Transcript Document

Health Technology Assessment and
evidence-informed decision making
Derek Cutler, MSc
NICE International
Health systems
everywhere are
under pressure…
Burden of
chronic
disease and
ageing
populations
Users’
expectations
and the promise
of universal
coverage
Policy and
practice
Growth in
technologies –
expanding
marketplace
Finite budgets
and financial
pressures
We cannot afford everything
that is clinically effective
“The NHS, just like every other healthcare
system in the world—public or private—has to
set priorities and make choices. The issue is
not whether there are choices to be made, but
how those choices are made. There is not a
service in the world, defence, education or
health, where this is not the case.”
UK Parliamentary Health Committee
Payers’ responses
• Accumulating debt
• (Arbitrary) price cuts
• Divergence between coverage (in principle) and
access
• Cost-shifting to service users and their families
• Price negotiations
• Risk sharing and Value-Based Pricing
• ‘Institutionalising’ technology adoption decisions:
Health Technology Assessment agencies
• A combination of the above…
What is Health Technology
Assessment?
“A multi-disciplinary field of policy analysis that examines
the medical, economic, social and ethical implications of
the incremental value, diffusion and use of a medical
technology in health care.”
Medical technology: “Any intervention that may be used to
promote health, to prevent, diagnose or treat disease or for
rehabilitation or long-term care. This includes
pharmaceuticals, devices, procedures and organizational
systems used in health care.”
INAHTA (International Network of Agencies for Health Technology Assessment)
HTA as a tool
• HTA can help policy makers to:
– effectively prioritise health interventions and
services
– improve their quality
– make consistent decisions
– reduce inappropriate variation
– signal ‘value’ to industry
– inform the selection of indicators to assess
performance and incentivise providers,
especially in the context of capitation
HTA as a tool
• Not a ‘cure all’ for all system inefficiencies and problems
• But, combined with inclusive, transparent processes can
confer legitimacy on decisions
• Particularly important in the case of ‘no’ decisions and
saving money to reinvest and to expand coverage
HTA audiences
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Policy-makers - payers
Medical products developers – industry
Healthcare professionals
Academic community - researchers
General public: taxpayers; insured population;
informal sector
• Patients and their families
• NGOs / third sector
• Donors
Dimensions of HTA
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Comparative clinical effectiveness
Comparative cost-effectiveness
Service delivery organisation aspects
Legal framework
Ethical, social implications – equity,
fairness and other societal norms
Comparative clinical and costeffectiveness
1. How well does the technology/intervention work compared to
standard practice in OUR healthcare system? Health gain can be
estimated using quality adjusted life years (QALYs)
2. How much does the technology/intervention cost compared to
standard practice in OUR healthcare system?
• cost of technology, monitoring, length of inpatient or outpatient stay,
costs of treating adverse events
3. Incremental cost effectiveness can be calculated by comparing (1)
and (2)
Difference in costs
Difference in effect
Role of cost effectiveness in NICE
guidance
• “Those developing clinical guidelines, technology
appraisals or public health guidance must take into
account the relative costs and benefits of interventions
(their ‘cost effectiveness’) when deciding whether or
not to recommend them.” (Principle 2, Social Value
Judgements, NICE 2008)
BUT
• “Decisions about whether to recommend interventions
should not be based on evidence of their relative costs
and benefits alone. NICE must consider other factors
when developing its guidance, including the need to
distribute health resources in the fairest way within
society as a whole.” (Principle 3)
Cost-effectiveness and…
Costeffectiveness
Legal and
policy
constraints
Extent of
uncertainty
ADVISORY GROUP
DECISIONS
Practicalities of
implementation
Non-utilitarian
criteria: ethics,
equity, rights
NICE Principles
Key procedural principles
Independence from government, industry, individual professional and
patient groups
Transparency: guidance products and methods are a public good; peer
review of methods and of products
Timeliness to meet the needs of a changing healthcare system
Consultation with all those affected by the decisions and direct
engagement with individuals and organisations
Scientific rigour in methods for guidance production and appropriate use
of the best available evidence
Contestability of decision making process through appeal mechanisms and
right to legal challenge
Process
Process matters
Open, consultative decision-making processes:
• Confer legitimacy
• Improve the quality and relevance of decisions
• Protect against vested interests and bias
Local institutions matter
“Successful development depends to
a large extent on a government‘s
capacity to implement its policies and
manage public resources through its
own institutions and systems”
The Paris Declaration on Aid Effectiveness (2005) and the
Accra Agenda for Action (2008)
Institutions: International Examples
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PHARMAC, New Zealand
IQWiG / GBS, Germany
NICE, UK
PBAC and MSAC, Australia
IETS, Colombia
HIRA/NECA, S Korea
AHTAPol, Poland
CADTH, Canada
MOH/GNDP/NHIS, Ghana
HITAP, Thailand
Building capacity
• Locally-led HTA-informed decision making
requires:
• Technical capacity
– Systematic reviews / meta analysis
– Health Economics
• Political backing
• Starting to do HTA can be a means of building
and reinforcing such capacity. Example:
Technical capacity at UK universities
Building capacity: HTA and policymaking: a symbiotic relationship?
1. Academics in the field of HTA driving policy
2. Policy makers driving academic HTA research
Result: Increased
• knowledge
• capacity
• impact
in both areas
Need, demand, and supply are different in
every country:
Need for HTA:
What policy decisions
will be informed by HTA?
Demand for HTA
Who (departments, institutions)
will be using the outputs of
HTA?
Supply of HTA:
Who (departments, institutions) will
be conducting HTA and running the
HTA process?
Summary
• HTA: a useful tool for policy makers to assess the
value of a range of health technologies, including
drugs, medical devices and disease prevention
interventions; and help maximise the impact of finite
healthcare budgets
• A means of legitimising disinvestment decisions, and
saving money to reinvest and expand coverage
• Countries starting out in HTA should not wait for ‘full’
capacity to do HTA, but rather concentrate on using
the policy need to drive capacity building
Some implications for Ghana
• HTA may be a useful tool for Ghanaian decision-makers
in achieving their joint aims of expanding coverage,
increasing care quality, and ensuring financial
sustainability
• Inclusive and transparent processes will be important in
managing political tensions and ensuring the legitimacy
of decisions
• Ghana has well-developed institutions which could
inform and contribute to such activity – important to build
on these.
• Need to consider who should convene and drive the
process