PubMed Health⌕ Search

Biomedical subjects

Douglas K Martin

Publications and source records attributed to Douglas K Martin.

At least 19 recordsLinked to original sources
PubMed2005

What do hospital decision-makers in Ontario, Canada, have to say about the fairness of priority setting in their institutions?

BACKGROUND: Priority setting, also known as rationing or resource allocation, occurs at all levels of every health care system. Daniels and Sabin have proposed a framework for priority setting in health care institutions called 'accountability for reasonableness', which links priority setting to theories of democratic deliberation. Fairness is a key goal of priority setting. According to 'accountability for reasonableness', health care institutions engaged in priority setting have a claim to fairness if they satisfy four conditions of relevance, publicity, appeals/revision, and enforcement. This is the first study which has surveyed the views of hospital decision makers throughout an entire health system about the fairness of priority setting in their institutions. The purpose of this study is to elicit hospital decision-makers' self-report of the fairness of priority setting in their hospitals using an explicit conceptual framework, 'accountability for reasonableness'. METHODS: 160 Ontario hospital Chief Executive Officers, or their designates, were asked to complete a survey questionnaire concerning priority setting in their publicly funded institutions. Eight-six Ontario hospitals completed this survey, for a response rate of 54%. Six close-ended rating scale questions (e.g. Overall, how fair is priority setting at your hospital?), and 3 open-ended questions (e.g. What do you see as the goal(s) of priority setting in your hospital?) were used. RESULTS: Overall, 60.7% of respondents indicated their hospitals' priority setting was fair. With respect to the 'accountability for reasonableness' conditions, respondents indicated their hospitals performed best for the relevance (75.0%) condition, followed by appeals/revision (56.6%), publicity (56.0%), and enforcement (39.5%). CONCLUSIONS: For the first time hospital Chief Executive Officers within an entire health system were surveyed about the fairness of priority setting practices in their institutions using the conceptual framework 'accountability for reasonableness'. Although many hospital CEOs felt that their priority setting was fair, ample room for improvement was noted, especially for the enforcement condition.

Attitude of Health Personnel↗
PubMed2004

SARS and hospital priority setting: a qualitative case study and evaluation.

BACKGROUND: Priority setting is one of the most difficult issues facing hospitals because of funding restrictions and changing patient need. A deadly communicable disease outbreak, such as the Severe Acute Respiratory Syndrome (SARS) in Toronto in 2003, amplifies the difficulties of hospital priority setting. The purpose of this study is to describe and evaluate priority setting in a hospital in response to SARS using the ethical framework 'accountability for reasonableness'. METHODS: This study was conducted at a large tertiary hospital in Toronto, Canada. There were two data sources: 1) over 200 key documents (e.g. emails, bulletins), and 2) 35 interviews with key informants. Analysis used a modified thematic technique in three phases: open coding, axial coding, and evaluation. RESULTS: Participants described the types of priority setting decisions, the decision making process and the reasoning used. Although the hospital leadership made an effort to meet the conditions of 'accountability for reasonableness', they acknowledged that the decision making was not ideal. We described good practices and opportunities for improvement. CONCLUSIONS: 'Accountability for reasonableness' is a framework that can be used to guide fair priority setting in health care organizations, such as hospitals. In the midst of a crisis such as SARS where guidance is incomplete, consequences uncertain, and information constantly changing, where hour-by-hour decisions involve life and death, fairness is more important rather than less.

Attitude of Health Personnel↗
PubMed2004

Setting priorities in health care organizations: criteria, processes, and parameters of success.

BACKGROUND: Hospitals and regional health authorities must set priorities in the face of resource constraints. Decision-makers seek practical ways to set priorities fairly in strategic planning, but find limited guidance from the literature. Very little has been reported from the perspective of Board members and senior managers about what criteria, processes and parameters of success they would use to set priorities fairly. DISCUSSION: We facilitated workshops for board members and senior leadership at three health care organizations to assist them in developing a strategy for fair priority setting. Workshop participants identified 8 priority setting criteria, 10 key priority setting process elements, and 6 parameters of success that they would use to set priorities in their organizations. Decision-makers in other organizations can draw lessons from these findings to enhance the fairness of their priority setting decision-making. SUMMARY: Lessons learned in three workshops fill an important gap in the literature about what criteria, processes, and parameters of success Board members and senior managers would use to set priorities fairly.

Academic Medical Centers↗
PubMed2004

Can a "good death" be made better?: A preliminary evaluation of a patient-centred quality improvement strategy for severely ill in-patients.

