Knowing What Works in Health Care A Roadmap for the Nation (2008) / Chapter Skim
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3 Setting Priorities for Evidence Assessment
3 Setting Priorities for Evidence Assessment
Pages 57-80
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From page 57... ...
If the nation is to resolve the current deficiencies in how it uses scientific evidence to identify the most effective clinical services, there must be a process for identifying the most important topics in order to preserve resources for evidence assessment itself. Most health technology assessment programs have an organized process for determining which topics merit comprehensive study.
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From page 58... ...
BACKGROUND This section provides background on the basic elements of a priority setting process: identifying potential topics, selecting the priority criteria, reducing the initial list of nominated topics to a smaller set of topics to be pursued, and choosing the final priority topics. Some approaches also incorporate quantitative methods that involve the collection of data that can be used to weigh priorities, the assignment of scores for each criterion to each topic, and the calculation of priority scores for each topic to produce a ranked priority list.
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From page 59... ...
Committee on Priorities for Assessment and Reassessment of Health Care Technologies proposed a method that could be used to aggregate various dimensions into a single priority score, including a technique that quantifies the potential gains that can achieved by assessing health interventions (IOM, 1992) . Various Contexts for Setting Priorities Organizations have different objectives and target audiences for evidence assessment.
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From page 60... ...
; BCBSA TEC (2007) ; NIH Consensus Development Program (2007)
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From page 61... ...
Thus, for example, an insurance company is not likely to assess the efficacy of a vaccine if it does not cover preventive services. The agenda of AHRQ, the lead federal health agency charged with conducting systematic reviews of clinical effectiveness, is circumscribed by statute.
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From page 62... ...
62 KNOWING WHAT WORKS IN HEALTH CARE TABLE 3-2 Methods Used to Identify Topics for Systematic Reviews in Selected Organizations Organization Methods Who Can Nominate Eligible Topics AHRQ Solicits topics Open to the public; Effectiveness of prevention, annually through AHRQ conducts diagnosis, treatment, and the Federal Register systematic reviews management of common and accepts for CMS, the clinical and behavioral nominations on an USPSTF, and the conditions; organization ongoing basis NIH Consensus and financing; and research Development methods; topics addressed Conference program by the Effective Health Care Program must relate to 1 of 10 priority conditions established by the secretary of HHSa BCBSA TEC Solicits topics from TEC staff, medical Effectiveness of surgical within BCBSA and directors of procedures, devices and from its advisers member plans, implants, diagnostic imaging, Medical Advisory laboratory tests, and targeted Panel (external and specialty pharmaceuticals advisers) , Medical Policy Panel, and pharmacy managers Cochrane Vary among 51 Open to the public; Broad range of clinical services Collaboration review groups reviews are author and population-based health initiated or the topic interventions is nominated and authors sought DERPb Program State Medicaid Comparative effectiveness of participants programs and drugs within classes of drugs nominate topics other participating organizations MedCAC and Internal decision MedCAC staff Devices, drugs, and procedures CMSb that are within the scope of Medicare coverage and subject to a national coverage decision NICE Internal decision by Individuals and Effectiveness of services that the department of groups are being considered for health in England coverage by the National and Wales; NICE Health Service, including uses the National drugs, devices, diagnostics, Horizon Scanning surgical procedures, and Centre to identify population-based health new and emerging promotion technologies
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From page 63... ...
Department of Health and Human Services; NICE = National Institute for Health and Clinical Excellence; NIH OMAR = National Institutes of Health Office of Medical Applications of Research. aThe priority conditions are arthritis and nontraumatic joint disorders, cancer, chronic obstructive pulmonary disease and asthma, dementia, depression and other mood disorders, diabetes mellitus, ischemic heart disease, peptic ulcer disease and dyspepsia, pneumonia, and stroke and hypertension.
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From page 64... ...
Although it is not clear that early effectiveness assessment would deter the rapid adoption of unproven interventions, assessments of the early evidence could underscore the risks of early adoption. A compelling example of what can go horribly wrong when a high-risk, untested procedure is promoted is high-dose chemotherapy with autologous bone marrow transplantation (HDC/ABMT)
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From page 65... ...
Preventive Services Task Force SOURCE: Personal Communication, J Slutsky, Agency for Healthcare Research and Quality, May 10, 2007.
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From page 66... ...
