Clinical priority setting

BMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a1846 (Published 9 October 2008)
Cite this as: BMJ 2008;337:a1846

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  1. Ole Frithjof Norheim, professor12
  1. 1Department of Thoracic Medicine, Haukeland University Hospital, 5020 Bergen, Norway
  2. 2Department of Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018 Bergen, Norway
  1. Correspondence to: O F Norheim ole.norheim{at}isf.uib.no

    Twelve years ago (BMJ 1996;312:1553-4) the BMJ argued that health systems needed to be explicit about rationing and published articles describing different ways of rationing fairly. Here a clinician, two ethicists (doi:10.1136/bmj.a1850), and four health economists (doi:10.1136/bmj.a1872) discuss how their ideas have developed—and been put into practice—since then

    There are no simple solutions to resource allocation in health care,1 2 but the principles guiding fair priority setting are quite straightforward.3 4 5 This article explains the key principles and criteria for fair and clinically relevant priority setting. Clinicians should know these basic principles and be active in improving priority setting at all levels of the healthcare system.

    Clinical priorities

    Clinical priority setting means choosing whom to investigate and what diagnostic tests to perform; sorting the flow of patients so some are diagnosed or treated before others; allocating patients to surgery, medical treatment, or watchful observation; and selecting or excluding patients for a given treatment.6 7 Justice requires a fair distribution of the benefits and burdens of priority setting.8

    Clinicians’ decisions rest on two types of information: the patient’s severity of disease (prognosis without the intervention) and the expected outcome (prognosis with the intervention). The evidence underlying their judgment is also important.9 Clinicians can help support priority setting by stopping procedures that have little evidence of effectiveness.

    Priority setting is an integral part of daily practice in many clinical specialties. Cardiology is but one example. Firm evidence supports sorting patients with risk of a cardiovascular event into prognostic priority groups.10 European clinical guidelines, for instance, distinguish between three prognostic groups (graded from high to low priority): patients with established cardiovascular disease; asymptomatic patients with a 10 year risk of cardiovascular death ≥5%; asymptomatic …

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