Equity Issues in HTA:Finding a Way to be Systematic…ish

Presentation by Kristen Moulton

May 6, 2013

Outline

• Why ethical considerations?

• Why equity?

• What do we need?

• What is out there?

• Can we make it work for us?

• Application of the framework

• Next Steps

Why are ethical issues important in HTA?

• Health technologies are value laden

• HTA is a tool for informing decision making

• Policy decisions go beyond clinical and

cost-effectiveness

• Putting evidence into context makes it

easier to use

Why Equity?

• “Ethical Issues” is a large domain to tackle

• Despite the absence of a consensus of

scope or definition of equity – it is still an

important element or factor of ethical

considerations

Ethical & equity issues important, but rarely

addressed

• 2009 Survey of HTA in Canada: HTA reports

rarely explicitly addressed ethical issues

(DeJean et al.)

• 2011

• Gender sensitive approach rarely taken

(Panteli et al.)

• Not much concrete guidance as to how

to incorporate issues (Duthie& Bond)

What do we need?

• Tool to help systematically identify, address

equity issues

• Must be useable by HTA producers

• Incorporate values of Canada Health Act,

Public Health Agency of Canada social

determinants of health

• Ultimate goal: minimize risk of overlooking

an equity consideration

What is out there?

• Not quite enough?

What is out there?

• Not quite enough?

What is out there?

• Too much?

What is out there?

• Too much?

What is out there?

• Is it right?

Can we make it work for us?

• Some of the domains:

• Equality vs. Equity

• Embedded Inequities

• Implicit Stereotyping

Applying the framework

Surgical Robotics

• 9 of 13 domains seemed applicable

• CADTH report addressed 1 domain

• Health Information and Quality report

addressed 6

Next Steps

• Framework is not perfect

• Positive elements: a good base

• Negative elements: not user-friendly…yet

Next Steps

• Is it “the one”

Help Wanted

• Tweet me one equity consideration you

think is important to address:

@kristen_moulton

#CADTHSymp

• kristenm@cadth.ca

Questions?

References

• Hofmann B. Why ethics should be a part of health technology assessment. Int J

Technol Assess Health Care. 2008 Fall;24(4):423-9.

• DeJean D, Giacomini M, Schwarz L, Miller F. Ethics in Canadian health

technology assessment: A descriptive review. Int J Technol Assess Health Care.

2009 Oct;25(4):463-9.

• Panteli D, Zentner A, Storz-Pfennig P, Busse R. Gender in health technology

assessmen: Pilot study on agency approaches. Int J Technol Assess Health

Care. 2011. Jul;27(3):224-9.

• Duthie K, Bond K. Improving ethics analysis in health technology assessment. Int

J Technol Assess Health Care. 2011 Jan;27(1):64-70.

• Hofmann B. Toward a procedure for integrating moral issues in health technology

assessment. Int J Technol Assess Health Care. 2005 Summer;21(3):312-8.

• Daniels N, Sabin J. The ethics of accountability in managed health care reform.

Health Affairs. 1998 17 (5):50-64.

• Culyer A, Bombard Y. An Equity Framework for Health Technology Assessments.

Medical Decision Making. 2012 May-June: 428-441

A4R

Hofmann Checklist

Elements of Culyer& Bombard Framework

• Equity vs. Equality

• Domains of equity

• Legal obligations

• Embedded Inequity

• Institutional Bias

• Implicit Stereotyping

• Contexts, Behaviours, & Circumstances

• Processes in HTA

• Hidden opportunity costs

• Processes in delivery of care

• Special Claims

• Cumulative bias

Cochrane Equity Checklist – suggests

ensuring an equity lens in all steps

1. Develop a logic model

2. Define disadvantage and for whom the intervention is

intended

3. Decide on important study designs

4. Identify important outcomes

5. Evaluate processes and understand context

6. Analyze and present the data

7. Discuss applicability of findings