technology assessment and quality improvement

Technology Assessment and Technology Assessment and Quality ImprovementQuality Improvement

TH Tulchinsky MD MPHTH Tulchinsky MD MPH

Braun School of Public HealthBraun School of Public Health

Dec 2004Dec 2004

Technology Advances, 18th CenturyTechnology Advances, 18th Century

• Thermometer• Lime juice supplements (Lind) • Vaccination (Jenner) • Surgical anatomy (Hunter)• Clinical sciences (Sydenham)• Obstetrical forceps

Technology Advances, 19th CenturyTechnology Advances, 19th Century

• Anesthesia • Stethoscope, laryngoscope, ophthalmoscope, blood

pressure cuff, syringes, X-ray• Sanitation • Antisepsis • Braille printing• Hygiene in obstetrics• Nursing, well child care• Cellular pathology, pathological chemistry• Microbiology, immunology and vaccines• National health insurance

Technology Advances, 1900-1930Technology Advances, 1900-1930

• Improved biomedical education • Salvarsan• Insulin• Blood groups• Vitamins • Conquest of yellow fever • Cost benefit analysis


• Penicillin • Randomized clinical trials, • Antimalarials and vector controls


• Vaccines • Anti-hypertensives • Psychotropic drugs • Cancer chemotherapy

• Prepaid group practice • Risk factors for CVD• Smoking and lung cancer


• DNA • Oral rehydration • Vaccines for polio, measles, mumps, rubella • Cost-effectiveness analysis• Smoking and CVD risk factors• Open heart surgery and intensive care • Pacemakers, organ transplantation, • Computerized Tomography (CT) • Eradication of smallpox • HMOs, DRGs, district heath systems


• Magnetic Resonance (MRI) • Positron emission tomography (PET) • Endoscopic surgery to improve surgical care• Eradication of polio • H pylori control to prevent stomach cancer and

chronic peptic ulcers and surgery• Managed care to provide quality care and

prevention to enrolled population• Folic acid to prevent NTDs

Appropriate Health TechnologyAppropriate Health Technology

• WHO - level of medical technology needed to improve health conditions in keeping with the epidemiologic, demographic and financial situation of each country

• All countries have limited resources and must select strategies of health care and appropriate technology to use those resources effectively to achieve health benefits

• Traditional Birth Attendants and Community Health Workers for prenatal preparation and normal deliveries and preventive primary care to reduce maternal and child mortality

Appropriate Health Technology: Appropriate Health Technology: National Drug FormulariesNational Drug Formularies

• NDFs are consensus lists of essential drugs sufficient for major health needs of a country to reduce duplication, combined products of the commercial market

• To ensure availability and rational use of drugs and vaccines and economic procurement

• Assist regulatory agencies, legislation, quality control, information, supply, training, reference laboratories

• International Pharmacopoeia, WHO Drug Bulletin, WHO Model List of Essential Drugs

• To improve quality and cost management in national health systems

Basics of TA for a Medical InnovationBasics of TA for a Medical Innovation

• Is it new or replace a less efficient service?• Is there a need for it?• Where is it in the order of priorities?• Does it duplicate a service already available?• Does it help diagnosis, treatment for patient's benefit?• What are the alternatives?• What resources are needed to purchase, staff, maintain? • Can the facility afford it?• What could otherwise be done with these resources?

Canadian Coordinating Office for Health Canadian Coordinating Office for Health

Technology Assessment (CCOHTA)Technology Assessment (CCOHTA) • Conference of Deputy Minister of Health 1989• Board of Directors• To provide evidence-based information on

emerging and existing health technologies, primarily to Canadian health care policy makers and managers

• 'Technologies' is broadly defined as any medical procedures, devices, systems or drugs used in the maintenance, treatment and promotion of health

Canadian Technology AssessmentCanadian Technology Assessment

• Technology ReportsTechnology Reports • Bisphosphonate agents for the management of pain

secondary to bone metastases: a systematic review of effectiveness and safety

• Telephone triage services: systematic review and a survey of Canadian call centre programs

• Spinal Manipulation for Infantile Colic • Emerging Technologies SeriesEmerging Technologies Series• Wireless Capsule Endoscopy • Insulin Glargine: a long-acting insulin for Diabetes Mellitus • Transcatheter Enfuvirtide, a new treatment for HIV

infection

Research Projects Medical Devices and Research Projects Medical Devices and Health Systems: CanadaHealth Systems: Canada

• Impact of Delay in Initiation of Radiation Treatment Post surgery for Women with Early-stage Breast Cancer receiving chemotherapy

