Technology Assessment and Quality Improvement

1. Technology Assessment and Quality Improvement TH Tulchinsky MD MPH Braun School of Public Health Dec 2004

2. Technology Advances, 18th Century • Thermometer • Lime juice supplements (Lind) • Vaccination (Jenner) • Surgical anatomy (Hunter) • Clinical sciences (Sydenham) • Obstetrical forceps

3. Technology Advances, 19th Century • Anesthesia • Stethoscope, laryngoscope, ophthalmoscope, blood pressure cuff, syringes, X-ray • Sanitation • Antisepsis • Braille printing • Hygiene in obstetrics • Nursing, well child care • Cellular pathology, pathological chemistry • Microbiology, immunology and vaccines • National health insurance

4. Technology Advances, 1900-1930 • Improved biomedical education • Salvarsan • Insulin • Blood groups • Vitamins • Conquest of yellow fever • Cost benefit analysis

5. Technology Advances, 1931-1945 • Penicillin • Randomized clinical trials, • Antimalarials and vector controls

6. Technology Advances, 1946-1960 • Vaccines • Anti-hypertensives • Psychotropic drugs • Cancer chemotherapy • Prepaid group practice • Risk factors for CVD • Smoking and lung cancer

7. Technology Advances, 1961-1980 • DNA • Oral rehydration • Vaccines for polio, measles, mumps, rubella • Cost-effectiveness analysis • Smoking and CVD risk factors • Open heart surgery and intensive care • Pacemakers, organ transplantation, • Computerized Tomography (CT) • Eradication of smallpox • HMOs, DRGs, district heath systems

8. Technology Advances, 1981-2000 • Magnetic Resonance (MRI) • Positron emission tomography (PET) • Endoscopic surgery to improve surgical care • Eradication of polio • H pylori control to prevent stomach cancer and chronic peptic ulcers and surgery • Managed care to provide quality care and prevention to enrolled population • Folic acid to prevent NTDs

9. Appropriate Health Technology • WHO - level of medical technology needed to improve health conditions in keeping with the epidemiologic, demographic and financial situation of each country • All countries have limited resources and must select strategies of health care and appropriate technology to use those resources effectively to achieve health benefits • Traditional Birth Attendants and Community Health Workers for prenatal preparation and normal deliveries and preventive primary care to reduce maternal and child mortality

10. Appropriate Health Technology: National Drug Formularies • NDFs are consensus lists of essential drugs sufficient for major health needs of a country to reduce duplication, combined products of the commercial market • To ensure availability and rational use of drugs and vaccines and economic procurement • Assist regulatory agencies, legislation, quality control, information, supply, training, reference laboratories • International Pharmacopoeia, WHO Drug Bulletin, WHO Model List of Essential Drugs • To improve quality and cost management in national health systems

11. Basics of TA for a Medical Innovation • Is it new or replace a less efficient service? • Is there a need for it? • Where is it in the order of priorities? • Does it duplicate a service already available? • Does it help diagnosis, treatment for patient's benefit? • What are the alternatives? • What resources are needed to purchase, staff, maintain? • Can the facility afford it? • What could otherwise be done with these resources?

12. Canadian Coordinating Office for Health Technology Assessment (CCOHTA) • Conference of Deputy Minister of Health 1989 • Board of Directors • To provide evidence-based information on emerging and existing health technologies, primarily to Canadian health care policy makers and managers • 'Technologies' is broadly defined as any medical procedures, devices, systems or drugs used in the maintenance, treatment and promotion of health

13. Canadian Technology Assessment • Technology Reports • Bisphosphonate agents for the management of pain secondary to bone metastases: a systematic review of effectiveness and safety • Telephone triage services: systematic review and a survey of Canadian call centre programs  • Spinal Manipulation for Infantile Colic • Emerging Technologies Series • Wireless Capsule Endoscopy • Insulin Glargine: a long-acting insulin for Diabetes Mellitus  • Transcatheter Enfuvirtide, a new treatment for HIV infection

