Adelaide Health Technology Assessment (AHTA)

Life Impact | The University of Adelaide

Tuesday, June 26, 2012

KEEPING AN ‘EYE’ ON THE PROBLEM:

Developing a disinvestment methodology to review Australian medical services - ‘ophthalmology’ as a test case

Tracy Merlin and Jackie Street

Background

2009-2010: • Government funding put aside to develop an evidence

based method of managing the Medicare Benefits Schedule into the future. » MBS Quality Framework

Broad aims:• Maximise health outcomes - safe, effective, appropriately

used• Promote efficient use of limited health care resources -

could we get better outcomes using our health dollar elsewhere?

What is the Medicare Benefits Schedule?

• List of services performed primarily by clinicians that are subsidised by the Government

https://www.chf.org.au/pdfs/chf/What-is-the-MBS.pdf

Demonstration Whole-of-Specialty Review: ophthalmology

Participants– Adelaide Health Technology Assessment , University of Adelaide –

consultants (responsible for the methodology, identification, analysis and synthesis of evidence)

– Clinical Working Group – experts in the field of ophthalmology– Australian Government Department of Health and Ageing – Consumer representation– Policy advisors – Medical Services Advisory Committee

Guiding principles– Evidence based– Fit for purpose– Consult key stakeholders

Challenge 1: What is the service?• MBS descriptors are non-descriptive

Item 42809 RETINA, photocoagulation of, not being a service associated with photodynamic therapy with verteporfin

WHAT IS IT?• Direct photocoagulation• Perifovial photocolagulation• Macular grid photocoagulation• Pan-retinal photocolagualtion• Continuous wave vs pulsed in micro, nano,

pico or femto seconds• Argon, YAG, Krypton, YLF, HeNe, Diode• 350nm to 750nm wavelength• Laser power levels from 1.5 to 8 Watts• Optically pumped semiconductor lasers

based on near-infrared-pumped quantum-well structures

WHY IT IS DONE?• Retinal detachment• Diabetic retinopathy• Choroidal neovascularisation

associated with pathologic myopia• Macular oedema• Age-related macular degeneration• Macular holes• Retinoblastoma

Challenge 2: How to evaluate established services? • Thin evidence base

– Reimbursed on basis of expert opinion– Data collection ↓ after technology adoption– Services often difficult to evaluate in trials ie consultations

, number of follow-up tests/re-treatments

• Lack of comparator– How to determine comparative effectiveness and safety

when technology/service being reviewed is the benchmark (rightly or wrongly)?

• Level of entrenchment– Consumer expectations / preferences– Stakeholder beliefs / income – Practice variation / usage

Mixed Methods Approach

Slide 7© T. Merlin 2011

Health technology / service

Analysis of claims data

Mini-HTA

Guidelines Concordance

Consumer Perspective

Stakeholder Negotiation

MBS data analysis

• Pattern of claims consistent with disease burden and patient demographics?

• Regional variation in practice?

• Rural vs urban uptake?

• Pattern of services used together?

Guideline concordance

• Appropriate clinical practice guidelines identified for each item

• AGREE appraisal instrument used to rate quality of guideline.– Recommendations in those guidelines with high AGREE

rating were given more credence than lower rated guidelines

• Judgement made whether MBS item descriptor was similar to recommendations in guideline or whether it did not reflect evidence-based “best practice”

Mini-HTA - optimisation

• Research questions:– Are there particular populations or settings where the

technology works better than others?– Are there particular forms of the technology that are

more effective?

• Pre-defined PICO (Population, Intervention, Comparator, Outcomes) criteria → study eligibility

• Databases: Cochrane Library, Embase/Medline, EconLit.

Mini-HTA - optimisation

• Search limits: English language, humans, publ 2005-2011

• Hierarchical literature selection by study design: – Limit 1 – SRs– Limit 2 – controlled clinical trials, RCTs or

meta-analyses– Limit 3 - any articles + progressive

retrospective 5 year time periods

• Critical appraisal + narrative synthesis (NHMRC body of evidence matrix)

Ascertainment of consumer preferences

• Qualitative literature search – Embase.com, Scopus• Analysis of weblogs – identified through Google advanced

domain search. Commercial blogs excluded• Literature imported into NVivo – thematic coding and analysis

Styes...One became big and bad enough that I was prompted to see an eye doctor in Lapeer- not knowing he was going to remove it right there in his office- I was in for a huge surprise- They froze it- felt like they pulled my eyelid back and tied it to my ponytail- took the stye out- and left me with a huge bruise and a patch to cover it. That wont [sic] happen again- I assure you. I have since had styes- but use over the counter stye medication which seems to be doing a good job.

(TJ, United States, November 13, 2003).

Stakeholder negotiation

Review Process

• Protocol for Stage 1 drafted and released for public consultation – Dec 2010

• Stage 1: Review of 61 Medicare items undertaken using mixed methods approach– Tailored approach; not all items received all analyses– Oct 2011: released for public consultation – Review recommendations – only 20 / 61 services escaped

change– March 2012: recommendations provided to MSAC →

MSAC provided advice to Minister

• Stage 2: Review of remaining 23 Medicare items is underway

Slide 15© T. Merlin 2011

Review recommendations

+ Items split to separate out services of different complexity (subsidy implications) or Items merged

Descriptors modified/restrictedServices deleted

Policy outcomes of demonstration review

• 2011-2012 Budget Comprehensive Management Framework for the MBS: – Commitment to rolling reviews of the appropriateness,

clinical quality, safety and fee levels of existing MBS items

– Aim is to maximise health outcomes for patients and be cost neutral

– Methodology feasible and accepted. » template for all subsequent whole-of-specialty

reviews

• Co-author – Jackie Street (consumer preferences)• Researchers applying methodology – David Tamblyn, Linda

Mundy, Edith Reddin, Ben Ellery, Vineet Juneja, Sophie Hennessy, Sophia Scrimgeour

• Feedback from Eliza Hazlett, Amy Lambert, Kelly Cameron, Alex Hunyor, Guy D’Mellow, Russell Bach, Mark Daniell

• Funded by – Australian Government Department of Health & Ageing.

tracy.merlin@adelaide.edu.au

Reference

Merlin T, Street J, Holton C, Mundy L, Tamblyn D, Ellery B, Juneja V, Reddin E, Scrimgeour S, Hennessy S (2011) Review of MBS Items for specific ophthalmology services under the MBS Quality Framework. Canberra, ACT: Commonwealth of Australia

http://www.msac.gov.au/internet/msac/publishing.nsf/Content/Ophthalmology_Review

Slide 18© T. Merlin 2011