The health technology assessment something gaining
momentum in hospitals as a way to improve patient care can be a challenge to
implement. How should this be done and what should a physician's role be?
Welcome to ReachMD, The Channel for Medical Professionals. I am Bruce Japsen,
the healthcare reporter with The Chicago Tribune and with me today is Dr.
Winifred Hayes. She is the founder and chief executive officer of the Hayes Group.
Hayes Inc. is a Health Technology Research and Consulting Firm based on the
Philadelphia suburb of Lansdale, Pennsylvania. Ms. Hayes has her doctor of
philosophy degree from the Johns Hopkins University School of Hygiene and
Public Health, and is also a graduate of the University of Maryland School of
Nursing, with Primary Care Nurse Practitioner and Master of Science degrees.
Under her leadership, Hayes Inc. has become a leader in evidence-based reports
to health plans, hospitals, managed care companies, government agencies, and
Dr. Winifred Hayes, welcome to ReachMD XM-157, The Channel
for Medical Professionals.
DR. WINIFRED HAYES:
Thank you, it's a pleasure to be here.
So, tell us a little bit about this phenomenon of
evidence-based technology assessment and how a hospital or a provider can get
DR. WINIFRED HAYES:
Well, the phenomenon is being driven in part by runaway cost
and healthcare and ongoing concerns about the quality and safety of the
healthcare we provide the American consumer and this is not just a US problem,
it's a worldwide problem, but I think in the US, we are at a crisis point.
There is a growing recognition by physicians and others that the old way of
making decisions about the appropriate in reduction, dissemination, and
utilization of health technologies is not working very well and let me take a
minute to make sure we are on listening page. Our Health technology is any
kind of intervention for diagnostic or screening procedure that we provide to
patients in the context of preventing disease or treating disease or providing
some kind of clinical support. So, it could be a drug, it could be a diagnostic
study, it could be a piece of imaging equipment, it could be a surgical device,
it could be an orthopedic implant, it's really anything that we use in
providing healthcare and so there's this recognition that the current system is
not working very well and we have major problems in overuse, underuse, misuse
of health technologies and waste in our system and at the same time, we have
got big problems in terms of patient safety. So, hospitals and physicians
increasingly recognize that evidence should be the grounding for the decisions
that we make and we are beginning to recognize that a reliance on expert
opinion on thought leaders, on marketing information can mislead us in terms of
the direction we take. So, that's kind of the background and I think most of
your audience understands that our cost for healthcare at nearly 17% of gross
national product and other indices that we measure healthcare effectiveness
like life expectancy and infant mortality are not where they should be as
compared to the rest of the world. So, we have got a lot of work to do. So,
that's kind in the background. So, how does it fit into hospitals? Well, as
hospitals make difficult decisions around what kind of new technology needs to
be introduced into their setting and doctors are certainly part of that
decision-making process, and as we look at what kind of equipment we should
replace, the old way of relying on some evidence, some marketing information,
some opinion is slowly being replaced with more of robust evaluation of
evidence and an insistence that there should be some scientific proof that
really supports the clinical benefit and the cost benefit of this item.
So, when you get into a hospital though, one of the things
that comes to mind and I am sure you ran into this as this is the political
nature. You know, you could have a doctor, who is a big hitter, who wants to
do a brand new thing and they go out and they recruit this gentleman. He comes
in because of the procedure that he can do on this new machine and brings in
revenue, but you find yourself on a committee saying "wait a minute, the
evidence just does not show this works." Could you tell us what the
committee does and how they deal with situation?
DR. WINIFRED HAYES:
Sure and I think you have characterized it very accurately.
It's a very complex environment. So, to have a Health Technology Assessment
Committee to be successful, there is a basic requirement upfront and that is
that the executive team, the leadership team, the board of directors, the
trustees need to be behind the incorporation of evidence and the
decision-making. They need to see this as fundamentally part of how that
hospital is going to operate. They need to buy into it. With that as a
grounding, then the formation of a health technology assessment team can occur
and its makeup needs to include physician leadership within that organization.
Physicians to have buy-in need to basically buy into the process that's going
to be used and feel that they are going to have a voice in the analysis of the
data that will drive the decisions about the purchase and use of new health
technologies for that institution. There are other people that also need to serve
on that committee, other members of that committee, representation from the
finance office, representation that's speaking about risk-management issues,
safety issues at <_____> (5:33). Those are 2 important components that
need to be represented on that committee. Often times, it's useful to have
somebody from bioengineering on that committee as well because they have got to
maintain that equipment and certainly somebody from the, what we call the
supply chain or the purchasing side of the institution needs to be involved.
So, the committee is kind of a cross-section within the hospital and it needs
to have an ability to evaluate and interpret evidence that is used to help both
inform future decisions around technology as well as more immediate decisions
around the purchase of health technology and one of the battles they are gonna
have to fight is over the other drivers that operate in that hospital, drivers
like physician requesting preferences, drivers like their marketing physician
and competition in their area and drivers like the strong marketing presence of
device manufacturers and pharmaceutical company.
