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Janet Martin, PharmD, MSc(HTA&M)Director, Medical Evidence, Decision Integrity, Clinical Impact (MEDICI)
Co-Director, High Impact Technology Evaluation Centre (HiTEC)
& Evidence-Based Perioperative Clinical Outcomes Research (EPiCOR)
Assistant Professor, Department of Anesthesia & Perioperative Medicine
Epidemiology & Biostatistics, Schulich School of
Medicine & Dentistry
London Health Sciences Centre/St Joseph’s Health Care London
University of Western Ontario
How to Win Friends & Influence Policy Stories from the Hospital Perspective
OVERVIEW: Winning & Influencing
I. Traditional HTA II. Traditional Decision/Policy MakingIII. A Proposed SolutionIV. Stories from Hospital HTA
Slide Title Goes Here A partnership of the London Hospitals (LHSC/SJHC), Lawson Health Research Institute (LHRI), Western University (UWO)
Slide Title Goes Here1. Create timely and contextualized evidence-
based reviews for high-stakes intra-operative and perioperative therapies
2. Translate evidence to definitive decisions using the Know4Go Framework
3. Develop and Implement policy with supporting tools, and build institution-wide capacity for Know4go-informed decision-making
4. Evaluate the impact across multiple domains & multiple objectives
Hospital HTA: HiTEC @ MEDICI CENTRE
Topics Completed in 2012
Blood Conservation Strategies (EPO periop, T Tx) Perioperative Antibiotics for clean surgery Transcatheter aortic valve implantation (TAVI) Thoracic Endovascular Aortic Repair (TEVAR) Ultrafiltration devices for cardiac surgery (UF) Biocompatible circuits for surgery Dexmedetomidine for ICU, Neurosurg, AFOI, MAC Ketamine for Periop Pain Collatamp for preventing SSI Colloids (ie, Voluven for volume replacement in
surgery and critical care patients) Antibiotic-impregnated sutures Harmonic scalpel for various surgeries (ongoing)
…and for 2013
Orthopedic surgery Vascular surgery Robotic surgery Cardiac surgery Mental Health
Hospital HTA: A Perfect Petri Dish for HTA to Action
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.
….and, are clearly not decision-ready.
The average man’s judgment
is so poor, he runs a risk
every time he uses it.
- Edgar W. Howe
Occam’s RazorMake everything as simple as possible, but no simpler.
-Albert Einstein
Innovation
Innovation
HTA Assessment
Training
Knowledge Translation (KT) Cycle
Techno Hype Cycle
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 bifurcated stents, peripheral stents, harmonic scalpels, etc
Need local considerations of infrastructure, existing technologies, patient population, health professional skills, learning curves, competing priorities
Hospital-Based Collaborative HTA&M Fast-paced, real-time, in “decision-making
time” Collaboratively with decision-makers Contextualized to local setting Accountable to “predictions” Decision impact is “felt” very quickly
“HTA in a box”Truly, madly, deeply.
Where the rubber meets the road.Decisions become moral dilemmas.
Systematic Review ≠ Decision
Economic Analysis ≠ Decision
Evidence is one consideration, but not the only consideration.
Why Traditional Approaches FailTraditional application of Evidence to Decisions: Too technical Too linear Too blunt Too many assumptions
Evidence from expanded domains of influence social, legal, ethical, environmental, etc opportunity costs need to be made explicit before decisions can be
made comfortably
Deliberate Collaborate Iterate Implement Account Reiterate
Hospital-Based HTA: A perfect petri dish for Knowledge Translation
Key Questions
PublishedEvidence
Contextualized Evidence
Can it work …in the ideal setting? …here?
Does it work …in real world settings? ...here?
Is it worth it …for whom? ...here?
From traditional to collaborative & contextual
Now
Be CLEAR, EXPLICIT, CONTEXTUALIZED.And, Go where the evidence dares not…
B:R SLEEPERs
What is a SLEEPER?
SocialS
E
E
L
P
ER
Legal
Ethics/Equity
Environmental
Entrepreneurial-Research-Innovation
Political
S ‘Stickiness’
SLEEPERs Assessment: Rate the Importance of Each of the Domains for this Decision
B:R 4Go SLEEPERs
Know4Go
What is Know4Go?
Evidence Synthesis
Cost-effectiveness SLEEPERs Opportunity Cost
= Contextualized Evidence-Based Decision-Making
+ + +
Tradeoff Table
‘Go,
No-Go’
Benefit Index
Bu
dg
et I
mp
act
Voluven
A collaobrative, contextual, dynamic approach to increase decision-maker uptake of best available evidence:
Collaborative: End-Users (all stakeholders) and HTA’ers
Multilevel: Practitioners, Managers, Policymakers
Multidimensional, Contextual: Addresses SLEEPERs
Honest & Accountable: Considers opportunity cost
Embeds the decision in context of past, present, future
Decisions are always “live” (not a single event)
Clarity (not over-confident)
“Just Give me the Number”
(…and no one gets hurt)
Timely (not too fast)
It’s always too soon…
It’s always too soon…Until it’s too late
Contextual (what does it mean here?)
Accountable (did our evidence ‘predictions’ come true?)
Iteratively (did the evidence change? Do the results still apply?)
Summary Hospitals juxtaposes evidence, decision-makers, and
consequences of decisions within a fixed set of resources and circumstances (a perfect petri dish)
Traditional approaches attempt a linear approach (post-hoc) to what should be nuanced and multifactorial decision-making
Engage rather than alienate decision makers; ensure HTA relevant, explicit and tangible
Make transparent 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
Winning & Influencing?
or“The joy is in the journey”
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