PROMs in reimbursement and real-world assessments of clinical

interventions

Stirling Bryan, PhD

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Disclosures

• Some of my relevant current activities:– Director, Centre for Clinical Epidemiology & Evaluation,

Vancouver Coastal Health Research Institute

– Chair, CADTH’s Health Technology Expert Review Panel

– Member, BC’s Health Technology Assessment Committee

– Member, EuroQol Group

• My Centre has a contract to conduct HTA projects for the BC Ministry of Health.

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

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Overview of talk

• Example PROMs

• PROMs in support of HTA

• Moving from HTA to health technology management (HTM)

• PROMs in support of HTM

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Generic utility-based PROMs

Short Form Health Survey instruments

EQ-5D

5Whitehead S J , Ali S Br Med Bull 2010;96:5-21

PROMs give us Quality-Adjusted Life Years (QALYs)

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Example Markov model

State 1 Mild

State 2 Moderate

State 3 Severe

State 4 Terminal

State 5 Death

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CEA / CUA results

“Riluzole is recommended for the treatment of

individuals with amyotrophic lateral sclerosis (ALS)

form of Motor Neurone Disease (MND).”

Results

Life-years gained 0.13 QALYs gained 0.09 Increase in costs $9,100 Incremental cost-effectiveness ratio Cost per life-year gained

$70,000

Cost per quality-adjusted life-year gained

$100,000

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Cost-effectiveness plane

Drummond, et al. 2005. Methods for the economic evaluation of health care programmes:

Oxford University Press

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MOVING FROM HTA TO HEALTH TECHNOLOGY MANAGEMENT

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Areas of concern

Primary concern: The ‘performance’ of health technologies in routine use

(1) Model validation questions: How good are our models? Are the predicted benefits and costs really delivered?

(2) Improvement questions: Can we get better value from existing technologies?

(3) Appropriateness questions: Do we see indication creep? (e.g., Statins for primary prevention in low-risk patients)

(4) Withdrawal questions: Are technologies nearing the end of their useful life?

14Copyright ©2005 BMJ Publishing Group Ltd.

Miners, A H et al. BMJ 2005;330:65

Logged pairwise comparison of incremental cost effectiveness ratios

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Michael Fish and the Great Storm of 1987

www.youtube.com/watch?v=uqs1YXfdtGE

“The Great Storm of 1987

occurred on the night of 15–16

October 1987, when an

unusually strong weather

system caused winds to hit

much of southern England and

northern France. It was the

worst storm to hit England

since the Great Storm of 1703

(284 years earlier) and was

responsible for the deaths of at

least 22 people in England and

France.”

But what did the BBC weather forecaster say?

Wikipedia

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Areas of concern

Primary concern: The ‘performance’ of health technologies in routine use

(1) Model validation questions: How good are our models? Are the predicted benefits and costs really delivered?

(2) Improvement questions: Can we get better value from existing technologies?

(3) Appropriateness questions: Do we see indication creep?

(4) Withdrawal questions: Are technologies nearing the end of their useful life?

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Technology management

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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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HTA and HTM

• Life-cycle evaluation of health technologies

– Data systems (including PROMs) to facilitate monitoring of technologies in use

– In part to validate analysis predictions made at the time of coverage/reimbursement

Early HTA Adoption Ongoing

assessment

DisinvestmentAppropriate

Use

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A pan-Canadian HTM Strategy?

• CADTH leading this work

• Pan-Canadian HTM agenda (input from all jurisdictions)

• Consideration of overall system impact (including clinical guidelines, health human resources, fee codes)

• Common processes for new and in-use technologies

• Post-market surveillance programs (incorporating real world evidence)

• Enhanced knowledge mobilization

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stirling.bryan@ubc.ca