Payment for what works HTA and Comparative Effectiveness

1. Payment for what worksHTA and Comparative Effectiveness Egon Jonsson Institute of Health Economics Alberta Canada ___________________________________ “International Meeting for HTA- Emerging Countries” Ankara, March 4-6, 2009.

2. Great Bear Lake Great Slave Lake Lake Athabasca Lake Winnipeg Lake Lake Winnipegosis Nipigon Lake Superior Lake Lake Huron Ontario Lake Lake Michigan Erie ELLESMERE ISLAND Canada 9,093,507 Km2 Baffin DEVON ISLAND Bay Beauton MELVILLE Sea BANKS ISLAND SOMERSET ISLAND ISLAND PRINCE OF WALES ISLAND Davis Strait VICTORIA ISLAND BAFFIN PRINCE CHARLES ISLAND Iqaluit ISLAND YUKON NUNAVUT Whitehorse SOUTHHAMPTON NORTHWEST ISLAND Labrador TERRITORY Sea Yellowknife NEWFOUNDLAND Hudson Bay St. John's NEWFOUNDLAND BRITISH ALBERTA MANITOBA James COLUMBIA SASKATCHEWAN Bay Gulf of QUEBEC Pacific Ocean St. Lawrence Edmonton Prince Edward Island NEW ONTARIO VANCOUVER BRUNSWICK NOVA ISLAND Fredericton SCOTIA Victoria Quebec Regina Halifax Winnipeg Ottawa Toronto

3. Alberta 661,848 Km2

4. Alberta 661,848 Km2 Turkey 780,000 Km2

5. Great Bear Lake Great Slave Lake Lake Athabasca Lake Winnipeg Lake Lake Winnipegosis Nipigon Lake Superior Lake Lake Huron Ontario Lake Lake Michigan Erie ELLESMERE ISLAND Canada 9,093,507 Km2 Baffin DEVON ISLAND Bay Beauton MELVILLE Sea BANKS ISLAND SOMERSET ISLAND ISLAND PRINCE OF WALES ISLAND Davis Strait VICTORIA ISLAND BAFFIN PRINCE CHARLES ISLAND Iqaluit ISLAND YUKON NUNAVUT Whitehorse SOUTHHAMPTON NORTHWEST ISLAND Labrador TERRITORY Sea Yellowknife NEWFOUNDLAND Hudson Bay St. John's NEWFOUNDLAND BRITISH ALBERTA MANITOBA James COLUMBIA SASKATCHEWAN Bay Gulf of QUEBEC Pacific Ocean St. Lawrence Edmonton Prince Edward Island NEW ONTARIO VANCOUVER BRUNSWICK NOVA ISLAND Fredericton SCOTIA Victoria Quebec Regina Halifax Winnipeg Ottawa Toronto

6. Technologies recently proposed to be funded by the government • Photoselective vaporisation of the prostate • Double balloon endoscopy • Portable prothrombin time systems • Assistive reproductive technologies • Artificial cervical disc arthroplasty • Islet cell transplantation • Insulin delivery systems

7. Technologies recently proposed to be funded by the government • Photodynamic technologies for esophageal cancer, skin cancer, and Barrett’s syndrome • Probiotic infusion • Screening during first and second trimester • Endoscopic ultrasound • Brain naturatic peptide essays • Virtual colonoscopy

8. A selection of HTAs at IHE • Hepatitis A, B, and C • Childhood vaccinations • Childhood obesity • Alzheimer’s disease • Fetal alcohol syndrome • Management of chronic pain • Pre-operative routine investigations • Management of Parkinson's disease • Community vs. hospital based mental health services • Effectiveness/cost-effectiveness of the utilization of MRI and CT

9. Other projects at IHE • Health care financing • Health and economic growth • Barriers to cost awareness among physicians • Effective dissemination of findings from research • Assessment of alternative payment plans to doctors • Measures for cost containment and improved efficiency

10. The process of HTA 1) Do a systematic review of the scientific literature about safety, efficacy, and effectiveness 2) Perform a cost-effectiveness analysis 3) Address ethical and social issues 4) Develop policy options and policy implications

11. Payment for what worksHTA and Comparative Effectiveness Egon Jonsson Institute of Health Economics Alberta Canada ___________________________________ “International Meeting for HTA- Emerging Countries” Ankara, March 4-6, 2009.

