Barriers and facilitators to implementing priority setting and resource allocation tools in hospital decisions: A systematic review

Health care budgets in high-income countries are having issues coping with unsustainable growth in demand, particularly in the hospital setting. Despite this, implementing tools systematising priority setting and resource allocation decisions has been challenging. This study answers two questions: (1) what are the barriers and facilitators to implementing priority setting tools in the hospital setting of high-income countries? and (2) what is their fidelity? A systematic review using the Cochrane methods was conducted including studies of hospitalrelated priority setting tools reporting barriers or facilitators for implementation, published after the year 2000. Barriers and facilitators were classified using the Consolidated Framework for Implementation Research (CFIR). Fidelity was assessed using priority setting tool's standards. Out of thirty studies, ten reported program budgeting and marginal analysis (PBMA), twelve multi-criteria decision analysis (MCDA), six health technology assessment (HTA) related frameworks, and two, an ad hoc tool. Barriers and facilitators were outlined across all CFIR domains. Implementation factors not frequently observed, such as 'evidence of previous successful tool application', 'knowledge and beliefs about the intervention' or 'external policy and incentives' were reported. Conversely, some constructs did not yield any barrier or facilitator including 'intervention source' or 'peer pressure'. PBMA studies satisfied the fidelity criteria between 86% and 100%, for MCDA it varied between 36% and 100%, and for HTA it was between 27% and 80%. However, fidelity was not related to implementation. This study is the first to use an implementation science approach. Results represent the starting point for organisations wishing to use priority setting tools in the hospital setting by providing an overview of barriers and facilitators. These factors can be used to assess readiness for implementation or to serve as the foundation for process evaluations. Through our findings, we aim to improve the uptake of priority setting tools and support their sustainable use.