Difficult Decision -Making at User Interface: Why …...Hospital-Based Health Technology Assessment Difficult Decision -Making at User Interface: Why The Traditional Approach Doesn’t

Hospital-Based Health Technology Assessment

Difficult DecisionDifficult Decision --Making at User Interface:Making at User Interface:

Why The Traditional Approach Doesn’t Work

Janet Martin, PharmD, MSc(HTA&M)

Director, High Impact Technology Evaluation Centre

Co-Director, Evidence-Based Perioperative Clinical Outcomes Research Unit

Assistant Professor, Departments of Medicine, Anesthesia & Perioperative Medicine,

London Health Sciences Centre, University of Western Ontario, London, Canada

Hospital-Based Health Technology Assessment

Difficult DecisionDifficult Decision --Making at User Interface:Making at User Interface:

Why The Traditional Approach Doesn’t Work

“Truly, Madly, Deeply”

Janet Martin, PharmD, MSc(HTA&M)

Director, High Impact Technology Evaluation Centre

Co-Director, Evidence-Based Perioperative Clinical Outcomes Research Unit

Assistant Professor, Departments of Medicine, Anesthesia & Perioperative Medicine,

London Health Sciences Centre, University of Western Ontario, London, Canada

Many thanks . . .

LHSC

CIHR

CADTH

…our team

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Davy Cheng, John Parker, Kirsten Krull-Naraj, Glen Kearns, Richard Jones

Hospital HTA Decision-Making

I. Importance of HTA in HospitalsII. Traditional Decision MakingIII. Key ChallengesIV. ‘Know4Go’ as a SolutionV. Future Directions

Why Hospital HTA?

� Technological innovations are restructuring health care in profoundly beneficial and unsettling ways

� Demand for innovative technologies has outpaced our capacity to provide them

� Technological innovations are especially concentrated in the hospital setting

� Innovations relevant to hospitals often not assessed by national, provincial, or academic HTA units. Even when they are, they are rarely ready for decision-making.

Shortcomings in External HTA

� HTA reports produced by external agencies are useful, but (necessarily) insufficient

� External HTA agencies cannot informatively advise whether our hospital needs another CT scanner, a surgical robot, bifurcated stents, or another fluoroquinolone

� These decisions need to be taken with local considerations of infrastructure, existing technologies, patient population, health professional skills, learning curves, competing priorities

…though, there is room for more collaboration acros s hospitals.

Hospital HTA is Unique

� Fast-paced, real-time, at the point of decision-making

� In collaboration with decision-makers (“end-users”)

� Contextualized to local setting (not hypothetical)

� Accountable to “predictions”� Decision impact is “felt” very quickly

“HTA in a box”Truly, madly, deeply.

Decisions become moral dilemmas.

Hospitals are Costly

30%

Hospitals account for >30% of health care expenditures in Canada (CIHI, 2004)

Then Now

ThenGet the evidence straightGet the evidence straight

“Evidence is biased”

“HTA is biased”

“Numbers are Tortured & Statistics Lie”

Evidence schmevidence…let’s just get on with it

“It works. And, I want it. No time for assessments here.”

“That’s not the way I see it”

New is inherently better.

If it is “better”, it must be “worth it”.

Symptoms ofCompromised Decision-Making

“The evidence doesn’t apply to my patient”� Aprotinin versus Tranexamic Acid”� Antipsychotics for dementia in elderly� Spinal fusion for low back pain� Arthroscopic knee surgery

Obviously the evidence is wrong, because everyone i s still doing it.� Beta-blocker for immediate treatment of AMI� Beta-blocker for patients undergoing non-CV surgery

This place is archaic…only about the cost!� COX-II selective inhibitors not admitted to formula ry� Insulin glargine and detemir not admitted to formular y� Nandrolone not admitted to formulary

Key Challenges: Too Fast or Too Slow Adoption?

