cadth 2015 a1 symposium talk 2015

In Search of Efficiency, Consistency, Fairness, and Impact in HTA: The Case for Clinical

Pathway Management and Modelling

Stirling Bryan, PhDGraham Scotland, PhD

Mohsen Sadatsafavi, PhD

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Overview of session

• Stirling Bryan:– In Search of Efficiency, Consistency, Fairness, and

Impact in HTA

• Graham Scotland– Modelling screening and treatment pathways for

diabetic retinopathy

• Mohsen Sadatsafavi– The case for whole disease modelling in COPD

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Disclosures and Acknowledgements

• I am not aware of any actual or potential conflicts of interest in relation to this presentation.

• Some of my relevant current activities:– Chair, CADTH’s Health Technology Expert Review Panel– Member, CADTH’s Economic Evaluation Guidelines Working Group– Member, BC’s Health Technology Assessment Committee– Director, VCH’s Centre for Clinical Epidemiology & Evaluation

• Collaborators on this topic– Graham Scotland, University of Aberdeen; Mohsen Sadatsafavi, UBC;

Craig Mitton, UBC; Cam Donaldson, Glasgow Caledonian University; Laurie Goldsmith, SFU; Rick Sawatzky, TWU

– And many, many more…

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Technology adoption

Technology management

Pathway management

Overview of talk

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Technology management questions

• Assessment: – Does the technology, as currently used, deliver value?

• Improvement: – Can more cost-effective utilization of the technology be

achieved through modification of the clinical protocol?

• Withdrawal: – Should the technology no longer be in routine use and,

hence, a process of withdrawal commenced?

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Technology management questions

• Assessment: – Does the technology, as currently used, deliver value?

• Improvement: – Can more cost-effective utilization of the technology be

achieved through modification of the clinical protocol?

• Withdrawal: – Should the technology no longer be in routine use and,

hence, a process of withdrawal commenced?

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GRAHAM’S TALK

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Technology adoption

Technology management

Pathway management

Overview of talk

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Pathway management

• Clinical pathway: defined sequence(s) of use of alternative health technologies

• Pathway modelling becomes the foundation of HTA activity

Barton et al, 2004

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Chen et al, 2006

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Pathway management and ‘resource stewardship’

• ‘Resource stewardship’– A culture where resource scarcity is openly acknowledged and recognized as a

shared responsibility

• Pathway model development is a collaborative effort– Active engagement of, and ownership by, key stakeholders, including clinical

leaders, policy makers, patients and analysts

• The reference pathway model defines the resource envelope– Constraints on pathway reconfiguration are transparent

• Proposed changes to the clinical pathway evaluated using the reference model– Opportunity cost considered explicitly

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Stewardship facilitated through pathway modelling

Clinical leaders and care teams

HTA analysts

Policy makers and managers

Patients and carersIndustry

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Pathway management and ‘resource stewardship’

• ‘Resource stewardship’– A culture where resource scarcity is openly acknowledged and recognized as a

shared responsibility

• Pathway model development must be a collaborative effort– Active engagement of, and ownership by, key stakeholders, including clinical

leaders, policy makers, patients and analysts

• The reference pathway model defines the resource envelope– Constraints on pathway reconfiguration are transparent

• Proposed changes to the clinical pathway evaluated using the reference model– Opportunity cost considered explicitly

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Pathway management example

In RA, recent evidence suggests anti-TNF, biological treatment (infliximab) not superior to conventional combination therapy (MTX, SSZ, HCQ)

Barton et al, 2004

Eriksson et al, 2013

17Scholz & Mittendorf, 2014

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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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In conclusion

• Let’s break our addiction to technology adoption

• Pathway modelling as a centrepiece of HTA work supports development of a stronger ‘resource stewardship’ culture

• The mechanism:– Quantification of resource commitment to a given clinical area– Explicit consideration 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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MOHSEN’S TALK