BACKGROUND: Prior studies attempting to improve end-of-life care have focused on specific outcomes deemed important to healthcare providers, with disappointing results. Improvement may be best achieved by identifying concerns important to individual patients, communicating the patients' concerns to the treating medical team, and repeating the process frequently until all concerns are addressed. Our objective was to conduct a preliminary evaluation of this innovative patient-centred quality improvement strategy. METHODS: Initial interviews elicited participants' ideas for improvement, which were then fed back to health care providers by the study investigator. A rapid-cycle change model ensured frequent reassessment and continued feedback. The study involved 36 seriously ill, hospitalized patients on teaching general medical inpatient units of a tertiary care hospital. The main outcome measure was participants' ratings of satisfaction within different domains of care on follow-up interviews. RESULTS: The proportion of participants who rated various aspects of their care as "excellent" or "very good" on initial interview was 72% for overall care, 64% for symptom control, 66% for level of support, and 75% for discussions about life sustaining treatments. Patients and families identified many actionable steps for improvement such as; better control of pain and shortness of breath, better access to physicians and medical information, more help with activities of daily living, improving the patient's environment, and shorter waits for nursing care, diagnosis, and treatment. Following feedback to the clinical team, participants reported improvement in overall care (32%), symptom control (44%), and support (40%). Only a minority had further discussions about life sustaining treatments. CONCLUSION: A patient-centred approach using rapid-cycle change was feasible and shows promise for improving the quality of end-of-life care. It should be evaluated on a larger sample in a controlled trial.

Journal Article↗
PubMed2004

Stakeholders' views about cardiac report cards: a qualitative study.

CONTEXT: Health care report cards provide stakeholders with information on health care outcomes and other measures of care. Report cards are most well developed in cardiac care. A necessary first step to ground the development of cardiac report cards in actual experience is to understand the views of those most closely involved. To date, there has been no systematic description of stakeholders' views. OBJECTIVE: To describe stakeholders' views about cardiac report cards. DESIGN: The present study involved qualitative person-to-person interviews with 58 stakeholders from seven Canadian cities with major cardiac programs: Vancouver, Calgary, London, Toronto, Ottawa, Montreal and Halifax. PARTICIPANTS: A total of 58 participants from six stakeholder groups in cardiac care consisting of 15 administrators, 13 nurses, 12 cardiologists, seven outcomes researchers, six cardiac surgeons and five members of the media who report on health care. OUTCOME MEASURES: Participants' views and expectations of cardiac report cards were analyzed and organized into themes. RESULTS: The views of stakeholders on cardiac report cards were organized according to four themes: PURPOSE: Participants identified two purposes--accountability for quality care as well as public education and informed decision-making; DEVELOPMENT: Participants thought that the development of report cards should involve multistakeholder collaboration; CONTENT: Participants discussed three concepts--context, level of reporting and data; and Dissemination: Mechanisms discussed include the Internet, media and directly to health care providers. CONCLUSIONS: The views of stakeholders regarding cardiac report cards can be the basis of an evidence-based conceptual framework that can guide in the development, implementation and delivery of cardiac report cards. In the present study, the views of cardiologists, cardiac surgeons, cardiac nurses, administrators, outcomes researchers and members of media are described. A next step is to explore the views of cardiac patients.

Attitude of Health Personnel↗
PubMed2004

Ethical issues related to cardiac report cards.

Health care report cards are gaining a high profile among policy makers, clinicians and the public, and are most well developed in the context of cardiac care. Although there are important ethical issues relevant to developing and implementing cardiac report cards, there currently is no explicit examination of these issues. As a consequence, outcomes researchers lack ethical guidance while designing and implementing cardiac report cards. This paper will examine four key ethical issues related to cardiac report cards: quality, informed consent, equity and legitimacy. Cardiac report cards may help improve the quality of cardiac care, help cardiac patients make informed decisions and guide interventions to enhance regional equity in cardiac care. To achieve these important goals, different types of report cards may be required. However, to achieve these goals, cardiac report cards must be legitimate. To push forward the report card initiative, a close relationship among stakeholders is encouraged, ie, among those developing cardiac report cards, those whom report cards evaluate and the intended audiences of report cards.

Canada↗
PubMed2004

The leap to trust: perspective of cholecystectomy patients on informed decision making and consent.

BACKGROUND: Although experts in ethics and law prescribe autonomous decision making as an essential component of informed consent to operative treatment, patients with esophageal cancer told us in a previous study that they preferred to entrust decision making to their caregivers in the context of life-threatening illness. The purpose of this study was to describe the patients' perspective on the process of informed decision making and consent to operative treatment in the context of a less frightening illness and intervention. STUDY DESIGN: Face-to-face interviews with 33 patients recovering from elective cholecystectomy for cholelithiasis were conducted at Toronto General Hospital in Ontario, Canada. The views of patients were analyzed using a qualitative approach. RESULTS: Patients described a spectrum of initial attitudes toward operative treatment ranging from profound distrust to unquestioning faith. Important factors influencing the decision to accept cholecystectomy included increasingly intolerable symptoms and fear of complications of the disease. Patients managed their doubts and fear by various means, without fully resolving them. CONCLUSIONS: In the context of symptomatic chronic cholelithiasis, pathways to consent for operative treatment originated at diverse, culturally determined starting points. Patients work their way through the decision process along many paths. Some rely on gathering information, but eventually all set aside unresolved residual doubts and fears, enabling a leap to trust and a decision to act.

