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EVIDENCE-BASED TECHNOLOGY ASSESSMENT

The health technology assessment something gaining momentum in hospitals as a way to improve patient care can be a challenge to implement. How should this be done and what should a physician's role be? Welcome to ReachMD, The Channel for Medical Professionals. I am Bruce Japsen, the healthcare reporter with The Chicago Tribune and with me today is Dr. Winifred Hayes. She is the founder and chief executive officer of the Hayes Group. Hayes Inc. is a Health Technology Research and Consulting Firm based on the Philadelphia suburb of Lansdale, Pennsylvania. Ms. Hayes has her doctor of philosophy degree from the Johns Hopkins University School of Hygiene and Public Health, and is also a graduate of the University of Maryland School of Nursing, with Primary Care Nurse Practitioner and Master of Science degrees. Under her leadership, Hayes Inc. has become a leader in evidence-based reports to health plans, hospitals, managed care companies, government agencies, and healthcare system.

BRUCE JAPSEN:

Dr. Winifred Hayes, welcome to ReachMD XM-157, The Channel for Medical Professionals.

DR. WINIFRED HAYES:

Thank you, it's a pleasure to be here.

BRUCE JAPSEN:

So, tell us a little bit about this phenomenon of evidence-based technology assessment and how a hospital or a provider can get involved.

DR. WINIFRED HAYES:

Well, the phenomenon is being driven in part by runaway cost and healthcare and ongoing concerns about the quality and safety of the healthcare we provide the American consumer and this is not just a US problem, it's a worldwide problem, but I think in the US, we are at a crisis point. There is a growing recognition by physicians and others that the old way of making decisions about the appropriate in reduction, dissemination, and utilization of health technologies is not working very well and let me take a minute to make sure we are on listening page. Our Health technology is any kind of intervention for diagnostic or screening procedure that we provide to patients in the context of preventing disease or treating disease or providing some kind of clinical support. So, it could be a drug, it could be a diagnostic study, it could be a piece of imaging equipment, it could be a surgical device, it could be an orthopedic implant, it's really anything that we use in providing healthcare and so there's this recognition that the current system is not working very well and we have major problems in overuse, underuse, misuse of health technologies and waste in our system and at the same time, we have got big problems in terms of patient safety. So, hospitals and physicians increasingly recognize that evidence should be the grounding for the decisions that we make and we are beginning to recognize that a reliance on expert opinion on thought leaders, on marketing information can mislead us in terms of the direction we take. So, that's kind of the background and I think most of your audience understands that our cost for healthcare at nearly 17% of gross national product and other indices that we measure healthcare effectiveness like life expectancy and infant mortality are not where they should be as compared to the rest of the world. So, we have got a lot of work to do. So, that's kind in the background. So, how does it fit into hospitals? Well, as hospitals make difficult decisions around what kind of new technology needs to be introduced into their setting and doctors are certainly part of that decision-making process, and as we look at what kind of equipment we should replace, the old way of relying on some evidence, some marketing information, some opinion is slowly being replaced with more of robust evaluation of evidence and an insistence that there should be some scientific proof that really supports the clinical benefit and the cost benefit of this item.

BRUCE JAPSEN:

So, when you get into a hospital though, one of the things that comes to mind and I am sure you ran into this as this is the political nature. You know, you could have a doctor, who is a big hitter, who wants to do a brand new thing and they go out and they recruit this gentleman. He comes in because of the procedure that he can do on this new machine and brings in revenue, but you find yourself on a committee saying "wait a minute, the evidence just does not show this works." Could you tell us what the committee does and how they deal with situation?

DR. WINIFRED HAYES:

Sure and I think you have characterized it very accurately. It's a very complex environment. So, to have a Health Technology Assessment Committee to be successful, there is a basic requirement upfront and that is that the executive team, the leadership team, the board of directors, the trustees need to be behind the incorporation of evidence and the decision-making. They need to see this as fundamentally part of how that hospital is going to operate. They need to buy into it. With that as a grounding, then the formation of a health technology assessment team can occur and its makeup needs to include physician leadership within that organization. Physicians to have buy-in need to basically buy into the process that's going to be used and feel that they are going to have a voice in the analysis of the data that will drive the decisions about the purchase and use of new health technologies for that institution. There are other people that also need to serve on that committee, other members of that committee, representation from the finance office, representation that's speaking about risk-management issues, safety issues at <_____> (5:33). Those are 2 important components that need to be represented on that committee. Often times, it's useful to have somebody from bioengineering on that committee as well because they have got to maintain that equipment and certainly somebody from the, what we call the supply chain or the purchasing side of the institution needs to be involved. So, the committee is kind of a cross-section within the hospital and it needs to have an ability to evaluate and interpret evidence that is used to help both inform future decisions around technology as well as more immediate decisions around the purchase of health technology and one of the battles they are gonna have to fight is over the other drivers that operate in that hospital, drivers like physician requesting preferences, drivers like their marketing physician and competition in their area and drivers like the strong marketing presence of device manufacturers and pharmaceutical company.

