Hospital-Based Health Technology Assessment Difficult Decision-Making at User Interface: Why The Traditional Approach Doesn t Work

Transcription

1 Hospital-Based Health Technology Assessment Difficult Decision-Making at User Interface: Why The Traditional Approach Doesn t Work Janet Martin, PharmD, MSc(HTA&M) Director, High Impact Technology Evaluation Centre Co-Director, Evidence-Based Perioperative Clinical Outcomes Research Unit Assistant Professor, Departments of Medicine, Anesthesia & Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, London, Canada

2 Hospital-Based Health Technology Assessment Difficult Decision-Making at User Interface: Why The Traditional Approach Doesn t Work Truly, Madly, Deeply Janet Martin, PharmD, MSc(HTA&M) Director, High Impact Technology Evaluation Centre Co-Director, Evidence-Based Perioperative Clinical Outcomes Research Unit Assistant Professor, Departments of Medicine, Anesthesia & Perioperative Medicine, London Health Sciences Centre, University of Western Ontario, London, Canada

3 LHSC_CSTAR_POS_2C_RGB Many thanks... LHSC CIHR CADTH our team Davy Cheng, John Parker, Kirsten Krull-Naraj, Glen Kearns, Richard Jones

4 Hospital HTA Decision-Making I. Importance of HTA in Hospitals II. Traditional Decision Making III. Key Challenges IV. Know4Go as a Solution V. Future Directions

5 Why Hospital HTA? Technological innovations are restructuring health care in profoundly beneficial and unsettling ways Demand for innovative technologies has outpaced our capacity to provide them Technological innovations are especially concentrated in the hospital setting Innovations relevant to hospitals often not assessed by national, provincial, or academic HTA units. Even when they are, they are rarely ready for decision-making.

6 Shortcomings in External HTA HTA reports produced by external agencies are useful, but (necessarily) insufficient External HTA agencies cannot informatively advise whether our hospital needs another CT scanner, a surgical robot, bifurcated stents, or another fluoroquinolone These decisions need to be taken with local considerations of infrastructure, existing technologies, patient population, health professional skills, learning curves, competing priorities though, there is room for more collaboration across hospitals.

7 Hospital HTA is Unique Fast-paced, real-time, at the point of decisionmaking In collaboration with decision-makers ( endusers ) Contextualized to local setting (not hypothetical) Accountable to predictions Decision impact is felt very quickly HTA in a box Truly, madly, deeply. Decisions become moral dilemmas.

8 Hospitals are Costly 30% Hospitals account for >30% of health care expenditures in Canada (CIHI, 2004)

9 Then Now

10 Then Get the evidence straight

11 Evidence is biased HTA is biased

12 Numbers are Tortured & Statistics Lie

13 Evidence schmevidence let s just get on with it It works. And, I want it. No time for assessments here.

14 That s not the way I see it

15 New is inherently better. If it is better, it must be worth it.

16 Symptoms of Compromised Decision-Making The evidence doesn t apply to my patient Aprotinin versus Tranexamic Acid Antipsychotics for dementia in elderly Spinal fusion for low back pain Arthroscopic knee surgery Obviously the evidence is wrong, because everyone is still doing it. Beta-blocker for immediate treatment of AMI Beta-blocker for patients undergoing non-cv surgery This place is archaic only about the cost! COX-II selective inhibitors not admitted to formulary Insulin glargine and detemir not admitted to formulary Nandrolone not admitted to formulary

17 Key Challenges: Too Fast or Too Slow Adoption? Gizmo Idolatry. Technology is fun New is better, and certainly more fun on the market means done deal sufficient burden of proof is presumed Sooner is better than later For new technologies (and drugs), there is constant pressure to take them up Just let us try it out, and then we can decide May save money We have responsibility to be leading edge Innovation is our job Teaching is our mandate Discovery is up to us

18 Technology Hype Cycle

19 Multiple Opposing Pressures

20

21 Then B:R

22 Systematic Review Decision Economic Analysis Decision Evidence is one consideration, but not the only consideration.

23 Yes No

24 Then Now Evidence is essential Evidence is essential, but insufficient

25 Application of Evidence to Decisions: Too technical Too linear Too blunt Evidence from expanded domains of influence social, legal, ethical, environmental, etc opportunity costs need to be made explicit before decisions can be made comfortably

26 Now B:R SLEEPERs Go where the evidence dares not

27 What is a SLEEPER? S L E E P ER S Social Legal Ethical & Equitable Environmental Political Entrepreneurial & Research Stickiness Stickiness

28 Kink in the Curve O'Brien B, et al. Is there a kink in consumers' threshold value for costeffectiveness in health care? Health Economics 2002;11:

