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5/2/2006 1
Hospital HTA: Mandate or Wishful Thinking?
Janet Martin, BScPhm, RPh, PharmD
High Impact Technology Evaluation Centre (HiTEC)
London Health Sciences Centre, ON
OUTLINE
I. Why HTA in the hospital?II. Is it a ‘mandate’?III. Is it possible?III. What are the challenges?IV. What opportunities remain?
Why Hospital HTA?
Hospital expenditures account for 30% of the total budget for health care in Canada …and growing!
Why Hospital HTA?
30%
Why Hospital HTA?
Expense-dense +Technology-dense +Decision-dense +Social-Ethical-Political Arena= High stakes game!
High Concentration of Technologies
HR
Programs Machines
Devices
Drugs
Patient
Technologies + Patients + Decisionmakers Interact
Context-SpecificProblem-Based, Decision-Driven
Hospital HTA = Living Laboratory
Hospital Spending: In control?
Drugs & Devices: Largest ‘Impactable’ Spending
Therefore, need a solid & principled decision-making framework
How decisions are made in Hospitals
‘Black & white’ decision-makingDouble standard evaluation & approvalLack of accountability for approvals & uptakeDecisions are regarded as permanentDisinvestment processes are lackingProspective planning for approvals non-existentPrioritization is lacking
Uncoordinated & Unaccountable
Hospital Cost per Weighted Case
Hospital HTA: A Cost-Cutting Program?
How can we say no?Every health technology has good rationale for its purported uses
Should we always say yes?We are dealing with ‘health’, which is often life-or-death in the hospital setting
How can we say no?• Every health technology has good
rationale for its purported uses
Should we always say yes?• We are dealing with ‘health’, which is
often life-or-death in the hospital setting
No!No!
Is yes better than no?
HTA
HTA in Hospital: Progressing Along the Innovation Curve
Producers and users need early contact
Translation into Action
Where are we now?
Why Hospital HTA?Costs are risingStakes are highProducer-user interactionProblem-based, Context-specific
But, is it happening?
Where the Action is Reported
Pockets of activity
Discrete parts of Canada
Hospital HTA: Not yet mainstream
Is it happening?So far, it’s a rarityMany related activities, but few coordinated groups
But, is it mandated?
A Mandate?
HTS 1.0Recognizes it as a priorityRecommends it
CCOHTA 5-Year PlanFuture priorityBut, no specific plan (yet)
Alas, is it possible?
Mandated?
Is it mandated?Except in Quebec, no!Consensus is that it should be
Decision-making dichotomiesUninformed by evidence = double standardInconsistent interpretation and delivery of ‘medically necessary care’ within hospitals
Alas, is it possible?
HiTEC Mission
To minimize opportunities foregone and to maximize health outcomes within our given set of resources at the London Health Sciences Centre by informing high-impact decisions for drugs, devices, and procedures with best available evidence and information on benefits* and risks*
____________________________________* defined as clinical, economic, social, ethical, political
benefits and risks
HiTEC: Who we are
On Location:3 pharmacists (FT), 1 physician (PT)
On contract:Bioethicist, Medical Economist, others
HiTEC: Target Audience
Decision makers at London Health SciencesHealth Care PractitionersPolicy Makers
Pharmacy & TherapeuticsMedical Advisory CommitteeGuidelines CommitteesCare Pathway Committees
Purchasing, Planning, Bioengineering, FinanciersManagers, Senior Leaders
Areas of Focus
Devices
Machines
Procedures
People & Programs
Drugs*
What does it look like?
Receive or Generate Requests– MD, Rx, HiTEC, VP
Prioritize Requests– High impact clinically, economically, SEP
Perform HTA, Release Results– Collaborate with requestor, end-users– Explore policy options, remove barriers– Communicate results and implications
Formalize Decision & Generate Policy– Institutional policies and procedures
Implement Policy- Active strategies may be required (A&F, AD, reminders)
Evaluate Uptake & Dissemination
Full Circle HTA: From Assessment to Action
ASKASK ASSESSASSESS
ACT ACT
The Demand is Relentless
ASKASK ASSESSASSESS
ACT ACT
The Demand is Relentless
ASKASK ASSESSASSESS
ACT ACT
Rate
Limiting
Step
Swamped!Maybe it is NOT possible?
HTA
Relentless Demand + Long Appraisal Process= Outmoded
Decisions will be made, regardless!Decisions cannot wait ….
Relentless Demand + Long Appraisal Process= Outmoded
Decisions will be made, regardless!Decisions cannot wait ….
