Friday, June 26, 2009

Reflections on the HTAi meeting in Singapore

Reflections from the HTAi meeting this year

In the morning session, the Singapore health minister was talking about US Health CEA report, and discussed a lot of interesting points. One was the issue of high cost but low value treatments where much of medical technology falls. He thought health care market place is an information asymmetric market where the seller or the vendor is in control. However, this was not unique to medical marketplace because there are other markets like a car market for instance is similar and people buy cars lured by its shape, style, other features, not knowing much as to its real world. However, now reviews are available all over the web for different cars (and similar consumer goods). Similarly, with the credit rating agencies, same thing is going on – a system of review and then there is consumer driven reviews of their effectiveness. He thought medical technology solutions are cost increasing as opposed to cost saving, and this contrasts with what we get around to see with for instance, electronics. He cited the example of Richard Kahn and “Quality of Diabetes Care” report (On Archimedes Model here, speech here), praised NICE (Singapore adopts NICE for recommendations), talked about comparative effectiveness research budget allocation in the US (for proceedings of a Brookings Instituteion report see here, and about global initiative for health technology. He talked about GE Healthcare report in India about frugal innovation (read the article in economist here). Talked about Michael Porter and outcomes (an article by Michael Porter on Health Care Reform in NEJM here; more on Michael Porter here), Talked ahout systematic management and availability of publications from Singapore about two years of singapore data on the effectiveness of comprehensive dmp (which he termed as systematic management). While attending to his lecture, it occurred to me that we can start drafting an article outlining our papers on comprehensive disease management programmes for the management of chronic heart failure and have it publishde either in the international journal of health technology assessment or somewhere else. Finally, he talked about preventive care.

Harvey Fineberg followed on with a keynote address that was really worthy of listening (it'd be good to ask Harvey Fineberg if he'd be willing to share his powerpoint slides. They are great for teaching or research). Interestingly, Fineberg has written a paper on influenza immunization evaluation and is apparently reads well (got to search for it and get a copy. Perhaps keep it for personal reading Fineberg talked about the emergence of Australia (in addition to Singapore) as a country that has phenomenal growth in recent years and significant achievements in controlling non-commnicable diseases and increment in life expectancy. He talked about the achievements of Jacob Bigelow and the work by Bigelow titled, “Elements of technology” (have to check it in google books or from free online book site project gutenberg and if possible, download and read, click here The central thesis of Bigelow's work, according to Fineberg was “application of sciences to useful arts”, by which he described how science influenced technology and in turn affected everyday life. He mentioned about the work of Stanley Riser and how technology distanced the physician from the patient (citing the instance of stethoscope as a metaphor) and now, how telehealth was playing out the same thing. He mentioned that health technology assessments in the United States grew out of the need to assess unintended use of technology and its associated ethical and or social consequences. He talked about crafting those assessments that were relevant to all levels of decision making – clinical, regulatory, and payment or reimbursement communities. He talked about understanding the choices of the burden of disease (importance of burden of disease). I think what he meant was that, health technology assessment in certain contexts, say India, would be important if the focus was on which diseases were most important and which technologies addressed important disease management in those settings. He also mentioned that those countries that were least investing in technologies were most to gain if they conducted systematic technology appraisals regularly. He then laid out a table where he discussed the finer differences between health technology assessments, health services research, comparative effectiveness research, and evidence based medicine. His focus on hta was that, for hta, the keyword is “comprehensiveness”. I think this is a point worth keeping in mind as we start developing our own reviews. I was thinking of the dementia review as I heard him speak, how comprehensive have we been. Yet, it's a point where there is only so much we can do, given the time constraints (more on it later in the document). In any case, according to Fineberg, the worst that anyone can say to a health technologist is that ' you have not been very comprehensive in your scope of the topic”. I think it's a good point to keep in mind as a take away lesson from this conference, at least for the first day. The first day has been a very exhausting and long day with lots of presentations and a lot of stuff. It's also time to think of getting out publications for the dublin conference, writing more for the journals. In general, between reading about bayesian stats in the plane and all these conferences, I think it's time to focus more on writing out stuff and doing analyses rather than just revering or thinking about them. It's more important to “do” things while there are opportunities and less to talk about. Anyway, coming back to Fineberg, he talked about HSR as being managerial choices or “developing programmes” (I think it's a good idea to write these to Jim Romeis and see what he feels). He talked about comparative effectiveness research (CER) and laid out the options for clinicians and the patients. He talked about evidence based medicine (EBM) as making choices. It did not appear from his talk that he thought economic evaluations were considered to be part of comprative effectiveness research but only clinical consequences. I am not sure I understood this point. I think the most impressive part of his speech was his laying out of the objections to health technology assessment on the basis of fears it instills in the minds of several different types of stakeholders. Briefly, these are loss of choice for some patients and that's why they would object to any type of health tech assessment, loss of time and return on investment on part of innovators and technology vendors and that's why they would object, physicians would object because they would face loss of autonomic choices as a consequence of health tech assessment, and hospital administrations might perceive that they lose their technological “edge” if they heeded to tech assessments that went one way or other. He briefly talked about addressing each of these issues iin the talk (perhaps it'd be good to write to him requesting a copy of the presentaiton and tell him how profoundly it impacted the way I start thinking about health tech assessments and what might be the next steps). He talked about balancing about setting priorities among organizations, intents, populations, intervention types, and nature of the popultions. Also, according to Fineberg, there is a case of developing individual subject based tech assssments versus developing a portfolio of assessments. Then there were issues about time horizons, and measurement related issues. He briefly talked about A star programmes worth following up.