29 After B:R Go where the evidence dares not

30 What is true cost? Cost is the sacrifice of consequences in the best alternative use of resources

31 Newton s Third Law abides

32 Every decision to do one thing is a decision not to do another

33 Know4Go

34 Know4Go

35 Know4Go

36 B:R 4Go Know4Go

37 Tradeoff Table Budget Impact Benefit Index

38 What are we plotting? Budget Impact: {Incremental Cost per Patient} x {# Eligible} Benefit Index: {# Eligible Patients/NNTB}

39 Tradeoff Table Go, No-Go Benefit Index Budget Impact

40 Tradeoff Table No-Go Go Benefit Index Budget Impact

41 Tradeoff Table Benefit Index No-Go Go Budget Impact

42 B Tradeoff Table Budget Impact 1C Go, No-Go A D Benefit Index E

43 B Tradeoff Table A B C D ino for preemies ino for other ERT for rare dx Infliximab for UC Budget Impact 1C Go, No-Go A 6 19 E Off-pump CABG D Benefit Index E

44 B Tradeoff Table A B C D ino for preemies ino for other ERT for rare dx Infliximab for UC Go or no-go? Budget Impact 1C Go, No-Go A 6 19 E Off-pump CABG D Benefit Index E

45 What are we plotting? Budget Impact: {Incremental Cost per Patient} x {# Eligible} Benefit Index: {# Eligible Patients/NNTB} + ƒ{sleepers} SLEEPERs = Social, Legal, Ethical, Environmental, Political, Entrepreneurial/Research/Innovation issues

46 B Tradeoff Table A B C D ino for preemies ino for other ERT for rare dx Infliximab for UC Go? Go (because of SLEEPERs) Go Budget Impact 1C Go, No-Go 14 A E Off-pump CABG? D Benefit Index E

47 B:R 4Go Know4Go

48 A new approach to increase decision-maker uptake of best available evidence: Multilevel: Practitioners, Managers, Policymakers Multidimensional, Nuanced: Addresses SLEEPERs Honest & Accountable: Considers opportunity cost Embeds the decision in context of past, present, future

49 The average man s judgment is so poor, he runs a risk every time he uses it. - Edgar W. Howe

50 Then Focused on Go just given me the gizmo, and no one gets hurt I don t see the evidence, do you? it works, and I want it evidence, schmevidence. Just get on with it Now Focused on 4Go Now I understand Makes sense. I can live with that Finally! You ve shown me explicitly what I ve tried to understand for yrs We need to more of this How can we put the whole capital planning through Know4go?

51 Summary Hospital HTA juxtaposes evidence, decision-makers, and opportunity costs within a fixed set of resources and circumstances (a perfect petri dish) Traditional evidence-based decision-making forces a linear approach to what should be nuanced and multifactorial decision-making If we are to engage rather than alienate the end-user, we need to make HTA relevant, explicit and tangible Know4Go provides framework to explicate the evidence, and its uncertainty, while acknowledging the SLEEPERs, and enumerating what is 4Gone. Without explicit acknowledgment of SLEEPERs and the 4Go, decisions prematurely trumped by factors other than evidence, and decisions to 4Go anything are unbearable

52 Future Efforts Only in Research as an alternative to Yes/No decisions One study commissioned so far: Venofer vs IV Iron Dextran Decommissioning/Reinvestment Knee and back surgeries, beta-blockers, cerclage, ino Know4Go useful for other settings, other perspectives? Other hospitals, MOH, regions Canadian Surgical Technologies & Advanced Robotics (CSTAR) A living laboratory for testing surgical devices and procedures, and training for Ontario (John Parker, Director; Kirsten Krull-Naraj, VP) SLEEPERs need refining for surgery and devices Devices are only inherently as good as the skilled hands that it is within, and the effectiveness of the team around it

53 Technology Hype Cycle

54 HTA has often ignored the SLEEPERS % of HTA Reports Costs Efficacy C:E Safety QoL SES Legal Lehoux et al. Int J Technol Assess Health Care 2004;20:1-12.

55 The application of what we know will have a bigger impact on health and disease than any single drug or technology likely to be introduced in the next decade. Sir Muir Gray NHS Knowledge Service

56 We are drowning in information while starving for wisdom. E.O. Wilson

57 LHSC_CSTAR_POS_2C_RGB What we do HTA Reports

58 Receive Requests during Annual RFP Administration or Clinicians (formal application process) Prioritize Requests High impact clinically, economically, politically Systematically Review Evidence, Resources Collaborate with requestor and end-users to ensure relevance Define benefits, risks, costs, other resource issues What does it look like? Stakeholder Meeting (users, non-users) to Elicit SLEEPERS Elicit the SLEEPERs, Rate their Importance Plot Decision on Know4Go Tradeoff Table Benefit Index, Cost, SLEEPERs equation Present to Decision-Making Committee (Yes/No/CED) Surgical Services HTA, Drug & Therapeutics, Senior Leadership Committees Implement & Evaluate (& wait for appeals)

59 The Demand is Relentless ASK ASSESS Rate Limiting Step** ACT ** **Don t t reinvent the wheel (use INAHTA, EXCHANGE)