INTRODUCTION

Health care Healthier

Health care
technology population

HEALTH TECHNOLOGY ASSESSMENT Healthcare technology assessment

AN INTRODUCTION
Safe

Efficacious

Appropriately used
Iwan Dwiprahasto
CE&BU FK UGM/RSUP Dr. Sardjito benefit is worth the cost expa
expanded

Adoption of
• Medical Medical technology. What is it for
• Social Meet all
health care
technology • Ethical criteria
Diagnosis, assessment, management
• Legal
Identifying asymptomatic diseases
Helping physicians to confirm diagnosis

May not meet all criteria Research

• Abortion Teaching and training

• MRI (overuse)
• Caesarean section (misuse)
• Antibiotics for common cold

Why technology assessment is needed?

THE NEED FOR TECHNOLOGY ASSESSMENT
Ticrynafen (US, May • hepatocelullar injury (> 500 reports)
79 - May 80):
Benoxaprofen (April • 61 died (cholestatic
(cholestatic jaundice) di UK (BMJ)
82--August 82):
82 Overuse of technology: CT Scanner
Zomepirac (Okt 80
80-- • anaphylactoid reaction (N Engl J Med 1981):
March 83): 1100 reports

Suprofen (jan 86
86-- 1972: was introduced
• flank pain synd (> 300 reports).
May 87):
Temafloxacin (US, • anemia hemolytic, renal dysfunction, death
Feb 1992) CT Scanner for chronic headache
Sensitivity &
Doubtful Costly
specificity?
Viox (1999
(1999--2004): • cardiovascular events

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 Problems in the use of health care technology DEFINITION
Health care technology:
• OVERUSE the drugs, devices, and medical and
• UNDERUSE INAPPROPRIATE surgical procedures used in health care
• MISUSE and the organizational and supportive
systems within which such care is
provided
Inefficiencies Medical Error

• e.g., aspirin, beta-blockers,

Drugs: antibiotics, HMG-CoA reductase
inhibitors ("statins") • e.g., electronic patient record
Support systems, telemedicine systems,
systems drug formularies, blood banks,
• vaccines, blood products, cellular clinical laboratories
Biologics:
and gene therapies

Devices, • e.g., cardiac pacemakers, CT

equipment scanners, surgical gloves, diagnostic • e.g., prospective payment using
and supplies test kits Organizational diagnosis-related groups, alternative
& managerial health care delivery configurations,
Medical and • e.g., psychotherapy, nutrition systems clinical pathways, total quality
surgical counseling, coronary angiography, management programs
procedures: gall bladder removal

Innovation, development, & diffusion of

Medical technology

Established technology
Late adopters

Early adopters Obsolete

technology

Clinical trials
Abandoned
First medical use technology

Innovation Development Diffusion Evaluation

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 Basic Orientations to HTA THE ADOPTION OF HEALTH CARE TECHNOLOGY

Technology--oriented assessments
Technology
Basic research
• To determine the characteristics or impacts of
particular technologies, e.g., population-based
cancer screening Applied research

Problem--oriented assessments
Problem First human use
• To focus on solutions/strategies for managing a
particular problem for alternative/complementary
technologies, e.g., clinical practice guidelines for Clinical trials
dementia diagnosis

Project--oriented assessments
Project Adopted
• To focus on a local placement or use of a
technology in a particular project, e.g., a hospital’s
decision on whether or not to purchase a MRI Accepted

Problems in the use of diagnostic technology

Necropsy studies
diagnostic errors
in radiology
mammography
Intraobserver disagreement
in interpreting radiograph
Emergency
physicians: 33%
Error rate to dx stroke
death rates due to using CT Scan
missed diagnoses 40%, Neurologist &
radiologist: 14-
14-17%
30% from total
malpractice in the US
Emergency physicians:
17%
error rates up to 75%
Accuracy in identify
Neurologist: 40%
hemorrhagic stroke
20%

radiologist: 52%
* Lev, MH, Rhea, JT, Bramson RT Avoidance of variability-error in radiology
* Lev, MH, Rhea, JT, Bramson RT Avoidance of variability-error in radiology

