From Education to Engagement to Action:A Real-World KT Approach for Facilitating Evidence Decision Support in Health Care

Paule Poulin, Lea Austen, Elizabeth Oddone Paolucci,Gabrielle Zimmermann, and Trevor Schuler

CADTH Symposium 2015

When appraising a new health technology, local decision-makers need to consider:

• Local priority-setting• Local operations• Local population health needs• Local alternatives• Local presence of trained personnel• Local infrastructure impact• Local budget impact……..• As well as HTA reports by HTA agencies

Our Project:

Purpose

1. Educate and engage surgical divisions in Alberta Health Services in a real-world exercise on bringing evidence into practice during health technology appraisal

“After considering the results of the provincial review and stakeholder feedback and upon advice from the Alberta Advisory Committee Health Technologies, a decision was made by Alberta Health to re-evaluate Robot-Assisted Surgery (RAS) in one year. ..AHS is to collect data to inform the re-evaluation…..”

6

Advantages of Robotic Technology

Less blood loss

Fewer complications

Less pain

Shorter length of stay

Shorter recovery time

Patient Improved ergonomics

Improved visualization

Better surgical performance

Short learning curve

Surgeon

Slide provided by Danny Minogue, Minogue Medical Inc., Montreal, Quebec. Data adapted from CADTH Technology Report on Robot-Assisted Surgery, 2011

da Vinci® – The enabling technology

Slide provided by Danny Minogue, Minogue Medical Inc., Montreal, Quebec, and da Vinci® Surgical System

RAS Re-Evaluation Objectives:

 

1. Establish a RAS Steering Committee and smaller RAS Working Groups

2. Identify current RAS activity in Alberta and develop data collection and analysis strategies

3. Identify emerging RAS procedures of interest in Alberta

4. Identify current state of evidence and gaps in knowledge for RAS for procedures of interest

5. Establish a strategy for a provincial training and credentialing process

6. Inform a comprehensive economic and operational financial analysis

7. Consider patient engagement issues

1. Establish a RAS Steering Committee and smaller RAS Working Groups

• Surgical specialty representation: • Urology• Obstetrics and Gynecology• Cardiac Surgery• Thoracic Surgery• General Surgery • Otolaryngology

• Edmonton and Calgary Zones, North and South Zones (the Central Zone declined to participate at this time)

• AHS and AACHT (AH)

2. Identify current RAS activity Develop data collection & analysis strategies

• 3,101 da Vinci robots installed world-wide– 2,153 United States– 499 Europe– 322 in Asia (183 of those in Japan)– 38 in Latin America– 35 Australia and New Zealand– 28 in the Middle East– 26 Canada

Data provided by Danny Minogue, Minogue Medical Inc., Montreal, Quebec, and da Vinci® Surgical System

11Slide provided by Danny Minogue, Minogue Medical Inc., Montreal, Quebec. Data and da Vinci® Surgical System

Top RAS procedures: Number of cases between 2003-2014

Procedure Canada AlbertaTotal 15,018 3,305Prostatectomy 8,559 2,571Hysterectomy 3,115 379Partial Nephrectomy 675 198Pyeloplasty 448 74Nephrectomy 236 0

RAS is growing worldwide

• Worldwide, the largest growth is in gynecological procedures

RAS is growing in Canada

2003 2014Types of procedures (total) 8 65Types of Urology procedures

1 16

Types of Gynecology procedures

0 11

RAS is growing in Alberta

2008/2009 2013/14

Prostatectomy 297 488

Hysterectomy 9 84

Partial nephrectomy 0 60

Pyeloplasty 1 38

Possible strategies:

1. Use published data (Ontario ICES & literature)

2. Retrospective analysis of Alberta RAS cases (limited data, may lack functional outcomes)

3. Collaborate with the Institute for Clinical Evaluative Sciences (ICES) in Ontario to combine Alberta data with Ontario data

4. Develop an Alberta data collection strategy similar to ICES

2. Identify current RAS activity Develop data collection & analysis strategies

Data Elements to Consider:

• All relevant health care resources utilization data, e.g. • length of hospital stay, operating room time• diagnostic investigations • both inpatient and outpatient resources to track cost

shifting• Any relevant clinical outcomes data

• oncologic and functional• Patient satisfaction metric• Utility metric – EQ-50

• Disease-specific if possible

2. Identify current RAS activity Develop data collection & analysis strategies

3. Identify emerging RAS procedures of interest in Alberta

A survey was distributed to Alberta’s surgeons and completed by 81 respondents:

• General surgery (25%)• Urology (25%)• Orthopedics (15%)• Otolaryngology (11%)• Other specialities (24%)

What role do you anticipate for RAS in your area in Alberta in the next 5-10 years?

