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The purpose of this study is to provide a decision support tool to deal with the problem of seting priorites among patients competing for limited health care resources. Limited resources and unlimited demands prevent health-care services to be provided to all those in need. This became publicity evident with the current Covid-19 pandemic. Although controversial, health care rationing has always existed and is now inevitable. Setting priorities becomes then inevitable. How to define those priorities is a complex and yet irresolvable issue mainly because it involves several and conflicting criteria, translated into efficiency and equity considerations. This is why multi-criteria decision analysis (MCDA) was introduced to health care as an appropriate decision-support framework for solving complex problems.

This paper proposes the application of two combined approaches – analytic hierarchy process (AHP)-Technique for Order of Preference by Similarity to Ideal Solution (TOPSIS) and AHP-VlseKriterijumska Optimizacija I Kompromisno Resenje (VIKOR), as decision support tools to rank patients with competing needs in a more effective and equitable way. A rationing scenario involving four patients, differentiated by personal characteristics and health conditions, is used to illustrate, test and compare the applicability of both approaches. After extraction of the relative weights of the prioritization criteria involved in the hypothetical scenario from paired wise comparison methods, TOPSIS and VIKOR priority setting methods were designed.

Results suggest that patients ranking from both combination approaches are similar and in accordance with the order made directly by health-care professionals. Therefore, the relative weights computed by AHP in combination with TOPSIS and/or VIKOR methods could be used with suitable applicability by health-care decision-makers.

This study is the first attempt to apply a combination of MCDA methods to patients’ prioritization context and the first to cross previous studies to deepen and consolidate the research.

The purpose of this paper is to seek to elicit, in a context of economic crisis, the social preferences for the microallocation of scarce healthcare resources.

Data were collected from an online questionnaire which includes a hypothetical rationing choice scenario with four patients differentiated by their personal characteristics and health states competing for treatments and a set of statements that embodies: distributive criteria for prioritizing patients; the authorship of these types of decisions; and the likelihood of these decisions to be taken. Descriptive statistics, factor analysis and non-parametric test were used for describing and validating the data.

Findings suggest that respondents: support a pluralism of distributive principles in prioritizing patients with an incident in utilitarianism and the reducing of inequalities in health, translated in the fair-inning and in emotional arguments of fragility; trust in the health professional to make prioritization decisions; and are conscious that rationing decisions will be real in the short term.

The pursuit of efficiency and the equalizing of a lifetime health seem to be the criteria that should guide any rationing policy at the micro level.

This study addresses simultaneously several ethical principles inherent to microallocation healthcare resources in a suitable context in which Portugal is facing an economic crisis and where, consequently, rationing healthcare policies gain prominence on the political agenda.

The purpose of this paper is to explore Croatian views about issues regarding bedside rationing decisions.

An online questionnaire was used to collect data from a sample of 243 Croatian citizens. In a context of hypothetical scenarios involving priority setting decisions taking by physicians, the present study elicits Croatian respondents’ views concerning: the ethical principles that should guide patients prioritization; the parties that should make prioritization decisions; and the likelihood of healthcare rationing becoming a reality. Descriptive analysis, factor analysis and parametric and non-parametric tests were performed.

Findings suggest that Croatian respondents: support multiple substantive rationing criteria, with an incident in favoring the worst-off, reducing inequalities in health, translated in the fair-innings argument and efficiency achievement; appoint health professionals as rationing decision makers; and do not seem to believe in the possibility of patient selection becoming a reality.

Favoring the worst-off, equalizing life time health and the pursuit of efficiency seem to be the criteria most preferred by Croatian respondents to guide rationing policy at the micro level.

This study is the first attempt to elicit Croatian opinions concerning several rationing criteria inherent in healthcare micro allocation decisions. Healthcare rationing is a serious challenge to Croatian policy makers and so it would be useful for the public’s perceptions and beliefs to be considered.

The purpose of this study is to explore and compare citizens’ attitudes in Portugal, Bulgaria and Croatia towards rationing criteria that should support an explicit priority setting process at the micro level.

Preferences were collected through an online questionnaire containing 14 statements concerning lottery, economic and person-based priority criteria. Respondents indicated their level of agreement with each criterion. Non-parametric tests were applied to compare the levels of agreement among 355, 298 and 243 Portuguese, Bulgarian and Croatian respondents, respectively.

