Developing a disinvestment methodology to review Australian medical services - ‘ophthalmology’ as a test case.
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Developing a disinvestment methodology to review Australian medical services - ‘ophthalmology’ as a test case. Tracy Merlin and Jackie Street

Developing a disinvestment methodology to review Australian medical services - ‘ophthalmology’ as a test case. Tracy Merlin and Jackie Street

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  • The Medicare Benefits Schedule is a list of attendances or procedures performed primarily by clinicians or medical practitioners that are subsidised by the Government. It covers everything from hip replacements, surgery for appendicitis and delivering babies to an annual diabetes check, genetic counselling and the common visit to the GP to get a sick certificate.
  • All well and good but how do we do a whole-of-specialty review?? Several challenges.Stakeholder beliefs re effective service. Income from subsidised service.How to address all of these challenges??
  • Need to use different data sources. Use multiple sources to provide a holistic view of the technology’s worth.Level of entrenchment explored through analysis of claims data, consumer perspective, stakeholder negotiation.Guidelines concordance and mini-HTA supplement each other ie evidence and expert opinion when evidence is lacking. Also establishes benchmark practice and delivery of a service.
  • Level of entrenchment
  • Analysis of the concordance between clinical practice guideline recommendations and MBS item descriptors (outlining eligible patient indications for the service).
  • Qualitative analysis of patient/consumer literature on values and preferences concerning specific ophthalmology services;
  • And negotiation with stakeholders on minor wording amendments to item descriptorsie terminology
  • Implications for the health system: A framework for reviewing the public funding of established technologies has been developed. This methodology is now standard for ‘whole-of-specialty’ reviews of established medical services in Australia and may be a suitable model for other health systems.
  • It turns out that, for our friend photocoagulation of the retina, there was a range of evidence available depending upon its use. It ranged from poor quality to not so poor quality. Few studies to swaths of systematic reviews. Though often the evidence was some years old – which meant that direct photocoagulation of choroidal neovascularisation with microsecond pulsed Argon lasers had long since been replaced with continuous wave grid photocoagulation with diode lasers and therefore the evidence had applicability issues to a present day clinical setting.However, a mixed methods approach mitigated, in some cases, the lack of evidence able to be derived from a single source.

Developing a disinvestment methodology to review Australian medical services - ‘ophthalmology’ as a test case. Presentation Transcript

