SHTG Development Day Slides 2013 (1)

8/15/2019 SHTG Development Day Slides 2013 (1)

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INTERNATIONAL APPROACHES TO TOPIC GENERATION & PR

P d b K M h


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Agency Source of HTA topics

Canadian Agency for Drugs & Technologies in Health,

CADTH

Canadian healthcare decision makers

Healthcare Quality Ontario, Canada Sponsored by a potential Ontario purchaser orprovider of insured health services

Swedish Council on Health Technology Assessment,SBU

Individuals, organisations, government audecision-makers, SBU scientific advisory

Belgian Healthcare Knowledge Centre, KCE Individuals, organisations, institutions with ain health care, policy makers

National Health Committee, New Zealand District Health Boards

NICE, UK MTAs – Department of HealthMTEP – sponsored by a manufacturer

Australian Safety and Efficacy Register of NewInterventional Procedures - Surgical (ASERNIP-S)

Surgeons, Consumers Health Forum, hospcredentialling committees,


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• Most agencies use guidelines or explicit• Variability in approaches used• Quantitative rating and consideration of

expected costs & benefits of assessmentuncommon

• Extent of linkage with government progrelated to influence on priority setting


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Clinical & economic impact oftechnology

Disease burden

Budget impact

Availability of relevant evidence

Expected interest(from government, health


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CADTH, Canada

• Twice yearly priority setting exercise• Topics must link to a relevant public

or practice policy decision• Topics scored according to criteria

and ranked• Meeting with health ministry,

hospital and federal governmentrepresentatives to consider rankingalong with contextual informationTh i h

National Health Commit

• Ran a referral round with into health sector

• 26 referrals received and 60organisations commented

• 11 decision making criteria• Pull model and mega-analy

approach


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• Ongoing consultation with clinical speciality groups• Using routine data to identify variations in use of techn

and/or associated outcomes

• Using routine data to identify technologies associated wbudget impact

• Monitoring published studies and systematic reviews• Routine identification of technologies for optimisation• Feasibility assessment to support prioritisation


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• Chest physiotherapy as an adjunctivetreatment for adults with pneumonia

• Adjuvant radiotherapy with surgery forendometrial cancer

Over 150 potentiallylow-value health care

practices: an Australianstudy (Elshaug et al.)

• June 2011 updated literature review

• BMJ Best Practice, EBM database,Cochrane library and associated databases,NICE

Scottish Public HealthNetwork Disinvestment

List

• Taken from NICE HTAs and NICE guidelines

• Already piloted by SHTG

NICE ‘Do not Do’

recommendations


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• High cost per procedure or high cost by volumeCost of service

• Likely health impact or Likely cost effects• Impact on equity in care

Potential impact

• Cheaper but more or equally effective alternativCost-effective alternative

• Degree of disability or morbidity• Rates of mortality

Disease burden

• Available and adequate to offer decision makingSufficient evidence available

• “pay for evidence” • “only in research” provisions Scope for time-limited funding


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hallenges toDisinvestment


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Disinvestment

Elshaug et al. (2007) defined disinvestment as:

‘The process of partially or completely withdrawinghealth resources from any existing health care practprocedures, technologies or pharmaceuticals that ardeemed to deliver little or no health gain for their coand thus are not efficient health resource allocations’.”


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ScotPHN disinvestment work

• To update previous work from 2007• To develop and promote public health

contribution to disinvestment

• To develop and promote contribution towider efficiency and productivity agenda

• Create and support HENS


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Previous & existing work

• 2007 case study (Sheila Scott, Director ofPublic Health, NHS Western Isles) includingliterature review of disinvestment - foursentinel surgical procedures

• NICE programme – the ‘don’t dos’ list(s)

• NHS Healthcare Improvement Scotland

(SHTG)


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ScotPHN 2011 updateSOURCES:• BMJ Best Practice• EBM database• DARE/HTA/NHS EED• NICE programme:

– don’t do’s’ list – Optimal Reviews: Recommendation Reminders– Cost saving guidance

• Request to Directors of Public Health regarding localdisinvestment work


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Disinvestment targetsIneffective Healthcare Interventionsby type)

Surgery

Treatment (inc. drugs, tests etc.)

Therapy (inc. psychotherapy and devices)

Model of care

Screening

Total


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Examples of interventions for possible disinvestment include:• types of coronary artery stent in ischaemic heart disease;• the use of many classes of drugs in the treatment of anxiety a

depressive states;• oxygen therapy in certain presentations of chronic obstructiv

pulmonary disease;• the use of alcohol brief interventions in hospital inpatient

settings; or• several categories of clinical tests used in conditions such as

chronic obstructive pulmonary disease, dyspepsia, epilepsy, familial breast cancer, fertility, growth hormone deficiency,

hypertension, lung cancer, and Parkinson’s disease.

