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

2

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

3

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…

4

Technology adoption

Technology management

Pathway management

Overview of talk

5

6

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?

7

8

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?

9

GRAHAM’S TALK

10

Technology adoption

Technology management

Pathway management

Overview of talk

11

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

12

Chen et al, 2006

13

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

14

Stewardship facilitated through pathway modelling

Clinical leaders and care teams

HTA analysts

Policy makers and managers

Patients and carersIndustry

15

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

16

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

18

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’

19

20

21

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

22

MOHSEN’S TALK