• Tandem mass spectrometry in newborns • Intravenous immunoglobulin (IVIG) • Devices to monitor anticoagulation in a community

based setting • Virtual colonoscopy/virtual endoscopy • Smoking cessation therapies

Research Projects CanadaResearch Projects Canada: PharmaceuticalsPharmaceuticals

• Activated protein C for severe sepsis • Direct Thrombin Inhibitors for

anticoagulation: an economic analysis • Teriperitide for osteoporosis: an economic

analysis

• Insulin pen-fill formulations

Hitech Medical Equipment/Procedures Rates (per Million Population) In Selected Countries and Years, 1985-1996

USA 12.8 26.9 0.5 16.0

France 4.7 9.4 0.5 2.3

Germany 6.9 16.4 0.7 5.7

Netherlands

3.2 9.0 0.1 3.9

UK 2.7 6.3 0.3 3.4

Canada - 7.9 - 1.3

Sweden - 13.7 - 6.8

Australia - 18.4 - 2.9

Country CTs1986 to 1993/96

MRIs1986 to 1995/96

Japan 27.5 69.7 0.1 18.8

Infectious disease Treatment Vaccination

Breast cancer screening

Mammography Breast self exam, nutrition

Colon cancer Colonoscopy Occult blood, nutrition

Acute MI Coronary angioplasty

Streptokinase, aspirin, diet, exercise

Gall stones LithotropterAbdominal surgery

Endoscopic surgery

Head injuries Intensive care Helmets for bicycle riders

Thalassemia Transfusions, Chelating agentsPrenatal Dx,

Screening, education

Liver failure Liver transplant Hepatitis B vaccinationScreening blood donations

Problem Hitech Lotech

Dehydration Infusion Oral rehydration

Quality AssuranceQuality Assurance

• QA Measures and evaluates proficiency or quality of services rendered.

• QA is an integral part of public health function • Involves ensuring the quality of both health

practitioners and facilities.

Quality Assurance OrganizationQuality Assurance Organization

• Professional Standards Review Organizations (PSROs)

• Medical Audit Committees • Maternal mortality review committees• Death rounds/clinical pathological conferences• Infant mortality reviews• Utilization reviews

StandardsStandards

• Control of Communicable Diseases Manual• American Academy of Pediatrics “Red Book”• AAP Committees published in Pediatrics• MMWR regular• MMWR RR and SS series

Clinical GuidelinesClinical Guidelines

• Apgar score - standardized infant assessment• APACHE system (acute physiology and chronic

health evaluation) • Clinical algorithm - defined sequence of alternative,

logical steps depending on outcomes of previous ones, incorporating clinical, laboratory and epidemiological information, applied to maximize benefits and minimize risks for the patient.

• Health Care Financing Administration (HCFA)• National Institutes of Health (NIH) have consensus

programs to develop guidelines

Clinical GuidelinesClinical Guidelines

• WHO• American Medical Association - 2200 practice

guidelines• Managed care companies, pharmacy benefit

managers, governmental bodies• Professional organizations such as the

American Academy of Pediatrics• Psychiatric Association and the American

Academy of Child and Adolescent Psychiatry

Clinical Practice Guidelines NHLBI Clinical Practice Guidelines NHLBI (NIH)(NIH)

• Asthma• Guidelines for the Diagnosis and Management of Asthma

Update on Selected Topics 2002 • Cholesterol• Clinical Guidelines on Cholesterol Management in Adults

(ATP III) • Recommendations Regarding Public Screening for

Measuring Blood Cholesterol • Hypertension High Blood Pressure Guidelines (JNC 7) • Obesity Clinical Guidelines on Overweight and Obesity • Other National Guidelines Clearinghouse

• http://www.nhlbi.nih.gov/health/indexpro.htm

Organizations to Promote Quality in Health Organizations to Promote Quality in Health in the United States in the United States

• NCQA - National Council for Quality Assurance: This non profit organization was founded in 1979 by the managed care industry to conduct surveys among managed care plans to evaluate clinical standards, members rights and health service performance. It accredits over 50% of the 630 managed care plans in the US (1997)

• AHPCR - Agency for Health Care Policy Research: Part of the US Public Health Service (1995), and mandated to develop an Evidence-Based Practice Program in 12 centers in the US and Canada. It conducts systematic reviews of the literature, publishes its analyses and findings with guidelines for care, quality improvement projects and purchasing decisions for health plans

• Source: Medical News and Perspectives. Journal of the American Medical Association, 1997;278:155-1562.

