Comparative Effectiveness in Orthopaedics: Stakeholder Perspectives

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Comparative Effectiveness in Orthopaedics
Stakeholder Perspectives

• Kevin J. Bozic, MD, MBA
• Associate Professor and Vice Chair
• UCSF Department of Orthopaedic Surgery and Philip
  R. Lee Institute for Health Policy Studies

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Disclosures/Conflicts of Interest

• External Advisory Role
• AAOS (HCSC, GTOC)
• AAHKS (Education, Health Policy, EBPC)
• COA (Executive Committee)
• CMS (MedCAC)
• UCSF Medical Center (HTAP)
• United Health Care, BCBSA, Integrated Healthcare
  Association, Pacific Business Group on Health
• Research Support
• OREF, AHRQ, NIH

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Objectives

1. To identify considerations in the decision making
   process for the adoption of new technologies in
   orthopaedics
2. To understand the strengths and limitations of
   comparative effectiveness research
3. To develop an algorithm for evaluating and
   adopting new technologies in an orthopaedic
   practice

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Technology in Orthopaedics
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What Factors Influence Patient Outcomes?
Surgeon Factors
Patient Factors
Hospital Factors
Implant Factors
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Benefits of Technology
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Technology Unintended consequences
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Technology Cost Implications

• The general consensus among health economists
  is that growth in real health care spending over
  the past 4 decades was principally the result of
  the emergence of new medical technologies and
  their adoption and widespread diffusion by the
  U.S. health care system.
• -CBO Report, Technological Change and the Growth
  of Health Care Spending, Feb, 2008

• however, the benefit of many of these new
  technologies has not yet been rigorously
  demonstrated.

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Comparative Effectiveness Value
Value?
Cost
??
1.5-2X
2-3X
??
4-6X
??
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Evaluating Technologies Perspective

• Surgeons
• Evidence standard
• Adequacy of evidence
• Magnitude of benefit
• Relationships with industry
• Peers
• Hospitals/payers
• Short-term cost-containment
• Patients
• Internet, friends, family
• DTCA
• Policymakers
• Comparative Effectiveness

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Clinician Perspective

• Level of Evidence (I-V)
• Efficacy
• The extent to which medical interventions achieve
  health improvements under ideal circumstances
• Effectiveness
• The extent to which medical interventions achieve
  health improvements in real practice settings

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Effectiveness Registry Data
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Effectiveness Registry Data
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Hospital Perspective
1990s
2000s
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UCSF Healthcare Technology Assessment Program
(HTAP)

• HTA is the bridge between the world of research
  and the world of clinical decision making
• Alan Garber, Health Affairs, 2004

• Considerations
• Patient population
• Surgeon experience
• Relationships with vendor, hospital
• Price
• Service
• Programmatic needs

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Patient Perspective DTCA
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DTCA Policy Implications
DTCA



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Policy Maker Perspective Comparative
Effectiveness?
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Comparative Effectiveness Research

• As applied in the health care sector, an
  analysis of comparative effectiveness is simply a
  rigorous evaluation of the impact of different
  options that are available for treating a given
  medical condition for a particular set of
  patients.
• Congressional Budget Office, 2007
• See http//www.cbo.gov/ftpdocs/88xx/doc8891/12-18
  -ComparativeEffectiveness.pdf

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Evolutionary or Revolutionary?
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Trends in Orthopaedic Implant Costs in the U.S.
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Overshooting the Needs of our Patients

• The functionality of todays healthcare
  technologies, although impressive, often
  outstrips the ability of consumers to absorb it

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Impact of Technology on Surgeon Value

• Take hip replacement surgery for example. Here
  much of the cost and skill, as it were, have
  moved from the surgeon to the device.

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Considerations in Technology Decisions

• Is there a clinical need?
• Patient population
• Results with existing technology
• Use data whenever possible
• Factors influencing decision
• Device company
• Peers
• Hospital
• Patients
• Impact on
• Patient outcomes
• Hospital margins
• O.R. Efficiency

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My Algorithm

• Versatility of product line
• Service
• Price
• Benefits vs. Risks of switching

Price
Impact on efficiency
Potential improvement in clinical outcomes
Uncertainty in patient outcomes
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Summary

• Explosion of new technologies in orthopaedics
• Consumerism
• Increased scrutiny, transparency regarding costs,
  clinical effectiveness
• Questions
• Comparative effectiveness
• Clinical effectiveness vs. gold-standard?
• Cost-effectiveness?
• Impact on clinical, shared decision making

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Newer Is Not Always Better

• Novelty cannot necessarily be equated with
  benefit, and an intervention or devices value
  resides not in its newness but rather in its
  ability to improve patient outcomes, reduce
  morbidity, and/or reduce the overall cost of
  care.
• Emanuel EJ, Fuchs VR, Garber AM. Essential
  elements of a technology and outcomes assessment
  initiative. JAMA. Sep 19 2007298(11)1323-1325.

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Thank You!!!