‘In with the old, out with the new’ In search of ways to break the addiction

to technology adoption

Stirling Bryan, PhD

Graham Scotland, PhD

University of British Columbia; Vancouver Coastal Health; University of Aberdeen

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Overview of talk

• Background, definitions

• Technology management

• Areas of concern

• Conceptual model for moving forward

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Definitions and the premise

• Definition: health care technology – ‘methods used to promote health, prevent and treat

disease and improve rehabilitation and long term care’

• Definition: ‘adoption’ – Technology coverage or reimbursement decisions – e.g., Should a new medical technology be available for use

in the health care system?

• The premise: – Health economics and HTA researchers devote a

disproportionate amount of their time and energy to technology adoption questions.

(NIHR HTA Programme)

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Technology as a cost driver

• Technological change – One of the largest contributors to cost growth – And so efforts to address cost growth cannot ignore

technology

• Health technology assessment (HTA) – Both Canada and the UK have long (and glorious) HTA

traditions

• But… the HTA ‘industry’ has… – become obsessed by technology adoption questions – largely ignored technology management issues

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Technology management

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Further support for technology management focus

• An additional driver of cost growth

– Rapid increases in utilization of existing technology

• E.g., medical imaging examinations

– In 2010 in Canada, 1.4 million MRI examinations and 4.2 million CT examinations were performed, representing annual increases over recent years of 6.9% for MRI and 6.2% for CT

(CIHI, 2011)

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Published CEAs (BMJ, 2005-2012)

54 economic evaluation

papers

47 with 'adoption' focus

29 (62%) advocated ‘adoption’

18 did not advocate

‘adoption’

7 with 'management'

focus

5 focused on evaluation of a broad service

2 explored clinical practice

variation

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Examples of service evaluations (n=5)

• Turner et al. (2011): Chlamydia Screening Program – Explored alternative approaches to improving cost-

effectiveness of existing program

– Conclusion: efficiency gains most likely through focus on partner notification

• Richardson et al. (2009): GI endoscopy and flexible sigmoidoscopy – Analysis goal: efficiency gains in delivery of established

technologies – physician or nurse delivered procedures?

– Findings: physician-delivered care both more effective and cost-effective

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Areas of concern

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

Technology management questions: (a) Improvement: Can we get better value from existing

technologies? (b) Appropriateness: Do we see indication creep?

Inappropriate use of technologies? [Choosing Wisely] (c) Withdrawal questions: Are technologies nearing the end

of their useful life?

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

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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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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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Addiction pathology?

• Why is so much of our analytic effort focussed on adoption decisions?

• Demand side: ‘He who pays the piper calls the tune’ – The dollars lie in adoption decision making – Lack of demand for analysis to support technology

management

• Supply side – Revenue flows lead analysts actively to encourage the

adoption focus

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Technology adoption

Technology management

Pathway management

Disease management

Health system

management

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Broader framework for economic evaluation

• Conventional CEA is piecewise – e.g., the cost-effectiveness of drug A for patients with

disease X

• A broader pathway approach – Explicit quantification 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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Example: Enhanced MRI for prostate cancer

EMRS

Watch Wait

EMRS+WW

Baseline

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In conclusion

• We encourage the health economics/HTA community to move towards broader modelling approaches

– Rejection of the current, almost exclusive, emphasis on technology adoption

– Replace with a broader analytic frame to consider clinical pathways and whole diseases

– Use of modelling to help identify inefficiencies in current care pathways

• This broadening of the scope of decision models offers the possibility of fundamentally changing the nature of the contribution health economists and their HTA colleagues can make.