The three groups of respondents appear to be concerned with both a fair and efficient allocation of resources. The severity of health conditions and patient’s age were the criteria most accepted by the respondents. This study suggests that Portuguese, Bulgarian and Croatian respondents have similar social values concerning patient prioritization, although the Portuguese adhere slightly more to efficiency criteria and less to person-based and lottery criteria than Bulgarian and Croatian respondents.

A majority of respondents across the three countries report having opinion about the bedside rationing criteria. Portuguese, Bulgarian and Croatian respondents accept a combination of personal and economic criteria in patient’s prioritization.

This study represents the first attempt to compare citizen’s opinions of three member states of the European Union.

Research paper

This study aimed to compare mortality rate, length of stay (LOS) and hospitalization costs at different priority levels for a patient admitted to an intensive care unit (ICU) at a public tertiary hospital in Qazvin, Iran. This study also aimed to predict influencing factors on patients’ mortality, ICU LOS and hospitalization costs in different admission groups.

The authors conducted a retrospective cohort study among patients who mainly suffered from internal diseases admitted to an ICU of a public hospital. This study was conducted among 127 patients admitted to ICU from July to September 2019. The authors categorized patients into four groups based on two crucial hemodynamic and respiratory status criteria. The authors used a logistic regression model to predict the likelihood of mortality in ICU admitted patients during hospitalizations for the four prioritization groups. Furthermore, the authors conducted a multivariate analysis using the “enter” method to identify risk factors for LOS.

Results showed a statistically significant relationship between the priority of being admitted to ICU and hospitalization costs. The authors’ findings revealed that age, LOS and levels of consciousness had a predictability role in determining in-hospital mortality. Besides, age, gender, consciousness level of patients and type of the disease were mentioned as affecting factors of LOS.

This study’s findings emphasize the necessity of categorizing patients according to specific criteria to efficiently use available resources to help health-care authorities reduce the costs and allocate the budget to different health sectors.

The purpose of this paper is to define a clinical pathway for total joint replacement (TJR) surgery, estimate the effect of delays between steps of the pathway on wait time for surgery and to identify factors contributing to more efficient operations and challenges to their implementation.

This is a case study with a mixed methods approach. The authors conducted interviews with hospital staff. Data collected in the interviews and through on-site observation were analyzed to map the TJR process and identify the steps of the care pathway. The authors extracted and analyzed data (time stamps) from 60 hospital patient records for each step in the pathway and ran a regression on the duration of the whole trajectory.

There were wide variations in the delays observed between the seven steps identified. The delay between Step 1 and Step 2 was the only significant variable in predicting the total wait time to surgery. In one hospital, one delay explained 50 percent of the variation. There was misalignment between findings from the qualitative data in terms of strategies implemented to increase efficiency of the clinical pathway to the quantitative data on delays between the steps.

The study identified the clinical pathway from the consultation with an orthopaedic surgeon to the surgery. However, it did not go beyond the surgery. Future research could investigate the relationship between specific processes and delays between steps of the process and patient outcomes, including length of stay, mobilization and functionality in activities of daily living, as well as potential complications from surgery, readmission and the services required after the patient was discharged.

Wait times can be addressed by implementing strategies at the health system level or at the organizational level. The authors found and discuss areas where there could be efficiency gains for health care organizations.

Stakeholders in care processes are diverse and they each have their preferences in how they practice (in the case of providers) and how they perceive and wish to respond adequately to patients’ needs in contexts that have different norms and approaches. The approach in this study enables a better understanding of the processes, the organizational culture and how these may affect each other.

Our mixed methods enabled a process mapping and the identification of factors that significantly affected the efficiency of the TJR surgery process. It combines methods from process engineering with health services and management research. To some extent, this study demonstrates that although managers can define and enforce processes, organizational culture and practices are harder to influence.

The Swedish health-care system currently implements cancer care pathways (CCPs) for better and more timely cancer diagnostics. The purpose of this paper is to elucidate and define “crowding out” effects associated with the CCP implementation.

A document study based on implementation reports and action plans from Swedish county councils (n = 21) and a case study in one county council were conducted. Qualitative data collection and analysis were used to acquire more knowledge about the “crowding out” effects associated with the CCP implementation.

