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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

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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

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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, CADTHs Health Technology Expert Review Panel Member, CADTHs Economic Evaluation Guidelines Working Group Member, BCs Health Technology Assessment Committee Director, VCHs 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

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4 Technology adoption Technology management Pathway management Overview of talk

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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?

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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?

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9 GRAHAMS TALK

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10 Technology adoption Technology management Pathway management Overview of talk

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11 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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12 Chen et al, 2006

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13 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

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

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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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16 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

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17 Scholz & Mittendorf, 2014

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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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21 In conclusion Lets 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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22 MOHSENS TALK