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Egon Jonsson Professor, Director The Swedish Council on Technology Assessment in Health Care, SBU Role of Health Technology Assessment – A European perspective

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Page 1: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Egon Jonsson

Professor, DirectorThe Swedish Council on Technology

Assessment in Health Care, SBU

Role of Health Technology Assessment– A European perspective

Page 2: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Technology means

APPLIED SCIENCE

Page 3: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Health Technology

The equipment, devices and drugs, andthe medical and surgical proceduresused in prevention, diagnosis, treatment,and rehabilitation.

Page 4: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Health Technology Assessment

HTA

Page 5: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

The process of HTA

• A systematic review of thescientific literature

• Cost-effectiveness analysis• Ethical and social considerations• Policy options

Page 6: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Countries withagencies / institutions for HTA

• Germany• Hungary• Israel• Latvia• Lithuania• New

Zealand• Norway

• Poland• Spain• Sweden• Switzerland• The Netherlands• United Kingdom• United States

• Australia• Austria• Canada• Chile• Cuba• Denmark• Finland• France

Page 7: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

A selection of completedassessments by SBU

• Back pain• Alcohol and drug abuse• Preoperative routines• Bone density measurement• Prostate cancer screening• Urinary incontinence• Asthma and COL• Radiotherapy in cancer

treatment• Patient – doctor relationship

• Hypertension• Stroke• Routine ultrasound in

pregnancy• Oestrogen Treatment• Stomac ulcer• Smoking cessation• Prevention by antioxioxidants• Prevention by life-style

changes

Page 8: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Working days lost due to

19801985199019951999

Strikes/lockouts

4.478.500504.200770.400926.10078.700

Page 9: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Working days lost due to

19801985199019951999

Strikes/lockouts

4.478.500504.200770.400926.10078.700

Sickness absence

96.167.00093.656.000

113.513.00057.000.000

72.000.000

Page 10: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Methods used in treatment of back painAcupunctureAntidepressantsBack exercisesBack SchoolBehavioral therapyBiofeedbackColchicineColdCold spray and stretchingContinued activityCorsetsCortisone

Electromagnetic therapyHealth resortsHeatInfrared lightInjections in facet jointsInjections in ligamentsInjections in triggerpointsLaser therapyManual therapyMassageMultidisciplinary treatmentNSAIDs

Neck supportParacetamolPatient educationPhysical exerciseRest/bed-restShortwave diathermySteroid injectionsSurgical proceduresTENSTractionUltrasound

Page 11: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Total 22 000Thereof RCT:s 1 000Studies examined by SBU 2 000

Number of studies on back pain

Page 12: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Grading of evidenceStrong evidence – consistent findings in two

or several scientific studies of high quality.Moderate evidence – consistent findings in two

or several scientific studies of acceptable quality.Limited evidence – only one study available

or inconsistent findings in several studies.No evidence – no study of acceptable scientific

quality available.

Page 13: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Low Back PainChronic

Strong evidence againstModerate evidence againstModerate evidence against

Moderate evidence againstNo evidenceNo evidenceNo evidenceNo evidenceNo evidenceNo evidenceNo evidenceLimited evidenceLimited evidenceStrong evidence for

ABB

BDDDDDDDCCA

Acute

Strong evidence againstLimited evidence forNo evidenceNo evidence

No evidenceNo evidenceNo evidenceNo evidenceNo evidenceNo evidenceNo evidenceNo evidenceNo evidenceNo evidenceStrong evidence, notmore effective than othertreatments

ACDD

DDDDDDDDDDA

Rest/bed-restTractionAntidepressantsBiofeedbackEpidural steroid injections no nerve root painColdHeatInjections in triggerpointsInjections in ligamentsMassageShortwave diathermyUltrasoundAcupunctureCorsetsBack exercises

Page 14: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Low Back PainChronic

Strong evidence forStrong evidence for

No evidence forLimited evidence forLimited evidence for

Limited evidence for

Limited evidence forStrong evidence forLimited evidence forLimited evidence for

Strong evidence for

AA

DCC

C

BACC

A

Acute

No evidenceNo evidence

No evidence forLimited evidence forLimited evidence for

Limited evidence forLimited evidence forLimited evidence forLimited evidence forModerate evidence forModerate evidence forStrong evidence forStrong evidence forNo evidence

DD

DCC

CCCCBBAAD

Health resortsMultidisciplinary treatmentAll forms of surgery – Except for herniated discBack schoolTENSEpidural steroid injections nerve root painColchinineCortisonBehavioral therapyManual therapyParacetamolNSAIDsContinued activitiesSurgery for herniated disc

Page 15: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Technologies used in thediagnosis of back and neck pain

• Physical examination• Mobility and muscle tests• X-ray• MRI• CT-scanning• Neurophysiologic tests

incl EMG

• Facet blocks• Stress radiography• Discography• Nerve root infiltration• Bone scintigraphy• Termography• Ultrasound

Page 16: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Economic impact of evidence-basedtreatment for back pain

In millions of dollarsper million population

Investment – 7Reduced sick-leave + 64Reduced early retirement + 18

Net savings 75

Page 17: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Alcohol and drug abuse

• The evidence shows:– Many treatment methods available are

effective– Several treatment methods used are

ineffective– There are effective measures available for

prevention, however, these are under-used.

