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Priority Setting in Neurosurgery as Exemplified by an Everyday Challenge

Published online by Cambridge University Press:  23 September 2014

George M. Ibrahim ,
Michael Tymianski  and
Mark Bernstein
George M. Ibrahim
Affiliation:
Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada Department of Surgery, Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada
Michael Tymianski
Affiliation:
Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada Department of Surgery, Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada Department of Physiology, University of Toronto, Toronto, Ontario, Canada Toronto Western Hospital Research Institute, University of Toronto, Toronto, Ontario, Canada
Mark Bernstein*
Affiliation:
Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
*
Toronto Western Hospital, 399 Bathurst Ave, Toronto, Ontario, M5T 2S8, Canada. Email: mark.bernstein@uhn.ca
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Abstract

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Background:

The allocation of limited healthcare resources poses a constant challenge for clinicians. One everyday example is the prioritization of elective neurosurgical operating room (OR) time in circumstances where cancellations may be encountered. The bioethical framework, Accountability for Reasonableness (A4R) may inform such decisions by establishing conditions that should be met for ethically-justifiable priority setting.

Objective:

Here, we describe our experience in implementing A4R to guide decisions regarding elective OR prioritization.

Methods:

The four primary expectations of the A4R process are: (1) relevance, namely achieved by support for the process and criteria for decisions amongst all stakeholders; (2) publicity, satisfied by the effective communication of the results of the deliberation; (3) challengeability through a fair appeals process; and (4) Oversight of the process to ensure that opportunities for its improvement are available.

Results:

A4R may be applied to inform OR time prioritization, with benefits to patients, surgeons and the institution itself. We discuss various case-, patient-, and surgeon-related factors that may be incorporated into the decision-making process. Furthermore, we explore challenges encountered in the implementation of this process, including the need for timely neurosurgical decision-making and the presence of hospital-based power imbalances.

Conclusion:

The authors recommend the implementation of a fair, deliberative process to inform priority setting in neurosurgery, as demonstrated by the application of the A4R framework to allocate limited OR time.

Résumé:

Résumé:Contexte:

L'allocation de ressources limitées en matière de soins de santé constitue un défi constant pour les cliniciens. Un exemple quotidien en est la priorisation du temps opératoire pour les cas électifs en neurochirurgie, dans des circonstances où des annulations peuvent survenir. Le cadre bioéthique, la responsabilité pour la raisonabilité (A4R), peut éclairer de telles décisions en établissant les conditions qui devraient être remplies pour une priorisation éthiquement justifiable.

Objectif:

Nous décrivons notre expérience de l'application de l'A4R pour guider les décisions concernant la priorisation du temps opératoire en neurochirurgie élective.

Méthode:

Les quatre principales attentes du processus A4R sont les suivantes: 1) la pertinence, établie notamment par le soutien pour le processus et les critères de décision de la part de toutes les parties prenantes ; 2) la publicité, réalisée par la communication efficace des résultats de la délibération ; 3) la possibilité d'appel par un processus équitable ; 4) la surveillance du processus afin de s'assurer de saisir les occasions de l'améliorer.

Résultats:

L'A4R peut être appliquée pour clarifier la priorisation du temps opératoire, ce qui bénéficie aux patients, aux chirurgiens et à l'institution elle-même. Nous discutons de différents facteurs relatifs aux cas, aux patients et aux chirurgiens qui peuvent être incorporés dans le processus décisionnel. De plus, nous explorons les défis rencontrés dans l'implantation de ce processus, dont le besoin de prendre des décisions neurochirurgicales en temps opportun et la présence de déséquilibre de pouvoir au sein du milieu hospitalier.

Conclusion:

Les auteurs recommandent l'implantation d'un processus de délibération juste pour clarifier la priorisation en neurochirurgie, comme nous l'avons démontré par l'application du cadre A4R pour l'allocation de temps opératoire limité en neurochirurgie.

Type
Research Article
Information
Canadian Journal of Neurological Sciences , Volume 40 , Issue 3 , May 2013 , pp. 378 - 383
Copyright
Copyright © The Canadian Journal of Neurological 2013

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