Craig Mitton

 
Prospective Graduate Students / Postdocs

This faculty member is currently not actively recruiting graduate students or Postdoctoral Fellows, but might consider co-supervision together with another faculty member.

Professor

Research Classification

Health Policies

Research Interests

Health care resource allocation

Relevant Degree Programs

 

Research Methodology

Health technology assessment
priority setting
Economic evaluation

Graduate Student Supervision

Doctoral Student Supervision (Jan 2008 - May 2019)
Economic evaluation of the Community-Level Interventions for Pre-eclampsia (CLIP) in Sindh, Pakistan (2018)

Background: Hypertensive disorders of pregnancy, particularly pre-eclampsia and eclampsia (PE/E), can lead to life-threatening complications or even the death of a mother or a newborn. Because there are few clinical trials of community-based interventions for PE/E, there is little evidence about the cost-effectiveness of these interventions. The aim of this dissertation is to conduct an economic evaluation of the Community-Level Interventions for Pre-eclampsia (CLIP) combined with routine pregnancy care, compared to routine pregnancy care alone, in Sindh, Pakistan.Methods: A mixed-methods (i.e., qualitative and quantitative) approach to economic evaluation was undertaken alongside the CLIP Trial. A literature review of published epidemiological and economic studies was carried out to document evidence on PE/E interventions and guide the design of the economic model. Data were collected through focus groups, a structured questionnaire embedded into CLIP Trial surveillance, a cross-sectional survey of health facilities, and program budgetary reviews. The cost-effectiveness analysis was performed using a societal perspective. Probabilistic analysis was applied to estimate incremental cost-effectiveness ratios (ICERs), and sensitivity analysis was done to characterize uncertainties.Results: The literature review found economic studies mainly in developed countries and focused only on costs to the health system. Focus groups revealed a large burden of out-of-pocket spending and productivity losses to pregnant women and families. Health care providers and decision makers identified upfront technology costs as a key challenge for the health system. Maternal and newborn care costs varied significantly between and within public and private sectors. In the probabilistic analysis of the base case, the incremental cost of the intervention as compared to control was $20,438, while the years of life lost was -37 (i.e., negative health gains), indicating a wide range of statistical uncertainty around ICERs. Overall, the probability that ICERs fell below the country-specific threshold was less than 30%.Conclusion: This dissertation highlights knowledge gaps for costs and cost-effectiveness of PE/E interventions in low- and-middle-income countries (LMICs). The economic analysis indicates that CLIP is not a cost-effective strategy, compared to routine pregnancy care. More research is needed to conduct the process evaluation to inform policy decisions on resource allocation in Sindh, Pakistan.

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To what extent should the public be involved in health disinvestment decision making : a mixed methods investigation into the views of health professionals in the English NHS (2016)

Demand for health services is growing, but funding is often failing to keep pace. To ensure that budgets are balanced and that delivered services continue to be high quality, decision makers are having to set priorities, removing funding from some services- this is disinvestment. This thesis details research incorporating a literature review followed by a two stage empirical investigation into the way that disinvestment decisions are made and whether or not the public should be involved. The first stage is a Q-Methodology study, the second is in-depth interviews. The population for the study is NHS health professionals (including managers and clinicians). 55 participants took part in the Q-study, and of these, 20 took part in follow-up interviews. The study highlighted three distinct perspectives, all of which supported public involvement. One was unequivocal in its support, another highlighted some potential disadvantages to involving the public and the third suggested that the public should have the freedom to choose whether they became involved. The follow up interviews re-iterated participants’ support for involvement but suggested that the public should become involved earlier and to a greater extent in those disinvestment decisions which affected more patients and/or resulted in a tangible loss of services.