Three effects discussed under “crowding out” were defined. The first effect, called the push-out effect, occurs when other patients have to wait for care longer in favour of CCP patients. Another effect is the inclusion effect, whereby “crowding out” is reduced for vulnerable patients due to the standardised procedures and criteria in the referral process. The final effect is the exclusion effect, where patients in need of cancer diagnostics are, for some reason, not referred to CCP. These patients are either not diagnosed at all or diagnosed outside CCP by a non-standard process, with the risk of longer waiting times.

“Crowding out” effects are an urgent topic related to CCP implementation. While these effects have been reported in international research studies, no shared definition has been established to describe them. The present paper creates a common base to measure the “crowding out” effects and support further development of CCPs to avoid the negative effects on waiting times.

Centralized waiting lists (CWLs) for patient attachment to a primary care provider have been implemented across Canada, including Quebec. Little is known about the implementation of CWLs and the factors that influence implementation outcomes of such primary care innovations. The purpose of this paper is to explain variations in the outcomes of implementation by analyzing the characteristics of CWLs and contextual factors that influence their implementation.

A multiple qualitative case study was conducted. Four contrasting CWLs were purposefully selected: two relatively high-performing and two relatively low-performing cases with regard to process indicators. Data collected between 2015 and 2016 drew on three sources: 26 semi-structured interviews with key stakeholders, 22 documents and field notes. The Consolidated Framework for Implementation Research was used to identify, through a cross-case comparison of ratings, constructs that distinguish high from low-performing cases.

Five constructs distinguished high from low-performing cases: three related to the inner setting: network and communications; leadership engagement; available resources; one from innovation characteristics: adaptability with regard to registration, evaluation of priority and attachment to a family physician; and, one associated with process domain: engaging. Other constructs exerted influence on implementation (e.g. outer setting, individual characteristics), but did not distinguish high and low-performing cases.

This is the first in-depth analysis of CWL implementation. Results suggest important factors that might be useful in efforts to continuously improve implementation performance of CWLs and similar innovations.

This article addresses issues of calculation and economization in contemporary public organizations. In particular, it investigates how choices of organizing emergency health-care have been affected by accounting as a performative device. Special attention has been paid to how accounting brings about performative consequences in shaping the medical profession and its context.

The article employs qualitative research methods and draws its analysis on empirical data from in-depth interviews at an emergency health-care unit in Sweden.

It is demonstrated how accounting, in the form of calculations of treatment time and number of patients, enables performative consequences for medical professional work. It is also demonstrated how the use of accounting engages (re)descriptions of practices and roles, creates accounts of patients, and helps to sustain such (re)descriptions. Accounting terms (such as efficiency and control) have been reframed into medical terminology (such as health-care quality and security), ensuring and retaining (re)described medical professional work in terms of practices and emerging roles.

This article contributes to (1) the literature on accounting practices within health-care contexts by demonstrating a case where the accounting ideas and practices of medical professionals are coexistent and interwoven and (2) the increasing body of literature focusing on accountingization by showing how emerging calculative technologies carry performative power over medical professional work through formative (re)descriptions.

This chapter examines why managed clinical networks are an appropriate approach to sustainable healthcare, and discusses the conditions for the effectiveness of these multi-stakeholder, clinician-led modes of organizing. It describes the development of a national clinical network to achieve system-wide improvement in the provision of publicly funded cardiac surgery services in New Zealand, and the subsequent evolution of a broader network encompassing the whole cardiac care patient pathway.

The case study of the two cardiac clinical networks focuses on the emergence and evolution of the networks over a four-year period from 2009. Data were collected from interviews with key stakeholders of both networks and from internal and published documentary evidence. Analysis of the case study is informed by network theory and prior studies of managed clinical networks.

Progress made towards the achievement of the goals of the initial cardiac surgery network encouraged a broadening of focus to the entire cardiac care pathway and the establishment of the national cardiac network. An important benefit has been the learning and increase in understanding among the different stakeholders involved. Both clinical networks have demonstrated the value of clinician engagement and leadership in improving the delivery of health services, and serve as a best practice model for the development of further clinical networks for health services that require a national population base.

The case study analysis of the two cardiac clinical networks identifies five mutually reinforcing themes that underpin network effectiveness: network structure, management and governance, and internal and external legitimation. These themes encompass a number of factors suggestive of successful managed clinical networks, and offer insights into the use of such networks in organizing for sustainable healthcare.