Hodgetts Katherine, Hiller Janet E, Street Jackie M, Carter Drew, Braunack-Mayer Annette J, Watt Amber M, Moss John R, Elshaug Adam G
Menzies Centre for Health Policy, Sydney School of Public Health, Sydney Medical School, The University of Sydney, Coppleson Building D02, Sydney, NSW 2006, Australia.
BMC Health Serv Res. 2014 May 5;14:204. doi: 10.1186/1472-6963-14-204.
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.
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.
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).
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.
提高医疗实践与服务的质量及可持续性的措施已成为政策关注点。此外,由于在资源有限的情况下,围绕资金安排结构出现了复杂问题,因此提倡利益相关者参与卫生政策决策。通过辅助生殖技术(ART)的案例研究,就如何优化澳大利亚该领域公共资金分配这一主题,与一系列利益相关者群体进行了审议性交流。
与ART消费者、临床医生和社区成员群体进行了审议性交流。这些论坛以对ART治疗安全性和有效性的系统评价(尤其关注产妇年龄和治疗周期数)、国际政策比较以及伦理和成本分析为依据。论坛讨论内容被转录并进行了主题分析。
每个论坛都表明,利益相关者有能力理解资源稀缺和撤资情况下的选择概念,并接受ART资金选项,这些选项并不总是与他们的利益一致。每次交流中的审议都确定了围绕“公平”和“患者责任”的问题,最终普遍倾向于(可能的)ART补贴限制应基于个体因素,而非产妇年龄或治疗周期数。社区参与者对基于体重指数(BMI)和吸烟状况的限制持开放态度,而消费者和临床医生则将改善这些因素的支持视为ART治疗计划的一部分,这与资金标准不同。所有群体都主张继续让患者共同支付费用,并采取措施确保无法支付费用的人能够获得治疗(即获得治疗的公平性)。
审议产生了定性的、经过社会协商的证据,可为ART及更广泛医疗保健特定领域的符合伦理、可问责的政策决策提供参考。值得注意的是,事实证明,对利益相关者“自身利益”的简化、确定性描述毫无根据,因为每个群体都试图将普遍价值观(特别是“公平”和“责任”)置于特定的群体内部关切之上。我们从ART这一情绪化案例研究中得出的结果表明,基于证据的撤资决策是可行的,而且可能不像通常认为的那样具有争议性。