From Education to Engagement to Action: A Real-World KT Approach for Facilitating Evidence Decision Support in Health Care Paule Poulin, Lea Austen, Elizabeth Oddone Paolucci, Gabrielle Zimmermann, and Trevor Schuler CADTH Symposium 2015

When appraising a new health technology, local decision-makers need to consider: Local priority-setting Local operations Local population health needs Local alternatives Local presence of trained personnel Local infrastructure impact Local budget impact…….. As well as HTA reports by HTA agencies

Our Project: Purpose 1.Educate and engage surgical divisions in Alberta Health Services in a real-world exercise on bringing evidence into practice during health technology appraisal

“After considering the results of the provincial review and stakeholder feedback and upon advice from the Alberta Advisory Committee Health Technologies, a decision was made by Alberta Health to re-evaluate Robot- Assisted Surgery (RAS) in one year...AHS is to collect data to inform the re- evaluation…..”

6 Advantages of Robotic Technology Less blood loss Fewer complications Less pain Shorter length of stay Shorter recovery time Patient Improved ergonomics Improved visualization Better surgical performance Short learning curve Surgeon Slide provided by Danny Minogue, Minogue Medical Inc., Montreal, Quebec. Data adapted from CADTH Technology Report on Robot-Assisted Surgery, 2011

da Vinci ® – The enabling technology Slide provided by Danny Minogue, Minogue Medical Inc., Montreal, Quebec, and da Vinci® Surgical System

RAS Re-Evaluation Objectives: 1.Establish a RAS Steering Committee and smaller RAS Working Groups 2.Identify current RAS activity in Alberta and develop data collection and analysis strategies 3.Identify emerging RAS procedures of interest in Alberta 4.Identify current state of evidence and gaps in knowledge for RAS for procedures of interest 5.Establish a strategy for a provincial training and credentialing process 6.Inform a comprehensive economic and operational financial analysis 7. Consider patient engagement issues

1. Establish a RAS Steering Committee and smaller RAS Working Groups Surgical specialty representation: Urology Obstetrics and Gynecology Cardiac Surgery Thoracic Surgery General Surgery Otolaryngology Edmonton and Calgary Zones, North and South Zones (the Central Zone declined to participate at this time) AHS and AACHT (AH)

2. Identify current RAS activity Develop data collection & analysis strategies 3,101 da Vinci robots installed world-wide –2,153 United States –499 Europe –322 in Asia (183 of those in Japan) –38 in Latin America –35 Australia and New Zealand –28 in the Middle East –26 Canada Data provided by Danny Minogue, Minogue Medical Inc., Montreal, Quebec, and da Vinci® Surgical System

11 Slide provided by Danny Minogue, Minogue Medical Inc., Montreal, Quebec. Data and da Vinci® Surgical System

Top RAS procedures: Number of cases between ProcedureCanadaAlberta Total15,0183,305 Prostatectomy8,5592,571 Hysterectomy3, Partial Nephrectomy Pyeloplasty44874 Nephrectomy2360

RAS is growing worldwide Worldwide, the largest growth is in gynecological procedures

RAS is growing in Canada Types of procedures (total)865 Types of Urology procedures 116 Types of Gynecology procedures 011

RAS is growing in Alberta 2008/ /14 Prostatectomy Hysterectomy984 Partial nephrectomy060 Pyeloplasty138

Possible strategies: 1.Use published data (Ontario ICES & literature) 2.Retrospective analysis of Alberta RAS cases (limited data, may lack functional outcomes) 3.Collaborate with the Institute for Clinical Evaluative Sciences (ICES) in Ontario to combine Alberta data with Ontario data 4.Develop an Alberta data collection strategy similar to ICES 2. Identify current RAS activity Develop data collection & analysis strategies

Data Elements to Consider: All relevant health care resources utilization data, e.g. length of hospital stay, operating room time diagnostic investigations both inpatient and outpatient resources to track cost shifting Any relevant clinical outcomes data oncologic and functional Patient satisfaction metric Utility metric – EQ-50 Disease-specific if possible 2. Identify current RAS activity Develop data collection & analysis strategies