Adult↗
PubMed2004

A qualitative study of attitudes toward error in patients facing brain tumour surgery.

BACKGROUND: Medical error is an extremely important component of patient safety and requires intense study. The present investigation undertook to examine patients' perceptions and attitudes regarding medical error. METHODS: Qualitative case study methodology was used. We conducted 30 face-to-face interviews with patients within one week of undergoing a neurosurgical operation for a brain tumour. Interviews were audiotaped and transcribed and the data subjected to thematic analysis. RESULTS: Three overarching themes emerged from the data: 1) trust in the patient's surgeon was of paramount importance; 2) patients' views toward medical error varied between fear and vulnerability to no concern; and 3) discussion of error was felt to be beneficial as it could help the medical profession decrease future errors and could help dispel the patient's fear and anxiety about the upcoming surgery. CONCLUSIONS: Patients' trust in their physician/surgeon is of paramount importance in allaying their fears about the possible occurrence and impact of medical error during their treatment. The level of concern about error varies among patients, but most felt that discussion of error was a good thing.

Adolescent↗
PubMed2003

Interdisciplinary research: putting the methods under the microscope.

BACKGROUND: While the desirability of interdisciplinary inquiry has been widely acknowledged, indeed has become 'the mantra of science policy', the methods of interdisciplinary collaboration are opaque to outsiders and generally remain undescribed. DISCUSSION: Many have analysed interdisciplinarity, especially in relation to the creation of new disciplines and institutions. These analyses are briefly outlined. Still, there currently persists a silence about the methods of interdisciplinary collaboration itself, and the core of this paper proposes a template for such methods. SUMMARY: Breaking this silence--by making the methods of interdisciplinary projects transparent--could further invigorate interdisciplinary research.

Academies and Institutes↗
PubMed2003

Priority setting in surgery: improve the process and share the learning.

Surgeons and surgical programs encounter priority-setting challenges every day, such as in regard to purchasing new technologies or managing waiting lists for elective surgery. The purpose of this paper was to explore priority setting in surgery. Traditionally in surgery, priority-setting decisions for new technologies have been based on evidence of effectiveness and cost-effectiveness; and decisions about managing waiting lists for elective surgery have been based on urgency rating scores. The fairness of priority-setting processes in surgical programs should be enhanced to permit all relevant information and values to be considered. The quality of these decisions can be improved by using an approach that captures and shares lessons from each priority-setting experience. The approach we propose in this paper- describe, evaluate, and improve using a leading conceptual framework for priority setting, called "accountability for reasonableness"-can be used by any surgical program to improve its priority setting, share lessons with others, and develop an evidence base for how these important health policy decisions should be made.

Biomedical Technology↗
PubMed2003

Priority setting in a hospital drug formulary: a qualitative case study and evaluation.

Dramatically rising costs for new drugs are posing major challenges for hospital budgets. In response to these pressures, hospitals must set priorities for which drugs they will list on their formularies. While there have been studies relevant to decision making in hospitals regarding drugs, none have described how priority setting for drugs in hospitals is done and evaluated it against a framework of how it should be done. In this paper we describe the process of priority setting for new drugs in a hospital formulary and evaluate it using a leading conceptual framework for healthcare priority setting--Daniels and Sabin's 'accountability for reasonableness'. The findings from this study provide an evidence base for developing strategies to improve this hospital's priority setting regarding its drug formulary. The process we utilized here, describing using case study methods and evaluating using 'accountability for reasonableness', is a generalizable process for improving the fairness of priority setting in hospital drug formularies.

Data Collection↗
PubMed2003

Seasonal bed closures in an intensive care unit: a qualitative study.

