Disruptive TechnologiesA Perspective from the UKMichael DrummondCentre for Health Economics,University of York
Outline of Presentation• What do I understand by ‘disruptivetechnologies’?• Have I ever seen one?• What are the main features of disruptivetechnologies?• Are current HTA methods sufficient fordealing with them?
Search on the NICE Websitefor ‘Disruptive Technology’
Search on the NICE Website for‘Disruptive Technology’Pemetrexed for NSCLC......
Search on the NICE Websitefor ‘Disruptive technology’Pemetrexed for NSCLC............’ an antifolate agent that works bydisrupting folate dependent metabolicprocesses’.
My First Encounter with a DTFinasteride for treatment of benign prostatichypertrophy (BPH)A new drug indicated for BPH. Evidence suggested that it had thepotential to delay, or avert, the need for prostatectomyProblem was that urologists were more interested in operating thangiving drugsAlso, the manufacturer targeted its marketing predominantly towardsgeneral physicians, thereby potentially taking ‘business’ away fromsurgeonsPayers were also sceptical and introduction in some settings was onlyby way of a risk-sharing acheme (eg if the drug did not avert thesurgery, the manufacturer would pay for the prostatectomy.
Characteristics of DTs• Large budgetary impact (especially within year)• Need for re-alignment of, or creation of new,budgets• Need for organizational adjustments (eginvestment in new facilities, re-deployment of staff)• Need for re-training or acquisition of new skills• Requirement for change in existing clinical roles orresponsibilities• Requirements for change run counter to existingincentives
HTA of Disruptive TechnologiesUK Perspective• Debate about disruptive technologies ismostly discussed in the context ofdifficulties in implementation• NICE technology appraisals are requiredto consider ‘Impact on the NHS’• NICE has an Implementation Programmeto assist the NHS in implementing itsguidance
Problems with Implementation• Analysis of 12 pieces of NICE guidance• Implementation very variable• Guidance more likely to be adopted whenthere is:- strong professional support- a stable and convincing evidence base- no increased or unfunded costs- a good system for tracking implementation- no isolation of the professionals involvedSheldon et al British Medical Journal 2004; 329:1-8
NICE Methods Guide 20135.12 Impact on the NHSImplementation of NICE guidance5.12.1 Information on the net impact of theimplementation of the health technology on the NHS (andpersonal and social services, when appropriate) isrequired.5.12.2 As outlined in more detail below, when possible, theinformation on NHS impact should include details on keyepidemiological and clinical assumptions, resource units andcosts with reference to a general England and Walespopulation, and patient or service base (for example, per100,000 population, per average primary care trust or perward).National Institute for Health and Care Excellence. Guide to the methods of technology appraisal.London, NICE, 4 April 2013
NICE Methods Guide 2013Implementation or uptake and population healthimpact5.12.3 Evidence-based estimates of the currentbaseline treatment rates and expected appropriateimplementation or uptake or treatment rates of theappraised and comparator technologies in the NHSshould be supplied. In addition, an estimate of theresulting health impact (for example, QALYs or life-years gained) in a given population should ideally beattempted. These should take account of theconditions epidemiology and the appropriate levels ofaccess to diagnosis and treatment in the NHS. Itshould also highlight any key assumptions oruncertainties.
NICE Methods Guide 2013Resource impact5.12.4 Implementation of a new health technology will have directimplications for the provision of units of the appraised andcomparator technologies (for example, doses of drugs or theatrehours) by the NHS. In addition, the technology may have a knock-onimpact (increase or decrease) on other NHS and personal andsocial services resources, including alternative or avoided treatmentand resources required to support the use of the new technology.These might include:staff numbers and hourstraining and educationsupport services (for example, laboratory tests)service capacity or facilities (for example, hospital beds, clinicsessions, diagnostic services and residential home places).5.12.5 Any likely constraints on the resources required to supportthe implementation of the appraised technology should behighlighted, and comment should be made on the impact this mayhave on the implementation timescale.
NICE Methods Guide 2013Costs5.12.6 Estimates of net NHS (and personal and social services, whenappropriate) costs of the expected resource impact should be provided toallow effective national and local financial planning. The costs should bedisaggregated by appropriate generic organisational (for example, NHS,personal and social services, hospital or primary care) and budgetarycategories (for example, drugs, staffing, consumables or capital). Whenpossible, this should be to the same level and detail as that adopted inresource unit information. If savings are anticipated, the extent to whichthese finances can actually be realised should be specified. Supplied costsshould also specify the inclusion or exclusion of VAT. The cost informationshould be based on published cost analyses or recognised publiclyavailable databases or price lists.5.12.7 If implementation of the technology could have substantial resourceimplications for other services, the effects on the submitted cost-effectiveness evidence for the technology should be explored.5.12.8 The Institute produces costing tools to allow individual NHSorganisations and local health economies to quickly assess the impactguidance will have on local budgets. Details of how the costing tools aredeveloped are available in the Institutes document, Assessing cost impact:methods guide.
Michael DrummondCentre for Health Economics,University of York
Other Analytic Considerations• Is the test already in place for an existing targetedtherapy in this indication?– Then comparator could simply be the new targeted drug vsexisting targeted therapy• No targeting of existing therapies in this indication?– Then comparator is ‘world without the test or the targetedtherapy’– Modelled population is larger, as need to capture the testnegative patients• Clinical trial often only conducted in test-positivepatients, but economic model needs to consider‘world without test+drug’ vs ‘world withtest+drug’