12. Definition of what works and what is affordable in HTA • The risk of the technology must be known (Safety). • The technology must be able to do what it is supposed to do (Efficacy). • The technology must produce positive outcomes for the patient (Effectiveness). • There must be a reasonable relationship between cost and effectiveness of the technology (Cost-Effectiveness)

15. Comparative Effectiveness

16. Dietary counseling VLCD Carbohydrate-rich diets Protein-rich diets Lactovegetarian diets Dietary fiber supplements Starvation Behavior therapy Physical exercise Pharmacotherapy Surgery Acupuncture Aromatherapy Caffeine Hypnosis Cromium Vinegar Treatments used in obesity

17. Environment therapy Self image therapy Drama therapy Self identity therapy Confrontative interventions Self help courses Methods used in the treatment of alcohol- and drug abuse with no support of scientific evidence • Psychodynamic insight therapy • General support therapy • Therapeutic society model • Acupuncture • Relaxation therapy • Biofeedback

18. Physical examination Mobility and muscle tests X-ray MRI CT-scanning Neurophysiologic tests incl EMG Facet blocks Stress radiography Discography Nerve root infiltration Bone scintigraphy Termography Ultrasound Technologies used in diagnosing back pain

19. Acupuncture Antidepressants Back exercises Back School Behavioural therapy Biofeedback Colchicines Cold Cold spray Stretching Continued activity Corsets Cortisone Electromagnetic therapy Health resorts Heat Infrared light Injections in facet joints Injections in ligaments Injections in trigger points Laser therapy Manual therapy Massage Multidisciplinary treatment NSAIDs Technologies used in treatment of back pain Neck support Paracetamol Patient education Physical exercise Rest/bed-rest Shortwave diathermy Steroid injections Surgical procedures TENS Traction Ultrasound

20. Treatment of Low Back Pain

21. Economic impactof evidence-basedtreatment for back pain In millions of dollars per million population __________________________________________ Investments needed – 7 Reduced sick-leave + 64 Reduced early retirement + 18__________________________________________ Net savings 75

22. The International Journal of Technology Assessment in Health Care • 100 issues • 2,000 manuscripts • 20,000 printed pages • 6,000 authors

23. Comparative Effectiveness

26. CT Scanner

28. Examples of health technologies • Prevention of cancer; for example breast, lung, colorectal and prostate. • Treatment of depression, hypertension, diabetes, obesity, alcohol and drug abuse, head ache, etc • Specific technologies such as ultrasound in pregnancy, CT scanning in mild head injury, MRI in back pain, bone density measurement in osteoporosis

29. Evidence for health policy making • Evidence from research usually not tailor made for health policy makers • To retrieve scientific evidence is time consuming and requires special skill • To synthesize evidence is difficult

30. Definition of Health Technology “The drugs, devices, and equipment, and the medical, surgical and other procedures used in prevention, diagnosing, treatment and rehabilitation of disease and disability”

31. Health technology assessmentHTA • A synthesis of the medical, ethical, organizational, social, equity and economic implications of both established and new procedures and technologies. • Viewed in a policy perspective.

32. Examples of questions to the WHO Network • What are the effects of air pollution on children's health and development? • What is the evidence on school health promotion in improving health or preventing disease? • What evidence is there for better health by screening for osteoporosis? • What are the main risk factors for disability in old age and how can it be prevented? • Should mass screening for prostate cancer be introduced at the national level?

33. Examples of questions to the WHO Network • How can hospital performance be measured and monitored? • What are the most effective diagnostic and therapeutic strategies for the management of depression in specialist care?    • How effective are different types of day care services for people with severe mental disorders? • What discharge arrangements from inpatient hospital care for the elderly may improve health, reduce length of stay and readmission rates.

34. Should we introduce screeningfor prostate cancer at the population level in Alberta?

35. Screening technologies • FOBT • Sigmoidoscopy • Colonoscopy • Barium Enema • CT scanning (virtual or CT colonoscopy) • Fecal based DNA • Combinations of the above

36. Screening for colorectal cancerrecommendation by AHS-CB FOBT every one to two years, of men and women ages 50 – 74. If positive refer to colonoscopy or Sigmoidoscopy every five years Barium Enema every five years Colonoscopy every ten years

37. Screening for colorectal cancer Many agencies and institutions recommend screening of men and women ages 50 – 74 in line with the AHS-CB model, for example: • Canadian Task Force on Preventive Health Care • Health Canada • The US Preventative Services Task Force • Numerous other groups in the US • Several agencies in Europe

