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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
DISCLOSURES Slide Title Goes Here ,[object Object]
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,[object Object]
Medical Innovation in the   Information Age
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.”
ENIAC Computer The first mainframe computer in 1946 took up 1800 sq. ft. of floor space and weighed 30 tons!
Moore’s Law
8 Technology Momentum Reminders ,[object Object]
"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),[object Object]
Scanning electron micrograph of the surface of a silicon microchip
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
Nanotechnology Applications  Information Technology Energy ,[object Object]
 Solar cells
 Fuel cells
 Batteries
 Bio fuels
Smaller, faster, more energy efficient and powerful computing and other IT-based systemsConsumer Goods Medicine ,[object Object]
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,[object Object]
Accountability A Brown, ADM; S FitzPatrick, ADM; T Huynh, Director
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.
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.
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
OHTAC Decision-Making Model
Alberta Health Services: Evaluation Criteria
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
Strategies to improve organization in support of evidence-informed health policymaking
Knowledge Translation Gaps in KT and Decision Making Research	Publication	Knowledge Translation         Patients  - Guidelines, Consensus Statements 		-Technology, Technique, Monitor, Tests
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
Anesthesia & Perioperative Medicine, Surgery, Critical Care
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
4Go B:R SLEEPERs Opportunity Cost Cost- effectiveness Evidence  Synthesis Opportunity Cost SLEEPERs Know4Go

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Dr. Davy Cheng

  • 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.
  • 4. Canadian Institute of Health Research (CIHR)
  • 7. Canadian Agency for Drugs & Technologies in Health (CADTH) (Committee member)
  • 8.
  • 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!
  • 13.
  • 14. "Computers in the future may weigh no more than 1.5 tons." (Popular Mechanics, 1949)
  • 15.
  • 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.
  • 23.
  • 24. Advanced packaging materials, sensors, and lab-on-chips for food quality testing
  • 26. Stain proof, water proof and wrinkle free textiles
  • 28. Self-cleaning and scratch free products, paints, and better cosmetics
  • 36.
  • 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
  • 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
  • 54.
  • 57.
  • 59.
  • 60. Systems(4) (2) Paul Glasziou, Oxford
  • 61. Resisting EBM: How Do Some Docs Think?
  • 65. Microwave : Early Clinical Reports No dose-response curves on living tissue were available!!
  • 66.
  • 67.
  • 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.
  • 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.
  • 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