Technology and Health Care

HCA 701

November 10, 2005

Technology Assessment

The process that examines the available evidence to form a conclusion as to the merits or role of a particular technology in relation to its possible use, purchase or reimbursement in current medical practice. Examines the safety, effectiveness, efficiency and

appropriateness Includes medical devices, procedures and standards, and

pharmaceuticals To maximize quality: the most effective health care

service that science can provide Can we afford it?

Categories of Technology

Devices - "the quiet heroes of health-care innovation" Diagnostic devices (MRI, CAT, SPECT, etc.) Treatment devices

Medical and surgical procedures (examples): Radial keratotomy used to improve vision. Genetic testing Treatment head injuries, cancers, joint replacements, etc.

Pharmaceuticals Efficient and appropriate uses for FDA approved drugs Labeling – language used to delineate the clinical use of a

drug (indications, dosage, adverse effects, etc.). Understanding the long-term affects of uses of some drugs, Understanding alternative uses for drugs (e.g., manoxodil)

Technology Life Cycle

Investigation – laboratory and clinical studies to discover or create, refine and package a new diagnostic or treatment modality.

Promotion – introducing the technology into the buying community.

Acceptance and utilization – incorporating the technology into practice.

Decline – as technology is supplanted by superior new technology.

Obsolesce – when the new technology is obsolete and no longer appropriate.

Targeting Technologies for Assessment Improve individual patient outcome Positively affect a large population Reduce treatment costs Reduce unexplained treatment variation.

Three Components of Technology Assessment High Utilization

Rapidly increase uses of a technology may signal inappropriate or excessive utilization. (e.g., Cesarean births rates)

Uses of high technology for common conditions may be inappropriate

E.g., use of mammography for women under the age of 50 has sparked controversy on the practice of high technology.

Potential for Harm Requires different standards and assessment priorities for

different risk factors in patients. High Cost – willingness of payers to pay form some

technological procedures or diagnoses.

Performing Technology Assessment Scientific assessment: does it work? Clinical assessment: does it work better than

something that already exists? Economic assessment: Cost (use of Cost

benefit analysis). Social or societal issues:

will providers use it? Will patients use it? Are secondary benefits more detrimental than

primary benefits?

Problems in Performing Technology Assessment Lack of Evidence (not enough literature or patients to

study, or poorly conducted research) Lack of Agreement on How to Perform the Assessment

(may lead to different results using different techniques) Inconsistent Evidence (may result from different or

inconsistent research methods) Legal Interference (can be influenced from biased

resources) Breadth of Topics (difficult to successfully study or

assess all technologies) New Information (assessment process must be ongoing

to adequately compare new uses)

The Impact of Pharmaceuticals on Health Care Prescription drugs account for more than 15% of

health care spending ($162 billion) Faster growth than all other segments of health

care Prescription drug coverage over the last 10

years has been a catalyst for growth Primarily a large multinational corporate

enterprise 10 largest pharmaceutical companies accounted for

60% of all Rx sales in U.S. in 2004

Components of Pharmaceutical Development Manufacturing and Production Research and Development Selling and Promotion

Top 10 Pharmaceutical Companies, U.S. Sales 2004Corp. U.S. Sales in

(Billions)% Growth over

previous year% Market Share

Pfizer $30.7 5 13.1

Glaxo Smith Kline 18.8 1 8.0

J & J 16.2 7 6.9

Merck & Co. 15.0 8 6.4

Astra Zenneca 11.3 13 4.8

Novartis 10.2 7 4.3

Sanofi-Aventis 10.0 13 4.3

Amgen 9.5 23 4.1

Bristol-Myers Squibb

9.2 -4 3.9

Wyeth 8.2 11 3.5

Total Top 10 139.1 59.3

Top 10 Products 2004Product Manufacturer Rx in Millions Market Share

Lipitor Pfizer 74.8 2.1

HYCD/APAP Mallinckrodt 49.5 1.4

Synthroid Abbot 47.4 1.3

Norvasc Pfizer 38.3 1.1

Toprol AstraZeneca 35.0 1.0

Zoloft Pfizer 33.1 0.9

Zocor Merck 29.6 0.8

HYCD/APAP Watson 29.0 0.8

Albuterol Warrick 26.8 0.8

Amoxicillin Teva 26.2 0.7

Where the promotional money goes (In Billions of Dollars)

0

2

4

6

8

10

12

1996 1997 1998 1999 2000 2001

Retail Value ofSampling

Detailing

Direct to ConsumerAdvertising

Professional JournalAdvertising

Major Issues for Prescription Drug Policy Consumerism and the results of direct to

consumer marketing Brand drugs vs. generic drugs

Benefits Controlling patents

Drug importation Government’s role in controlling prices

Can the market place take care of this?