Safety of health care technology Health care Technology proven to be “INEFFECTIVE”

and even harmfull for human use

1. Autologous bone marrow transplant with high-

high-
Bronchoscopy (n=414) dose chemotherapy for advanced breast cancer
2. Colectomy to treat epilepsy
3. Diethylstilbestrol (DES) to improve pregnancy
9,4% experience nosocomial infection outcomes
4. Electronic fetal monitoring during labor without
access to fetal scalp sampling
66,7% : P. aeruginosa 5. Episiotomy (routine or liberal) for birth
6. Extracranial
Extracranial--intracranial bypass to reduce risk
of ischemic stroke
Outbreak Pseudomonas infection-bronchoscophy- 7. Gastric bubble for morbid obesity
N Engl J Med 2003;348:221-7. 8. Gastric freezing for peptic ulcer disease

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 Development ot diagnostic technology
9. Rofecoxib for osteoarthritis
10. Hormone replacement therapy for healthy
menopausal women Invasive Less invasive Non invasive
11. Hydralazine for chronic heart failure
12. Intermittent positive pressure breathing
13. Mammary artery ligation for coronary artery
disease More
14. Optic nerve decompression surgery for nonarteritic comfortable
anterior ischemic optic neuropathy
15. Quinidine for suppressing recurrences of atrial
fibrillation
16. Radiation therapy for acne Less painful More practical
17. Sleeping face down for healthy babies
18. Supplemental oxygen for healthy premature
babies
19. Thalidomide for sedation in pregnant women
Cost effective

Marginal analysis
VALUE
An analytical technique which examines the
relationship between incremental changes in
investment in a product and incremental changes in
outputs
Consequences

Health
Cost Outcome

C0 C1 C2 C3
COST

The interaction between costs and benefits Cost-effectiveness threshold

Higher cost
Area of rejection
Cost-effectiveness
Cost-
Incremental costs

threshold?
NO ?
Less More
benefit benefit
Area of acceptance
? YES
(probably no)

Incremental health benefit

Lower cost

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ENDOSCOPE Surgery Laparotomy (open Laparoscopy (minimally
surgery) access surgery)
+
hospitalization

Less invasive

1. Removing appendix
Surgery
2. Cholecystectomy by laparoscope
3. Repair of inguinal hernias +
4. Tx of joint problem no hospitalization

US: 50% (1990) ---> 75% (2000)

Minimally invasive surgery Minimal access surgery

Meta analysis of 15 studies comparing conventional

appendectomy vs laparoscopic appendectomy
conventional laparoscopic
Cholecystectomy Laparoscopic cholecystectomy Appendectomies appendectomies
(n 5 820) (n 5 742)
Operating Time (min) 48.4 68.6
Wound infection 7.24% 2.86%
Average operating time: 95-
95-110 min
Hospitalization 3.5 3.1
Average hospital stay: 1-
1-2 (US), 3-
3-7 days (France)
Intra--abdominal abscess
Intra 0.83% 1.84%
Return to normal activity: 3-
3-7 days
Postoperative pain worse better
Complication rate: 1-
1-5%
Return to normal activity 17.6 11.4
Return to full-
full-time employement
employement:: 10 days
A meta-analysis of randomized controlled trials of laparoscopic versus conventional appendectomy.pdf
Charge: US$3620 vs 4252 (standard) THE AMERICAN JOURNAL OF SURGERY® VOLUME 177 MARCH 1999

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 Laparoscopic Minimal access techniques
Cholecystectomy
cholecystectomy ESTABLISHED
Laparoscopic cholecystectomy
Diagnostic laparoscopy
Average operating time • 95-110 min
Laparoscopic appendicectomy

Average hospital stay • 1-2 (US), 3-7 days (France) Laparoscopic Nissen fundoplication
Laparoscopic (or thoracoscopic
thoracoscopic)) Heller's myotomy25
Return to normal
• 3-7 days Laparoscopic adrenalectomy
activity
Laparoscopic splenectomy
Complication rate • 1-5%
Thoracoscopic sympathectomy
Return to full-time
• 10 days Laparoscopic rectopexy26
employement

Charge • US$3620 vs 4252 (standard) Paper: recent advances Minimally Access Surgery.pdf

FACTOR INFLUENCING ADOPTION
• Characteristics of the technology
• Characteristics of the adopter
• Characteristics of the environment
1. technology inovated countries
2. technology adapted countries
3. technology excluders countries
What to assess?
 New vs existing technology
 How importance
 Accuracy & reproducibility
 Sensitivity & specificity
 Access to the treatment procedure
 Harmful or harmless
 False positive vs misleading
 Cost

Why do we adopt Health Technology Assessment

• The need for technology vs incidence &
prevalence to identify technology that
• Predicting its utilization • improve health
• Specialist vs operator
• reduce cost
• Environment (space, AC)
• increased costs are justified by
• Maintanance
sufficiently improved health
• Spare parts
• Single vs multiple function
• Operational vs opportunity cost

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 Life cycle of technology
• Future technology
• Emerging technology
• New technology
• Accepted technology
• Obsolete technology
Iterative loop technology assessment
Burden of illness
Monitoring & reassessment
Synthesis & implementation
Efficiency
2. Efficacy
• Apakah mungkin dilakukan studi
eksploratori?
• Do more good than harm
• Apakah untuk derajat keparahan
tertentu?
• Apakah untuk populasi tertentu
Health care technology
• Prospective assessment
• Assessment for efficacy & safety
• Assessment for cost-effectiveness
• Assessment after diffusion
1. Burden of illness
Menetapkan morbiditas & mortalliitas
– Apakah ukuran yang digunakan relevan?
– Apakah metode pengukuran akurat?
Efficacy – Apakah hasilnya mudah diinterpretasi
Unmodifiable burden of illness
– Disability, symptom, mortality karena tidak ada teknologi
medik untuk intervensi (kanker stadium akhir, multiple
sclerosis, Alzheimers)
Screening & diagnosis – Focus: etiologi, pencegahan, penyembuhan
Modifiable burden of illness
– Ada teknologi medik untuk diagnostik, pencegahan,
penyembuhan & paliatif
– Fokus: effectiveness of technology
Community effectiveness
3. Screening & diagnosis
• Kelompok mana yang paling
diuntungkan oleh teknologi (CT,
NMR, MRI)
– Technological capability
– Diagnostic accuracy
– Effect on the health care provider
– Therapeutic effect
– Patient outcome
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 4. Community effectiveness
• Seberapa besar dampak positifnya bagi
populasi yang lebih luas?
• Comm. Effectiveness =
efficacy x diagnostic accuracy x health
professional compliance x patient
compliance x coverage
5. Efficiency
• = patient benefit (outcome)/cost
• = net costs = costs - benefits
• Cost effectiveness: lives saved, proporsi
pasien dengan gejala yang terkontrol
• Cost benefit
• Cost utility
7. Monitoring & reassessment
• Short-term, intermediate, long-term
• Dasar:
– pertimbangan struktural
– kemampuan SDM (satisfactory training)
– Appropriate utilization (cukup jumlah
pasien yang direkomendasikan)
– indikator untuk patient outcomes
Community effectiveness
• Evaluasi terhadap health professional
compliance
• Evaluasi terhadap patient compliance
• Evaluasi coverage
6. Synthesis & implementation
• Risk & benefit assessment
• Community Effectiveness?
• Coverage
• Economic analysis
• Human Resource and Development
• Maintenance of technology
Decision making criteria
• Efficacy & effectiveness
• Safety
• Profitability
• Social responsibility
• Institutional strategy
• Feasibility
• Risk