66 KNOWING WHAT WORKS IN HEALTH CARE BOX 3-2 Topics of Evidence-based Practice Center Reports, 2005 to present Bioterrorism Pediatric Anthrax, Bioterrorism Preparedness Cancer and blood disorders Adnexal Mass Cancer Care Quality Measures, Colorectal Cancer Cancer Care Quality Measures, Symptoms and End-of-Life Cancer Clinical Trials, Recruitment of Underrepresented Populations Hereditary Nonpolyposis Colorectal Cancer Ovarian Cancer, Genomic Tests for Detection and Management Small Cell Lung Cancer, Management Complementary and alternative care Meditation Practices for Health Dietary supplements B Vitamins and Berries and Age-Related Neurodegenerative Disorders Multivitamin/Mineral Supplements, Chronic Disease Prevention Omega-3 Fatty Acids Series: Effects on Cancer, Child and Maternal Health, Cognitive Functions, Eye Health, Mental Health, Organ Transplantation Soy, Effects on Health Outcomes Ear, nose, and throat conditions Sinusitis, Acute Bacterial -- Update Heart and vascular diseases Abdominal Aortic Aneurysm, Endovascular and Open Surgical Repairs Heart Failure Diagnosis and Prognosis, Testing for BNP and NT-proBNP Left Ventricular Systolic Dysfunction, Cardiac Resynchronization Therapy and ICDs Post-Myocardial Infarction Depression Information technology Health Information Technology, Costs and Benefits Telemedicine for the Medicare Population -- Update Lung conditions Asthma, Work-Related Chronic Obstructive Pulmonary Disease, Spirometry Mental health conditions and substance abuse Adults with Non-Psychotic Depression Treated with SSRIs, CYP450 Testing Eating Disorders, Management Tobacco Use: Prevention, Cessation, and Control The emphasis on horizon scanning appears to have led to a considerable duplication of effort among health plans and private technology assessment firms in the United States. In response to a request by the committee, UnitedHealthcare provided a sample list of the screening, diagnostic, therapeutic, and disease management services and devices that it had
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From page 67... ...
The committee then asked three additional health plans (Aetna, Kaiser Permanente, and WellPoint) and TEC, the ECRI Institute, and Hayes, Inc., if they had also conducted reviews of the 20 services that UnitedHealthcare had reviewed (Table 3-4)
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From page 68... ...
for birth • Extracranial-intracranial bypass to reduce the risk of ischemic stroke • Fenfluramine plus phentermine to treat obesity • Gastric bubble for morbid obesity • Gastric freezing for peptic ulcer disease • Home uterine activity monitoring to prevent preterm birth • Hydralazine for chronic heart failure • Lidocaine to prevent arrhythmia and sudden death in acute myocardial infarction • Mammary artery ligation for coronary artery disease • Optic nerve decompression surgery for nonarteritic anterior ischemic optic neuropathy • Quinidine for suppressing recurrences of atrial fibrillation • Radiation therapy for acne • Spinal manipulation to treat migraine or cluster headaches • Subcutaneous interferon alfa-2a to treat age-related macular degeneration • Supplemental oxygen for healthy premature babies • Thalidomide for sedation in pregnant women • Traction to treat low back pain • Triparanol (MER-29) for cholesterol reduction NOTE: Adapted from Goodman (2004)
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From page 69... ...
colonoscopy ✓ ✓ ✓ ✓ ✓ ✓ ✓ Disease management Ambulatory blood pressure monitoring ✓ ✓ ✓ ✓ ✓ ✓ ✓ Intermittent intravenous insulin therapy ✓ ✓ ✓ ✓ ✓ Diagnosis CT angiography for suspected coronary artery disease ✓ ✓ ✓ ✓ ✓ ✓ ✓ Microvolt T-wave alternans ✓ ✓ ✓ ✓ ✓ ✓ ✓ Wireless capsule endoscopy ✓ ✓ ✓ ✓ ✓ ✓ ✓ Treatment Brachytherapy for various cancers: breast, ovarian, and ✓ ✓ ✓ ✓ ✓ ✓ ✓ prostate cancer and brain tumors Dysfunctional uterine bleeding and fibroids ✓ ✓ ✓ ✓ ✓ ✓ ✓ Fallopian tube occlusion for permanent contraception ✓ ✓ ✓ ✓ ✓ Growth factor-mediated lumbar spinal fusion ✓ ✓ ✓ ✓ ✓ Intracoronary brachytherapy ✓ ✓ ✓ ✓ ✓ ✓ ✓ Minimally invasive surgery for low back pain ✓ ✓ ✓ ✓ ✓ ✓ ✓ Photodynamic therapy for Barrett's esophagus and esophageal ✓ ✓ ✓ ✓ ✓ ✓ cancer Vagus nerve stimulation for intractable depression ✓ ✓ ✓ ✓ ