1. Health Technology Assessments What are they and how are they produced? Karen Ritchie, Senior Health Services Researcher

2. What is a Health Technology? Any intervention that may be used to promote health, to prevent, diagnose or treat disease or for rehabilitation or long-term care. The term encompasses drugs, devices, clinical procedures and health care settings

3. Health Technology Assessment (INAHTA, 2000) Health Technology Assessment (HTA) is a multi-disciplinary field of policy analysis, which studies the medical, social, ethical and economic implications of development, diffusion and use of health technology.

4. Health Technology Assessments Completed Organisation of services for diabetic retinopathy screening PET imagine in cancer management Prevention of relapse in alcohol dependence Troponin testing in acute coronary syndromes Ultrasound scanning in early pregnancy

5. Current The use of B-type natriuretic peptides in the investigation of heart failure The use of alcohol hand gel to increase hand washing compliance and reduce healthcare associated infection rates Health Technology Assessment (HTA)

6. Health Technology Assessment Scientific evidence Views of health service users Health professionals judgement

7. NHSQIS Advice Economic Evaluation Model of what would happen to Scottish patients in the long-term, taking account of costs and benefits Organisational Issues Whats needed to use the technology in a quality assured manner Staffing, legal issues, etc Patient Issues Patients needs and preferences Psychological, social and ethical issues Clinical effectiveness Does the technology work in clinical practice and is it safe? Health Technology Assessment (HTA)

8. Organisational Issues Whats needed to use the technology in a quality assured manner Staffing, legal issues, etc Health Technology Assessment (HTA)

9. Organisational Issues Survey Routine scan programme –13 units offer first trimester scan only –3 units offer a second trimester scan only –21 units offer two scans Variation reported in: –content and timing of scans –staffing and training –equipment used –consent procedures

10. Clinical effectiveness Does the technology work in clinical practice and is it safe? Health Technology Assessment (HTA)

11. Clinical Effectiveness Evaluation of benefit to risk using outcome measures of importance to patients in a standard clinical setting

12. Literature search Initial searches to identify HTAs, systematic reviews and evidence-based guidelines Key health-related databases (e.g. Medline, Embase) Web sites of relevant organisations (e.g. patient groups, professional bodies) Ongoing research (e.g. MRC Funded Research, National Research Register)

13. Clinical Effectiveness Secondary literature –fetal viability –multiple pregnancies –gestational age Primary literature –fetal abnormalities

14. Search methodology Question broken down into concepts -Population AND intervention AND outcome -e.g. Pregnancy AND ultrasound AND morbidity

15. Initial results Pregnancy AND ultrasound = 32,000 records (Medline) Records filtered: –RCTs –Diagnostic accuracy –Outcomes

16. Initial results 2446 RCTs identified 315 selected on title and abstract 2923 diagnostic accuracy records 373 selected on title and abstract

17. Patient Issues Patients needs and preferences Psychological, social and ethical issues Health Technology Assessment (HTA)

18. Issues for pregnant women Methods Review of literature 2 expert interviews Focus groups –deprived, low income mothers –teenage mothers –middle income, urban mothers –middle income, rural mothers

19. Economic Evaluation Model of what would happen to Scottish patients in the long-term, taking account of costs and benefits Health Technology Assessment (HTA)

20. Economic evaluation has been defined as the comparative analysis of alternative courses of action in terms of both their costs and consequences (Drummond & McGuire, 2001) It is concerned with choices about how to use scarce resources Economic evaluation

21. Economic Modelling Model Cohort studies Observational studies Clinical trials Epidemiology Patient pathways Economic data Costs of screening Costs of outcomes

22. Scanning Strategies Strategy 1 st trimester scan 1 st trimester markers 2 nd trimester markers 2 nd trimester scan 1NTY Y 2 Y N 3 YAFPY 4NTYAFPN 5Booking-double testY 6Booking-double testN

23. StrategyAnomalies detected Iatrogenic losses Cost 1 0 NT scan + 2 0 scan 1768£151 1 0 NT scan 718£107 1 0 scan + blood test + 2 0 scan 17616£147 1 0 scan + blood test 8716£104

24. Recommendations First trimester scan should be offered to all –fetal viability, multiple pregnancy, gestational age First trimester screen for chromosomal abnormalities including NT measurement All women should be offered a second trimester anomaly scan

25. Issues for women I dont think they give you enough scans. I think its lovely, I could lie there all day watching this little thing. I dont think they explained it enough. My doctor just booked the appointment…you just went ahead and thats what you did. Nobody said did you want to do it?

26. Recommendations Appropriate patient information prior to ultrasound scan Information should included conditions identifiable and risks of invasive tests Time should be available for discussion

27. Aim and Legal Status of Advice NHSScotland should take account of advice and evidence from the NHS Quality Improvement Scotland and ensure that recommended drugs or treatments are made available to meet clinical need

28. Principles of Health Technology Assessment Global Evidence National Advice Local/National Implementation

29. For more information on Health Technology Assessments and the other work of NHS QIS: nhshealthquality.org