Organizations to Promote Quality in Organizations to Promote Quality in Health in the United StatesHealth in the United States

• FACCT - Foundation for Accountability is a non profit organization with the purpose of providing information to consumers, with a stress on quality of care for chronic diseases and measuring tools to develop standards and assess health plan performance in conditions such as diabetes, asthma, breast cancer, CHD and alcoholism

• HCFA - Health Care Financing Administration, a federal agency of the Department of Health and Human Services responsible for administering the Medicare and Medicaid health plans

Organizations to Promote Quality in Health in the United States

• IHI - Institute for Healthcare Improvement is a non-profit organization to improve health care in Canada and the US by fostering collaboration among health care organizations

• NPSF - National Patient Safety Foundation of the American Medical association as a response to findings of high rates of injury and death from iatrogenic disease in the US

• JCAHO - Joint Commission on Accreditation of Healthcare organizations; Internet http://www.jcaho.org

Hospital AccreditationHospital Accreditation

• Long standing method of QA in North America• Used in teaching and community hospitals and long

term care facilities, as well as ambulatory, home care and mental health services

• Initial focus on acute care hospitals, accreditation extended to special hospitals, long term facilities, home care programs, public health departments, ambulatory care services

• Major contribution to raising standards of patient care throughout Canada and US

• Provides a working model for replication or adaptation internationally e.g. UK, Philippines

Hospital Accreditation in CanadaHospital Accreditation in Canada

• Voluntary grouping of professional associations, including the College of Physicians and Surgeons, the Hospital Associations and the College of Nurses

• Joint Council carries out regular inspections of hospitals – “voluntary”

• Other organizations are included: federal Department of Health and Welfare, provincial Ministries of Health, Canadian Diabetic Association, Public Health Association, the Standards Council of Canada as observers

Services Evaluated in Hospital Accreditation, CanadaServices Evaluated in Hospital Accreditation, Canada

Ambulatory careChild life servicesClinical record servicesCritical care unit (generic)Discharge planningDiagnostic servicesEducation servicesEmergency servicesGoverning bodyHousekeeping servicesHuman resource servicesIntensive, cardiac careTransplant units Laboratory servicesLaundry and linen servicesLibrary servicesLong term care/geriatric unitManagement servicesMaterial management Medical equipment services

Medical servicesNeonatal intensive careNuclear medicineNursing servicesNutrition and food servicesObstetrical servicesOccupational therapy servicesOperating suite, recovery unitPalliative care unit Pastoral servicesPharmacy servicesPhysical plant maintenance Physiotherapy servicesPsychiatric servicesPsychology services Rehabilitation servicesRespiratory therapy servicesSocial work servicesSpeech and audiology unitVolunteer services

Standards for Internal QA programStandards for Internal QA program

• Utilization review– Appendectomy rates– Caesarian rates

• Records reviews– Management of AMI (tracer conditions)

• Risk management • Infection control, • Employee health and safety • Disaster and emergency planning

Standards for Acquisition of Costly Medical Equipment, Israel 1996

CT Hospital >300 beds

1/200,000

Cardiac catheterization unit

Hospitals >300 beds with cardiac intensive care >5 beds

1/200,000

NMR Hospitals >400 beds with approved radiology dep't + CT

1/300,000

Gamma camera Hospitals >300 beds + approved radiology dep't

1/100,0001/80,0001/500,000

Linear accelerator

Only in ministry approved centers for Radiation Rx

1-3 units in regional radiation therapy centers, 1-3:millionLithotropters Major hospital

center 1/:million

Technology Conditions Ministry Permitted Rate

PET Research purposes

1/5.5 million

Source: Adapted from Regulating medical technology in Israel, in Shemer J, Schersten T [eds]. Jerusalem: Gefen, 1995.

Total Quality Management and Total Quality Management and Continuous Quality ImprovementContinuous Quality Improvement

• Involves multi-disciplinary approaches to review problems, and to seek better ways of functioning and improving consumer satisfaction.

• Process includes all those involved in providing care, support services and administration of a department, hospital, clinic or community health program.

• Professional self-policing to find better ways of meeting needs and using resources

• Improves performance and morale

SourcesSources

• The New Public Health, Chapter 15• NCHS• JCAHO at http://www.jcaho.org • JAMA. 1997;278:155-157 • US Public Health Service (PHS) Preventive Services

Task force Guide to Clinical Preventive Services • National Institutes of Health Consensus Program,

Office of Medical Applications Research http://opd.od.nih.gov/consensus/about/about.htm

• American Academy of Pediatrics Policy Statements http://www.aap.org/policy

http://opd.od.nih.gov/consensus/about/about.htm

technology assessment and quality improvement

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