Or, can they? (eureka!)Or, can they? (eureka!)
An ‘AHA!’ Moment
Decisions CAN waitCAN wait–– Most decisions to use new technology are not Most decisions to use new technology are not
urgenturgent
Decisions SHOULD wait Decisions SHOULD wait –– Coordinate with the budget cycleCoordinate with the budget cycle
Decisions should not be made in isolationDecisions should not be made in isolation–– Place multiple decisions on the table Place multiple decisions on the table
simultaneouslysimultaneously
The The HiTECHiTEC ApproachApproach
Call for Proposals ApproachCall for Proposals Approach
Coordinate with the budget planningCoordinate with the budget planning
Allows for prospective budget planningAllows for prospective budget planning
Consider multiple tradeoffs simultaneouslyConsider multiple tradeoffs simultaneously
Table all relevant decisions at onceTable all relevant decisions at once
What is ‘cost’?
Cost is the sacrifice of consequences in the best alternative use of resources
Knonow44GoGo
B:R 4Go
5/2/2006 42
Every decision to do one thingis a decision not to do another
Project Know4Go: Impact on Decision-Making
‘No-G
o’
62
8
10
4
9
1
17
3 57
11
12
14
35
16
18 19
2021
2223
32
‘Go’
Bud
get I
mpa
ct
Benefit Index
Completed Topics
Topic B:R BIA CEA
SEP M/m Decision
APC M Accept*
L-AMB M Accept*
Rituximab m Accept# Argatroban M Reject
Bivalirudin M Accept*
IV Panto M Accept*
BLES M Accept
IV Iron sucrose M Reject
Etomidate M Accept*
Ibutilide m/M Accept*
* With Limitations # One-Time M = Major HTPA m = mini-HTA
Completed Topics
Topic B:R BIA CEA
SEP M/m Decision
APC M Accept*
L-AMB M Accept*
Rituximab m Accept# Argatroban M Reject
Bivalirudin M Accept*
IV Panto M Accept*
BLES M Accept
IV Iron sucrose M Reject
Etomidate M Accept*
Ibutilide m/M Accept*
* with limitations # one-time In-house evaluation
Ongoing & Completed TopicsTopic B:R BIA CEA
SEP M/m Decision
OPCAB M Accept*
MAZE M Ongoing
TMR M Ongoing
Octreotide M Ongoing
IL-2 m Accept# Imipenem M Ongoing
Linezolid M Ongoing
LMWH M Ongoing
EPO/NESP M Ongoing
Aprotinin M Ongoing
Sevoflurane M Ongoing
Infliximab m/M Accept#
* with limitations # one-time
Ongoing & Completed TopicsTopic B:R BIA CEA
SEP M/m Decision
OPCAB M Accept*
MAZE M Ongoing
TMR M Ongoing
Octreotide M Ongoing
IL-2 m Accept# Imipenem M Ongoing
Linezolid M Ongoing
LMWH M Ongoing
EPO/NESP M Ongoing
Aprotinin M Ongoing
Sevoflurane M Ongoing
Infliximab m/M Accept#
* with limitations # one-time In house evaluation
A new approach to increase decision maker uptake:A new approach to increase decision maker uptake:Addresses socialAddresses social--ethicalethical--political issuespolitical issues
Considers the opportunity costConsiders the opportunity cost
Embeds decision in context of past/present/ futureEmbeds decision in context of past/present/ future
Organizes decisionOrganizes decision--making with the budget prospectivelymaking with the budget prospectively
Technology is not ‘inherently good’
Does Hospital HTA Differ?
Turn challenges into opportunitiesTurn challenges into opportunities
““Just another way to say no!Just another way to say no!””
““Cost cutting programCost cutting program””
““HTA should be about HTA should be about ‘‘acquisitionacquisition’’, not , not ‘‘assessmentassessment’”’”
““Economic analyses are wizardryEconomic analyses are wizardry””
Does Hospital HTA Differ?
Turn challenges into opportunitiesTurn challenges into opportunities
Fixed BudgetFixed Budget
Large Deficit Large Deficit
HiTECHiTEC: Prove your worth!: Prove your worth!
Pace and gravity of decision makingPace and gravity of decision making
Conflicted recommendations (advising on the same Conflicted recommendations (advising on the same global budget that pays for global budget that pays for HiTECHiTEC and technologiesand technologies))
Institutional PoliticsInstitutional Politics
Does Hospital HTA Differ?
