Disinvestment policy and the public funding of assisted reproductive technologies: outcomes of deliberative engagements with three key stakeholder groups

BMC Health Services Research

Adam G Elshaug¹  John R Moss³  Amber M Watt³  Annette J Braunack-Mayer³  Drew Carter³  Jackie M Street³  Janet E Hiller²  Katherine Hodgetts³ 

[1] Menzies Centre for Health Policy, Sydney School of Public Health, Sydney Medical School, The University of Sydney, Coppleson Building D02, Sydney, NSW 2006, Australia;School of Health Sciences, Faculty of Health, Arts and Design, Swinburne University of Technology, PO Box 218, Hawthorn, VIC, Australia;School of Population Health, The University of Adelaide, North Terrace, Adelaide, SA 5006, Australia

关键词: Assisted reproductive technology;    Disinvestment;    Discourse analysis;    Deliberative methods;    Evidence-based health policy;    Australia;   

Others  :  1131295
DOI  :  10.1186/1472-6963-14-204

 received in 2013-04-24, accepted in 2014-04-25,  发布年份 2014

【 摘 要 】

Background

Measures to improve the quality and sustainability of healthcare practice and provision have become a policy concern. In addition, the involvement of stakeholders in health policy decision-making has been advocated, as complex questions arise around the structure of funding arrangements in a context of limited resources. Using a case study of assisted reproductive technologies (ART), deliberative engagements with a range of stakeholder groups were held on the topic of how best to structure the distribution of Australian public funding in this domain.

Methods

Deliberative engagements were carried out with groups of ART consumers, clinicians and community members. The forums were informed by a systematic review of ART treatment safety and effectiveness (focusing, in particular, on maternal age and number of treatment cycles), as well as by international policy comparisons, and ethical and cost analyses. Forum discussions were transcribed and subject to thematic analysis.

Results

Each forum demonstrated stakeholders’ capacity to understand concepts of choice under resource scarcity and disinvestment, and to countenance options for ART funding not always aligned with their interests. Deliberations in each engagement identified concerns around ‘equity’ and ‘patient responsibility’, culminating in a broad preference for (potential) ART subsidy restrictions to be based upon individual factors rather than maternal age or number of treatment cycles. Community participants were open to restrictions based upon measures of body mass index (BMI) and smoking status, while consumers and clinicians saw support to improve these factors as part of an ART treatment program, as distinct from a funding criterion. All groups advocated continued patient co-payments, with measures in place to provide treatment access to those unable to pay (namely, equity of access).

Conclusions

Deliberations yielded qualitative, socially-negotiated evidence required to inform ethical, accountable policy decisions in the specific area of ART and health care more broadly. Notably, reductionist, deterministic characterizations of stakeholder ‘self-interest’ proved unfounded as each group sought to prioritise universal values (in particular, ‘equity’ and ‘responsibility’) over specific, within-group concerns. Our results - from an emotive case study in ART - highlight that evidence-informed disinvestment decision-making is feasible, and potentially less controversial than often presumed.

