Aumann Ines, Litzkendorf Svenja, Damm Kathrin, von der Schulenburg J Matthias Graf
Center for Health Economics Research Hannover (CHERH), Leibniz Universität Hannover, Deutschland.
Center for Health Economics Research Hannover (CHERH), Leibniz Universität Hannover, Deutschland.
Z Evid Fortbild Qual Gesundhwes. 2017 Aug;125:3-13. doi: 10.1016/j.zefq.2017.04.010. Epub 2017 Jul 8.
BACKGROUND/OBJECTIVE: In the face of rising expenditure among statutory sickness funds in Germany it is necessary to start a discussion about priority setting in the healthcare system. For a long time this issue has been avoided in healthcare debates. As a result, normative directives are still missing, which can lead to priority setting among healthcare providers in daily healthcare practice. Prioritization can be conducted at three different levels: at the government (macro), the institutional (meso), and the patient (micro) level. Surveys about societal preferences for different criteria exist; however, specifications on their respective weighting in the situation of approval and reimbursement of pharmaceuticals (meso) are missing. For this reason, the present study analyzed the implementation and weighting of the criteria for priority setting at the meso level, taking values and experiences of the participants into account.
Six qualitative focus groups were carried out with representatives from the fields of medicine, ethics, public health and economics. During the discussions four fictitious drugs for the treatment of different lung diseases were prioritized based on guidelines. The discussion processes were analyzed according to Bohnsack's documentary method.
The criteria "quality of life", "life expectancy" and "other patient-relevant outcomes" were discussed in relation to each other. The evaluation of change in patient-relevant outcomes was difficult to perform for non-medical participants. The second argument concerned the criteria "costs", disease severity and "number of patients". Costs were given less weight, but were often used to support other criteria. Other challenges in reaching a consensus included emerging role conflicts between profession and personal opinion, and the transfer of the discussion to a different level of decision-making.
In the discussions the problem of prioritizing did not arise from different preferences for prioritization criteria, but from the weighting of the criteria. The operationalization of the criteria seemingly depends on the decision-making situation, the participants' personal connection with the relevant disease and on the correspondence between evidence and personal experiences.
背景/目的：面对德国法定疾病基金支出的不断增加，有必要展开一场关于医疗体系中优先事项设定的讨论。长期以来，这个问题在医疗辩论中一直被回避。因此，仍然缺乏规范性指令，这可能导致在日常医疗实践中医疗服务提供者之间进行优先事项设定。优先事项设定可以在三个不同层面进行：政府（宏观）、机构（中观）和患者（微观）层面。存在关于社会对不同标准偏好的调查；然而，在药品审批和报销（中观）情况下对各自权重的具体规定却缺失。因此，本研究分析了中观层面优先事项设定标准的实施情况和权重，同时考虑了参与者的价值观和经验。
与医学、伦理学、公共卫生和经济学领域的代表进行了六个定性焦点小组讨论。在讨论过程中，根据指南对四种用于治疗不同肺部疾病的虚拟药物进行了优先排序。讨论过程根据博恩萨克的文献法进行分析。
“生活质量”“预期寿命”和“其他与患者相关的结果”这几个标准相互关联进行了讨论。对于非医学参与者来说，评估与患者相关结果的变化很难进行。第二个论点涉及“成本”“疾病严重程度”和“患者数量”这些标准。成本的权重较小，但经常被用来支持其他标准。达成共识的其他挑战包括职业角色与个人观点之间出现的冲突，以及将讨论转移到不同决策层面。
在讨论中，优先事项设定的问题并非源于对优先标准的不同偏好，而是源于标准的权重。标准的操作化似乎取决于决策情况、参与者与相关疾病的个人关联以及证据与个人经验之间的对应关系。