Disinvestment targets - treatme


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How to implement?

• Not actually easy to disinvest:– What is the “unit” of disinvestment: the service; t

intervention / treatment?– Clinical services usually ahead of the game and h

switched! (c.f. NHS Greater Glasgow & Clyde re& NHS Lothian work)– Savings potential can be illusory – lots of little

my not actually ever be sufficient for cash-release

– Cash release v pressure release?


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How to implement?• Approaches to benefits realisation with disinvestment should

include:– service redesign : using disinvestment to allow service red

reconfiguration to be progressed beyond LEAN approaches– substitution : within service disinvestment to allow reinves

to address service pressure or allow limited service develop– resource release : managed service removal or closure.

• First principles approach – good old fashioned “public healthHCNA, HIA, etc.!


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Way forward?

• Disinvestment at the level of individual treatment,device or intervention likely to be insufficient to seecash-releasing – lots of “little bits” too easilyabsorbed locally

• As a minimum , consideration of the disinvestmentpotential of the target within its service context isneeded to help local systems

• Big cash-release in the system comes at the level of

services, staffing & procurement – for this typedisinvestment we need to be courageous


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Phil Mackie, Lead Consultant

• e-mail: [email protected]

• voicemail: 0141 414 2755

www.scotphn.net


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THE STORY SO FAR...

• SHTG topic referral system – process, topic referral form, selection criteria – source of topic referrals – topic acceptance rate

• SHTG published outputs – types of evidence review – technologies & patient groups – value added?

• SHTG work programme – trends and issues


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TOPIC REFERRAL PROCESS


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1. Name and address of topic referrer.

2. Brief description of technology to be investigated.3. Patient condition or disease/s to be treated.

4. Other interventions as alternatives/comparators to technology.

5. Outcomes of interest from using the technology in this condition.

6. Rationale for undertaking an assessment.

7. State how Healthcare Improvement Scotland will demonstrate the impact ofthis technology assessment in terms of clinical and cost effectiveness?

8. State the main question you want to be resolved by the assessment.

9. Describe the preferred time frame.

10.Summarise the evidence base for the technology of which you are aware.

11 State how the technology is currently being used within NHSScotland

TOPIC REFERRAL FORM


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Topic must have at least one of the following:

1. Is a clear additional health benefit to patients anticipated or evidentfrom the use of this technology?

2. Is there uncertainty about the clinical or cost-effectiveness of thetechnology?

3. Is there wide variation in provision or outcome of the technologyacross Scotland?

4. Is the technology likely to have a major impact on NHS resources(consuming or releasing)?

5 Is the technology likely to have a major impact on NHSScotland?

CRITERIA FOR TOPIC SELECTION


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Topic must have all of the following:

1. Is there potential for quality improvement from undertaking anassessment of this technology at this time?

2. Is it likely that one or more focussed technology assessmentquestions can be prepared?

3. Are there likely to be sufficient published research findings availableupon which to base a technology assessment?

CRITERIA FOR TOPIC SELECTION


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• Volume, source and quality highly variable• Acceptance rate 62%• Reasons for rejection

– Insufficient evidence to inform assessment – Evidence review underway or available elsewhere – Out with SHTG remit – Topic referrer withdrew topic

TOPIC ACCEPTANCE RATE


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SOURCE OF SHTG TOPIC REFERRALS

Source of referral Scoping

report Evidence

note Other

SGHSC delivery & nationalreview groups

9 11 1

National Planning Forum 2 7 1

NHS boards 6 2 0

SHTG 1 5 1

Chief Dental Officer 2 0 0

Industry 0 0 0

P ti t & bli 0 0 0


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• Health Technology Assessment 1• Systematic Review 1• Evidence Notes 25• Technologies Scoping Reports 20• Horizon Scanning Reports 20• Costing Reports 6• Advice Statements 27

SHTG PUBLISHED OUTPUTS 2008-


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SHTG – TECHNOLOGIES


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SHTG – PATIENT GROUPS


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£284,000/YEAR


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SHTG VALUE ADDED"[SHTG] has been very, very helpful for making a very difficult decision at anational level that protects boards, and I think protects the public from growth in

an area that perhaps isn’t as effective as being suggested” (TAVI)“This will inform a national debate which will propose a new policy for thescreening programme” (HPV screening)

“This is a really good example of evidence review guiding policy developmentand will form the basis for a radical new policy in this area of intervention”

(Bariatric surgery) “The BDA applauds this commonsense decision, which has been taken on thebasis of available evidence” (Dental instruments)

“It really helped us to get to a conclusion on vascular about what the evidencesaid” (Vascular services)

“This evidence statement has already informed our new referral protocol for


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SHTG VALUE ADDED


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• Inform (re)allocation technology spend from less to more efficient

purposes• Caution against routine adoption of technologies in advance of a

supporting evidence base• Flag potential technology disinvestment candidates• Key questions

– Optimising use of the limited resource? – Opportunity costs of the topics forgone?