【 授权许可】

   
2014 Hodgetts et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Williams IP, Bryan S: Cost-effectiveness analysis and formulary decision making in England: findings from research. Soc Sci Med 2007, 65:2116-2129.
• [2]Mitton C, Patten S, Waldner H, Donaldson C: Priority setting in health authorities: a novel approach to a historical activity. Soc Sci Med 2003, 57:1653-1663.
• [3]Mackean G, Noseworthy T, Elshaug AG, Leggett L, Littlejohns P, Berezanski J, Clement F: Health technology reassessment: the art of the possible. Int J Technol Assess Health Care 2013, 29:418-423.
• [4]Gerdvilaite J, Nachtnebel A: Disinvestment: overview of disinvestment experiences and challenges in selected countries. Ludwig Boltzmann Institut fur Health Technology Assessment: HTA-Projektbericht; 2011.
• [5]Polisena J, Clifford T, Elshaug AG, Mitton C, Russell E, Skidmore B: Case studies that illustrate disinvestment and resource allocation decision-making in health care: a systematic review. Int J Technol Assess Health Care 2013, 20:1-11. Epub ahead of print
• [6]Watt AM, Hiller JE, Braunack-Mayer AJ, Moss JR, Buchan H, Wale J, Riitano DE, Hodgetts K, Street JM, Elshaug AG: The ASTUTE health study protocol: deliberative stakeholder engagements to inform implementation approaches to healthcare disinvestment. Implement Sci 2012, 7:101. BioMed Central Full Text
• [7]Watt AM, Willis CD, Hodgetts K, Elshaug AG, Hiller JE, The ASTUTE Health Study Group: Engaging clinicians in evidence-based disinvestment: role and perceptions of evidence. Int J Technol Assess Health Care 2012, 28:211-219.
• [8]Lomas J, Culyer T, McCutcheon C, McAuley L, Law S: Conceptualizing and combining evidence for health system guidance. Ottawa: Canadian Health Services Research Foundation; 2005.
• [9]Elshaug AG, Moss J, Littlejohns P, Karnon J, Merlin T, Hiller JE: Identifying existing health care services that do not provide value for money. Med J Aust 2009, 190:269-273.
• [10]Elshaug AG, Watt AM, Mundy L, Willis CD: Over 150 potentially low-value health care practices: an Australian study. Med J Aust 2012, 197:556-560.
• [11]Watt A, Elshaug A, Willis C, Hiller JE, The ASTUTE Health study group: Assisted reproductive technologies: a systematic review of safety and effectiveness to inform disinvestment policy. Health Policy 2011, 102:200-213.
• [12]Street JM, Hennessy S, Watt A, Hiller JE, Elshaug AG: News and social media: windows into community perspectives on disinvestment. Int J Technol Assess Health Care 2011, 27:376-383.
• [13]Carter D, Watt AM, Braunack-Mayer A, Elshaug AG, Moss JR, Hiller JE, The ASTUTE Health study group: Should there be a female age limit on public funding for assisted reproductive technology? differing conceptions of justice in resource allocation. J Bioeth Inq 2013, 10:79-91.
• [14]Griffiths A, Dyer S, Lord S, Pardy C, Fraser I, Eckermann S: A cost-effectiveness analysis of in-vitro fertilization by maternal age and number of treatment attempts. Hum Reprod 2010, 25:924-931.
• [15]Russell J, Greenhalgh T: Rhetoric, evidence and policymaking: a case study of priority setting in primary care. London: Research Department of Primary Care and Population Health, UCL; 2009.
• [16]Entwhistle V, Calnan M, Dieppe P: Consumer involvement in setting the health services research agenda: persistent questions of value. J Health Serv Res Policy 2008, 13:76-81.
• [17]Leneghan J: Involving the public in rationing decisions: the experience of citizens juries. Health Policy 1999, 49:45-61.
• [18]Davies C, Wetherell M, Barnett F: Citizens at the centre: deliberative participation in healthcare decisions. Bristol: Policy Press; 2006.
• [19]Tritter JQ, McCallum A: The snakes and ladders of user involvement: moving beyond Arnstein. Health Policy 2006, 76:158-168.
• [20]Carter D, Braunack-Mayer A: The appeal to nature implicit in certain restrictions on public funding for assisted reproductive technology. Bioethics 2011, 25:463-471.
• [21]Braunack-Mayer AJ, Street JM, Rogers WA, Givney R, Moss JR, Hiller JE, FluViews team: Including the public in pandemic planning: a deliberative approach. BMC Public Health 2010, 10:501. BioMed Central Full Text
• [22]Gillett WR, Peek JC, Herbison GP: Development of clinical priority access criteria for assisted reproduction and its evaluation on 1386 infertile couples in New Zealand. Hum Reprod 2012, 27:131-141.
• [23]Hendriks C, Dryzek JS, Hunold C: Turning up the heat: partisanship in deliberative innovation. Polit Stud 2007, 55:362-383.
• [24]Shapiro I: The state of democratic theory. Princeton University Press: Princeton; 2003.
• [25]Smith G, Wales C: Citizens’ juries and deliberative democracy. Polit Stud 2000, 48:51-65.
• [26]Carson L, Hartz-Karp J: Adapting and combining deliberative designs: Juries, Polls, and Forums. In The deliberative democracy handbook: strategies for effective civic engagement in the twenty-first century. Edited by Gastil J, Levine P. San Francisco: Jossey-Bass; 2005.
• [27]Chambers S: Deliberative democratic theory. Ann Rev Polit Sci 2003, 6:307-326.
• [28]Rogers W, Street JM, Braunack-Mayer A, Hiller JE, TheFluViews team: Pandemic influenza communication: views from a deliberative forum. Health Expect 2009, 12:331-342.
• [29]Braun V, Clarke V: Using thematic analysis in psychology. Qual Res Psychol 2006, 3:77-101.
• [30]O’Doherty K, Burgess M: Engaging the public on biobanks: outcomes of the BC biobank deliberation. Public Health Genomics 2009, 12:203-221.
• [31]Rauprich O, Berns E, Vollman J: Who should pay for assisted reproductive techniques? answers from patients, professionals and the general public in Germany. Hum Reprod 2010, 25:1225-1233.
• [32]Hodgetts K, Elshaug AG, Hiller JE: What counts and how to count it: physicians’ constructions of evidence in a disinvestment context. Soc Sci Med 2012, 75:2191-2199.
• [33]Mansbridge J, Bohman J, Chambers S, Estlund D, Føllesdal A, Fung A, Lafont C, Manin B, Martí J: The place of self-interest and the role of power in deliberative democracy. J Polit Philos 2010, 18:64-100.
• [34]Bolam B, Murphy S, Gleeson K: Individualization and inequalities in health: a qualitative study of class identity and health. Soc Sci Med 2004, 59:1355-1365.
• [35]Scutchfield FD, Ireson C, Hall L: The voice of the public in public health policy and planning: the role of public judgement. J Public Health Policy 2004, 25:197-205.
• [36]Dawson A, Diedrich K, Felberbaum R: Why do couples refuse or discontinue ART? Arch Gynecol Obstet 2005, 273:3-11.
• [37]Haas MR, Hall JP, Viney RC, Gallego G: Breaking up is hard to do: why disinvestment in medical technology is harder than investment. Aust Health Rev 2012, 36:148-152.