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”