Turn challenges into opportunitiesTurn challenges into opportunities
Fixed Budget Fixed Budget Quantify & Know4GoQuantify & Know4Go
Demand > ResourcesDemand > Resources Call for Proposals Call for Proposals
Politics/Ethics ArisePolitics/Ethics Arise Add dimensions to HTAAdd dimensions to HTA
Urgent RequestsUrgent Requests OnOn--Call Rapid HTACall Rapid HTA
Reactive Reactive vsvs Proactive Track Top 50 TechnologiesProactive Track Top 50 Technologies
Does Hospital HTA Differ?
A What is unique about Hospital HTA?A What is unique about Hospital HTA?
DecisionDecision--maker proximity & involvementmaker proximity & involvement
Explicit recommendations made & acted uponExplicit recommendations made & acted upon
Assessment is just the beginning!Assessment is just the beginning!
External HTA reports can be localizedExternal HTA reports can be localized
New and old technologies are fair gameNew and old technologies are fair game
Opportunities for Hospital HTA to developOpportunities for Hospital HTA to develop
OnOn--Call Rapid HTA (realCall Rapid HTA (real--time HTA, minitime HTA, mini--HTA)HTA)
Collaboration with provincial HTACollaboration with provincial HTA
Collaboration with other hospitalsCollaboration with other hospitals
Collaboration for field evaluationCollaboration for field evaluation
A HTA Unit in Every Hospital?
Why not simply use outside HTA reports?Why not simply use outside HTA reports?
Not yet availableNot yet available
No recommendations givenNo recommendations given
No analyses of local opportunity cost No analyses of local opportunity cost
Wrong question (Wrong question (rituximabrituximab for for cryoglobinemiacryoglobinemia))
Collaborate Compete
Collaboration is Key
A National/International Network for Hospital HTA?A National/International Network for Hospital HTA?
To share experiences, tools, and frameworksTo share experiences, tools, and frameworks
To centralize core activities (literature review)To centralize core activities (literature review)
To pool evaluations (field evaluations)To pool evaluations (field evaluations)
To maximize progress of researchers, To maximize progress of researchers, producers, usersproducers, users
To ensure consistency and quality of keyTo ensure consistency and quality of keydecisionsdecisions
Opportunity Money
HTA in Real-Time =Decision 911
Many thanks . . .
LHSC
CIHR
UWO
LHRI
CCOHTA
…our team!
Technology is not ‘inherently good’
‘Call for Proposals’ Approach
• Why allow decisions to run amok• Decisions should be coordinated with the
budget cycle
• Hold a call for proposals for requests for new technologies
• Plan prospectively for the budget cycle• Capture tradeoffs for multiple decisions
simultaneously
Does Hospital HTA Differ?
xxxxxxxx is unique about is unique about HostpitalHostpital HTA?HTA?
DxxnDxxn--maker proximity & involvementmaker proximity & involvement
x is just the beginning!x is just the beginning!
x old technologies are fair gamex old technologies are fair game
Does Hospital HTA Differ?
xxxxxxxx is unique about is unique about HostpitalHostpital HTA?HTA?
DxxnDxxn--maker proximity & involvementmaker proximity & involvement
x is just the beginning!x is just the beginning!
x old technologies are fair gamex old technologies are fair game
• The average man’s judgment is so poor, he runs a risk every time he uses it
• -Edgar W Howe
• Most real world problmes involve uncertain info. Althou uncertainty can be oftern reduced, it can be seldom eliminated
Impact on Decision-making
‘No-G
o’
62
8
10
4
9
1
17
3 57
11
12
14
35
16
18 19
2021
2223
32
‘Go’
Bud
get I
mpa
ct
Benefit Index
What you get What you get …… What you 4Go What you 4Go ……PCI = 0.5 lives PCI = 0.5 lives
APC = 0.75 livesAPC = 0.75 lives
LL--AmphoAmpho = 4 lives= 4 lives
Unknown clinical Unknown clinical benefitbenefit
Political Political ‘‘CorrectnessCorrectness’’
Media FriendlinessMedia Friendliness
What you 4Go What you 4Go ……
Unknown clinical benefitUnknown clinical benefit
Political Political ‘‘CorrectnessCorrectness’’
MediaMedia--FriendlinessFriendliness
What you Get What you Get ……
PCI = 0.5 lives PCI = 0.5 lives
APC = 0.75 livesAPC = 0.75 lives
LL--AmphoAmpho = 5 lives= 5 lives
Recommended Resources
See also ‘References’
Weighing the Costs & Benefits
What is the real cost?
gohitec.com
know4go.org
Many thanks . . .
LHSC
CIHR
UWO
LHRI
CCOHTA
…our team!