Comment Number of

MentionsWill expand 39Minimal role, has not lived up to its potential 20Too expensive for little benefit 6Needs more evidence and monitoring 5Driven by community or patient demand 5Alberta needs to be at the forefront 3

Which RAS procedures do you anticipate being important in your area in Alberta in the next 5-10 years?

Procedure Number of Mentions

1. Radical Prostatectomy 212. Partial Nephrectomy 193. Pyeloplasty 164. Cystoprostatectomy 145. Simple prostatectomy 126. Nephroureterectomy 127. Adrenalectomy 118. Trans-Oral Robotic Surgery (TORS) 119. Colectomy/rectal cancer 910. Sacrocolpopexy/pelvic floor 8

What conditions should be considered for RAS use in a publically funded system? [multiple choice question]

Comment % of Respondents

Used under the guidance of a committee that approves indications for use and monitors outcomes and cost

59%

Used only for indications that have proven benefits over open or laparoscopic surgery

54%

Used only if equipment donated and additional costs paid by patient

10%

Used without restriction regardless of cost provided outcomes are equivalent or better

7.5%

Not used at all 2.5%

4. Identify gaps in knowledge for RAS for procedures of interest

Currently performed procedures identified for re-evaluation are:• Prostatectomy (simple and radical)• Hysterectomy (simple and radical)• Partial Nephrectomy

Emerging procedures of interest for review include: • Pyeloplasty• Cystoprostatectomy• Nephroureterectomy• Pelvic floor surgery • TORS• Adrenalectomy• Colon/rectal cancer

Procedure Reviewed by CADTH?

Comments

Prostatectomy 2011 Needs appropriate comparator: laparoscopic method hardly used in Alberta

Hysterectomy 2011 Currently only used for oncological cases in AlbertaBenign and oncological procedures need to be considered separately

Partial nephrectomy

2011 Only used for partial nephrectomy in AlbertaReview needs to consider partial nephrectomy separately

• Existing reviews now out-dated• Reviews need to have a clinical focus• Prior to a request for new reviews, context experts should be consulted to

make sure that relevant questions and review processes are addressed

5. Establish a strategy for a provincial training and credentialing process

• A robust process should be developed for RAS credentialingo As it should for all areas of surgical practiceo RAS should not be seen as unique

• Goes beyond surgeons - Nurses, biomed., MDRD• Given volume, consideration should be given to developing a training

centre

This will require:• Systemic literature review and critical

appraisal of RAS credentialing• Review and appraisal of guidelines from

national or international surgical societies• Consultation with local, national and

international expert• Development of a Steering Committee to

oversee and monitor the training and credentialing process and outcomes

6. Commission a comprehensive economic and operational financial analysis

• RAS may be cost-effective under certain circumstanceso Unlikely that RAS will show cost savingso High cost of disposables, single vendor o Requires high output of existing robotso Worse when additional robots are added

• Value for money and outcomes related to cost need to be considered

• Will require high level economic expertise o AHS, AH, IHE, U of A, U of Co Will require robust oncological and functional outcome datao Ideally local data

RAS Funding in Alberta

Strategies to minimize cost of RAS procedures:• Require high volume centres and practitioners• Awareness of costs and outcomes• Training/mentoring of the entire surgical team• Maximize the number of cases surgeons do; clear

correlation between provider volume and outcomes• Compare the RGH, UAH and RAH urology robotic

work/program and pathways for efficiencies

Assess if current robotic capacity is maximized prior to purchasing another platform

7. Consider patient engagement issues

• Develop a consultation process to ensure the outcomes of importance to patients are included in the planned RAS re-evaluation

• Involve patients with all known patient safety issues associated with RAS

• Invite patient representative to join the advisory steering committee

• A communication plan

Conclusions• RAS identified by both our surgical community and the

Alberta government as an important technology to review

• RAS is on the rise in Alberta, Canada and Worldwide

• Cost of RAS is a central issue

• Responsible use of RAS requires:o An oversight advisory steering committeeo Accurate data collection, maintenance,

monitoring/reportingo Getting the most out of the existing equipmento A robust but reasonable training and credentialing

processo Patient & family engagemento Must consider the impact of elimination or reduction of

robotics on the number of care providers