� Gizmo Idolatry. Technology is fun� New is better, and certainly more fun� “on the market” means “done deal”� sufficient burden of proof is presumed

� Sooner is better than later� For new technologies (and drugs), there is constant

pressure to take them up� Just let us “try it out”, and then we can decide� May save money

� We have responsibility to be leading edge� Innovation is our job� Teaching is our mandate� Discovery is up to us

Technology Hype Cycle

Multiple Opposing Pressures

ThenThen

B:R

Comprehensive Meta Analysis V2.exe.lnk

Systematic Review ≠ Decision

Economic Analysis ≠ Decision

Evidence is one consideration, but not the only consideration.

Yes No

Then NowEvidence is essentialEvidence is essential Evidence is essential, Evidence is essential,

but insufficientbut insufficient

Application of Evidence to Decisions:� Too technical � Too linear� Too blunt

Evidence from expanded domains of influence� social, legal, ethical, environmental, etc� opportunity costsneed to be made explicit before decisions can

be made comfortably

Now

Go where the evidence dares not…

B:R

SLEEPERs

What is a SLEEPER?

SocialSocialSocialSocialS

E

E

L

P

ER

LegalLegalLegalLegal

Ethical & EquitableEthical & EquitableEthical & EquitableEthical & Equitable

EnvironmentalEnvironmentalEnvironmentalEnvironmental

Entrepreneurial & Research Entrepreneurial & Research Entrepreneurial & Research Entrepreneurial & Research

PoliticalPoliticalPoliticalPolitical

S ‘‘‘‘StickinessStickinessStickinessStickiness’’’’

Kink in the Curve

O'Brien B, et al. Is there a kink in consumers' thr eshold value for cost-effectiveness in health care? Health Economics 2002 ;11:175-180.

After

Go where the evidence dares not…

B:R

What is true ‘cost’?

Cost is the sacrifice of consequences in the best alternative use of resources

Newton’s Third Law abides…

Every decision to do one thingis a decision not to do another

KnowKnow 44GoGo

KnowKnow 44GoGo

Knonow44GoGo

Knonow44GoGo

B:R 4Go

Tradeoff Table

Benefit Index

Bud

get I

mpa

ct

What are we plotting?

Budget Impact:• {Incremental Cost per Patient} x {#

Eligible}Benefit Index:• {# Eligible Patients/NNTB}

Tradeoff Table

‘Go,

No-Go’

Benefit Index

Bud

get I

mpa

ct

Tradeoff Table

No-Go

Benefit Index

Bud

get I

mpa

ct

Go

Tradeoff Table

No-Go

Bud

get I

mpa

ct

Benefit Index

Go

Tradeoff Table

‘Go,

No-Go’

68

10

4

9

1

17

3 57

12

14

15

16

18 19

2021

22

A

E

D

C

B

28

33 Benefit Index

Bud

get I

mpa

ct

Tradeoff Table

‘Go,

No-Go’

68

10

4

9

1

17

3 57

12

14

15

16

18 19

2021

22

A

E

D

C

B

28

33 Benefit Index

Bud

get I

mpa

ct

ERT for rare dx

C

Infliximabfor UC

D

Off-pump CABG

E

iNO for other

B

iNO for preemies

A

Tradeoff Table

‘Go,

No-Go’

68

10

4

9

1

17

3 57

12

14

15

16

18 19

2021

22

A

E

D

C

B

28

33 Benefit Index

Bud

get I

mpa

ct

ERT for rare dx

C

Infliximabfor UC

D

Off-pump CABG

E

iNO for other

B

iNO for preemies

A

Go or no-go?

What are we plotting?

Budget Impact:• {Incremental Cost per Patient} x {# Eligible}Benefit Index:• {# Eligible Patients/NNTB} + ƒ{SLEEPERs}

SLEEPERs = Social, Legal, Ethical, Environmental, Political,

Entrepreneurial/Research/Innovation issues

Tradeoff Table

‘Go,

No-Go’

68

10

4

9

1

17

3 57

12

14

15

16

18 19

2021

22

A

E

D

C

B

28

33 Benefit Index

Bud

get I

mpa

ct

Go (because of SLEEPERs)