The other person who I think is worth discussing is Prof David Matchar. It's worthwhile to follow up and introduce myself to him and discuss how I find his work and his ideas close to what I have been working on (it'd be good to do a google search on David Matchar and read his writings and discuss). His area was the area of coverage with evidence development. It'd be good to get his slides from him, in particular the flowchart. It'd be good if we can introduce the topics of coverage with evidence development in the introductory course on health technology assessment that we are teaching in the next semester. Specifically, include the slides from David Matchar about what it is. He introduced Sean Tunis and the concept of “residual uncertainty” and the context in which coverage with evidence decisions occur. Briefly he discussed that an item is drawn out and clinical policy questions are framed. Then, it is examined if there are adequate data to support a list or tableau of information. Then, current evidence is reviewed as comprehensively as possible. From here, there are two possibilities – 1) adequate information is available for making one of the two decisions – a) rejection of coverage that the evidence does not justify support, or unconditional support. In either case, one does not need coverage with evidence development type of steps to follow up. The other possibilty, 2) draw up a list of alternative strategies to address as to the “value of information” and this leads to further evidence development. His talk was followed by the talk by Louis Jacques who talked about NOPR (National O?? PET Registry???); David then followed up with a talk on PET scanning for Alzheimer's disease and discussed variants of pragmatic RCTs (pragmatic RCTs are topics worth looking up in Google). Questions that occurs to me now on this topic, “How do we synthesize pragmatic RCTs, are they any different from synthesizing standard RCTs?? “. Perhaps it'd be worthwhile to catch up on David Matchar and ask him questions, introduce and discuss mutual plans. Will he be attending the CED interest group? Looks like. Sean Tunis talked about Barry Brazzleton (is that spelling correct, another googling candidate) and generally talked about some issues associated with coverage with evidence development. I remember Pam did some work with the ministry about coverage with evidence development about a tumor treatment, quite forgot what the deal was about. As I heard the talks, it occurred to me that we might discuss the possibilities whether colorectal cancer screening might qualify as a topic for further coverage with evidence development. Certainly, we can toy this idea and throw this to Stephen. Cecilia sent him the final version of the fobt report and requested if they are going to put the stamp of completion (as I understand) and he comes back with the statement that they were not going to do it right away and “much water is going to flow beneath the bridge”. What does that mean? Ray doesn't know and advised I ask Stephen about it. Maybe ask him that.

The lunchtime seminar, was, quite literally, full of foods for thought. I attended the one about rapid HTA versus full HTA and I am not sure I understood the core issue. To me, it seems that for any HTA, there are two steps – first, you establish the internal validity of a study and if the study is not internally valid enough to answer the question you pose, you move on and select the next one and the next and so on. In the second step, you appraise the materials in these studies and start putting together a summary and extract information enough to make a decision one way or other. It that takes time, so be it. Guy Maddern from Australia presented data about the dichotomy between what he termed as rapid HTA versus full HTA. I requested the slides from Guy (perhaps it's a good time to remind him or send him an email while it is hot). Nothing much came out of that seminar. Meanwhile, before these sessions, I met Maarten Izerman (meet him again today at Wasan's presentation session) – email A good contact to discuss issues related to device evaluation. He suggested about medical decision making. The medical decision making and the society for medical decision making sounded very interesting. I wanted to ask what is the role of simulation in HTA (perhaps that's a topic worth considering for the next years' round in Dublin Ireland). I got the subscription squared away. It's time to claim the refunds when I return. They sent me receipts at both gmail and canterbury email address.

The session on Telehealth was particularly interesting and important for me for the Ako Aotearoa project. Three important people to chase up and grow contact with following this conference are Brendon Kearney (see where he will be today and follow up with him), Jose Asua (, and David Bailey. Had a chase up conversation with David Bailey (got to find out his email address and remind him to send any information on his programmes) David gave me names of Richard Wootlon (Centre for Online Health, Queensland) and Anthony Smith (Centre for Online Health, Queensland) and it's good to discuss with David, Richard, and Anthony about issues related to pedagogy of providers (physicians and nurses) on Telehealth. It appears this kind of shook them and they didn't think about it as they went on developing the programmes and talking about it. Asua certainly thought that there was nothing to be “taught” about it Telehealth being so intuitive. Bailey thought it was a niche area worth pursuing. The other point is to check with SBU website about dementia care review that they have done.

More reflections for the 23rd June

Basically, joined two special interest groups – one for the developing countries, and the other for developing coverage with evidence development. These are the two net benefits of coming to this conference. Got to track the email address of Clifford Goodman, vice president of the Lewin Group and ask him to send me the copy of the literature review they did for the coverage with evidence development. It is supposed to contain some really good materials for studying and teaching others about coverage with evidence development. The discussion around coverage with evidence development, the whole NOPR story and other issues were very good today. It essentially laid out the foundations of when to conduct a coverage with evidence development type of study, who can initiate these studies and so on. Good stuff, I thought. Got to write to Sean Tunis perhaps today or tomorrow to share my email address and request him to add me to the interest group. It will be interesting to see where it heads. The other interesting group was that for the developing country interest group because of my natural interest towards working with the developing country settings and I think it's important to do some overview of the kind of health technology assessment that might be possible to do there. In particular, India might be a good place to start thinking about setting up a few coverage with evidence development kind of work particularly with the insurance sector. At least, a few concept papers on that line may not be altogheterh out of place. Speaking of coverage with evidence development, there was a good direction to the study by the EUNEHTA group, paper WP7. Got to see if they already carry it in their booth. Got to keep an eye on pharmacoeconomics and development of pharmacoceononics in developing countries. Netherlands has some codified protocols in place that are worth considering. Then there was this excellent reference to The Economist on the use of personal digital medical devices and their usage.