3. Identify emerging RAS procedures of interest in Alberta A survey was distributed to Alberta’s surgeons and completed by 81 respondents: General surgery (25%) Urology (25%) Orthopedics (15%) Otolaryngology (11%) Other specialities (24%)

What role do you anticipate for RAS in your area in Alberta in the next 5-10 years? CommentNumber of Mentions Will expand39 Minimal role, has not lived up to its potential20 Too expensive for little benefit6 Needs more evidence and monitoring5 Driven by community or patient demand5 Alberta needs to be at the forefront3

Which RAS procedures do you anticipate being important in your area in Alberta in the next 5-10 years? ProcedureNumber of Mentions 1. Radical Prostatectomy21 2. Partial Nephrectomy19 3. Pyeloplasty16 4. Cystoprostatectomy14 5. Simple prostatectomy12 6. Nephroureterectomy12 7. Adrenalectomy11 8. Trans-Oral Robotic Surgery (TORS)11 9. Colectomy/rectal cancer9 10. Sacrocolpopexy/pelvic floor8

What conditions should be considered for RAS use in a publically funded system? [multiple choice question] Comment% of Respondents Used under the guidance of a committee that approves indications for use and monitors outcomes and cost 59% Used only for indications that have proven benefits over open or laparoscopic surgery 54% Used only if equipment donated and additional costs paid by patient 10% Used without restriction regardless of cost provided outcomes are equivalent or better 7.5% Not used at all2.5%

4. Identify gaps in knowledge for RAS for procedures of interest Currently performed procedures identified for re-evaluation are: Prostatectomy (simple and radical) Hysterectomy (simple and radical) Partial Nephrectomy Emerging procedures of interest for review include: Pyeloplasty Cystoprostatectomy Nephroureterectomy Pelvic floor surgery TORS Adrenalectomy Colon/rectal cancer

ProcedureReviewed by CADTH? Comments Prostatectomy2011Needs appropriate comparator: laparoscopic method hardly used in Alberta Hysterectomy2011Currently only used for oncological cases in Alberta Benign and oncological procedures need to be considered separately Partial nephrectomy 2011Only used for partial nephrectomy in Alberta Review needs to consider partial nephrectomy separately Existing reviews now out-dated Reviews need to have a clinical focus Prior to a request for new reviews, context experts should be consulted to make sure that relevant questions and review processes are addressed

5. Establish a strategy for a provincial training and credentialing process A robust process should be developed for RAS credentialing o As it should for all areas of surgical practice o RAS should not be seen as unique Goes beyond surgeons - Nurses, biomed., MDRD Given volume, consideration should be given to developing a training centre This will require: Systemic literature review and critical appraisal of RAS credentialing Review and appraisal of guidelines from national or international surgical societies Consultation with local, national and international expert Development of a Steering Committee to oversee and monitor the training and credentialing process and outcomes

6. Commission a comprehensive economic and operational financial analysis RAS may be cost-effective under certain circumstances o Unlikely that RAS will show cost savings o High cost of disposables, single vendor o Requires high output of existing robots o Worse when additional robots are added Value for money and outcomes related to cost need to be considered Will require high level economic expertise o AHS, AH, IHE, U of A, U of C o Will require robust oncological and functional outcome data o Ideally local data

RAS Funding in Alberta Strategies to minimize cost of RAS procedures: Require high volume centres and practitioners Awareness of costs and outcomes Training/mentoring of the entire surgical team Maximize the number of cases surgeons do; clear correlation between provider volume and outcomes Compare the RGH, UAH and RAH urology robotic work/program and pathways for efficiencies Assess if current robotic capacity is maximized prior to purchasing another platform

7. Consider patient engagement issues Develop a consultation process to ensure the outcomes of importance to patients are included in the planned RAS re- evaluation Involve patients with all known patient safety issues associated with RAS Invite patient representative to join the advisory steering committee A communication plan

Conclusions RAS identified by both our surgical community and the Alberta government as an important technology to review RAS is on the rise in Alberta, Canada and Worldwide Cost of RAS is a central issue Responsible use of RAS requires: o An oversight advisory steering committee o Accurate data collection, maintenance, monitoring/reporting o Getting the most out of the existing equipment o A robust but reasonable training and credentialing process o Patient & family engagement o Must consider the impact of elimination or reduction of robotics on the number of care providers