ERT for rare dx

C

GoInfliximabfor UC

D

?Off-pump CABG

E

?iNO for other

B

GoiNO for preemies

A

Knonow44GoGo

B:R 4Go

A new approach to increase decisionA new approach to increase decision --maker uptake of best maker uptake of best available evidence:available evidence:

�� Multilevel: Practitioners, Managers, PolicymakersMultilevel: Practitioners, Managers, Policymakers

�� Multidimensional, Nuanced: Addresses Multidimensional, Nuanced: Addresses SLEEPERsSLEEPERs

�� Honest & Accountable: Considers opportunity costHonest & Accountable: Considers opportunity cost

�� Embeds the decision in context of past, present, fu tureEmbeds the decision in context of past, present, fu ture

The average man’s judgment is so poor, he runs a risk

every time he uses it.

- Edgar W. Howe

ThenFocused on “Go”

“just given me the gizmo, and no one gets hurt”

“I don’t see the evidence, do you?”

“it works, and I want it”

“evidence, schmevidence. Just get on with it”

NowFocused on “4Go”“Now I understand”

“Makes sense. I can live with that”

“Finally! You’ve shown me explicitly what I’ve tried to understand for yrs”

“We need to more of this”

“How can we put the whole capital planning through Know4go?”

Summary

� Hospital HTA juxtaposes evidence, decision-makers, and opportunity costs within a fixed set of resources and circumstances (a perfect petri dish)

� Traditional evidence-based decision-making forces a linear approach to what should be nuanced and multifactorialdecision-making

� If we are to engage rather than alienate the end-user, we need to make HTA relevant, explicit and tangible

� Know4Go provides framework to explicate the evidence, and its uncertainty, while acknowledging the SLEEPERs, and enumerating what is 4Gone.

� Without explicit acknowledgment of SLEEPERs and the 4Go, decisions prematurely trumped by factors other than evidence, and decisions to 4Go anything are unbearable

Future Efforts

“Only in Research” as an alternative to Yes/No decisions� One study commissioned so far: Venofer vs IV Iron Dextran

Decommissioning/Reinvestment� Knee and back surgeries, beta-blockers, cerclage, iNO

Know4Go useful for other settings, other perspectives?� Other hospitals, MOH, regions

Canadian Surgical Technologies & Advanced Robotics (CSTAR)

� A living laboratory for testing surgical devices and procedures, and training for Ontario (John Parker, Director; Kirsten Krull-Naraj, VP)

� SLEEPERs need refining for surgery and devices

� Devices are only inherently as good as the skilled hands that it is within, and the effectiveness of the team around it

Technology Hype Cycle

HTA has often ignored the SLEEPERS

05

101520

253035

404550

% of HTA Reports

CostsEfficacyC:ESafetyQoLSESLegal

Lehoux et al. Int J Technol Assess Health Care 2004;20 :1-12.

The application of what we know will have a bigger impact on health and disease than any single drug or technology likely to be introduced in the next decade.

Sir Muir Gray

NHS Knowledge Service

We are drowning in informationwhile starving for wisdom.

E.O. Wilson

What we do

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HTA Reports

What does it look like?

� Receive Requests during Annual RFP – Administration or Clinicians (formal application process)

� Prioritize Requests– High impact clinically, economically, politically

� Systematically Review Evidence, Resources– Collaborate with requestor and end-users to ensure relevance

– Define benefits, risks, costs, other resource issues

� Stakeholder Meeting (users, non-users) to Elicit SL EEPERS– Elicit the SLEEPERs, Rate their Importance

� Plot Decision on Know4Go Tradeoff Table– Benefit Index, Cost, SLEEPERs equation

� Present to Decision-Making Committee (Yes/No/CED)– Surgical Services HTA, Drug & Therapeutics, Senior Leadership Committees

� Implement & Evaluate (& wait for appeals)

The Demand is Relentless

ASKASKASSESSASSESS

ACT ACT

****DonDon ’’ t reinvent the wheelt reinvent the wheel(use INAHTA, EXCHANGE)(use INAHTA, EXCHANGE)

Rate

Limiting

Step**