‘In with the old, out with the new’ – In search of ways to help health economists break their addiction to technology adoption. CHE Seminar presented by Professor Stirling Bryan, Director, Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Professor, School of Population & Public Health, University of British Columbia. 17th October 2014

1. ‘In with the old, out with the new’ In search of ways to break the addiction to technology adoption
Stirling Bryan, PhD
Graham Scotland, PhD
University of British Columbia; Vancouver Coastal Health; University of Aberdeen

2. 2
Overview of talk
•Background, definitions
•Technology management
•Areas of concern
•Conceptual model for moving forward

3. 3
Definitions and the premise
•Definition: health care technology
–‘methods used to promote health, prevent and treat disease and improve rehabilitation and long term care’
•Definition: ‘adoption’
–Technology coverage or reimbursement decisions
–e.g., Should a new medical technology be available for use in the health care system?
•The premise:
–Health economics and HTA researchers devote a disproportionate amount of their time and energy to technology adoption questions.
(NIHR HTA Programme)

4. 4
Technology as a cost driver
•Technological change
–One of the largest contributors to cost growth
–And so efforts to address cost growth cannot ignore technology
•Health technology assessment (HTA)
–Both Canada and the UK have long (and glorious) HTA traditions
•But… the HTA ‘industry’ has…
–become obsessed by technology adoption questions
–largely ignored technology management issues

5. 5
Technology management

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Further support for technology management focus
•An additional driver of cost growth
–Rapid increases in utilization of existing technology
•E.g., medical imaging examinations
–In 2010 in Canada, 1.4 million MRI examinations and 4.2 million CT examinations were performed, representing annual increases over recent years of 6.9% for MRI and 6.2% for CT
(CIHI, 2011)

7. 7
Published CEAs (BMJ, 2005-2012)
54 economic evaluation papers
47 with 'adoption' focus
29 (62%) advocated ‘adoption’
18 did not advocate ‘adoption’
7 with 'management' focus
5 focused on evaluation of a broad service
2 explored clinical practice variation

8. 8
Examples of service evaluations (n=5)
•Turner et al. (2011): Chlamydia Screening Program
–Explored alternative approaches to improving cost- effectiveness of existing program
–Conclusion: efficiency gains most likely through focus on partner notification
•Richardson et al. (2009): GI endoscopy and flexible sigmoidoscopy
–Analysis goal: efficiency gains in delivery of established technologies – physician or nurse delivered procedures?
–Findings: physician-delivered care both more effective and cost-effective

9. 9
Areas of concern
Primary concern: The ‘performance’ of health technologies in routine use
Technology management questions:
(a)Improvement: Can we get better value from existing technologies?
(b)Appropriateness: Do we see indication creep? Inappropriate use of technologies? [Choosing Wisely]
(c)Withdrawal questions: Are technologies nearing the end of their useful life?
Model validation questions: How good are our models? Are the predicted benefits and costs really delivered?

10. 10
Model validation…
“Computer models are no different from fashion models…
seductive, unreliable, easily corrupted and they lead sensible people to make fools of themselves.”
Jim Hacker, ‘Yes, Prime Minister’

11. 11
Technology management examples
•Knee arthroplasty:
–20% of patients ‘dissatisfied’, many with ongoing poor outcomes
•Asthma:
–we have highly effective low cost therapies that people don’t use
•Rheumatoid Arthritis:
–recent evidence suggests high cost biological treatment not superior to conventional therapy

12. 12
Addiction pathology?
•Why is so much of our analytic effort focussed on adoption decisions?
•Demand side: ‘He who pays the piper calls the tune’
–The dollars lie in adoption decision making
–Lack of demand for analysis to support technology management
•Supply side
–Revenue flows lead analysts actively to encourage the adoption focus

13. 13
Technology adoption
Technology management
Pathway management
Disease management
Health system management

14. 14
Broader framework for economic evaluation
•Conventional CEA is piecewise
–e.g., the cost-effectiveness of drug A for patients with disease X
•A broader pathway approach
–Explicit quantification of opportunity cost
–Simultaneous consideration of investments and disinvestments
–Analysis of technologies at different points in a clinical pathway, or even across different disease pathways

15. 15
Example: Enhanced MRI for prostate cancer
EMRS
Watch Wait
EMRS+WW
Baseline

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In conclusion
•We encourage the health economics/HTA community to move towards broader modelling approaches
–Rejection of the current, almost exclusive, emphasis on technology adoption
–Replace with a broader analytic frame to consider clinical pathways and whole diseases
–Use of modelling to help identify inefficiencies in current care pathways
•This broadening of the scope of decision models offers the possibility of fundamentally changing the nature of the contribution health economists and their HTA colleagues can make.