1. PROMs in reimbursement and real-world assessments of clinical interventions Stirling Bryan, PhD

2. 2 Disclosures Some of my relevant current activities: –Director, Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute –Chair, CADTH’s Health Technology Expert Review Panel –Member, BC’s Health Technology Assessment Committee –Member, EuroQol Group My Centre has a contract to conduct HTA projects for the BC Ministry of Health. I am not aware of any other actual or potential conflicts of interest in relation to this presentation.

3. 3 Overview of talk Example PROMs PROMs in support of HTA Moving from HTA to health technology management (HTM) PROMs in support of HTM

4. 4 Generic utility-based PROMs Short Form Health Survey instruments EQ-5D

5. 5 Whitehead S J, Ali S Br Med Bull 2010;96:5-21 PROMs give us Quality-Adjusted Life Years (QALYs)

6. 6 Example Markov model

7. 7 CEA / CUA results “Riluzole is recommended for the treatment of individuals with amyotrophic lateral sclerosis (ALS) form of Motor Neurone Disease (MND).”

8. 8 Cost-effectiveness plane Drummond, et al. 2005. Methods for the economic evaluation of health care programmes: Oxford University Press

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11. 11 MOVING FROM HTA TO HEALTH TECHNOLOGY MANAGEMENT

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13. 13 Areas of concern Primary concern: The ‘performance’ of health technologies in routine use (1)Model validation questions: How good are our models? Are the predicted benefits and costs really delivered? (2)Improvement questions: Can we get better value from existing technologies? (3)Appropriateness questions: Do we see indication creep? (e.g., Statins for primary prevention in low-risk patients) (4)Withdrawal questions: Are technologies nearing the end of their useful life?

14. 14 Copyright ©2005 BMJ Publishing Group Ltd. Miners, A H et al. BMJ 2005;330:65 Logged pairwise comparison of incremental cost effectiveness ratios

15. 15 Michael Fish and the Great Storm of 1987 www.youtube.com/watch?v=uqs1YXfdtGE “The Great Storm of 1987 occurred on the night of 15–16 October 1987, when an unusually strong weather system caused winds to hit much of southern England and northern France. It was the worst storm to hit England since the Great Storm of 1703 (284 years earlier) and was responsible for the deaths of at least 22 people in England and France.” But what did the BBC weather forecaster say? Wikipedia

16. 16 Areas of concern Primary concern: The ‘performance’ of health technologies in routine use (1)Model validation questions: How good are our models? Are the predicted benefits and costs really delivered? (2)Improvement questions: Can we get better value from existing technologies? (3)Appropriateness questions: Do we see indication creep? (4)Withdrawal questions: Are technologies nearing the end of their useful life?

17. 17 Technology management

18. 18 Technology management examples Knee arthroplasty: –20% of patients ‘dissatisfied’, many with ongoing poor outcomes Asthma: –we have highly effective low cost therapies that people don’t use Rheumatoid Arthritis: –recent evidence suggests high cost biological treatment not superior to conventional therapy

19. 19 HTA and HTM Life-cycle evaluation of health technologies –Data systems (including PROMs) to facilitate monitoring of technologies in use –In part to validate analysis predictions made at the time of coverage/reimbursement Early HTAAdoptionOngoing assessment DisinvestmentAppropriate Use

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21. 21 A pan-Canadian HTM Strategy? CADTH leading this work Pan-Canadian HTM agenda (input from all jurisdictions) Consideration of overall system impact (including clinical guidelines, health human resources, fee codes) Common processes for new and in-use technologies Post-market surveillance programs (incorporating real world evidence) Enhanced knowledge mobilization

22. 22 stirling.bryan@ubc.ca