38. Issues • Benefits • Risks • Cost

39. Benefits of screening for colorectal cancer • Several RCT:s have demonstrated increased survival by screening with FOBT followed by colonoscopy in those with positive findings • Survival rates in early detection: stage 1 survival rate > 90 % stages 2 – 3 “ 65 – 85 % stage 4 “ < 10 % ______________________________________________________________________

40. Benefits of screening for colorectal cancer There are about 1,500 new cases of colorectal cancer diagnosed per year in Alberta of which about 600 die from colorectal cancer. • The number of diagnosed colorectal cancer in early stages (1 and 2) would increase from 46% to 59% in an effective screening program • This means that about 170 lives may be saved per year in Alberta. All the above are about the clinical aspects of screening – now the economist comes in, and economics is not only about money, economics is about effective use of scarce resources and for this a critical view is needed.

41. Risks of screening for colorectal cancer • False positive and/or false negative findings • Anxiety and fear • Uncertain accuracy of CT colonography in community settings • Potential radiation-harm • Serious complications from perforation and bleeding (1.4 in sigmoidoscopy and 10.0 in colonoscopy per 10,000 procedures) • Death from invasive examinations ( 2.0 per 10,000 colonoscopy examinations. If 70% of the target population participates in screening there may be 1 death per year in Alberta related to invasive examinations)

42. Cost of screening for colorectal cancer Estimated direct annual cost of biennial screening in Alberta. Million $, 2007 price level • Head office and promotion 1.0 • FOBT kit and processing 1.7 • Colonoscopies 1.1 • Gastroenterologists 0.5 • Family Physicians 7.1 Total cost per year $ 11.3 million (Caution; does not include all costs, such as for training and infrastructure)

43. Screening for colorectal cancerEconomic assessments • At least 10 comprehensive cost-effectiveness analyses published • Similar findings; screening is cost-effective • Cost-effective in the sense that the cost is less than $ 50,000 per year of life saved • Published studies show a wide range of results, usually from $10,000 to $40,000 per year of life saved, however, the latest study shows that the cost may be as high as $ 40,000 to 80,000 per year of life saved • Treatment for early stages of colorectal cancer may cost about $ 30,000, and $ 120,000 in later stages. • Not known which combination of screening tools is most cost-effective

44. Concerns raised in the literature • High rates of false positive findings; variable test accuracy related to skill and competence • Relatively low compliance among otherwise healthy people at low risk • The expertise, equipment and organization needed. Universal screening for colorectal screening would significantly increase the number of colonoscopies performed per year. Since existing out-patient clinics would be unable to handle the increased demand, specialized clinics would have to be setup, probably outside the confines of hospitals. • NNT = 1,200 people need to be screened for 10 years to avert 1 death from colorectal cancer

45. Concerns raised in the literature • The insufficient evidence to assess the benefits and harms from CT colonography and fecal DNA testing • Cost and benefits of limiting a screening program to high risk groups not known • Newer fecal screening tests with better sensitivity and specificity than those currently in use. Cost unknown. • Widespread uncertainty about many factors like the natural history of colorectal cancer, the clinical benefit of detecting small polyps, the effectiveness of some of the screening tools, the compliance rate, the adverse effects of colonoscopy, direct and indirect medical costs, and the ability of the health care system to respond to the increased demand for health care

46. Recommendation • Build a decision analytic model and make a more accurate estimate of the most cost-effective strategy of screening for colorectal cancer as far as possible based on test results specific to Alberta. • Perform a Comparative Effectiveness analysis of prevention, diagnosing, treatment and rehabilitation in colorectal cancer. • Organize a Consensus Development Conference on the subject with the aim of developing a clear recommendation for Alberta that has broad support among the profession and the general public.

48. Germany Hungary Israel Latvia New Zealand Malaysia Norway Poland Spain Sweden Switzerland The Netherlands United Kingdom United States Countries with agencies for HTA Australia Austria Canada Chile China Cuba Denmark Finland France

49. INAHTAThe International Network of Agencies in Health Technology Assessment • 43 agencies • 22 countries • 850 ongoing assessments • 2 300 published assessments • 2 000 people working in the network

50. Other Networks in the field • Cochrane collaboration • Evidence Practice Centers • WHO Health Evidence Network (HEN)