Orthopaedics: Stakeholder Perspectives Kevin J. Bozic, MD, MBA Associate Professor and Vice Chair UCSF Department of Orthopaedic Surgery and Philip R. Lee Institute for Health Policy Studies
Dec 28, 2015
Comparative Effectiveness in Orthopaedics: Stakeholder Perspectives
Kevin J. Bozic, MD, MBA
Associate Professor and Vice Chair
UCSF Department of Orthopaedic Surgery and Philip R. Lee Institute for Health Policy Studies
Disclosures/Conflicts of Interest
External Advisory Role:
AAOS (HCSC, GTOC)
AAHKS (Education, Health Policy, EBPC)
COA (Executive Committee)
CMS (MedCAC)
UCSF Medical Center (HTAP)
United Health Care, BCBSA, Integrated Healthcare Association, Pacific Business Group on Health
Research Support:
OREF, AHRQ, NIH
Objectives
1. To identify considerations in the decision making process for the adoption of new technologies in orthopaedics
2. To understand the strengths and limitations of comparative effectiveness research
3. To develop an algorithm for evaluating and adopting new technologies in an orthopaedic practice
Technology in Orthopaedics
ImplantFactors
SurgeonFactors
PatientFactors
HospitalFactors
What Factors Influence Patient Outcomes?
Benefits of Technology
Technology: Unintended consequences
Technology: Cost Implications
• “The general consensus among health economists is that growth in real health care spending over the past 4 decades was principally the result of the emergence of new medical technologies and their adoption and widespread diffusion by the U.S. health care system.”
-CBO Report, “Technological Change and the Growth of Health Care Spending”, Feb, 2008
•“…however, the benefit of many of these new technologies has not yet been rigorously demonstrated.”
Comparative Effectiveness: Value
1.5-2X
4-6X
2-3X
Cost Value?
??
??
??
Evaluating Technologies: Perspective Surgeons
“Evidence standard”
Adequacy of evidence
Magnitude of benefit
Relationships with industry
Peers
Hospitals/payers Short-term cost-containment
Patients Internet, friends, family
DTCA
Policymakers Comparative Effectiveness
Clinician Perspective
Level of Evidence (I-V)
Efficacy The extent to which medical
interventions achieve health improvements under ideal circumstances
Effectiveness The extent to which medical
interventions achieve health improvements in real practice settings
Effectiveness: Registry Data
Effectiveness: Registry Data
Hospital Perspective
1990’s 2000’s
UCSF Healthcare Technology Assessment Program (HTAP)
“HTA is the bridge between the world of research and the world of clinical decision making”
Alan Garber, Health Affairs, 2004
Considerations
Patient population
Surgeon experience
Relationships with vendor, hospital
Price
Service
Programmatic needs
Patient Perspective: DTCA
DTCA: Policy Implications
DTCA
$$
$$ $$
Policy Maker Perspective: Comparative Effectiveness?
Comparative Effectiveness Research
“As applied in the health care sector, an analysis of comparative effectiveness is simply a rigorous evaluation of the impact of different options that are available for treating a given medical condition for a particular set of patients.”
Congressional Budget Office, 2007
See: http://www.cbo.gov/ftpdocs/88xx/doc8891/12-18-ComparativeEffectiveness.pdf
Evolutionary or Revolutionary?
Trends in Orthopaedic Implant Costs in the U.S.
“Overshooting” the Needs of our Patients
“The functionality of today’s healthcare technologies, although impressive, often outstrips the ability of consumers to absorb it”
Impact of Technology on Surgeon “Value”
“Take hip replacement surgery for example. Here much of the cost and “skill”, as it were, have moved from the surgeon to the device.”
Considerations in Technology Decisions Is there a clinical need?
Patient population
Results with existing technology
Use data whenever possible
Factors influencing decision Device company
Peers
Hospital
Patients
Impact on Patient outcomes
Hospital margins
O.R. Efficiency
My Algorithm
Versatility of product line
Service
Price
Benefits vs. Risks of switching
Potential improvement in clinical outcomes
Uncertainty in patient outcomes
Impact on efficiency
Price
Summary Explosion of new technologies
in orthopaedics
Consumerism
Increased scrutiny, transparency regarding costs, clinical effectiveness
Questions:
Comparative effectiveness:
Clinical effectiveness vs. gold-standard?
Cost-effectiveness?
Impact on clinical, shared decision making
“Newer” Is Not Always “Better”
“Novelty cannot necessarily be equated with benefit, and an intervention or device’s value resides not in it’s newness but rather in its ability to improve patient outcomes, reduce morbidity, and/or reduce the overall cost of care. “
Emanuel EJ, Fuchs VR, Garber AM. Essential elements of a technology and outcomes assessment initiative. JAMA. Sep 19 2007;298(11):1323-1325.
Thank You!!!