This document summarizes a presentation on using clinical pathway management and modeling to improve the efficiency, consistency, fairness and impact of health technology assessment. It discusses using pathway modeling as the foundation for HTA activities to quantify the resource commitment to a clinical area and explicitly consider opportunity costs when evaluating proposed changes to clinical pathways. Pathway modeling is presented as a collaborative effort between clinicians, policymakers, patients and analysts to define a reference pathway model that establishes resource constraints and evaluates proposals in a transparent manner. An example is given of using pathway modeling to re-evaluate the use of anti-TNF biological treatment versus conventional therapy for rheumatoid arthritis based on new evidence.

1. In Search of Efficiency, Consistency, Fairness,
and Impact in HTA: The Case for Clinical
Pathway Management and Modelling
Stirling Bryan, PhD
Graham Scotland, PhD
Mohsen Sadatsafavi, PhD

2. 2
Overview of session
• Stirling Bryan:
– In Search of Efficiency, Consistency, Fairness, and
Impact in HTA
• Graham Scotland
– Modelling screening and treatment pathways for
diabetic retinopathy
• Mohsen Sadatsafavi
– The case for whole disease modelling in COPD

3. 3
Disclosures and Acknowledgements
• I am not aware of any actual or potential conflicts of
interest in relation to this presentation.
• Some of my relevant current activities:
– Chair, CADTH’s Health Technology Expert Review Panel
– Member, CADTH’s Economic Evaluation Guidelines Working
Group
– Member, BC’s Health Technology Assessment Committee
– Director, VCH’s Centre for Clinical Epidemiology & Evaluation
• Collaborators on this topic
– Graham Scotland, University of Aberdeen; Mohsen Sadatsafavi,
UBC; Craig Mitton, UBC; Cam Donaldson, Glasgow Caledonian
University; Laurie Goldsmith, SFU; Rick Sawatzky, TWU
– And many, many more…

4. 4
Technology adoption
Technology management
Pathway management
Overview of talk

5. 5

6. 6
Technology management questions
• Assessment:
– Does the technology, as currently used, deliver value?
• Improvement:
– Can more cost-effective utilization of the technology
be achieved through modification of the clinical
protocol?
• Withdrawal:
– Should the technology no longer be in routine use
and, hence, a process of withdrawal commenced?

7. 7

8. 8
Technology management questions
• Assessment:
– Does the technology, as currently used, deliver value?
• Improvement:
– Can more cost-effective utilization of the technology
be achieved through modification of the clinical
protocol?
• Withdrawal:
– Should the technology no longer be in routine use
and, hence, a process of withdrawal commenced?

9. 9
GRAHAM’S TALK

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Technology adoption
Technology management
Pathway management
Overview of talk

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Pathway management
• Clinical pathway:
defined sequence(s) of
use of alternative
health technologies
• Pathway modelling
becomes the
foundation of HTA
activity Barton et al, 2004

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Chen et al, 2006

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Pathway management and ‘resource
stewardship’
• ‘Resource stewardship’
– A culture where resource scarcity is openly acknowledged and
recognized as a shared responsibility
• Pathway model development is a collaborative effort
– Active engagement of, and ownership by, key stakeholders, including
clinical leaders, policy makers, patients and analysts
• The reference pathway model defines the resource envelope
– Constraints on pathway reconfiguration are transparent
• Proposed changes to the clinical pathway evaluated using the
reference model
– Opportunity cost considered explicitly

14. 14
Stewardship facilitated through pathway
modelling
Clinical leaders
and care teams
HTA analysts
Policy makers and managers
Patients and carers
Industry

15. 15
Pathway management and ‘resource
stewardship’
• ‘Resource stewardship’
– A culture where resource scarcity is openly acknowledged and
recognized as a shared responsibility
• Pathway model development must be a collaborative effort
– Active engagement of, and ownership by, key stakeholders, including
clinical leaders, policy makers, patients and analysts
• The reference pathway model defines the resource envelope
– Constraints on pathway reconfiguration are transparent
• Proposed changes to the clinical pathway evaluated using the
reference model
– Opportunity cost considered explicitly

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Pathway management example
In RA, recent evidence
suggests anti-TNF,
biological treatment
(infliximab) not superior
to conventional
combination therapy
(MTX, SSZ, HCQ)
Barton et al, 2004
Eriksson et al, 2013

17. 17Scholz & Mittendorf, 2014

18. 18
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’

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In conclusion
• Let’s break our addiction to technology adoption
• Pathway modelling as a centrepiece of HTA work supports
development of a stronger ‘resource stewardship’ culture
• The mechanism:
– Quantification of resource commitment to a given clinical area
– Explicit consideration 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

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MOHSEN’S TALK