HOW TO GET OF THE MOST OUT OF HTA? Maurice McGregor Cardiovascular Division and Technology Assessment Unit McGill University Health Centre CADTH Symposium. Ottawa. April 6, 2009
PLAN: For this discussion let us assume that getting the most out of HTA Means Having the greatest impact on policy. I plan to consider first how we currently do HTA in Canada, and how we might increase its impact, And then briefly consider whether we should make HTA recommendations mandatory,binding.
AXIOM. A self evident truth. The only reason for an HTA is to inform policy decisions, about uptake/use of health technologies. SO: HTA is not an abstract activity. We are not putting messages in bottles and throwing them overboard. HTAs are developed for specific decision makers. RULE 1: Every HTA should start by identifying exactly to whom it is addressed. Who are we advising?
AXIOM An HTA that has no effect on policy is wasted effort. So: Knowing to whom the HTA was addressed, it should be possible to find out whether it has influenced their policy. At least we can try. RULE 2: We should study, and report, the impact of every HTA that we carry out.
There are two sorts of HTA. Evaluation Content: Data, Evidence, Analysis Activity: Objective. Science-based. Evaluation + Policy Reccomendations.( 80%) Content: What should be done. Activity: Subjective. Values-based.
Two sorts of HTAs. Evaluations: are generalisable. Applicable to many jurisdictions. Appropriate for large agencies. CADTH Policy (what should be done):site specific. Not determined by evidence alone. Policy is also determined by the values of the users, and their resources. RULE 3. Agencies should not recommend policy for jurisdictions over which they have no budgetary responsibility.
Question: Who should develop HTAs? They influence large sums of money, people s lives. Who should exercise this privilege? Evaluations Good scientists. Scientific rigour. Integrity. Recommendations How we ought to use our resources is a values based activity. Whose values? The scientists who did the evaluations? The responsible administrators? Often behind closed doors? No transparency
At the McGill University Health Centre we have given this matter some thought. Since 2002, HTAs have consisted of both evaluations and policy recommendations. Evaluations prepared by professional staff. Recommendations, developed by an elected, representative, committee. 10 members. Nurses, allied health professionals, administrators, doctors, patients, consultants (topic experts, ethicists) + stakeholders.
These are only recommendations.. Administration takes final decisions. But they are made public (www.mcgill.ca/tau/ Visits 9,365/month) Q. Does Administration accept recommendations? Do they have impact? A. Policy Impact Of 28 reports with policy recommendations: 26 have been incorporated into hospital policy. Economic Impact Cost of implementing positive recommendations = $ 1,070,014 Estimated savings of negative recommendations =$12,228,154
Technology Recommend 1) IV safety catheters No 2) Antiviral treatment of chronic Hep C Yes 3) GPIIb/IIIa inhibitors for PCI Limited 4) Mitoxantrone for Multiple Sclerosis Limited 5) Colorectal stents Yes 6) L-M-W Heparin for DVT/PE Yes 7) Video Capsule endoscopy system No 8) Risk of PRCA? Use of Eprex Yes (IV) 9) Drug eluting stents for PCI Limited 10) Implantable cardiac defibrillators Limited 11) Esophageal stents for dysphagia Yes 12) Drotrecogin alfa (activated) in sepsis No 13) Biventricular pacing for heart failure No 14) Gliadel wafer for malignant glioma Limited 15) Gastric banding for morbid obesity No 16) Matrix coils for cerebral aneurysm No 17) Probiotics for C difficile infections No
Technology Recommend 18) Expansion of stem cell transplantation No 19) Expansion of VAC wound therapy No 20) Neuro monitoring in spinal surgery Yes 21) Microdialysis after brain trauma No 22) Botox for refractory anal fissure Limited 23) Testing for HER2 +ve breast cancer Yes 24) Mitoxantrone for MS (update of 4) Limited 25) Needlestick safety devices (update of 1) No 26) Wait times at MUHC 1(IMAGING,ORTHO,CATARACT,CARDIAC)n/a 27) Wait times at MUHC 2 (MEDICINE<SURGERY) n/a 28) Wait times at MUHC 3 (FRACTURE MANAGEMENT) n/a 29) Drotrecogin alfa in severe sepsis Limited 30) Navitrack computer assist system Limited 31) Pulsatile perfusion for renal transplant Yes 32) Wait Times, MUHC 4 ( DIAGNOSTIC IMAGING) n/a 33) Impact of TAU reports n/a 34) Coblation Tonsillectomy N Reports available at www.mcgill.ca/tau
Q. Why the high impact (26/28)? 1. Most HTAs are in response to a question [requested advice is usually taken] 3. The make up of the committee. (Health care workers, Administrators, Patients, Stakeholders ) The committee is in touch with the institution 4. Transparency. Making reports public. (It is not easy to go against a scientifically supported, well argued, clearly stated policy recommendation.)
Should HTA recommendations be binding? No question, this would give impact to HTAs Eg. NICE a single national agency, HTAs binding. When NICE recommends a technology, Trusts must make it available, within three months. We are currently considering a Quebec NICE, L Institut national d excellence en santé et services sociaux du Québec. INESSS. As proposed: INESSS will make recommendations. If accepted, ministry will ecourage compliance, using fiscal and administrative means. [Castonguay 09]
Is this a good idea? Should we support it? Personally, I will be a supporter (conditional). Why? HTAs are about rationing. We can t give all health services to everyone. So rationing is essential. We are doing it now. With wait times. Very inefficient. HTA is about rationing more efficiently. About favouring efficient interventions. If we fail public health care will eventually fail. RULE 4 How we use our shared resources needs more than voluntary compliance.
There is a feature of NICE we must not copy. NICE recommendations come without budget. Opportunity cost is ignored. Without extra budget, new technologies are acquired at the expense of an existing item. This causes budget creep. Erosion of the quantity and quality of existing health services to finance new technology.
This does not have to happen. Israel also has a national, HTA agency. Each HTA must include an estimate of budget impact, and each new technology approved, must by law, be accompanied by an appropriate addition to the heath budget.[ Rabinovich 2007] Any Canadian NICE should do the same. RULE 5 No technology should ever be acquired without the first identifying funding.
5 TAKEAWAY RULES: Every HTA should start by identifying exactly to whom it is addressed. We should study, and report, the impact of every HTA we produce. Agencies should never recommend policy for those for whom they have no responsibility. How we use our shared resources needs more than voluntary compliance. No technology should be acquired without prior identification of funding.
REFERENCES Rabinovich M, Wood F, Shemer J. Impact of new medical technologies on health expenditures in Israel 2000-07. Internat J Tech Assess in Health Care 2007; 23:443-448. Castonguay C, et le Comité d implantation. L institut national d excellence en santé et services sociaux du Québec. www.msss.gouv.qc.ca
Health Expenditure % GDP 11% 9%
Slope: 0.1% per year