If you are just joining us or even if you are new to our
channel, you are listening to the Clinician’s Roundtable on ReachMD, The
Channel for Medical Professionals. I am Bruce Japsen, the healthcare reporter
with The Chicago Tribune and with me today is Dr. Winifred Hayes. She is the
founder and the chief executive officer of the Hayes Group and she is talking
to us about evidence-based technology assessment, which can stem from the
rising cost of healthcare.
We are talking about how to implement these assessments to
evaluate purchases of equipment and what should be done and what shouldn’t be
done and she was just telling us about how certain forces can enter the picture
that might get in the way of hospital's decision-making. If you could go on
from there doctor, that would be great.
DR. WINIFRED HAYES:
Well, let's take an example of a situation that might and
could typically occur in a hospital around the technology acquisition decision
and let's take something that's getting lot of press right now, proton beam.
DR. WINIFRED HAYES:
Proton beams are radiation sources that can be used to treat
a variety of conditions, cancer in particular, but other things as well, highly
focused beam of radiation that can very precisely treat a mass for example.
It's most frequent use if probably with prostate cancer. This technology is
very expensive in the neighborhood of 160 to 200 million dollars to put one of
the proton beams in place and make it operational. There are others, what we
call, stereotactic radiosurgical devices, which proton beams run that are also
available. Gamma knife is a device that may be your audience is familiar
with. The price for gamma knife while expensive 3-5 million dollars is much
less expensive than 150 to 200 million dollars. The evidence regarding proton
beam as compared to say a gamma knife or other ways of treating prostate cancer.
The evidence does not demonstrate that proton beam is superior. It certainly
is a device that has been shown to be reasonably safe if it's used appropriate,
but from a clinical outcome point of view, there is not strong evidence that
shows it's superior and we are starting to see a proliferation of this
particular device. This is a good example of how a close scrutiny of the
evidence should inform the decision about whether a hospital is going to
acquire this or participate in the consortium to acquire it and it also should
be part of the deliberation about what are the patient's indications that would
really make the compelling case to say, we do or we don’t need a proton beam
device. So, it's an example of how that kind of information could be used to
make decisions, and perhaps also to position the hospital to be able to respond
when patients request that procedure. Because part of the problem hospital
face, is the impact of direct consumer advertising that occurs and it occurs on
the part of other competing hospitals as well as manufacturers and
pharmaceuticals. So, hospitals have to have some way of responding to explain
why they made the decisions they did and evidence certainly should be part of
that communication that goes back out to their customers.
And how is this with the Technology Assessment Committee
interact with other areas of the hospital and what would the challenges and
opportunities be if a couple of physicians are swayed by the company that they
absolutely have to have this device.
DR. WINIFRED HAYES:
Well, I guess the first question that needs to be asked as
part of the answer to your question is, is this an advisory committee or is it
a determinate committee. In other words, is the output of this committee used
in the advisory fashion or will it in fact be used to decide whether the
organizations purchases or does not purchase the device. The second thing
that's important for this committee to do is to communicate widely among
clinicians, physicians what the methodology is and what the bases, the ground
rules are for the decisions that get made and in this process there needs to be
an opportunity for physician advocates for this technology to present his or
her case. So, they need to know that they can present the reason that they feel
this technology is compelling and when the committee finishes its work, it's deliberations
and draws a conclusion, they need to communicate that conclusion in such way
that it's transparent on stake-holders why the decision was made. Certainly,
that committee should look at information provided by the manufacturer, but it
should never rely on manufacturer data, it really needs to go to the peer reviewed
research evidence and in the absence of evidence, there should be strong
cautionary position taken about the adoption of a technology for which there is
insufficient evidence. If those technologies are brought in, the committee
should have the ability to require that there be some kind of oversight and
clinical followup on the clinical outcomes for this procedure and any adoption
should be on a conditional basis. Now, clearly there is some hospitals and
some physicians, who work in that research phase, University Medical Centers
are clearly the setting where early adoption is expected, but when we move into
the community and we look at Community Hospitals, and perhaps that's less
compelling for many hospitals, but again if they see themselves as an early
adopter because of their roles in a given clinical area like orthopedics. When
they bring things in for which there is insufficient evidence, it should be
brought in, in a controlled way and with some kind of oversight.
Well, with that I would like to thank Dr. Winifred Hayes,
who has been our guest. She is with the Hayes Group and she was talking about
a growing trend in healthcare to evaluate technology using evidence.
Physicians and hospitals will be hearing about this and I would like to thank
Dr. Hayes for being our guest.
You have been listening to the Clinicians Roundtable on
ReachMD, The Channel for Medical Professionals. If you have comments or
suggestions about today's show, and I would like to thank you today for
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