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Dr. Davy Cheng

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  • 1. Strategies and Best Practice For Adoption of Medical Technology
    Davy Cheng, MD MSc FRCPC FCAHS
    Distinguished University Professor & Chair / Chief
    Department of Anesthesia & Perioperative MedicineEvidence-Based Perioperative Clinical Outcomes Research (EPiCOR)
    London Health Sciences Centre/St Joseph’s Health Care London
    University of Western Ontario
  • 2. DISCLOSURES
    Slide Title Goes Here
    • AFP Innovation Fund
    • 3. AMOSO Opportunity Fund
    • 4. Canadian Institute of Health Research (CIHR)
    • 5. LHRI funds
    • 6. MOHLTC OBAC (Vice-Chair)
    • 7. Canadian Agency for Drugs & Technologies in Health (CADTH) (Committee member)
    • 8. No Industries Conflict of Interests
  • OBJECTIVES
    Slide Title Goes Here
    To discuss innovation, role of HTA and KT
    To discuss the challenges of knowledge translation to best practice at MD-Patient level
    To discuss the Strategies to facilitate HTA adoption process within Health Institutions
  • 9. Medical Innovation in the
    Information Age
  • 10. What is ‘innovation’?
    A new way of doing something or A way of doing something new?
    Must it be substantially different to be innovative?
    Health Canada: “An innovation represents effective treatment, prevention or diagnosis of a disease or condition for which no drug (or medical device) is currently licensed in Canada.”
  • 11. ENIAC Computer
    The first mainframe computer in 1946 took up 1800 sq. ft. of floor space and weighed 30 tons!
  • 12. Moore’s Law
  • 13. 8
    Technology Momentum Reminders
    • "There is no reason anyone would want a computer in their home." (Ken Olsen, Digital Equipment Corp, 1977)
    • 14. "Computers in the future may weigh no more than 1.5 tons." (Popular Mechanics, 1949)
    • 15. "I think there is a world market for maybe five computers." (IBM's Thomas Watson, 1943)
  • Ant holding a microchip in serrated mandibles
  • 16. Scanning electron micrograph of the surface of a silicon microchip
  • 17. What is Nanoscale?
    ww.mathworks.com
    Fullerenes C60
    www.physics.ucr.edu
    22 cm
    0.7 nm
    12,756 Km
    1.27 × 107 m
    0.7 × 10-9 m
    0.22 m
    1 billion times smaller
    10 million times smaller
  • 18. Nanotechnology Applications
    Information Technology
    Energy
    • More efficient and cost effective technologies for energy production
    • 19. Solar cells
    • 20. Fuel cells
    • 21. Batteries
    • 22. Bio fuels
    • 23. Smaller, faster, more energy efficient and powerful computing and other IT-based systems
    Consumer Goods
    Medicine
    • Foods and beverages
    • 24. Advanced packaging materials, sensors, and lab-on-chips for food quality testing
    • 25. Appliances and textiles
    • 26. Stain proof, water proof and wrinkle free textiles
    • 27. Household and cosmetics
    • 28. Self-cleaning and scratch free products, paints, and better cosmetics
    • 29. Cancer treatment
    • 30. Bone treatment
    • 31. Drug delivery
    • 32. Appetite control
    • 33. Drug development
    • 34. Medical tools
    • 35. Diagnostic tests
    • 36. Imaging
  • 37. Accountability
    A Brown, ADM; S FitzPatrick, ADM; T Huynh, Director
  • 38. Health Technology Assessment
    Health Technology is broadly defined to include the drugs, devices, medical and surgical procedures, as well as measures for prevention and rehabilitation of disease, and the organisational and support systems in which health care is provided.
    HTA seeks to inform health policy makers by using best scientific evidence on the medical, social, economical and ethical implications of investments in Health Care.
  • 39. Health CanadaMedical Devices Program
    the program monitors and evaluates the safety, efficacy and quality of diagnostic and therapeutic medical devices so that consumers and health care professionals can use them with confidence.
  • 40. HTA Gate-Keeper: Hospitals / MDs?
    Health Canada
    (Drugs & Devices Licensed for Market)
    Pre market
    Procedures
    Drugs
    Devices & Machines
    Postmarket
    Canadian HTA Agency (CADTH)
    Advice on New Drugs from CEDAC (non-binding)
    Ontario MOH
    Drug Committee
    (CED)
    Drug reimbursement policy
    for pts >65y or on social
    assistance (non-hospital)
    Ontario MOH
    HTA Committee
    (OHTAC)
    Advice on non-drug
    technologies
    (non-binding)
    Ontario Hospitals
    (ad hoc decision-making)
    *evidence exists, but
    few decisions are made
    in full light of the evidence*
    Consumers
  • 41. OHTAC Decision-Making Model
  • 42.
  • 43. Alberta Health Services: Evaluation Criteria
  • 44. Multi-Criteria Decision Analysis (MCDA) – NICE, UK
    Decide on the appropriate criteria
    • Clinical effectiveness
    • Cost-effectiveness
    • Acceptability/Preferences
    • Terminality
    • Orphan drug
    • Other equity considerations
    • DH / Ministry priorities
    • HS Feasibility
    • Innovativeness
    • Wider societal considerations
    Weight the criteria
    Use evidence (and judgement) to rate the criteria
    Score the interventions being compared
  • 45.