14. Research Projects Medical Devices and Health Systems: Canada • Impact of Delay in Initiation of Radiation Treatment Post surgery for Women with Early-stage Breast Cancer receiving chemotherapy • Tandem mass spectrometry in newborns  • Intravenous immunoglobulin (IVIG) • Devices to monitor anticoagulation in a community based setting • Virtual colonoscopy/virtual endoscopy • Smoking cessation therapies

15. Research Projects Canada: Pharmaceuticals • Activated protein C for severe sepsis • Direct Thrombin Inhibitors for anticoagulation: an economic analysis • Teriperitide for osteoporosis: an economic analysis  • Insulin pen-fill formulations

16. Hitech Medical Equipment/Procedures Rates (per Million Population) In Selected Countries and Years, 1985-1996 Country CTs 1986 to 1993/96 MRIs 1986 to 1995/96 USA 12.8 26.9 0.5 16.0 France 4.7 9.4 0.5 2.3 Germany 6.9 16.4 0.7 5.7 Netherlands 3.2 9.0 0.1 3.9 UK 2.7 6.3 0.3 3.4 Canada - 7.9 - 1.3 Sweden - 13.7 - 6.8 Australia - 18.4 - 2.9 Japan 27.5 69.7 0.1 18.8

17. Problem Hitech Lotech Infectious disease Treatment Vaccination Breast cancer screening Mammography Breast self exam, nutrition Colon cancer Colonoscopy Occult blood, nutrition Acute MI Coronary angioplasty Streptokinase, aspirin, diet, exercise Gall stones Lithotropter Abdominal surgery Endoscopic surgery Head injuries Intensive care Helmets for bicycle riders Thalassemia Transfusions, Chelating agents Prenatal Dx, Screening, education Liver failure Liver transplant Hepatitis B vaccination Screening blood donations Dehydration Infusion Oral rehydration

18. Quality Assurance • QA Measures and evaluates proficiency or quality of services rendered. • QA is an integral part of public health function • Involves ensuring the quality of both health practitioners and facilities.

19. Quality Assurance Organization • Professional Standards Review Organizations (PSROs) • Medical Audit Committees • Maternal mortality review committees • Death rounds/clinical pathological conferences • Infant mortality reviews • Utilization reviews

20. Standards • Control of Communicable Diseases Manual • American Academy of Pediatrics “Red Book” • AAP Committees published in Pediatrics • MMWR regular • MMWR RR and SS series

21. Clinical Guidelines • Apgar score - standardized infant assessment • APACHE system (acute physiology and chronic health evaluation) • Clinical algorithm - defined sequence of alternative, logical steps depending on outcomes of previous ones, incorporating clinical, laboratory and epidemiological information, applied to maximize benefits and minimize risks for the patient. • Health Care Financing Administration (HCFA) • National Institutes of Health (NIH) have consensus programs to develop guidelines

22. Clinical Guidelines • WHO • American Medical Association - 2200 practice guidelines • Managed care companies, pharmacy benefit managers, governmental bodies • Professional organizations such as the American Academy of Pediatrics • Psychiatric Association and the American Academy of Child and Adolescent Psychiatry

23. Clinical Practice Guidelines NHLBI (NIH) • Asthma • Guidelines for the Diagnosis and Management of AsthmaUpdate on Selected Topics 2002 • Cholesterol • Clinical Guidelines on Cholesterol Management in Adults (ATP III) • Recommendations Regarding Public Screening for Measuring Blood Cholesterol • Hypertension High Blood Pressure Guidelines (JNC 7) • Obesity Clinical Guidelines on Overweight and Obesity • Other National Guidelines Clearinghouse • http://www.nhlbi.nih.gov/health/indexpro.htm

24. Organizations to Promote Quality in Health in the United States  • NCQA - National Council for Quality Assurance: This non profit organization was founded in 1979 by the managed care industry to conduct surveys among managed care plans to evaluate clinical standards, members rights and health service performance. It accredits over 50% of the 630 managed care plans in the US (1997) • AHPCR - Agency for Health Care Policy Research: Part of the US Public Health Service (1995), and mandated to develop an Evidence-Based Practice Program in 12 centers in the US and Canada. It conducts systematic reviews of the literature, publishes its analyses and findings with guidelines for care, quality improvement projects and purchasing decisions for health plans   • Source: Medical News and Perspectives. Journal of the American Medical Association, 1997;278:155-1562.

