Presented by: Dr' Jill M' Sanders

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Evolving HTA in North AmericaInforming Health
System Decisions

• Presented by Dr. Jill M. Sanders
• President and CEO
• May 19, 2008

Scottish Health Technologies Meetings - Edinburgh
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Presentation Outline

• Healthcare Trends in Canada
• CADTHs evolution and programs
• HTA Addressing the Ongoing Challenges
• Thoughts about the Future

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Canadas Health Care System

• Federal government, 10 provinces, 3 territories
• Each Territory and Province is responsible for
  health care delivery
• Each makes independent decisions regarding
  coverage policies
• The federal government is responsible for the
  regulation of health technologies
• Universal public coverage for hospital and
  physician services, out-patient drugs not covered

• 33 million people
• Area 10 million km2, vast areas remote and
  challenging terrain
• Population density ranges 0.01 to 23 people/km2,
  average 3.3 UK is 245 Scotland is 64

• Provincial drug plans cover 30
• 40-50 of Canadians have drug coverage through
  work-based private insurance plans

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Canadian Health Expenditure Trends
Source CIHI
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Principal Stakeholders in Health Technology
Management
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Impact on Decision Makers

• High Priority
• Drugs and health technologies are major drivers
  of health care costs
• Constant Change
• More than 22,000 drugs in Canada an estimated
  68,000 devices 2000-4000 license applications
  per year for devices
• Information overload
• Over 2 million articles a year to stay informed

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What Drives the Need?

• Concerns about appropriate care
• Uncertainty regarding clinical benefit
• Quality problem overuse, underuse, misuse
• Affordability/sustainability issues
• Uncertainty regarding cost-effectiveness
• Practice or policy variation

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What Do Decision Makers Need?

• Independent, rigorously derived evidence based
  information
• Relevance answering the real policy questions
• Timeliness
• Messaging concise, understandable
• Context around decisions social, legal,
  ethical, political, patient, public
• Support to interpret and apply the information

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About CADTH

• Founded in 1989, by the Canadian federal,
  provincial, and territorial (F/P/T) Deputy
  Ministers of Health
• Not part of government
• Private, not-for-profit organization
• Funded by Health Canada, the provinces and
  territories
• Independent annual audit
• Frequent independent evaluations results
  submitted to all members
• Head office in Ottawa
• Second office in Edmonton
• Liaison presence in provinces/territories

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CADTHs Broad Role

• CADTH has evolved from HTA to a broad service
  agency with programs that directly link to
  decision makers, facilitating optimum management
  of health technologies in Canada
• The areas addressed include
• managing technologies from cradle to grave
• advice and recommendations rather than only
  scientific conclusions
• appropriate utilisation of health technologies
  and drugs
• focus on policy questions
• the right information to the right people
• decision-maker support

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CADTHs Evolution
Total Annual Budget

• 1989 CCOHTA launched 500 thousand
• 1993 Drug assessments added 1.7 million
• 2000 HTA expanded 4.3 million
• 2002 Common Drug Review launched 6.3 million
• 2003 Increased HTA funding 16.3 million
• 2004 COMPUS launched 19.3 million
• 2006 CADTH created 21.3 million
• 2007 CDR Expansion 24.2 million

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CADTH Governance Committee Structure
F/P/T Conference ofDeputy Ministers of Health
F/P/T Conference ofDeputy Ministers of Health
Policy Forum
The Exchange
Jurisdictional
CADTH Board
Advisory Committee on Pharmaceuticals (ACP)
Non Jurisdictional
Canadian Expert Drug Advisory Committee (CEDAC)
COMPUS Advisory Committee (CAC)
CADTH
COMPUS Expert Review Committee (CERC)
Devices and Systems Advisory Committee (DSAC)
External Scientific Advisors
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CADTHs Three Core Programs

• HTA (Health Technology Assessment)
• CDR (Common Drug Review)
• COMPUS (Canadian Optimal Medication Prescribing
  and Utilization Service)

CADTH
CDR
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CADTH Programs
Specialised programs for stages of technology
lifespan and type of decision
Obsolescence Decisions
Optimal Utilisation
Adoption Decisions
Ongoing and Re-assessment
Innovation and RD

• HTA
• HTIS

• Horizon Scanning
• Early Assessment
• HTIS

• HTA
• HTIS
• CDR (Drugs)

• HTA
• COMPUS

• HTA
• HTIS
• CDR
• COMPUS

Liaison Program and Knowledge Transfer
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CADTH Programs
HTA
Assessment
Advice
Tools
CDR
COMPUS
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Health Technology Assessment

• Health technologies include drugs, medical
  devices, surgical procedures, and health care
  systems
• Resources are approximately 50 to drug and 50
  to non-drug areas
• Reports are prepared using 65 internal and 35
  external resources
• Full HTAs 4-9 months
• Rapid Reviews 4 months

