Eliciting patient views on the allocation of limited healthcare resources: a deliberation on hepatitis C treatment in the Veterans Health Administration

Abstract

Background: In response to the development of highly effective but expensive new medications, policymakers, payors, and health systems are considering novel and pragmatic ways to provide these medications to patients. One approach is to target these treatments to those most likely to benefit. However, to maximize the fairness of these policies, and the acceptance of their implementation, the values and beliefs of patients should be considered. The provision of treatments for chronic hepatitis C (CHC) in the resource-constrained context of the Veterans Health Administration (VHA) offered a real-world example of this situation, providing the opportunity to test the value of using Democratic Deliberation (DD) methods to solicit the informed opinions of laypeople on this complex issue. Methods: We recruited Veterans (n = 30) from the VHA to attend a DD session. Following educational presentations from content experts, participants engaged in facilitated small group discussions to: 1) identify strategies to overcome CHC treatment barriers and 2) evaluate, vote on, and modify/improve two CHC treatment policies-"first come, first served" (FCFS) and "sickest first" (SF). We used transcripts and facilitators' notes to identify key themes from the small group discussions. Additionally, participants completed pre-and post-DD surveys. Results: Most participants endorsed the SF policy over the FCFS policy, emphasizing the ethical and medical appropriateness of treating the sickest first. Concerns about SF centered on the difficulty of implementation (e.g., how is "sickest" determined?) and unfairness to other Veterans. Proposed modifications focused on: 1) the need to consider additional health factors, 2) taking behavior and lifestyle into account, 3) offering education and support, 4) improving access, and 5) facilitating better decision-making.

Patient Values and Preferences for Managing Acute Dental Pain Elicited through Online Deliberation

“…Outside of dentistry, several methods are used for collecting PVP data during CPG development, including clinician testimony, literature searches, patient representation on guideline panels, surveys, and focus groups (Pahlke et al 2020). Outside of CPG development, public deliberation methods have been employed for close to 30 y in health care and health policy contexts to solicit views for a range of purposes, including allocation of scarce resources, assessment of risks and trade-offs, development of policy recommendations, and setting priorities (Carman et al 2013;Siegel et al 2013;Daugherty Biddison et al 2014;Morain et al 2017;Waljee et al 2020). CGA is an example of a "Brief Citizen's Deliberation" (Carman et al 2015), which incorporates the key elements of deliberative engagementaccess to expert information, facilitated small group engagement, participants' consideration of different options along with their trade-offs and possible consequences, and reporting and sharing of results-in 1 session of about 2 h; it was developed to expand opportunities for nonexperts to deliberate in community and educational settings (Dillard and Felts 2022).…”

Best Practices for an Equitable Covid-19 Vaccination Program

“…We created scripting for telephone staff on the basis of prior research suggesting that veterans prefer a sickest-first allocation strategy for limited health care resources. 18 An important hurdle was the large staffing resources needed to support personalized telephone outreach. This was made possible by repurposing staff whose typical duties were on hiatus because of the pandemic, as well as by authorization from hospital leadership to allow overtime.…”

Patients’ Willingness to Share Limited Endoscopic Resources: A Brief Report on the Results of a Large Regional Survey

“…It is possible that such conversations could appeal to one's sense of altruism (an intentional act performed to benefit another person as the primary motivation). 9 Altruism has been studied in a variety of domains in health care (e.g., judicious use of antibiotics to prevent antimicrobial resistance, public health benefits of vaccinations, and cost-prohibitive treatment of hepatitis C), [10][11][12][13] but not in CRC screening. This issue is of renewed relevance in the current COVID-19 recovery phase, when endoscopy units are working to reduce backlogs and there is a guideline-recommended alternative available-fecal immunochemical testing-which is not always known to patients.…”