OBJECTIVE: To describe perceptions of the administrative procedures for seasonal bed closures and their consequences in the intensive care unit (ICU), and to critique this example of health care priority setting for legitimacy and fairness. DESIGN: A qualitative study using case study methods and interviews with key participants. We evaluated fairness and legitimacy of the bed closure process using 4 domains of the ethical framework of "accountability for reasonableness." SETTING: An university-affiliated medical/surgical ICU in Eastern Canada. PARTICIPANTS: ICU clinicians (9 bedside nurses and 5 physicians), and administrators (3 ICU managers and 2 senior hospital executives). MAIN OUTCOME MEASURES: Perceptions of ICU clinicians and administrators regarding the ICU bed closure decision-making process and its consequences. RESULTS: Emerging themes concerned: (1) bed closure rationale (including arbitrary decision making, bed closure masquerading as a code for a nursing shortage, and suboptimal evidence base for implementing closures); (2) bed closure process (viewed as unclear with insufficient prior publicity and inadequate subsequent review); and (3) adverse consequences (including safety issues, negative professional working relationships, and poor morale). Although an appeals mechanism existed, nurses were not available to staff reopened beds so this condition is only partially met. The relevance, publicity, and enforcement conditions for accountability of reasonableness were not satisfied, offering opportunities for improvement. CONCLUSION: Clinicians and administrators are readily able to identify shortcomings in the seasonal bed closure process in the ICU. These shortcomings should be targeted for improvement so that intensive care health services delivery is legitimate and fair.

Decision Making↗
PubMed2003

Priority setting in a hospital critical care unit: qualitative case study.

OBJECTIVE: To describe priority setting for admissions in a hospital critical care unit and to evaluate it using the ethical framework of "accountability for reasonableness. DESIGN: Qualitative case study and evaluation using the ethical framework of accountability for reasonableness. SETTING: A medical/surgical intensive care unit in a large urban university-affiliated teaching hospital in Toronto, Canada. PARTICIPANTS: Critical care unit staff including medical directors, nurses, residents, referring physicians, and members of a hospital committee that formulated an admissions policy. INTERVENTIONS: Modified thematic analysis of documents, interviews with participants, and direct observation of critical care unit rounds. Evaluation using the four conditions of Daniels and Sabin's accountability for reasonableness: relevance, publicity, appeals/revisions, and enforcement. MEASUREMENTS AND MAIN RESULTS: We examined key features and participants' views about the priority setting process. Decisions to admit patients involve a complex cluster of reasons. Both medical and nonmedical reasons are used, although the nonmedical reasons are less well documented and understood. Medical directors, who are the chief decision makers, differ in their reasoning. Admitting decisions and reasons are usually explained to referring staff but seldom to patients and families, and nonmedical reasons are seldom surfaced. A hospital critical care admissions policy exists but is not used and is not known to all stakeholders. A formal appeals/revisions process exists, but appeals usually involve informal negotiations. The existence of priority programs in the hospital (e.g., transplantation) adds complexity and heightens disagreement by stakeholders. CONCLUSION: We have described and evaluated admissions decision making in a hospital's critical care unit. The key lesson of our study is not only the specific findings obtained here but also how combining a case study approach with the ethical framework of "accountability for reasonableness" can be used to identify good practices and opportunities for improving the fairness of priority setting in intensive care.

Attitude of Health Personnel↗
PubMed2002

Priority setting for new technologies in medicine: a transdisciplinary study.

BACKGROUND: Decision makers in health care organizations struggle with how to set priorities for new technologies in medicine. Traditional approaches to priority setting for new technologies in medicine are insufficient and there is no widely accepted model that can guide decision makers. DISCUSSION: Daniels and Sabin have developed an ethically based account about how priority setting decisions should be made. We have developed an empirically based account of how priority setting decisions are made. In this paper, we integrate these two accounts into a transdisciplinary model of priority setting for new technologies in medicine that is both ethically and empirically based. SUMMARY: We have developed a transdisciplinary model of priority setting that provides guidance to decision makers that they can operationalize to help address priority setting problems in their institution.

Consensus↗
PubMed2002

Fairness, accountability for reasonableness, and the views of priority setting decision-makers.

Fairness is a key goal of priority setting and 'accountability for reasonableness' has emerged as the leading framework for fair priority setting. However, it has not been shown acceptable to those engaged in priority setting. In particular, since it was developed in the context of a primarily privately funded health system, its applicability in a primarily publicly funded system is uncertain. In this paper, we describe elements of fairness identified by decision-makers engaged in priority setting for new technologies in Canada (a primarily publicly funded system). According to these decision makers, accountability for reasonableness is acceptable and applicable. Our findings also provide refinements to accountability for reasonableness.

Advisory Committees↗
PubMed2002

Top ten biotechnologies for improving health in developing countries.

Most research into genomics and other related biotechnologies is concerned with the priorities of industrialized nations, and yet a limited number of projects have shown that these technologies could help improve health in developing countries. To encourage the successful application of biotechnology to global health, we carried out a study in which we asked an international group of eminent scientists with expertise in global health issues to identify the top ten biotechnologies for improving health in developing countries. The results offer concrete guidance to those in a position to influence the direction of research and development, and challenge common assumptions about the relevance and affordability of biotechnology for developing countries.

Biotechnology↗