Value for money - recasting the problem in terms of dynamic access prioritisation.

Abstract

To develop an approach for achieving value for money in rehabilitation based on dynamic prioritisation of access to services according to individual capacity to benefit. A critical review of economic evaluation and adaptation of a prioritisation method used in determining access to elective surgical services in New Zealand to a rehabilitation context. The cost-effectiveness frontier is not straight but curved, suggesting that some people benefit more from a given intervention than others. An approach that identifies those most likely to benefit from inpatient rehabilitation following stroke (as an example) and enables access in order of capacity to benefit is presented in the context of a quality improvement programme. The approach is operationalised as a prioritisation tool that is dynamic in the sense that is can be reapplied subject to changes in the patient's clinical status. The steps proposed to develop such a tool include qualitative research with expert clinicians, pair-wise comparison of alternative scenarios (1000Minds survey), construction of an economic model of the tool's operation and an observational cohort study to help populate the model and calibrate the tool. A dynamic prioritisation approach to guide access to scarce health-care resources (such as inpatient rehabilitation following stroke) offers a transparent and equitable way of achieving value for money in the delivery of rehabilitation services.