Stirling Bryan, PhD Graham Scotland, PhD Mohsen Sadatsafavi, PhD

1. In Search of Efficiency, Consistency, Fairness, and Impact in HTA: The Case for Clinical Pathway Management and Modelling Stirling Bryan, PhD Graham Scotland, PhD Mohsen Sadatsafavi, PhD

2. Overview of session • Stirling Bryan: • In Search of Efficiency, Consistency, Fairness, and Impact in HTA • Graham Scotland • Modelling screening and treatment pathways for diabetic retinopathy • Mohsen Sadatsafavi • The case for whole disease modelling in COPD

3. Disclosures and Acknowledgements • I am not aware of any actual or potential conflicts of interest in relation to this presentation. • Some of my relevant current activities: • Chair, CADTH’s Health Technology Expert Review Panel • Member, CADTH’s Economic Evaluation Guidelines Working Group • Member, BC’s Health Technology Assessment Committee • Director, VCH’s Centre for Clinical Epidemiology & Evaluation • Collaborators on this topic • Graham Scotland, University of Aberdeen; Mohsen Sadatsafavi, UBC; Craig Mitton, UBC; Cam Donaldson, Glasgow Caledonian University; Laurie Goldsmith, SFU; Rick Sawatzky, TWU • And many, many more…

4. Overview of talk Technology adoption Technology management Pathway management

6. Technology management questions • Assessment: • Does the technology, as currently used, deliver value? • Improvement: • Can more cost-effective utilization of the technology be achieved through modification of the clinical protocol? • Withdrawal: • Should the technology no longer be in routine use and, hence, a process of withdrawal commenced?

8. Technology management questions • Assessment: • Does the technology, as currently used, deliver value? • Improvement: • Can more cost-effective utilization of the technology be achieved through modification of the clinical protocol? • Withdrawal: • Should the technology no longer be in routine use and, hence, a process of withdrawal commenced?

9. Graham’s talk

10. Overview of talk Technology adoption Technology management Pathway management

11. Pathway management • Clinical pathway: defined sequence(s) of use of alternative health technologies • Pathway modelling becomes the foundation of HTA activity Barton et al, 2004

12. Chen et al, 2006

13. Pathway management and ‘resource stewardship’ • ‘Resource stewardship’ • A culture where resource scarcity is openly acknowledged and recognized as a shared responsibility • Pathway model development is a collaborative effort • Active engagement of, and ownership by, key stakeholders, including clinical leaders, policy makers, patients and analysts • The reference pathway model defines the resource envelope • Constraints on pathway reconfiguration are transparent • Proposed changes to the clinical pathway evaluated using the reference model • Opportunity cost considered explicitly

14. Stewardship facilitated through pathway modelling Clinical leaders and care teams HTA analysts Policy makers and managers Patients and carers Industry

15. Pathway management and ‘resource stewardship’ • ‘Resource stewardship’ • A culture where resource scarcity is openly acknowledged and recognized as a shared responsibility • Pathway model development must be a collaborative effort • Active engagement of, and ownership by, key stakeholders, including clinical leaders, policy makers, patients and analysts • The reference pathway model defines the resource envelope • Constraints on pathway reconfiguration are transparent • Proposed changes to the clinical pathway evaluated using the reference model • Opportunity cost considered explicitly

16. Pathway management example In RA, recent evidence suggests anti-TNF, biological treatment (infliximab) not superior to conventional combination therapy (MTX, SSZ, HCQ) Eriksson et al, 2013 Barton et al, 2004

17. Scholz & Mittendorf, 2014

18. Model validation… “Computer models are no different from fashion models… seductive, unreliable, easily corrupted and they lead sensible people to make fools of themselves.” Jim Hacker, ‘Yes, Prime Minister’

21. In conclusion • Let’s break our addiction to technology adoption • Pathway modelling as a centrepiece of HTA work supports development of a stronger ‘resource stewardship’ culture • The mechanism: • Quantification of resource commitment to a given clinical area • Explicit consideration of opportunity cost • Simultaneous consideration of investments and disinvestments • Analysis of technologies at different points in a clinical pathway, or even across different disease pathways

22. mohsen’s talk