  • 1. Adelaide Health Technology Assessment (AHTA)Tuesday, June 26, 2012KEEPING AN ‘EYE’ ON THE PROBLEM:Developing a disinvestment methodology toreview Australian medical services -‘ophthalmology’ as a test caseTracy Merlin and Jackie Street Life Impact | The University of Adelaide
  • 2. Background2009-2010:• Government funding put aside to develop an evidence based method of managing the Medicare Benefits Schedule into the future. » MBS Quality FrameworkBroad aims:• Maximise health outcomes - safe, effective, appropriately used• Promote efficient use of limited health care resources - could we get better outcomes using our health dollar elsewhere?
  • 3. What is the Medicare Benefits Schedule? • List of services performed primarily by clinicians that are subsidised by the Governmenthttps://www.chf.org.au/pdfs/chf/What-is-the-MBS.pdf
  • 4. Demonstration Whole-of-SpecialtyReview: ophthalmologyParticipants – Adelaide Health Technology Assessment , University of Adelaide – consultants (responsible for the methodology, identification, analysis and synthesis of evidence) – Clinical Working Group – experts in the field of ophthalmology – Australian Government Department of Health and Ageing – Consumer representation – Policy advisors – Medical Services Advisory CommitteeGuiding principles – Evidence based – Fit for purpose – Consult key stakeholders
  • 5. Challenge 1:What is the service? • MBS descriptors are non-descriptive Item 42809 RETINA, photocoagulation of, not being a service associated with photodynamic therapy with verteporfinWHAT IS IT? WHY IT IS DONE?• Direct photocoagulation • Retinal detachment• Perifovial photocolagulation • Diabetic retinopathy• Macular grid photocoagulation • Choroidal neovascularisation• Pan-retinal photocolagualtion associated with pathologic myopia• Continuous wave vs pulsed in micro, nano, • Macular oedema pico or femto seconds • Age-related macular degeneration• Argon, YAG, Krypton, YLF, HeNe, Diode • Macular holes• 350nm to 750nm wavelength • Retinoblastoma• Laser power levels from 1.5 to 8 Watts• Optically pumped semiconductor lasers based on near-infrared-pumped quantum- well structures
  • 6. Challenge 2: How to evaluate establishedservices?• Thin evidence base – Reimbursed on basis of expert opinion – Data collection ↓ after technology adoption – Services often difficult to evaluate in trials ie consultations , number of follow-up tests/re-treatments• Lack of comparator – How to determine comparative effectiveness and safety when technology/service being reviewed is the benchmark (rightly or wrongly)?• Level of entrenchment – Consumer expectations / preferences – Stakeholder beliefs / income – Practice variation / usage
  • 7. Mixed Methods Approach Guidelines Concordance Consumer Mini-HTA Perspective HealthAnalysis of Stakeholder technologyclaims data / service Negotiation Slide 6 © T. Merlin 2011
  • 8. MBS data analysis• Pattern of claims consistent with disease burden and patient demographics?• Regional variation in practice?• Rural vs urban uptake?• Pattern of services used together?
  • 9. Guideline concordance• Appropriate clinical practice guidelines identified for each item• AGREE appraisal instrument used to rate quality of guideline. – Recommendations in those guidelines with high AGREE rating were given more credence than lower rated guidelines• Judgement made whether MBS item descriptor was similar to recommendations in guideline or whether it did not reflect evidence-based “best practice”
  • 10. Mini-HTA - optimisation• Research questions: – Are there particular populations or settings where the technology works better than others? – Are there particular forms of the technology that are more effective?• Pre-defined PICO (Population, Intervention, Comparator, Outcomes) criteria → study eligibility• Databases: Cochrane Library, Embase/Medline, EconLit.
  • 11. Mini-HTA - optimisation• Search limits: English language, humans, publ 2005-2011• Hierarchical literature selection by study design: – Limit 1 – SRs  – Limit 2 – controlled clinical trials, RCTs or meta-analyses  – Limit 3 - any articles + progressive retrospective 5 year time periods• Critical appraisal + narrative synthesis (NHMRC body of evidence matrix)
  • 12. Ascertainment of consumer preferences• Qualitative literature search – Embase.com, Scopus• Analysis of weblogs – identified through Google advanced domain search. Commercial blogs excluded• Literature imported into NVivo – thematic coding and analysisStyes...One became big and bad enough that I was prompted tosee an eye doctor in Lapeer- not knowing he was going toremove it right there in his office- I was in for a huge surprise-They froze it- felt like they pulled my eyelid back and tied it to myponytail- took the stye out- and left me with a huge bruise and apatch to cover it. That wont [sic] happen again- I assure you. Ihave since had styes- but use over the counter stye medicationwhich seems to be doing a good job. (TJ, United States, November 13, 2003).
  • 13. Stakeholder negotiation
  • 14. Review Process• Protocol for Stage 1 drafted and released for public consultation – Dec 2010• Stage 1: Review of 61 Medicare items undertaken using mixed methods approach – Tailored approach; not all items received all analyses – Oct 2011: released for public consultation – Review recommendations – only 20 / 61 services escaped change – March 2012: recommendations provided to MSAC → MSAC provided advice to Minister• Stage 2: Review of remaining 23 Medicare items is underway
  • 15. Review recommendations Services deleted Descriptors modified/restricted + Items split to separate out services of different complexity 2011 Slide 14 © T. Merlin (subsidy implications) or Items merged
  • 16. Policy outcomes ofdemonstration review• 2011-2012 Budget Comprehensive Management Framework for the MBS: – Commitment to rolling reviews of the appropriateness, clinical quality, safety and fee levels of existing MBS items – Aim is to maximise health outcomes for patients and be cost neutral – Methodology feasible and accepted. » template for all subsequent whole-of-specialty reviews
  • 17. • Co-author – Jackie Street (consumer preferences)• Researchers applying methodology – David Tamblyn, Linda Mundy, Edith Reddin, Ben Ellery, Vineet Juneja, Sophie Hennessy, Sophia Scrimgeour• Feedback from Eliza Hazlett, Amy Lambert, Kelly Cameron, Alex Hunyor, Guy D’Mellow, Russell Bach, Mark Daniell• Funded by – Australian Government Department of Health & Ageing. tracy.merlin@adelaide.edu.au
  • 18. ReferenceMerlin T, Street J, Holton C, Mundy L, Tamblyn D, Ellery B, Juneja V,Reddin E, Scrimgeour S, Hennessy S (2011) Review of MBS Items forspecific ophthalmology services under the MBS Quality Framework.Canberra, ACT: Commonwealth of Australiahttp://www.msac.gov.au/internet/msac/publishing.nsf/Content/Ophthalmology_Review Slide 17 © T. Merlin 2011