Assessing Relevance from the Policy Perspective

Transcription

1 Assessing Relevance from the Policy Perspective David Elliott MD, MSc Medical Advisor, NS Department of Health Adjunct Assistant Professor, Dalhousie University Department of Community Health and Epidemiology * * The opinions expressed herein are the author s alone and do not necessarily reflect the position of the Nova Scotia Department of Health or Dalhousie University

2 This is a slightly modified version of the slideshow given at the Symposium. It lacks the context given by the verbal presentation. I have attempted to compensate with some added text overlays. The initial slides parse out the words in the title to illustrate points regarding policy, technology and the challenges therein. To view this presentation fullscreen in your browser hit F11 then CTRL+L. If you have saved this presentation to disk and are using the standalone Adobe viewer, hit CTRL+L to view it in slideshow mode. (Which illustrates another point many people don t understand how to properly use the technology they already have!) DE

3 Relevance - definitions Closely connected or appropriate to the matter at hand WordPerfect Condensed Oxford Dictionary Microsoft Word Thesaurus (no dictionary) Significance Bearing Application Importance Consequence

4 Relevance - definitions Note Closely connected or appropriate that that I to I have just the just done matter a technology comparison and and at hand WordPerfect Condensed have concluded Oxford that that the the WordPerfect Dictionary technology is is Microsoft Word Thesaurus (no dictionary) Significance Bearing Application Importance Consequence superior. However, most people now now use use Word as as a consequence of of the the tied tied selling activities of of the the monopoly Operating System provider, Microsoft. Which illustrates another factor in in the the real real world of of how how technology gets gets applied.

5 Policy definitions What we usually do Who gets what Who gets, who pays, who gets paid - Canadian health economist, Bob Evans The process by which governments translate their political vision into programmes & actions to deliver outcomes desired changes in the real world - UK Centre for Management and Policy Studies People who enjoy eating sausage and respect the law should not watch either being made - Otto von Bismarck

6 perspective >noun Perspective the art of representing three-dimensional objects on a two-dimensional surface so as to convey the impression of height, width, depth, and relative distance. a view or prospect. a particular way of regarding something. understanding of the relative importance of things. originally in the sense 'optics': from Latin perspectiva ars 'science of optics'

7 perspective >noun Perspective Note that the word perspective is being used the art of representing three-dimensional off label or not in objects the manner in which it was on a two-dimensional surface originally so as to intended, convey the impression of height, width, depth, illustrating and another relative real distance. a view or prospect. a particular way of regarding something. world technology challenge. understanding of the relative importance of things. originally in the sense 'optics': from Latin perspectiva ars 'science of optics'

8 Health Technology can be so Complex

9 Or not so Complex...

10 or pretty darn Simple... but may not always be used as intended (off-label use)... and this device, although designated by manufacturer to be single-use only, was likely disinfected and is being reused

11 Introduction First try to get some understanding of the significance of the title... What is Policy Who decides it, who implements it, and How is it informed HT decision scenarios What determines relevance Information needs Unique challenges

12 Policy Making Levels Judicial Legislative Regulatory Administrative Procedural F O R M A L I S M D I S C R E T I O N

13 HT Policy Levels Macro Dealing with high cost, one or few-of-a-kind technologies often cross-jurisdictional Decisions for standardization on single product, technique for a jurisdiction High need for coordination and dialogue Meso Health Region or facility Micro Processes for ensuring proper principles are followed in making more minor HT decisions

14 But is policy the right concept here? Insofar as we can call any HT decision policy, then this is about policy But really we are most concerned with tools for decision-making, recognizing that a lot of these decisions are routine While policy may determine what facts we look for and how we interpret them, many HT decisions are subject to policy but not policy themselves

15 Needs Obviously the type of information requirements between these levels may differ The timescale for making decisions can vary widely The cost impact is different Oversight of outcomes or consequences may range from close scrutiny to none

16 Overview The decision-maker s milieu Consumers Firefighting Meetings 80 s/day Conflict Personnel Budget No time Polls More meetings

17 Needs in the Decision-Making Process Information gatherer Policy analyst or Content expert 1st order decision-maker director or executive director 2nd order Administrative decisions (ADM / Deputy) Political decisions (minister / cabinet) Needs Full background Highly technical Needs Detailed synthesis and options Needs Highly structured Main points Options / consequences

