Canada has a long and rich history of building resources and infrastructure to support health technology assessment (HTA), a process used to evaluate the social, economic, organizational and ethical issues of a health technology in order to inform policy decision-making.

Currently, HTA researchers are primarily focused on the first step of a health technology’s use: adoption. That is, researchers are focused on building the evidence needed to prove to health decision-makers why their technology should be adopted for routine use and funded by the public health system.

Assessments typically focus on factors such as the costs, effectiveness, safety, ethics and liability associated with adopting the new health technology. MaRS EXCITE introduces a new more collaborative and proactive HTA program for needed medical technologies in the Ontario health system. The goal of the program is to help the health system work collaboratively with the innovator in order to get their product to market faster using an integrated evaluation approach. (The program is currently accepting applications from health innovators until March 9.)

However, technology management—ensuring that, once a technology is in the system, it is used most effectively and efficiently—has not historically been an area of focus of HTA work, despite it being where much of the patient value and health system value of a new health technology is either created or destroyed.

In November, during the CADTH 25th Anniversary Lecture SeriesStirling Bryan, director of the Centre for Clinical Epidemiology and Evaluation at the University of British Columbia, re-imagined the role of HTA in supporting health system decision-making.

His key thesis was that health systems should focus much less on technology adoption and more on technology management, ultimately moving toward a clinical pathway management model in which a particular technology’s use over time by a particular clinical population is monitored and managed in an evidence-informed way.

Step 1: From technology adoption to technology management

In his lecture, Stirling began by discussing the first mindset shift needed in HTA: a shift from focusing on technology adoption to technology management.

Currently, decisions about technology adoption are narrowly focused on coverage or reimbursement (or “listing”) decisions based on the evidence package reviewed in the health technology appraisal. The result is that Canada’s incredibly skilled pool of HTA researchers and health economists devote a fair share of their resources to technology adoption questions (for example: What are the barriers and facilitators for the adoption of a technology?), while very little resources are used to support decisions about technology management. The paradox is that inappropriate use and obsolescence of existing technologies are two of the key drivers of cost inflation in the health sector.

There are three sets of evidence questions to be answered in a technology management paradigm.

  1. Assessment: Does the technology, as it is currently used in the field, (still) deliver value?
  2. Improvement: Could more cost-effective use of the technology be achieved through modifications to the clinical protocol or pathway?
  3. Withdrawal: Should the technology no longer be routinely used and, if so, should a process of disinvestment be commenced? (This final question aligns with the goals of Choosing Wisely Canada, a pan-Canadian initiative launched in 2014 where physicians and patients engage in conversations about unnecessary tests, treatments and procedures.)

Based on our experiences running the MaRS EXCITE program, we could add a fourth dimension focused on obsolescence management and called “replacement.”

The question to be answered would be: What alternative modality or tool could be used to feasibly achieve the same or better outcomes at the same or better cost?

Step 2: From technology management to clinical pathway management

With the case for using HTA for technology management well in hand, Stirling shifted to his main thesis of using HTA for clinical pathway management. His idea is to get away from looking at a discrete technology’s value in isolation from the broader system into which it is deployed, and to instead examine a sequence of use for a suite of alternative technologies that could be deployed in a given patient’s clinical pathway.

An example of a clinical pathway management model is a chronic illness condition, like asthma, where a suite of biomedical technologies could be deployed and where, at some time, the patient may need to switch to alternative modalities due to lack of effectiveness, side effects or other access issues (such as an inability to pay for or physically access the product or service).

A robust HTA evidence base that underpins a pathway management model would allow health system managers to predict on average how long patients will be able to receive effective care with a particular technology before they transition to an alternate course. The model would not just be about the changes of treatment path, but it would also reflect disease progression to make it adaptive to the given patient context.

Looking ahead: Is Canada ready for an HTA paradigm that focuses on downstream use of technology?

In an era where healthcare spending is highly constrained, pathway modelling is an HTA innovation whose time has come, argued Stirling. This new approach would build a stronger “resource stewardship” culture, where resource scarcity is openly acknowledged and where trade-offs are recognized as a shared responsibility between key stakeholders.

The transition from a focus on technology adoption to a focus on technology management within a clinical pathway has implications on a number of aspects of the current state approach to HTA.

  1. Technology scope: There must be a shift in focus from a discrete technology to multiple technologies in a patient’s clinical pathway.
  2. Care pathway scope: HTA is a narrow focus at a single point in a pathway, whereas pathway management considers all points along a patient’s journey. Further, traditional HTA tends to focus on technologies in the diagnosis or treatment stage; however, illness prevention might be a better area in which to invest HTA resources.
  3. Opportunity cost: This model encourages health system stakeholders to adapt a resource stewardship mindset where opportunity costs are an explicit trade-off.
  4. Evidence based: HTA for clinical pathway management opens the door to broader forms of evidence, rather than just clinical trials (the current gold standard of evidence that has significant limitations in generalizability to the real world).
  5. HTA agencies: In this model, the role of Canada’s HTA agencies can change from being passive to being active.

As health systems across Canada evolve their approaches to health innovation adoption, diffusion and appropriate use, it will be interesting to see how and where Stirling’s ideas get traction over the coming months.

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Adel Aziziyeh

Adel Aziziyeh is responsible for ensuring that clinical studies conducted within MaRS EXCITE are at the highest level of study co-ordination, quality and execution. Adel joined MaRS in October 2013. Previously, he held roles as a clinical research co-ordinator at the Centre for Addiction and Mental Health (CAMH) in Toronto and at the Baylor College of Medicine in Houston, TX. See more…