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Different Assessment Needs

• Rapid Assessments
• Typically reacting to a decision problem
• Partial, dimensions of analysis must be
  identified
• Summaries, limited need for synthesis
• Decision will be made, with or without evidence
• Traditional Assessments
• Anticipating a future decision problem
• Comprehensive, (social, ethical, clinical,
  economic)
• Involves environmental scanning activities
• Decision can await (to some extent) evidence

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Health Technology Assessment

• HTA Health Technology Inquiry Service (HTIS)
• Provides quick access to health technology
  information based on the best available evidence
• Responses provided within 24 hours and up to 30
  business days depending on urgency of request and
  type of request
• 20-30 per month
• 60 non-drug topics and 40 drug topics
• Restricted to health ministries and regional
  health authorities due to capacity of program
• Demand increasing more information, more types
  of users
• Hope to extend service to hospitals next year

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CADTH HTA Products
Assessment
Economic assessment/modeling/ budget impact
assessment
Expert consultation involvement
Expert guidance on research methodology
Surveys
RIGOUR
Rapid Assessment
Peer review
Literature search - comprehensive
Critical appraisal
Expert consultation
Literature search - selective
TIME
Literature search - limited
Days
Months
9 Months
Weeks
4 Months

• Rigorous, impartial, evidence-based approach
• Carefully examine existing evidence to reduce
  duplication and maximize use of limited resources
  and expertise

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Health Technology Assessment Reports

• 301 Reports and Overviews were produced in
  2007-08 in response to decision-maker requests
• 26 Partial and Comprehensive Peer-Reviewed
  Assessments
• 11 Overviews
• 264 Literature Searches and Summaries
• Examples of Comprehensive Assessments
• Reprocessing Single Use Medical Devices in Canada
  Feb 2008
• Liquid-based Techniques for Cervical Cancer
  Screening Feb 08
• Erythropoiesis-Stimulating Agents for Anemia of
  Chronic Kidney Disease Systematic Review and
  Economic Evaluation Mar 08
• HTA on-line Searchable Database

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HTA Then and Now

• THEN
• Academic endeavour not well linked to decision
  makers
• Quantitative evidence only
• Only full assessments delivered in 12-18 months
  (and longer in some cases)
• Limited range of products
• Some economic assessments

• NOW
• Evidence based but with qualitative aspects e.g.
  societal values, impact, etc.
• Many HTA types rapid to full tailored to meet
  user needs
• Full HTAs delivered in 4-12 months
• Rapid Response (HTIS) in a days to weeks
• Economic evaluations in all assessments

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HTA Then and Now cont.

• NOW
• Policy maker HTA gap bridged
• Real needs of policy and decision makers are
  addressed
• Recommendations and advice
• Expanded dissemination and knowledge transfer
• Decision makers wait upon HTA reports before
  making decision

• THEN
• Decision makers saw role for HTA in decision
  making but were separate from process
• Gap existed between the information needs of
  policy makers and what HTA reports provided
• Scientific conclusions only
• Relied on passive uptake by users
• Uptake of findings poor

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CADTHs Common Drug Review (CDR)

• A single process for Canada -
• replaced 18 separate jurisdictional processes
• providing formulary listing recommendations to
  the publicly funded drug plans in Canada (except
  Quebec)
• Formulary decisions are made by the drug plans
• based on CDR recommendation, and plan mandates,
  priorities, resources
• Objectives
• Reduce duplication, maximize use of limited
  resources and expertise, provide equal access to
  evidence and advice

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Common Drug Review
CANADAS FEDERAL GOVERNMENT Approves new drugs
for sale in Canada
HEALTH CANADA RESPONSIBILITY
Marketing Authorization
--------------------------------------------------
---------------
Submission clinical and economic evidence
MANUFACTURER RESPONSIBILITY
-----------------------------------------------
Clinical Reviewers
Pharmacoeconomic Reviewers
CADTH Reviews
CADTH RESPONSIBILITY
CEDAC Recommendation
-----------------------------------------------
Drug Plan Decision
Drug Plan Decision
Drug Plan Decision
GOVERNMENT RESPONSIBILITY
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CDR to Date

• Process complete in 5-6 months
• Incorporated 18 processes into one
• 90 agreement between CEDAC recommendations and
  drug plan decisions
• High quality systematic reviews of published and
  unpublished trials critical appraisals of
  economic submissions
• Publicly available reasons for recommendations
• Stakeholder consultations, including formal
  evaluation of CDR
• Addition of public members to CEDAC
• Ongoing process improvements

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Canadian Optimal Medication Prescribing and
Utilization Service (COMPUS)

• Identifies optimal therapies in drug prescribing
  and use
• Promotes their use to policy makers, educators,
  health care providers and consumers
• First pan-Canadian F/P/T initiative established
  to support optimal drug therapy amongst these
  stakeholders
• One of only a handful of programs of this nature
  in the world

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COMPUS mandate
Provide strategies and tools
Identify evidence- based optimal therapy
Improved prescribing and use