Using Outcomes and other Assessment Tools to Improve Quality

Quality Improvement

Consider quality as a major priority over cost, choice or doctor, or range of service

Sources for information comes from family and friends

Concerned about the physician’s skills, but place increasing emphasis on communication skills, care attitude and certification

How Individuals Determine Quality

The degree to which health services for individuals increases the likelihood of desired outcomes and are consistent with professional practices (IOM, 1990)

Quality Defined

The Debate on Variation of Care

Influenced the quality pursuit Variations to care can be found between

regions, between hospitals, and between physicians within hospitals

Typically a result of clinical decisions made based on individual physician’s experience and training

If you cannot measure quality, you cannot improve it

True definition of Quality

The perception of quality variesTechnical quality Service qualityArt of science of careEconomy of care

Overall standard: examine the efficiency, effectiveness and the appropriateness of care

Technical Performance (Quality of Care or clinical quality)

Interpersonal Care (Quality of Life or Service Quality)

Elements of Performance

Applying the best in current knowledge and technology to a personal health problem

Outcomes compared for effectiveness Based on future expectations

Technical Performance

Care that meets individual and social expectations and standards

Patients communication of symptoms to the clinician

Clinician communication of options to the patient

Interpersonal Performance

Organizations that measure performance Joint Commission on Accreditation of Healthcare Organizations

(JCAHO) Non-profit organization that surveys and rates health care organizations and sets

standards for care Voluntary organization for hospitals but usually essential in qualifying for

reimbursement National Committee for Quality Assurance (NCQA)

Uses HEDIS - standardized performance measures designed provide purchasers and consumers with information compare the performance of managed health care plans and their providers (Physician “report cards”)

Institute of Medicine Provides scientifically informed analysis outside government realm to improve

health Agency for Healthcare Research and Quality (AHRQ) (HHS)

Examines Evidence Based Medicine

(Donebedian, 1980)

Process Outcomes

Model of Health Care Quality

Structure

Creating the capacity for quality Staff qualifications Safety and Sanitation Care documentation Adequacy of care resources Organizational Structure measures

Structure Measures

Activities between the provider and patients or between provider and provider

Initial care assessment and comprehensiveness

Care plan based on assessment Compliance with treatment

protocols/guidelines/standards of care

Process Measures

Change in health status to due to antecedent (structure/process) activities

Short-term measures Long-term measures

Outcome Measures

Intervening FactorsSeverity of Illness

Non-Health FactorsPatient ComplianceSocial SupportPatient Motivation

Outcome Standards

Must consider the appropriateness of outcome standards

Assume that the are representative of the condition (do they reflect treatment goals)

Validity of Outcomes – the outcomes are attributable to prior success

Outcome Standards cont.

Mortality Rates Co-morbidity Health Status Patient Satisfaction Access to care

Measures of Quality Outcomes

Disease management targets disorders that require a comprehensive care system

Focus is on chronic illness Emphasis is on preventive care that delays of

prevents complications caused by acute care illness

Uses practice guidelines and clinical support tools

Uses a clinical team approach

Improving Outcomes through Disease Management

Structure

Staff Qualifications

Care Resources

Safety Standards

Documentation

Process

Needs Assess

Care Planning

Protocol Adherence

Outcomes

Short-term

Long-term

Intervening Factors

Severity of Illness

Patient Compliance

Social Support

Revised Model of Healthcare Quality

Practice Guidelines

Once referred to as “Cookbook Medicine” Intended to influence the direction of patient

care Systematically developed statements to assist

practitioner decisions about the appropriateness of care

Intended to decrease variations of care Criticized that de-emphasizes the “art” of care Prefers the use of “evidence based care”