamethasone for mild croup.

BACKGROUND: The benefits of dexamethasone treatment for moderate-to-severe croup are well established. However, most children with croup have mild symptoms, and it is unknown whether they would derive the same degree of benefit from dexamethasone treatment as children with more severe disease. METHODS: We conducted a double-blind trial at four pediatric emergency departments in which 720 children with mild croup were randomly assigned to receive one oral dose of either dexamethasone (0.6 mg per kilogram of body weight) or placebo. The children had mild croup, as defined by a score of < or =2 on the croup scoring system of Westley et al. The primary outcome was a return to a medical care provider for croup within seven days after treatment. The secondary outcome was the presence of ongoing symptoms of croup on days 1, 2, and 3 after treatment. Other outcomes included economic costs, hours of sleep lost by the child, and stress on the part of the parent in relation to the child's illness. RESULTS: Baseline clinical characteristics were similar in the two groups. Return to medical care was significantly lower in the dexamethasone group (7.3 percent vs. 15.3 percent, P<0.001). In the dexamethasone group, there was quicker resolution of croup symptoms (P=0.003), less lost sleep (P<0.001), and less stress on the part of the parent (P<0.001). CONCLUSIONS: For children with mild croup, dexamethasone is an effective treatment that results in consistent and small but important clinical and economic benefits. Although the long-term effects of this treatment are not known, our data support the use of dexamethasone in most, if not all, children with croup.

Administration, Oral↗
PubMed2004

Health care priority setting: principles, practice and challenges.

BACKGROUND: Health organizations the world over are required to set priorities and allocate resources within the constraint of limited funding. However, decision makers may not be well equipped to make explicit rationing decisions and as such often rely on historical or political resource allocation processes. One economic approach to priority setting which has gained momentum in practice over the last three decades is program budgeting and marginal analysis (PBMA). METHODS: This paper presents a detailed step by step guide for carrying out a priority setting process based on the PBMA framework. This guide is based on the authors' experience in using this approach primarily in the UK and Canada, but as well draws on a growing literature of PBMA studies in various countries. RESULTS: At the core of the PBMA approach is an advisory panel charged with making recommendations for resource re-allocation. The process can be supported by a range of 'hard' and 'soft' evidence, and requires that decision making criteria are defined and weighted in an explicit manner. Evaluating the process of PBMA using an ethical framework, and noting important challenges to such activity including that of organizational behavior, are shown to be important aspects of developing a comprehensive approach to priority setting in health care. CONCLUSION: Although not without challenges, international experience with PBMA over the last three decades would indicate that this approach has the potential to make substantial improvement on commonly relied upon historical and political decision making processes. In setting out a step by step guide for PBMA, as is done in this paper, implementation by decision makers should be facilitated.

Journal Article↗
PubMed2004

Physician involvement in setting priorities for health regions.

Although many authors have emphasized the importance of including physicians in organizational activities, especially in integrated delivery systems, much of the literature has focused on physician involvement in governance or as managers. In this paper, program budgeting and marginal analysis (PBMA) is suggested as a mechanism to link physicians into organizational decision-making processes. This research included a wide range of examples that demonstrate the versatility of PBMA, and many ways to involve physicians.

Alberta↗
PubMed2004

Evidence-based priority-setting: what do the decision-makers think?

OBJECTIVES: Resource scarcity dictates the need for health organisations to set priorities. Although such activity should be based, at least in part, on evidence, there are limited examples in the literature of decision-makers reflecting on their use of evidence in priority-setting. METHODS: A participatory action-research project was conducted in a single health authority in Alberta. It included in-depth interviews and focus groups with senior decision-makers both before and after development and implementation of a macro-level priority-setting framework (programme budgeting and marginal analysis, PBMA). Data were thematically coded and information on the use of evidence in priority-setting is reported. RESULTS: Barriers to the use of evidence in priority-setting identified by decision-makers included crisis-orientated management, time constraints and a lack of skills. Decision-makers suggested using a mix of 'soft' and 'hard' forms of evidence in priority-setting. Following PBMA implementation, decision-makers wanted better information on capacity to benefit, but preferred to do this pragmatically from multiple sources of information rather than using a single metric. CONCLUSION: In examining the perspectives of decision-makers in using evidence to support priority-setting, valuable information was derived which should provide insight for such processes in other jurisdictions. The main finding of a desire for pragmatic assessment of benefit is informative for those involved in both decision-making and research.

Alberta↗
PubMed2004

Listening to the decision makers: sustainability of PBMA in Alberta.

BACKGROUND: Decision makers within the Calgary Health Region adopted and applied programme budgeting and marginal analysis (PBMA) for priority-setting activity across major service portfolios within the Region. METHODS: Seventeen in-depth qualitative interviews were conducted with senior managers and clinicians to gain a user perspective and identify specific areas for process refinement. Data were thematically coded and categorised into relevant themes. RESULTS: Key strengths included a culture shift in thinking about the need to reallocate resources within a fixed funding envelope, whereas a key challenge identified was in putting forth genuine disinvestment options. Areas suggested for improvement included evoking an incentive system for stakeholder engagement and having a mechanism for tracking the effect of resource reallocations. CONCLUSIONS: Both an evidence-based approach to priority setting, as well as a way of thinking around managing resource scarcity, can be integrated into organisational processes. Findings reported in this article will influence further application in Calgary and should provide insight for those attempting such activity elsewhere.

Administrative Personnel↗
PubMed2004

Case study on priority setting in rural Southern Alberta: keeping the house from blowing in.

OBJECTIVE: This case study describes the priority-setting process undertaken by health care providers in the Municipal District of Taber, Alta., to improve and integrate chronic disease services within a fixed budget. METHODS: Providers first reviewed the current chronic disease management system, then considered alternatives based on program priorities and costs and benefits of potential changes. RESULTS: Despite reaching consensus that a chronic disease clinic was the top priority for funding, providers were unable to redesign services accordingly. Redesign efforts were hampered by the groups' difficulty in identifying services that should receive fewer resources in order to fund priority areas, inexperience with priority-setting frameworks, group composition, the belief that many programs were already at "bare bone" funding levels, and perceptions of limited budget control. In the end, recommendations were made to use attrition to release resources, establish multi-disciplinary teams and group visits, where appropriate, and relocate providers to a centralized location. Upon review of study outcomes, Taber providers were granted more decision-making authority. CONCLUSION: Overall, the use of a systematic priority-setting process, culminating in recommendations for action, has moved Taber providers closer to an integrated model of service delivery. It is recommended that formal priority-setting frameworks continue to be used in Taber for primary care renewal or at any level where consideration of existing evidence and projected costs is required.

Alberta↗