25. Organizations to Promote Quality in Health in the United States • FACCT - Foundation for Accountability is a non profit organization with the purpose of providing information to consumers, with a stress on quality of care for chronic diseases and measuring tools to develop standards and assess health plan performance in conditions such as diabetes, asthma, breast cancer, CHD and alcoholism • HCFA - Health Care Financing Administration, a federal agency of the Department of Health and Human Services responsible for administering the Medicare and Medicaid health plans

26. Organizations to Promote Quality in Health in the United States • IHI - Institute for Healthcare Improvement is a non-profit organization to improve health care in Canada and the US by fostering collaboration among health care organizations • NPSF - National Patient Safety Foundation of the American Medical association as a response to findings of high rates of injury and death from iatrogenic disease in the US   • JCAHO - Joint Commission on Accreditation of Healthcare organizations; Internet http://www.jcaho.org

27. Hospital Accreditation • Long standing method of QA in North America • Used in teaching and community hospitals and long term care facilities, as well as ambulatory, home care and mental health services • Initial focus on acute care hospitals, accreditation extended to special hospitals, long term facilities, home care programs, public health departments, ambulatory care services • Major contribution to raising standards of patient care throughout Canada and US • Provides a working model for replication or adaptation internationally e.g. UK, Philippines

28. Hospital Accreditation in Canada • Voluntary grouping of professional associations, including the College of Physicians and Surgeons, the Hospital Associations and the College of Nurses • Joint Council carries out regular inspections of hospitals – “voluntary” • Other organizations are included: federal Department of Health and Welfare, provincial Ministries of Health, Canadian Diabetic Association, Public Health Association, the Standards Council of Canada as observers

29. Ambulatory care Child life services Clinical record services Critical care unit (generic) Discharge planning Diagnostic services Education services Emergency services Governing body Housekeeping services Human resource services Intensive, cardiac care Transplant units Laboratory services Laundry and linen services Library services Long term care/geriatric unit Management services Material management Medical equipment services Medical services Neonatal intensive care Nuclear medicine Nursing services Nutrition and food services Obstetrical services Occupational therapy services Operating suite, recovery unit Palliative care unit Pastoral services Pharmacy services Physical plant maintenance Physiotherapy services Psychiatric services Psychology services Rehabilitation services Respiratory therapy services Social work services Speech and audiology unit Volunteer services Services Evaluated in Hospital Accreditation, Canada

30. Utilization review Appendectomy rates Caesarian rates Records reviews Management of AMI (tracer conditions) Risk management Infection control, Employee health and safety Disaster and emergency planning Standards for Internal QA program

31. Standards for Acquisition of Costly Medical Equipment, Israel 1996 Technology Conditions Ministry Permitted Rate CT Hospital >300 beds 1/200,000 Cardiac catheterization unit Hospitals >300 beds with cardiac intensive care >5 beds 1/200,000 NMR Hospitals >400 beds with approved radiology dep't + CT 1/300,000 Gamma camera Hospitals >300 beds + approved radiology dep't 1/100,000 1/80,000 1/500,000 Linear accelerator Only in ministry approved centers for Radiation Rx 1-3 units in regional radiation therapy centers, 1-3:million Lithotropters Major hospital center 1/:million PET Research purposes 1/5.5 million Source: Adapted from Regulating medical technology in Israel, in Shemer J, Schersten T [eds]. Jerusalem: Gefen, 1995.

32. Total Quality Management and Continuous Quality Improvement • Involves multi-disciplinary approaches to review problems, and to seek better ways of functioning and improving consumer satisfaction. • Process includes all those involved in providing care, support services and administration of a department, hospital, clinic or community health program. • Professional self-policing to find better ways of meeting needs and using resources • Improves performance and morale

33. Sources • The New Public Health, Chapter 15 • NCHS • JCAHO at http://www.jcaho.org • JAMA. 1997;278:155-157   • US Public Health Service (PHS) Preventive Services Task force Guide to Clinical Preventive Services • National Institutes of Health Consensus Program, Office of Medical Applications Research http://opd.od.nih.gov/consensus/about/about.htm • American Academy of Pediatrics Policy Statements http://www.aap.org/policy