b2 - equity issues in hta: finding a way to be systematic...ish - moulton - salon e
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Equity Issues in HTA:Finding a Way to be Systematic…ish
Presentation by Kristen Moulton
May 6, 2013
Outline
• Why ethical considerations?
• Why equity?
• What do we need?
• What is out there?
• Can we make it work for us?
• Application of the framework
• Next Steps
Why are ethical issues important in HTA?
• Health technologies are value laden
• HTA is a tool for informing decision making
• Policy decisions go beyond clinical and
cost-effectiveness
• Putting evidence into context makes it
easier to use
Why Equity?
• “Ethical Issues” is a large domain to tackle
• Despite the absence of a consensus of
scope or definition of equity – it is still an
important element or factor of ethical
considerations
Ethical & equity issues important, but rarely
addressed
• 2009 Survey of HTA in Canada: HTA reports
rarely explicitly addressed ethical issues
(DeJean et al.)
• 2011
• Gender sensitive approach rarely taken
(Panteli et al.)
• Not much concrete guidance as to how
to incorporate issues (Duthie& Bond)
What do we need?
• Tool to help systematically identify, address
equity issues
• Must be useable by HTA producers
• Incorporate values of Canada Health Act,
Public Health Agency of Canada social
determinants of health
• Ultimate goal: minimize risk of overlooking
an equity consideration
What is out there?
• Not quite enough?
What is out there?
• Not quite enough?
What is out there?
• Too much?
What is out there?
• Too much?
What is out there?
• Is it right?
Can we make it work for us?
• Some of the domains:
• Equality vs. Equity
• Embedded Inequities
• Implicit Stereotyping
Applying the framework
Surgical Robotics
• 9 of 13 domains seemed applicable
• CADTH report addressed 1 domain
• Health Information and Quality report
addressed 6
Next Steps
• Framework is not perfect
• Positive elements: a good base
• Negative elements: not user-friendly…yet
Next Steps
• Is it “the one”
Help Wanted
• Tweet me one equity consideration you
think is important to address:
@kristen_moulton
#CADTHSymp
Questions?
References
• Hofmann B. Why ethics should be a part of health technology assessment. Int J
Technol Assess Health Care. 2008 Fall;24(4):423-9.
• DeJean D, Giacomini M, Schwarz L, Miller F. Ethics in Canadian health
technology assessment: A descriptive review. Int J Technol Assess Health Care.
2009 Oct;25(4):463-9.
• Panteli D, Zentner A, Storz-Pfennig P, Busse R. Gender in health technology
assessmen: Pilot study on agency approaches. Int J Technol Assess Health
Care. 2011. Jul;27(3):224-9.
• Duthie K, Bond K. Improving ethics analysis in health technology assessment. Int
J Technol Assess Health Care. 2011 Jan;27(1):64-70.
• Hofmann B. Toward a procedure for integrating moral issues in health technology
assessment. Int J Technol Assess Health Care. 2005 Summer;21(3):312-8.
• Daniels N, Sabin J. The ethics of accountability in managed health care reform.
Health Affairs. 1998 17 (5):50-64.
• Culyer A, Bombard Y. An Equity Framework for Health Technology Assessments.
Medical Decision Making. 2012 May-June: 428-441
A4R
Hofmann Checklist
Elements of Culyer& Bombard Framework
• Equity vs. Equality
• Domains of equity
• Legal obligations
• Embedded Inequity
• Institutional Bias
• Implicit Stereotyping
• Contexts, Behaviours, & Circumstances
• Processes in HTA
• Hidden opportunity costs
• Processes in delivery of care
• Special Claims
• Cumulative bias
Cochrane Equity Checklist – suggests
ensuring an equity lens in all steps
1. Develop a logic model
2. Define disadvantage and for whom the intervention is
intended
3. Decide on important study designs
4. Identify important outcomes
5. Evaluate processes and understand context
6. Analyze and present the data
7. Discuss applicability of findings