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Identifying disinvestment options to increase the impact of priority setting in health care organizations (2011)

Choices about what to fund and what not to fund are necessary in health care because claims on resources always exceed those available. Moreover, the choices faced by decision-makers are often between or amongst a wide range of difficult to compare programs or interventions. It is no surprise, then, that processes that inform those choices are of considerable interest. Yet, we know that existing priority setting processes have found limited practical use and when used, are rarely used to their full potential. The objective of the current research was to produce new knowledge that would facilitate the use of formal priority setting processes in decision-making on resource allocation in health care. Based on a detailed review of the literature, a decision was made to focus on one particular aspect of priority setting in health care that has long been recognized as a significant barrier to the successful implementation of priority setting processes: the identification of disinvestment options. Building on initial exploratory research, a proposed procedural change to the Program Budgeting and Marginal Analysis (PBMA) priority setting process was designed to address challenges in identifying disinvestment options. The proposed procedural change was then evaluated in a case study as part of a real-world priority setting exercise. The key finding of this research project was that adding a step -- that focused on the determination and communication of acceptable service reductions, at the outset of process implementation -- to the standard PBMA process, has the potential to assist in ‘disarming’ organizational incentives that have been found to work against the identification of disinvestment options. This key finding is of critical importance because without practical disinvestment options, priority setting processes are likely to have limited impact on decision-making and therefore limited practical appeal. Further, without formal, structured priority setting processes that actually work in practice, resource allocation decisions will continue to follow historical patterns, leading to incremental growth without explicit consideration of return on investment. As such, this study makes a novel contribution to the literature in an area that is highly relevant to the everyday challenges faced by health care decision-makers.

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Master's Student Supervision (2010 - 2018)
Describing practices of priority setting in publicly funded health care systems of high-income countries (2018)

Spending in health care have grown considerably over the last decades in all developed countries. Aging populations and novel technologies are usually deemed as the main drivers for such unsustainable trend in the finances of health systems. In this scenario, setting priorities for investments becomes a central concern. Making hard choices in a rational, evidence-informed, systematic, transparent, legitimate, and fair manner has constituted an increasingly important target. Notwithstanding the voluminous body of literature in this area, most of work focus on developing and improving prescriptive approaches as well as presenting case studies. The present work aimed to describe existing practices of priority setting and resource allocation within the context of publicly funded health care systems of high-income countries. An online qualitative survey was used with decision makers and academics from 18 countries. Four hundred and fifty individuals were invited and 58 answered the survey questionnaire. We found that resource allocation in health care has been still largely done based on historical patterns and through ad hoc decisions, despite the wide understanding that decisions must be formally based on multiple explicit criteria. Health technology assessment (HTA) was the tool most commonly indicated by participants as a formal strategy of priority setting. Several approaches have been tested and published, with special emphasis on Program Budgeting and Marginal Analysis (PBMA), but there is limited evidence of their continuous and systematic use by health organizations across countries. A point of increasing convergence is the reliance of multiple types of evidence to judge the value of investment options. Disinvestment frameworks are very rare and the topic itself has only started to appear with any regularity. This work represents the first attempt to identify existing practices of priority setting in a systematic way through a qualitative descriptive study. Despite its methodological limitations, it provides a better understanding of the current scenario of policy making and research in this field.

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The influence of a pediatric palliative care program on health care utilization and costs (2015)

Pediatric palliative care program (PPCP) is believed to increase system efficiency. British Columbia (BC) relies on a free-standing hospice-based PPCP, and its effects on health care utilization and costs remain an outstanding question. This study aimed to gather evidence in a combined analysis of data from literature and BC PPCP. A systematic review was conducted through an electronic search of Medline, Embase, CINAHL, LILACS, and grey literature. Comparative studies reporting admissions, length of stay, and health care costs between PPCP users and usual care were included. Additionally, a similar comparison was applied to the data from BC PPCP using a retrospective matched-pairs cohort design (matched by ICD code and age at death) with a 3-year observational period prior to death. Data were obtained from Canuck Place Children’s Hospice and BC Children’s Hospital databases, and complemented by estimates from Canadian Institute for Health Information. A cost impact of the overall inpatient care provided by the hospice was presented. The review did not demonstrate a decrease in utilization by PPCP users yet suggested a shift to other health care settings, and potential cost saving in the Canadian context (1 article). The cohort study (n=11 pairs), suggests that children in both groups had similar upward trends in inpatient utilization and cost. However, PPCP users showed more inpatient care in the last year of life (especially critical care in the last 2 months), compared to their controls and to the period prior to referral. Post-referral, a shift in health care setting utilization from hospital to hospice was observed, representing approximately 50% of the costs. Without this shift PPCP users would have cost 32% more with a median monthly increment of $7,163 per child. All inpatient care provided by the hospice in the fiscal year 2011-2012 represented a potential cost saving ranging from approximately $1.1M to $4.3M. The findings of this study suggest that PPCP users may present higher health care needs, and that the shift of inpatient care to the hospice optimized resource use, offering a more holistic approach to EOL care, relieving hospital resources to meet other demands.