18 So then... It follows that different decision-making levels require different products Regardless of efforts to produce products for different levels, there will have to be contextualization depending on jurisdiction and audience Local factors may trump otherwise relevant evidence

19 The Place of Evidence Everyone talks about Evidence-Based policies Evidence is good to have, but, Sometimes you have evidence, but it isn t the evidence you need Evidence is in conflict - contradictory/equivocal Other times evidence (scientific) is not enough Decision-makers must always make decisions under some condition of uncertainty (and be willing to do so!) Rely on experience (which is a form of evidence in itself)

20 Health Technology Friend or Foe? While health technologies can and have helped in prevention and treatment They are unpredictable elements in managing healthcare Raise Expectations Cost-benefit Usage profile exceeds indications

21 Clinical Pressure & Imperatives I could save him if we had one of those new LC-32D7Us

22 HT Evaluations vs. Real World Stacking Cost benefit often out of context of use Costs are additive Benefits are not Cost Benefit # of Interventions

23 Evaluation & Screening Processes Vary by technology and cost Drugs Subject to more centralized decision making Culture of evidence Devices & Techniques Evaluation process varies with individual or aggregate costs Technical changes without immediate purchase implications may occur without any formal evaluation whatsoever.

24 Scenarios How technology gets in Big ticket items ~>$1M Multi-jurisdiction / Multi-level funding Highly formal process Can be politicized Midrange ~>$100K - $1M Single jurisdiction / facility Multidisciplinary Teams Small change ~<$100K Department or Materials Management

25 Oh yes, we gotta have one of those

26 Scenarios How technology gets in cont d The back door Surgeon buys equipment Equipment part of clinical trial and is donated to facility at end of trial (e.g., Bone Densitometer used in osteoporosis Rx trial) Foundation raises money in community Internal innovation The Big Deal Large scale purchase agreements & tied selling

27 The midrange scenario Department Heads Clinical Advocate HT Decision Biomedical Engineering VPs Clinical & Finance Materials Management

28 We think it works and we want it RCT & other trial results What does it cost? If they get it, we want our request filled as well The midrange scenario Clinical Advocate VPs Clinical & Finance Department Heads HT Decision Biomedical Engineering Materials Management Comparison of competing technology & suppliers What do we do with the stuff we ve already got? Standardization of equipment across departments

29 Relevance In the topic submission and prioritization process, someone had to suggest a HT topic and it had to get enough votes to get studied But did the subsequent assessment cover sufficient clinical scenarios and have proper sensitivity analysis Did it get done in time to affect decisions, or has an interim or permanent decision been taken that renders the HTA moot The HT(P)A, regardless of how well done, has to be contextualized to the local situation

30 Keys to Relevance On target Applies to the population and circumstances at hand In time Information and options are available within an adequate timeframe for decisionmaking Trusted Agency producing information has track record for quality, unbiased work Faith in generally accepted methods

31 Relevance cont d Effectiveness and cost-benefit scenarios must encompass a variety of real world possibilities E.g. DES and initial use in high risk populations at higher risk of restenosis Model the effect of market competition on price E.g. DES and price changes after introduction of competing products and alternate formats

32 The Decision-maker Has huge demands on their time May have no formal support structure for making HT decisions (smaller provinces) May not be a content expert Often there is one short opportunity to make a point Takes comfort, though, in being able to quote an impeccable authority

33 Products and Processes for the HT Future The two greatest needs: Information Understanding

34 Information Timely, relevant, credible and contextualized HT appraisals with policy overlay and discussion of options Horizon scanning Knowledgebase online searchable collection of Q&As Rapid assessments Other resources for HT decision-making Liaison Officers Individualized responses to field HT questions

35 Processes toward Increasing Understanding Capacity building Liaison officers Strategic meta -questions Challenges arising from moral-ethical overlays that accompany some technologies. E.g. genetic Help understanding and articulating cost-benefit analysis: the go or no-go threshold Adequacy of HT policy making in terms of knowledge and resources Develop Culture of Evidence

36 Summary Policy is made at many levels Inputs to policy-making are varied Packaging information for decision-makers is difficult information too soon or too complex is not useful information, however evidence-based it may be, may not be relevant to the heart of the decision needed