BRUCE JAPSEN

If you are just joining us or even if you are new to our channel, you are listening to the Clinician’s Roundtable on ReachMD, The Channel for Medical Professionals. I am Bruce Japsen, the healthcare reporter with The Chicago Tribune and with me today is Dr. Winifred Hayes. She is the founder and the chief executive officer of the Hayes Group and she is talking to us about evidence-based technology assessment, which can stem from the rising cost of healthcare.

We are talking about how to implement these assessments to evaluate purchases of equipment and what should be done and what shouldn’t be done and she was just telling us about how certain forces can enter the picture that might get in the way of hospital's decision-making. If you could go on from there doctor, that would be great.

DR. WINIFRED HAYES:

Well, let's take an example of a situation that might and could typically occur in a hospital around the technology acquisition decision and let's take something that's getting lot of press right now, proton beam.

BRUCE JAPSEN:

Hmm.

DR. WINIFRED HAYES:

Proton beams are radiation sources that can be used to treat a variety of conditions, cancer in particular, but other things as well, highly focused beam of radiation that can very precisely treat a mass for example. It's most frequent use if probably with prostate cancer. This technology is very expensive in the neighborhood of 160 to 200 million dollars to put one of the proton beams in place and make it operational. There are others, what we call, stereotactic radiosurgical devices, which proton beams run that are also available. Gamma knife is a device that may be your audience is familiar with. The price for gamma knife while expensive 3-5 million dollars is much less expensive than 150 to 200 million dollars. The evidence regarding proton beam as compared to say a gamma knife or other ways of treating prostate cancer. The evidence does not demonstrate that proton beam is superior. It certainly is a device that has been shown to be reasonably safe if it's used appropriate, but from a clinical outcome point of view, there is not strong evidence that shows it's superior and we are starting to see a proliferation of this particular device. This is a good example of how a close scrutiny of the evidence should inform the decision about whether a hospital is going to acquire this or participate in the consortium to acquire it and it also should be part of the deliberation about what are the patient's indications that would really make the compelling case to say, we do or we don’t need a proton beam device. So, it's an example of how that kind of information could be used to make decisions, and perhaps also to position the hospital to be able to respond when patients request that procedure. Because part of the problem hospital face, is the impact of direct consumer advertising that occurs and it occurs on the part of other competing hospitals as well as manufacturers and pharmaceuticals. So, hospitals have to have some way of responding to explain why they made the decisions they did and evidence certainly should be part of that communication that goes back out to their customers.

BRUCE JAPSEN:

And how is this with the Technology Assessment Committee interact with other areas of the hospital and what would the challenges and opportunities be if a couple of physicians are swayed by the company that they absolutely have to have this device.

DR. WINIFRED HAYES:

Well, I guess the first question that needs to be asked as part of the answer to your question is, is this an advisory committee or is it a determinate committee. In other words, is the output of this committee used in the advisory fashion or will it in fact be used to decide whether the organizations purchases or does not purchase the device. The second thing that's important for this committee to do is to communicate widely among clinicians, physicians what the methodology is and what the bases, the ground rules are for the decisions that get made and in this process there needs to be an opportunity for physician advocates for this technology to present his or her case. So, they need to know that they can present the reason that they feel this technology is compelling and when the committee finishes its work, it's deliberations and draws a conclusion, they need to communicate that conclusion in such way that it's transparent on stake-holders why the decision was made. Certainly, that committee should look at information provided by the manufacturer, but it should never rely on manufacturer data, it really needs to go to the peer reviewed research evidence and in the absence of evidence, there should be strong cautionary position taken about the adoption of a technology for which there is insufficient evidence. If those technologies are brought in, the committee should have the ability to require that there be some kind of oversight and clinical followup on the clinical outcomes for this procedure and any adoption should be on a conditional basis. Now, clearly there is some hospitals and some physicians, who work in that research phase, University Medical Centers are clearly the setting where early adoption is expected, but when we move into the community and we look at Community Hospitals, and perhaps that's less compelling for many hospitals, but again if they see themselves as an early adopter because of their roles in a given clinical area like orthopedics. When they bring things in for which there is insufficient evidence, it should be brought in, in a controlled way and with some kind of oversight.

BRUCE JAPSEN:

Well, with that I would like to thank Dr. Winifred Hayes, who has been our guest. She is with the Hayes Group and she was talking about a growing trend in healthcare to evaluate technology using evidence. Physicians and hospitals will be hearing about this and I would like to thank Dr. Hayes for being our guest.

You have been listening to the Clinicians Roundtable on ReachMD, The Channel for Medical Professionals. If you have comments or suggestions about today's show, and I would like to thank you today for listening.

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