Hospital HTA: Mandate or Wishful Thinking?€¦ · 5/2/2006 1 Hospital HTA: Mandate or Wishful Thinking? Janet Martin, BScPhm, RPh, PharmD High Impact Technology Evaluation Centre

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””



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



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


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


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


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!

Documents

Hospital HTA: Mandate or Wishful Thinking?€¦ · 5/2/2006 1 Hospital HTA: Mandate or Wishful Thinking? Janet Martin, BScPhm, RPh, PharmD High Impact Technology Evaluation Centre