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Abstract Details
Eliciting Patient Views on the Allocation of Limited Healthcare Resources: A Deliberation on Hepatitis C Treatment in the Veterans Health Administration
BMC Health Serv Res. 2020 May 1;20(1):369. doi: 10.1186/s12913-020-05211-8.
Akbar K Waljee123, Kerry A Ryan4, Chris D Krenz4, George N Ioannou56, Lauren A Beste67, Monica A Tincopa8, Sameer D Saini9810, Grace L Su98, Maria E Arasim9, Patti T Roman9, Brahmajee K Nallamothu91011, Raymond De Vries4
Author information
1VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI, 48105, USA. awaljee@med.umich.edu.
2Michigan Medicine, Department of Internal Medicine, Division of Gastroenterology and Hepatology, 3912 Taubman Center, 1500 East Medical Center Drive, SPC 5362, Ann Arbor, MI, 48109-5362, USA. awaljee@med.umich.edu.
3Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), 2800 Plymouth Road, North Campus Research Complex (NCRC), Building 16, Ann Arbor, MI, 48109-2800, USA. awaljee@med.umich.edu.
4Center for Bioethics and Social Sciences in Medicine, University of Michigan Medical School, 2800 Plymouth Road, North Campus Research Complex, Bldg. 14, G016, Ann Arbor, MI, 48109-2800, USA.
5Veterans Affairs Puget Sound Healthcare System, 1660 South Columbian Way, Seattle, WA, 98108, USA.
6Division of Gastroenterology, Department of Medicine, University of Washington, 1959 NE Pacific St., Box 356424, Seattle, WA, 98195-6424, USA.
7Division of General Internal Medicine, University of Washington, Harborview Medical Center, 325 Ninth Ave, Box 359780, Seattle, WA, 98104, USA.
8Michigan Medicine, Department of Internal Medicine, Division of Gastroenterology and Hepatology, 3912 Taubman Center, 1500 East Medical Center Drive, SPC 5362, Ann Arbor, MI, 48109-5362, USA.
9VA Ann Arbor Health Services Research and Development Center of Clinical Management Research, 2215 Fuller Road, Mail Stop 152, Ann Arbor, MI, 48105, USA.
10Michigan Integrated Center for Health Analytics and Medical Prediction (MiCHAMP), 2800 Plymouth Road, North Campus Research Complex (NCRC), Building 16, Ann Arbor, MI, 48109-2800, USA.
11Michigan Medicine, Department of Internal Medicine, Division of Cardiovascular Medicine, 1500 East Medical Center Drive, SPC 5856, Ann Arbor, MI, 48109-5362, USA.
Free PMC article
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.
Conclusions: DD offered a robust and useful method for addressing the allocation of the scarce resource of CHC treatment. Participants were able to develop a modified version of the SF policy and offered diverse recommendations to promote fairness and improve quality of care for Veterans. DD is an effective approach for incorporating patient preferences and gaining valuable insights for critical healthcare policy decisions in resource-limited environments.