SHTG VALUE ADDED


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• Responsive and planned elements?• Range of topic referral sources as we would wish?• How to make more effective use of our horizon scanning?• Specific technologies, disease areas, care pathways?• Relatively established versus innovative technologies?•

Investment versus disinvestment balance?• Gaps in coverage?• Alignment with national priority areas?• The most important topics?• Opportunity cost of topics forgone?

SHTG TOPICS – ISSUES TO CONSIDER


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SHTG ADVICE STATEMENT

Advice Statement SHTG December/2013

This advice has been produced following completion of EvidenceNote/systematic review/health technology assessment reference byHealthcare Improvement Scotland, in response to an enquiry from topicreferrer details

Background

Clinical effectiveness

Safety

Cost effectiveness

?


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Disinvestment in NHS Lothian..........“just say NO!”


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Disinvestment in NHS Lothian..........Attempting to use evidence to change

practice.....(and save money??)


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DISINVESTMENT

• Context: E&P........ Clinician “anaphylaxis” but why? • Data on efficacy........??? Evidence....?? Devices.....???• (is there any evidence that disinvestment has worked?)

• Surgeons “like to operate” etc.......... • Is your disinvestment a clinical problem?• Withdrawal of what is already available is unpopular with

patients and doctors.• Politically damaging• Can’t just say NO!!!


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Priority setting...... Which one?

• Patient- did we ask?? Most important?!??!• Financial- don’t need to ask!! • Quality- what questions to ask?• Outcomes- Was the question biased?

• Many more.................... -Croydon list-McKinsey


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Lothian RILCV process.

• Identify area of interest• Contact clinicians and seek “buy in” • Assessment of health intelligence (HIU and ISD, BQBV dashboar• EVIDENCE REVIEW - efficacy

- cost effectiveness- controversy in literature- Impact of change

• ENGAGE STAKEHOLDERS• Develop plan• Enact and review plan


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Cataract RILCV process.

• Identify area of interest- Cataract • Contact clinicians and seek “buy in” – Oph & optoms • Assessment of health intelligence – 4500 operations, half coded

second eye • EVIDENCE REVIEW -impact of threshold

- value of 2 nd eye surgery


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No evidence for the use ofthresholds in cataract

provision


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There is RCT data that 2 nd eye surgery is effective at

£17K per QALY


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Cataract RILCV process.

• Identify area of interest- Cataract

• Contact clinicians and seek “buy in” – Oph & optoms • Assessment of health intelligence – 4500 operations, half coded• EVIDENCE REVIEW -impact of threshold

- value of 2 nd eye surgery • ENGAGE STAKEHOLDERS – oph, other boards, RNIB, E&D unit,• Develop plan – Set threshold at driving test level plus other “soft”

then audit implementation as a “shadow”• Enact and review plan – 5% reduction in referrals, 0.4% reduction

surgeries


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Classes of interventions to target for decreased utilisation – Lancet Oncology Commission


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Over-utilisation

• Quicker to discuss TP than discussion of no treatment• Quicker to order a scan than history and exam• In breast cancer no benefit to follow up with tumour markers (Ros

JAMA, GIVIO study JAMA)• Many examples of futile care in last weeks and days of life (studie

suggest up to one third of cancer care costs)• Focus on end of life care: wishes of patients and families• In 2010 the US Federal Government used legislation: Patient

Protection and Affordable Care Act to establish Patient CentredOutcomes Research Institute

f d


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Limitations of evidence

• RCT’s do not imply clinical significance ONLY statistical significance• NCI Canada reported median overall survival benefit of 0.33 mon

for Erlotinib plus gemcitabine in advanced pancreatic cancer• Massive toxicity, FDA, EMA and SMC approved at cost of $500,

per life year gained (Threshold?? NICE 10%)• EUROCAN project- ethical, political and administrative barriers t

acquiring and sharing data on outcomes

C


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Cancer surgery

• Hunter “an armed savage trying to render by force that which acivilised man would render by strategem” - Main method of cusolid tumours globally

• In common cancers surgery alone 50% of direct costs (Warren JN2008)

• ASCO 2010- ACOSOG Z0011 study showed no benefit of ALNDwomen with 1-3 positive SNB- Surgical bias!!!

• Challenge the surgical dogma!!

We need to be able to do more


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We need to be able to do morethan “just say no”....... What?

Thank you!

Prof. Victor Lopes PhD FRCSNHS Lothian

[email protected]
mailto:[email protected]:[email protected]

Documents

SHTG Development Day Slides 2013 (1)