Strategies and Best Practice For Adoption of Medical Technology<br />Davy Cheng, MD MSc FRCPC FCAHS <br />Distinguished Un...
DISCLOSURES<br />Slide Title Goes Here<br /><ul><li>AFP Innovation Fund
AMOSO Opportunity Fund
Canadian Institute of Health Research (CIHR)
LHRI funds
MOHLTC OBAC (Vice-Chair)
Canadian Agency for Drugs & Technologies in Health (CADTH) (Committee member)
No Industries Conflict of Interests</li></li></ul><li>OBJECTIVES<br />Slide Title Goes Here<br />To discuss innovation, ro...
Medical Innovation in the  <br />Information Age<br />
What is ‘innovation’?<br />A new way of doing something or A way of doing something new?<br />Must it be substantially dif...
ENIAC Computer<br />The first mainframe computer in 1946 took up 1800 sq. ft. of floor space and weighed 30 tons! <br />
Moore’s Law<br />
8<br />Technology Momentum Reminders<br /><ul><li>"There is no reason anyone would want a computer in their home." (Ken Ol...
"Computers in the future may weigh no more than 1.5 tons." (Popular Mechanics, 1949)
"I think there is a world market for maybe five computers." (IBM's Thomas Watson, 1943)</li></li></ul><li>Ant holding a mi...
Scanning electron micrograph of the surface of a silicon microchip<br />
What is Nanoscale? <br />ww.mathworks.com<br />Fullerenes C60<br />www.physics.ucr.edu<br />22 cm<br />0.7 nm<br />12,756 ...
Nanotechnology Applications <br />Information Technology<br />Energy<br /><ul><li>More efficient and cost effective techno...
 Solar cells
 Fuel cells
 Batteries
 Bio fuels
Smaller, faster, more energy efficient and powerful computing and other IT-based systems</li></ul>Consumer Goods<br />Medi...
Advanced packaging materials, sensors, and lab-on-chips for food quality testing
Appliances and textiles
Stain proof, water proof and wrinkle free textiles
Household and cosmetics
 Self-cleaning and scratch free products, paints, and better cosmetics
Cancer treatment
Bone treatment
Drug delivery
Appetite control
Drug development
Medical tools
Diagnostic tests
Imaging</li></li></ul><li>
Accountability<br />A Brown, ADM; S FitzPatrick, ADM; T Huynh, Director<br />
Health Technology Assessment<br />Health Technology is broadly defined to include the drugs, devices, medical and surgical...
Health CanadaMedical Devices Program<br />the program monitors and evaluates the safety, efficacy and quality of diagnosti...
HTA Gate-Keeper: Hospitals / MDs? <br />Health Canada <br />(Drugs & Devices Licensed for Market)<br />Pre market<br />Pro...
OHTAC Decision-Making Model<br />
Alberta Health Services: Evaluation Criteria<br />
Multi-Criteria Decision Analysis (MCDA) – NICE, UK<br />Decide on the appropriate criteria<br />• Clinical effectiveness<b...
Strategies to improve organization in support of evidence-informed health policymaking<br />
Knowledge Translation<br />Gaps in KT and Decision Making<br />Research	Publication	Knowledge Translation         Patients...
Hospital HTA: Local decision-makers need to consider<br />• Local priority<br />• Local operations<br />• Local population...
Anesthesia & Perioperative Medicine, Surgery, Critical Care<br />
Hospital HTA: EPiCOR-HiTEC Know4Go<br />Create timely and contextualized evidence-based reviews for high-stakes intra-oper...
4Go<br />B:R<br />SLEEPERs<br />Opportunity Cost<br />Cost-<br />effectiveness<br />Evidence <br />Synthesis<br />Opportun...
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Dr. Davy Cheng

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Dr. Davy Cheng

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

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