Page 18: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Methods used in the treatmentof alcohol- and drug abuse

with no support of scientific evidence

• Environment therapy• Self image therapy• Drama therapy• Self idendity therapy• Confrontative

interventions• Self help courses

Non-manual based therapies:• Psychodynamic insight

therapy• General support therapy• Therapeutic society model• Acupuncture• Relaxation therapy• Biofeedback

Page 19: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Preoperative routines

There is no evidence of benefit to the patient,nor to the surgeon or the anaesthesiologist,to perform routine examinations beforeelective surgery on otherwise healthypatients.

Page 20: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Bone density measurementThere are no scientific basis for recommendingbone density measurement in mass screening,selective screening, or as an extra componentin health check-ups of asymptomaticindividuals (opportunistic screening).

Instead:The problems of low bone densityis a question of prevention:– Smoking– Low physical activity– Lack of oestrogen / calcium

Page 21: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Screening for prostate cancer

The scientific evidence shows thatthere are no compelling reasons torecommend neither mass screeningnor opportunistic screening forprostate cancer

Page 22: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

A selection of currentSBU-projects

• Prevention and treatment of obesity• Prevention and treatment of osteoporosis• Prevention of caries• Treatment of depression• Anxiety• Dementia• Chronic pain• Venous thrombosis• Hearing impairment• Treatment by sick-leave• Prevention of disease by physical activity

Page 23: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

SBU Alert

A programme for identification andearly assessment of new health

care technologies

Page 24: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

A selection among >50 assessmentsof emerging technologies

• Antiplatelet agents – clopidogrel• Brachytherapy for prostate cancer• BNCT – Radiotherapy with neutrons for brain tumors• Bupropion in smoking cessation• Cardiac Pumps in treating chronic heart failure• Gene therapy• Growth hormone in children with idiopathic short status• Implantable defibrillators• Screening for colorectal cancer• Testosterone therapy in men with age-related hormone

deficiency

Page 25: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

HTA within the EU

Agencies and institutions 25Full time working in the field 500No. of HTA:s up to now 1 300No. of HTA:s published per year 200

Page 26: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

EU-Sponsored Projects in HTA(1994 – 2001)

The ECHTA/ECAHIProject

2000 – 2001

Health promotionand diseaseprevention

Exchange ofinformation

Joint assessments Best practice

Education andtraining

HTA in policyand practice

HTA EUROPE1997 – 1999

Emergingtechnologies

Internationallycoordinated assessments

The future of healthcaresystems in Europe

Health outcomesmeasurement

EUR-ASSESS1994 – 1996

Methodology Priority setting Dissemination and impact Coverage

Page 27: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Structure• Steering Committee

(representatives and observers from15 EU countries + 8 non-EU countries)

• Working Groups(6 different tasks)

• Executive Committee(Sweden, Spain, The Netherlands, UK)

• Secretariat(SBU)

Totally over 100 people are involved in the project.

Page 28: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Working Groups• Health Promotion and Disease Prevention• Exchange of Information

– Clearinghouse function– Emerging technologies

• Joint Assessments• Best Practice• Education and Training• HTA in Policy and Practice

Page 29: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Recommendations to EUThe European Commission should put in place a

sustainable and properly funded support function for aEuropean Union-wide network on assessment of healthinterventions and technology.

This network should involve recognized organisations andagencies in the field of HTA, which will enable and facilitatethe coordination of assessment within the European Union.

The Commission will thereby demonstrate the benefits ofthese activities and the risks of not implementing them interms of quality of life, quality of care, and cost of healthcare.

Page 30: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

Challenge

Effective dissemination and impact

Page 31: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections

”I swear by Apollo, the physician,and invoking all the Gods andGoddesses to be my witnesses thataccording to my ability and judgement

and evidence basedinformation from HTA studies

I will keep this oath and stipulation.”

Page 32: Egon Jonssonpubhealth.spb.ru/EBM/ebm2002/Jonsson.pdf · Egon Jonsson Professor, Director ... Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections