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Albert J. Jovell

Health Technology Assessment: A DocPat alternative view May 18, 2010. Albert J. Jovell. I HTA views II How doctors think and act (and the patients) III Process vs results IV Eficaccy vs effectiveness V Early Spring reflections. Albert J. Jovell, 2010. I. HTA modern views.

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Albert J. Jovell

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  1. Health Technology Assessment: A DocPat alternative view May 18, 2010 Albert J. Jovell

  2. I HTA views • II How doctors think and act (and the patients) • III Process vs results • IV Eficaccy vs effectiveness • V Early Spring reflections Albert J. Jovell, 2010

  3. I. HTA modern views

  4. EU foundations: • We are democraticsocietiesmeaning HTA shouldengageonanequal basis allthestakeholders • Healthcareis a human right • WefollowtheAristotelianpath: equaltreatforequals, unequaltreatforunequals • Innovation in thecornerstoneofourPoliticalEconomy Albert J. Jovell, 2010

  5. HTA realities • 1.- Mostly based in methods (1995 EURASSES to 2010 EUnetHTA) • 2.- Seen as cost-containtment • 3.- Methods does not reflect all realities: • - Knoweldge is behind need • - Knowledge behind technology • - Ideal life behind real world • 4.- It should move forward faster to incorporate patient’s views Albert J. Jovell, 2010

  6. HTA realities 1987 - 2010: • Method *** -- no big progress in 20 years • Outcomes* -- Reductionist approach • Context ? – Theoretical approach • Meaning? – to whom? Albert J. Jovell, 2010

  7. II. How docs think and act (and patients)

  8. What influence medical decision making Evidence • Experience Previous knowledge Authority DM Conflict of interests Professional interaction Incentives Budget Number of visits Audit/self-control Pressumptions Albert J. Jovell, 2010

  9. The patient: • Assymmetric relationship • 3 diseases in 1 • Black and white approach • Subjective assessment • Individual values and preferences matter • High trust in docs but low trust in governments Albert J. Jovell, 2010

  10. III. Process vs results

  11. Yes: American Urological Assoc. American Radiologist Assoc. American Cancer Society NO: US Preventive Services Task Force Canadian PHE US College Physicians National Cancer Institute US PHC doctors Governments: Quebec, Suecia, Reino Unido Prostate Cancer Screening: DRE-PSA Albert J. Jovell, 2010

  12. Diabetes case shows pitfalls of treatment rules “This was the case in which the advocates of a disease got caught up in their disease rather than the interests of patients” Rodney Hayward, NYT August 2009 Albert J. Jovell, 2010

  13. The risk of HTA is to be focus on the methods rather than the outcomesOutcomes should be analyzed within a context and with a meaning walking on the patients’ shoes HTA is too government based approachThe disease experience pertains to the patients Albert J. Jovell, 2010

  14. Meaningful outcomes Caregiver’s quality of life in MS Intravenous vs oral treatment of colorectal cancer Adherence in cardiovascular prevention Albert J. Jovell, 2010

  15. Context considerations Angioplasty vs thrombolytics in Acute Myocardial Infarction Intravenous vs oral treatment for colorectal cancer One monthly injection vs daily oral treatment for osteoporosis Albert J. Jovell, 2010

  16. Other considerations • Assessment of process of care (continuity & longitudinality) vs specific single intervention • Complex interventions assessment • Personalized medicine • Relationship between volume and outcomes • Publicity of the health outcomes • Innovations at process of care level (ITS) Albert J. Jovell, 2010

  17. III. Eficaccy vs Effectiveness

  18. What happens (1st part) • “65 years old male diagnosed with type 2 diabetes with high LDL & high triglycerides” • Juan’s story • )

  19. My challenges/goals as Juan doc • Increase his diabetes literacy • A good therapeutic adherence • Better self monitoring • Side effects monitoring • Beware with interactions and iatrogenic events • Reduce unexpected events and complications • (People from NICE want a good QALY)

  20. What really happens (2nd part) • He has hearing problems • He lives alone • He has some memory lost • He suffers information overload • He has too many therapeutic goals to meet • He turns melancholic

  21. What our patient knows… • How diabetes affects his daily life and what is his experience as a patient • His attitude about risk • His values and preferences (including diet and exercise) • What he understands about this disease called diabetes • How it affects his social and family lifes

  22. Rogue Cancer Unit VA Hospital • 57 radioactive seeds carried out Dr. Kao (NYT June 2009): • - 57 were bad seeds because there were outside the prostate o because radiation was not appropriately distributed • - 35 seed results in overdose in other parts of the body • - An important number of patients got overdose or infradose • Joint Commission accredited the Unit • The Center ignored the bad practice despite it was known by managers Albert J. Jovell, 2010

  23. V. Early Spring reflections

  24. HTA in the EU: • Democratic process • Inform decision making • It has latent conflicts of values • 4. It should be based in meaning and assess HT within a context Albert J. Jovell, 2009

  25. Should there be a price for life? • - It seems to work only in UK (utilitarian approach) not in the rest of Europe (liberal egalitarian approach) • Should it be overall or be specific for a clinical condition? • - Common foundations and specific assessment • Should patient be involved? • - Deliberative democratic approach Albert J. Jovell, 2009

  26. Deliberative Democracy • Transparency and Openness in the process • Involve all the stakeholders • Decisions should be informed and grounded on data (quantitative or qualitative) • Right to appeal • Uncertainties should be made explicit • Latent conflict of interest and disagreements should be elicited and negotiated Albert J. Jovell, 2010

  27. Latent conflict of interests • Patient: • Citizen: • Payors: • Governments: • Clinical effectiveness • Safety • Cost • Access / Equity Albert J. Jovell, 2010

  28. Need to measure effectiveness • Time real research • Comparison of process of care • Consider clinical and ethical relevances • Not all patients follow the normal distribution • Combine EBM + medical humanism • Teach professionalism in medical schools • Personalized care (toxicity) • Disruptive innovations needed • Shared decision making (i.e. prostate cancer) Albert J. Jovell, 2009

  29. The Patients’ UniversityProject

  30. PARTICIPACIÓN EN POLÍTICA SANITARIA INFORMATION EDUCATION ACCESIBILIDAD A NUEVOS TRATAMIENTOS ENF. REUMÁT ICAS TOMA DE DECISIONES RESPIRATORIO SALUD MENTAL ENF. RENALES CARDIOLOGÍA EDUCACÍÓN MÉDICA DEPRESIÓN ALZHEIMER PARKINSON DIABETES RESEARCH SUPPPORT DERECHOS DE LOS PACIENTES CANCER DOLOR ASMA TDAH INFORMACIÓN TERAPÉUTICA COMUNICACIÓN MÉDICO-PACIENTE What we try to do

  31. HEALTH LITERACY Focus Ability to understand what happens with your health, what you need, and then take care of your health (or other people’s health)

  32. PATIENTS’ JURY Albert J. Jovell, 2009

  33. Patient Cancer Navigation Journey

  34. MANY THANKS www.webpacientes.org/fep www.universidadpacientes.org www.fbjoseplaporte.org albert.jovell@uab.cat

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