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Development and implementation of a priority setting and resource allocation evaluation tool for achieving high performance (2013)

Objective: Canadian healthcare decision makers are facing greater pressure in setting priorities and allocating resources. However, recent studies suggest that only about 50% of healthcare organizations follow a formal priority setting process, and that even fewer are evaluating their processes to achieve ongoing improvement. This research developed an evaluation tool to help organizations identify the strengths and weaknesses of their process, and performed a meta-evaluation of the tool itself to inform future refinements.Methods: A high performance framework for priority setting and resource allocation formed the foundation for this research. The framework was operationalized into an evaluation tool that took the form of a semi-structured interview. The tool was then implemented in test organization. Data from this application were analyzed using template and content analysis, and organizational strengths and weaknesses were identified. At the end of each evaluation interview, debriefs with participants were used to inform refinements for future applications of the tool.Results: The evaluation tool was successfully developed from the high performance framework, and was implemented through interviews with 27 members of the test organization. Strengths of the organization’s process included involvement of a strong leadership team and use of a proposal assessment tool. Weaknesses included lack of training, and the presence of proposals that circumvented the formal process. Refinements to the tool involved formatting of interview questions as well as the addition of a new element and a new sub-element.Conclusion: This research represents the first attempt at creating an evaluation tool using the high performance framework, and is novel in its application at a macro level within the test healthcare organization. Based on feedback from participants and the ability of the tool to capture relevant strengths and weaknesses of the organization’s process, further application is warranted. Future implementation will also serve to further refine the tool itself.

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The development of a disinvestment framework to guide resource allocation decisions in health service delivery organizations (2012)

Objective: Within publicly funded health care, there is an urgent need to reduce spending while maximizing benefits; however, processes to guide so-called disinvestment decisions are lacking. The purpose of this research is to develop a framework that will provide decision-makers with a more equitable approach to meeting budgetary constraints than current practices.Methods: Through a systematic review of the health care literature and a scoping review of the public sector and business literatures, a knowledge synthesis of disinvestment approaches was created, including analyses of current strategies and the modeling of appropriate processes. From this synthesis, a disinvestment framework has been developed. In collaboration with Chief Financial Officers from across Western Canada and an external reference group comprised of international researchers, the framework has been critiqued in keeping with current resource allocation practices. Results: Evidence from the two reviews revealed that while budgetary cutbacks are experienced across government, non-profit and the private sector, very few processes have been developed to identify and implement disinvestment options. In cases of budget re-allocation, program budgeting and marginal analysis (PBMA) was the most relevant framework described. However, PBMA fails to address stand-alone disinvestment requirements. Within the public sector and business literatures, cutback management and policy termination research offered strategies to mitigate barriers and facilitate implementation, however, details were absent. Drawing elements from the approaches identified in the reviews, and in collaboration with decision-makers and other researchers, a seven-step disinvestment framework was developed that can be incorporated into on-going priority setting practices or applied as a stand-alone activity. Conclusion: This work addresses a critical knowledge gap in how health service organizations approach disinvestment activities. The proposed framework provides detailed steps to equip health care decision makers with a clear and defined disinvestment process. Such a process will help to ensure limited funds are allocated based on evidence rather than across-the-board cuts or historical practices.

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