Priority setting: what constitutes success? A conceptual framework for successful priority setting

BACKGROUND: The sustainability of healthcare systems worldwide is threatened by a growing demand for services and expensive innovative technologies. Decision makers struggle in this environment to set priorities appropriately, particularly because they lack consensus about which values should guide their decisions. One way to approach this problem is to determine what all relevant stakeholders understand successful priority setting to mean. The goal of this research was to develop a conceptual framework for successful priority setting. METHODS: Three separate empirical studies were completed using qualitative data collection methods (one-on-one interviews with healthcare decision makers from across Canada; focus groups with representation of patients, caregivers and policy makers; and Delphi study including scholars and decision makers from five countries). RESULTS: This paper synthesizes the findings from three studies into a framework of ten separate but interconnected elements germane to successful priority setting: stakeholder understanding, shifted priorities/reallocation of resources, decision making quality, stakeholder acceptance and satisfaction, positive externalities, stakeholder engagement, use of explicit process, information management, consideration of values and context, and revision or appeals mechanism. CONCLUSION: The ten elements specify both quantitative and qualitative dimensions of priority setting and relate to both process and outcome components. To our knowledge, this is the first framework that describes successful priority setting. The ten elements identified in this research provide guidance for decision makers and a common language to discuss priority setting success and work toward improving priority setting efforts

Priority setting in developing countries health care institutions: the case of a Ugandan hospital

BACKGROUND: Because the demand for health services outstrips the available resources, priority setting is one of the most difficult issues faced by health policy makers, particularly those in developing countries. However, there is lack of literature that describes and evaluates priority setting in these contexts. The objective of this paper is to describe priority setting in a teaching hospital in Uganda and evaluate the description against an ethical framework for fair priority setting processes – Accountability for Reasonableness. METHODS: A case study in a 1,500 bed national referral hospital receiving 1,320 out patients per day and an average budget of US$ 13.5 million per year. We reviewed documents and carried out 70 in-depth interviews (14 health planners, 40 doctors, and 16 nurses working at the hospital). Interviews were recorded and transcribed. Data analysis employed the modified thematic approach to describe priority setting, and the description was evaluated using the four conditions of Accountability for Reasonableness: relevance, publicity, revisions and enforcement. RESULTS: Senior managers, guided by the hospital strategic plan make the hospital budget allocation decisions. Frontline practitioners expressed lack of knowledge of the process. Relevance: Priority is given according to a cluster of factors including need, emergencies and patient volume. However, surgical departments and departments whose leaders "make a lot of noise" are also prioritized. Publicity: Decisions, but not reasons, are publicized through general meetings and circulars, but this information does not always reach the frontline practitioners. Publicity to the general public was through ad hoc radio programs and to patients who directly ask. Revisions: There were no formal mechanisms for challenging the reasoning. Enforcement: There were no mechanisms to ensure adherence to the four conditions of a fair process. CONCLUSION: Priority setting decisions at this hospital do not satisfy the conditions of fairness. To improve, the hospital should: (i) engage frontline practitioners, (ii) publicize the reasons for decisions both within the hospital and to the general public, and (iii) develop formal mechanisms for challenging the reasoning. In addition, capacity strengthening is required for senior managers who must accept responsibility for ensuring that the above three conditions are met

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

Fungal plant pathogens and soil biodiversity

The role of biodiversity as it affects the control of soil-borne fungal pathogens is discussed. Soil-borne fungal plant pathogens have often proven difficult to manage with conventional methods of disease control. Nonetheless, researchers have characterized several naturally occurring “disease-suppressive” soils where crop loss from disease is less than would otherwise be expected. Suppressive soils can also result from the incorporation of various amendments into soil. In most cases, disease control in such soils has been shown to be biological in nature; that is, soil organisms appear to directly or indirectly inhibit the development of disease. Increased knowledge of the identity and functioning of these organisms may support the development of techniques that can be used to develop suppressiveness in soils that are otherwise disease-conducive. Populations of pathogens themselves have been shown to exhibit considerable genetic diversity; the ability of populations to respond to disease control measures should be considered when developing a management strategy. New molecular techniques can be exploited to better characterize soil communities, including the pathogens themselves, as well as community responses to various disease control options. The contributions of Canadian researchers to these areas are discussed and models for further study are proposed. Key words: Biocontrol, molecular technologies, functional diversity, integrated pest management </jats:p

Selection of strains of <i>Epicoccum purpurascens</i> for tolerance to fungicides and improved biocontrol of <i>Sclerotinia sclerotiorum</i>

A wild-type isolate of Epicoccum purpurascens was exposed to shortwave ultraviolet light. One of the resulting cultures (M-20-A) was grown on media amended with the fungicides iprodione or vinclozolin and fungicide-tolerant strains were obtained. Several comparisons were made between new strains and the wild type. Sporulation was improved compared with the wild type. Strains varied in their tolerance to iprodione and vinclozolin but were not tolerant to the fungicide benomyl. Strains R4000, 16-B, and 7-A inhibited Sclerotinia sclerotiorum in vitro more than either the wild type or M-20-A, and exhibited improved control of white mold of bean in the greenhouse compared with M-20-A. Key words: biological control, fungicide resistance, white mold, iprodione, vinclozolin. </jats:p

Effects of the pesticides maneb and carbaryl on the phylloplane microflora of lettuce

The effects of the fungicide maneb and the insecticide carbaryl on the microflora of lettuce leaves were studied in field plots in 1983 and 1984. In 1983, populations of filamentous fungi were significantly, but temporarily, reduced by a single application of maneb. This treatment did not reduce populations in 1984; however, two additional applications of maneb did result in a significant decline in fungal populations when compared with unsprayed plants. Maneb had no effect on bacterial populations in either year. Carbaryl altered neither bacterial nor fungal populations. Pesticide applications did not change the composition of the microflora. Phoma and Fusarium spp. were the fungi most frequently isolated from lettuce leaves. </jats:p

Influence of nutrients on growth of<i>Epicoccum nigrum</i>

Epicoccum nigrum is a potential biological control agent for certain plant diseases, such as white mold of bean caused by Sclerotinia sclerotiorum. To provide information that could be used to improve the production and efficacy of E. nigrum, the effects of nutrients, including specific carbohydrate sources and amino acids, on mycelial growth, sporulation, germination of conidia, and elongation of germ tubes were determined. In dual cultures of E. nigrum and S. sclerotiorum, the effects of nutrients on widths of inhibition zones between the two fungi were assessed. Standard mycological media supported faster radial growth than media with single carbohydrate sources and individual amino acids, but glutamic acid combined with maltose or dextrose was similar with respect to stimulation of sporulation when compared with media such as V8 juice and yeast extract agars. Dual culture inhibition zones were greater in certain simple media (dextrose and lysine, sucrose and lysine, and maltose and lysine) than in standard media. For germination and germ tube elongation, sucrose and maltose were superior to most other carbohydrate sources tested, and lysine and glutamic acid were superior amino acid sources. When standard broth media were compared for production of antifungal compounds by E. nigrum, both potato dextrose broth and malt extract broth were superior to Czapek solution. Culture filtrates of E. nigrum grown in potato dextrose broth were more inhibitory towards S. sclerotiorum than filtrates from malt extract cultures.Key words: biological control, white mold, Epicoccum purpurascens, antibiosis.</jats:p