Implementation

• Evidence- based reviews
• Recommendations

• Interventions
• Tools
• Rx for Change

COMPUS
Decision Makers
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COMPUS Provides
Scientists, researchers, experts
Policy makers, administrators, managers
Practitioners, physicians, prescribers
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COMPUS

• Topics identified by the government stakeholder
  committee
• First topic Proton Pump Inhibitors (PPIs)
• 2004 PPI Expenditures in Canada 1.1 billion- 91
  increase since 2000
• Large deviations from optimal use
  (over/under-use)
• Potential to effect change
• Impact on health outcomes cost-effectiveness
• PPI deliverables and user tools available and
  uptake underway
• 2 Provinces have changed drug plan status for
  PPIs, 4 more reviewing status
• Diabetes Management
• Insulin analogues draft recommendations posted
  shortly
• Blood glucose testing strips research underway

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Knowledge Transfer and Communications

• Bridge the gap between research and healthcare
  decisions
• Increase health care systems capacity to access,
  understand and use research
• User education to facilitate uptake of advice
• Support dissemination and uptake of HTA work
• Messaging of reports
• Tools to support uptake and application
• Feedback on utility and impact of HTA

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Liaison Officers

• Liaison Officers - on the ground in each
  jurisdiction
• CADTH employee in each province hired locally,
  works locally
• Strengthen linkages between CADTH and users and
  stakeholders
• Ensure stakeholders needs are known, topic
  requests are accurate re policy decision needs,
  feedback
• delivering information to stakeholders
• helping users with uptake and utilization of
  advice

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Decision Making Challenges

• Sometimes limited evidence
• Evidence changes over time
• Shortage of real world evidence
• Access to appropriate experts
• Political factors
• Industry, patient, advocacy group pressure
• Competing demands
• Local context

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Need for Pan-Canadian Coordination

• Provincial and territorial governments each have
  constitutional obligation and right to make
  independent decisions regarding health service
  delivery
• Canadian citizens expect equity across the
  country regarding the services they access
• Decisions made by an individual province can
  create citizen expectations in other
  jurisdictions
• Canada developed a national Health Technology
  Strategy to address this

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Policy Forum Collaboration on Policy

• Mechanism for policy makers from across Canada to
  meet and collaborate on adoption, management and
  replacement of health technologies
• Enables inter-jurisdictional collaboration
• Reduce whipsawing across jurisdictions
• Reduce surprises
• Fosters equity to patients across Canada

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Policy Forum Operations
Jurisdiction Information (e.g. practice patterns,
utilization, policy decisions)
Technology Information (e.g. horizon scanning)
HTA Reports (e.g. Exchange)
Expert Advice
Policy Options
Information Sharing
Common Policy Direction
Individual Jurisdictional Decision
Individual Jurisdictional Decision
Individual Jurisdictional Decision
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Impact of CADTH Independent Evaluation for
period 2003-07

• Evaluation concluded
• Significant expansion and change - 4.8 to 24
  million
• Established new programs and expanded existing
  ones
• Established new mechanisms to link health
  decision makers with the information they need
• Increased timeliness, relevance and quality
• Broader range of products and services which
  stakeholders report as meeting their needs
• Products are seen as a trusted, reliable source
  of evidence based information
• Increased uptake and utilization of products and
  services to inform policy decisions
• Users feel better equipped to utilise evidence
  based information in decision making

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Thoughts About the Future

• Demand for evidence-based advice will grow
• Further close the gap between the science and
  policy decisions
• policy analysis
• advice
• recommendations
• tools and services to support evidence use
• Increased inclusion of qualitative factors
• Patient expectations, willingness for risk etc
• Societal values
• Ethical, access and equity considerations
• Processes and methodologies to incorporate
  qualitative information without compromising
  evidence-based principles

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Thoughts About the Future (contd)

• Increased coordination between stages of
  technology lifespan - address boundary between
  HTA and pre-market regulation
• Increased cooperation on data production and
  availability - industry, regulators and policy
  makers work together to produce and share data
• Develop strategies to address uncertainty when
  the evidence is limited
• Decide how and when to discontinue use of
  technologies
• Ongoing or re-assessment using post-market data
• Increased cooperation and sharing across
  jurisdictions

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Thoughts About the Future (contd)

• Increased public involvement
• Public historically had limited input to health
  technology decisions
• Input from public important for debate on
• level of acceptable risk
• balancing expectations against resources
• prioritization of technologies vis-à-vis benefits
  to recipients
• Mechanisms are required to ensure
• public input
• incorporation of societal values into decision
  making
• public access to reliable information

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Conclusion

• Increasing complexity, costs and rate of
  technological change are fueling demand for
  improved Health System Management
• Technology will continue to make significant
  contributions to health but also presents
  decision making challenges
• Specialized programs with different products and
  services for different decision needs
• Direct links to stakeholders and policy makers
  are crucial
• Industry pressures and criticisms are ongoing
  issue
• Timeliness, rigour, and transparency key success
  factors

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www.cadth.ca