  • 46. Strategies to improve organization in support of evidence-informed health policymaking
  • 47. Knowledge Translation
    Gaps in KT and Decision Making
    Research Publication Knowledge Translation Patients
    - Guidelines, Consensus Statements
    -Technology, Technique, Monitor, Tests
  • 48. Hospital HTA: Local decision-makers need to consider
    • Local priority
    • Local operations
    • Local population health needs
    • Local alternatives
    • Local presence of trained personnel
    • Local infrastructures & resources
    • Local budget impact……..
    • As well as HTAs by HTA agencies
  • 49. Anesthesia & Perioperative Medicine, Surgery, Critical Care
  • 50. Hospital HTA: EPiCOR-HiTEC Know4Go
    Create timely and contextualized evidence-based reviews for high-stakes intra-operative and perioperative therapies
    Translate evidence to definitive decisions using the Know4Go Framework
    Develop and Implement policy with supporting tools, and build institution-wide capacity for Know4go-informed decision-making
    Evaluate the impact to Quality and Costs
    Slide Title Goes Here
  • 51. 4Go
    B:R
    SLEEPERs
    Opportunity Cost
    Cost-
    effectiveness
    Evidence
    Synthesis
    Opportunity Cost
    SLEEPERs
    Know4Go
  • 52. SLEEPERs Assessment:Rate the Importance of Each of the Domains for this Decision
  • 53. EPiCOR-HTA
    Research & Teaching
  • 54. Evidence-Based Medicine
    • Questioning
    • 55. Skills in EBM
    • 56. Evidence Resources
    • 57. Time (substitution)
    Patient Choice
    Unsound
    Research
    (5)
    (1)
    Aware Accepted Applicable Able Acted on Agreed Adhered to
    Sound
    Research
    (3)
    Systems
    (bottomline +/- ref)
    Synopses
    (user summary of research)
    Systematic Reviews and CATs
    (search; appraise; synthesis)
    Quality Improvement
    (4)
    (2)
    Paul Glasziou, Oxford
  • 61. Resisting EBM: How Do Some Docs Think?
  • 62. BART Trial
    POISE Trial
  • 63. Techno Hype Cycle
  • 64. Microwave Ablation Catheter
  • 65. Microwave : Early Clinical Reports
    No dose-response curves on living tissue were available!!
  • 66.
  • 67.
    • 11% of ACC/AHA recommendations are based on Level A evidence (RCTs)
    • 68. 48% are based on Level C (opinion)
    “These findings highlight the need to expand the evidence base from which clinical practice guidelines are derived”
    Tricoci et al. JAMA 2009;302:142-9.
  • 69.
  • 70. Why MD not follow clinical practice guideline?
  • 71. Additional Barrier in HTA Uptake
  • 72. Too Early or Too Late Adopters?
    Drug, Technology, Technique – Context!
  • 73. Medial Device or Surgical Innovation
    Surgical innovation - the stakes are high.
    Surgical research and innovation is more personal and intimate. It is not just the failure of a drug, a new device, it is always possibly the failure of the operator.
    unique conflict of interest: surgeons determine both who needs surgery and performs the operation once that decision is made.
    Development process and Learning curve – as innovator and early adopters
  • 74. How Do We Introduce Innovation In This New Era?
    Define innovation and openly address the efficacy and safety.
    Set up innovation task force or formal departmental or institutional organization to assist the innovators.
    Precautionary principle.
    Perform well-designed feasibility trials.
    Informed consent.
  • 75. Managing the Learning Curve
    Review the disease process.
    Review results with alternative procedures.
    Adequately train prior to initiating a clinical program with didactic course work, video review, and case observation, when possible.
    Carefully monitor and review morbidity and mortality.
    Case-by-case analysis
    CUSUM curves
  • 76. Rogers, et al
    J ThoracCardiovascSurg 2004;128:811-819
  • 77. Clinical Simulation Training Center
    Innovation
    HTA Assessment
    Training
    KT Cycle
  • 78. When is a procedure ready to disseminate to the wider medical community?
    Postpone widespread adoption until scientific evidence of efficacy and safety is available.
    Assurance that the innovator has defined his own learning curve (simulation)
    Proper HTA
    Develop training programs and competency guidelines for new procedures
  • 79. KT Determinants (macro-meso-micro level)
    • Decision makers: knowledge management skill
    • 80. Health care system: financial incentive
    • 81. Health care organization: infrastructure
    • 82. Health care team: champion
    • 83. Health care professionals: knowledge, attitudes, behavior, skill
    • 84. Patient: compliance
  • HTA & KNOWLEDGE TRANSLATION
    • Local Contextualization is important – HTA unit – Transparent process
    • 85. Institutional collaboration and incentive allignment
    • 86. In Technology e.g. OPCAB surgery, difficulty in uptake despite positive evidence in risk-benefits-cost ratios – learning curve, technical skill
    • 87. Technical Skill versus Cognitive Skill – training, learning curve, equipment)
    • 88. MD champion (clinical leaders and administration – collaborative partnership)
    Slide Title Goes Here