in with the old, out with the new
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‘In with the old, out with the new’ – In search of ways to help health economists break their addiction to technology adoption. CHE Seminar presented by Professor Stirling Bryan, Director, Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Professor, School of Population & Public Health, University of British Columbia. 17th October 2014TRANSCRIPT
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‘In with the old, out with the new’ In search of ways to break the addiction
to technology adoption
Stirling Bryan, PhD
Graham Scotland, PhD
University of British Columbia; Vancouver Coastal Health; University of Aberdeen
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Overview of talk
• Background, definitions
• Technology management
• Areas of concern
• Conceptual model for moving forward
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Definitions and the premise
• Definition: health care technology – ‘methods used to promote health, prevent and treat
disease and improve rehabilitation and long term care’
• Definition: ‘adoption’ – Technology coverage or reimbursement decisions – e.g., Should a new medical technology be available for use
in the health care system?
• The premise: – Health economics and HTA researchers devote a
disproportionate amount of their time and energy to technology adoption questions.
(NIHR HTA Programme)
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Technology as a cost driver
• Technological change – One of the largest contributors to cost growth – And so efforts to address cost growth cannot ignore
technology
• Health technology assessment (HTA) – Both Canada and the UK have long (and glorious) HTA
traditions
• But… the HTA ‘industry’ has… – become obsessed by technology adoption questions – largely ignored technology management issues
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Technology management
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Further support for technology management focus
• An additional driver of cost growth
– Rapid increases in utilization of existing technology
• E.g., medical imaging examinations
– In 2010 in Canada, 1.4 million MRI examinations and 4.2 million CT examinations were performed, representing annual increases over recent years of 6.9% for MRI and 6.2% for CT
(CIHI, 2011)
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Published CEAs (BMJ, 2005-2012)
54 economic evaluation
papers
47 with 'adoption' focus
29 (62%) advocated ‘adoption’
18 did not advocate
‘adoption’
7 with 'management'
focus
5 focused on evaluation of a broad service
2 explored clinical practice
variation
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Examples of service evaluations (n=5)
• Turner et al. (2011): Chlamydia Screening Program – Explored alternative approaches to improving cost-
effectiveness of existing program
– Conclusion: efficiency gains most likely through focus on partner notification
• Richardson et al. (2009): GI endoscopy and flexible sigmoidoscopy – Analysis goal: efficiency gains in delivery of established
technologies – physician or nurse delivered procedures?
– Findings: physician-delivered care both more effective and cost-effective
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Areas of concern
Primary concern: The ‘performance’ of health technologies in routine use
Technology management questions: (a) Improvement: Can we get better value from existing
technologies? (b) Appropriateness: Do we see indication creep?
Inappropriate use of technologies? [Choosing Wisely] (c) Withdrawal questions: Are technologies nearing the end
of their useful life?
Model validation questions: How good are our models? Are the predicted benefits and costs really delivered?
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Model validation…
“Computer models are no different from
fashion models…
seductive, unreliable, easily corrupted and
they lead sensible people to make fools
of themselves.” Jim Hacker, ‘Yes, Prime Minister’
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Technology management examples
• Knee arthroplasty: – 20% of patients ‘dissatisfied’, many
with ongoing poor outcomes
• Asthma: – we have highly effective low cost
therapies that people don’t use
• Rheumatoid Arthritis: – recent evidence suggests high cost
biological treatment not superior to conventional therapy
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Addiction pathology?
• Why is so much of our analytic effort focussed on adoption decisions?
• Demand side: ‘He who pays the piper calls the tune’ – The dollars lie in adoption decision making – Lack of demand for analysis to support technology
management
• Supply side – Revenue flows lead analysts actively to encourage the
adoption focus
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Technology adoption
Technology management
Pathway management
Disease management
Health system
management
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Broader framework for economic evaluation
• Conventional CEA is piecewise – e.g., the cost-effectiveness of drug A for patients with
disease X
• A broader pathway approach – Explicit quantification of opportunity cost
– Simultaneous consideration of investments and disinvestments
– Analysis of technologies at different points in a clinical pathway, or even across different disease pathways
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Example: Enhanced MRI for prostate cancer
EMRS
Watch Wait
EMRS+WW
Baseline
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In conclusion
• We encourage the health economics/HTA community to move towards broader modelling approaches
– Rejection of the current, almost exclusive, emphasis on technology adoption
– Replace with a broader analytic frame to consider clinical pathways and whole diseases
– Use of modelling to help identify inefficiencies in current care pathways
• This broadening of the scope of decision models offers the possibility of fundamentally changing the nature of the contribution health economists and their HTA colleagues can make.