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Priority setting and cardiac surgery: a qualitative case study.

Nancy A Walton1, Douglas K Martin, Elizabeth H Peter

  • 1Faculty of Community Services, The School of Nursing, Ryerson University, 350 Victoria Street, Toronto, Ont., Canada M5B 2K3. nwalton@ryerson.ca

Health Policy (Amsterdam, Netherlands)
|June 8, 2006
PubMed
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Priority setting in cardiac surgery involves both clinical and non-clinical factors, leading to potential unfairness. Improving transparency and institutional support is crucial for equitable patient care decisions.

Area of Science:

  • Cardiovascular Surgery
  • Medical Ethics
  • Health Services Research

Background:

  • Cardiac surgery represents a significant cost in hospital budgets, with daily priority setting decisions for increasing patient volumes.
  • Empirical research on the daily deliberation and resolution of priority setting decisions by decision-makers in cardiac surgery is limited.
  • Fairness is a key goal in priority setting, and the ethical framework 'accountability for reasonableness' can identify improvements and best practices.

Purpose of the Study:

  • To describe the actual processes of priority setting in cardiac surgery.
  • To evaluate these priority setting processes using the ethical framework 'accountability for reasonableness'.

Main Methods:

  • A case study approach was employed at three University of Toronto affiliated cardiac surgery centers.

Related Experiment Videos

  • Data collection involved examining relevant documents, observing weekly triage rounds for 27 months, and conducting interviews with 23 key participants.
  • Data analysis utilized the four conditions of 'accountability for reasonableness' (relevance, publicity, appeals, and enforcement) as an analytical lens.

    • Main Results:

    • Priority setting decisions are influenced by both clinical criteria (e.g., coronary anatomy) and non-clinical factors (e.g., patient lifestyle, surgical practice type, resource constraints).
    • Non-clinical reasons are not publicly accessible or clearly acknowledged, potentially leading to unfair and inconsistent decisions.
    • While appeal mechanisms exist, their effectiveness is limited by the lack of transparency regarding non-clinical decision-making factors.

    Conclusions:

    • This study is the first to describe and ethically evaluate actual priority setting practices in cardiac surgery using 'accountability for reasonableness'.
    • Findings highlight the contextual and dynamic nature of decision-making, revealing good practices (e.g., facilitating second opinions, holistic patient assessment) and areas for improvement (e.g., transparency, institutional support).
    • The combined approach of descriptive case study and ethical framework evaluation offers a valuable tool for enhancing the fairness and legitimacy of priority setting in cardiac surgery.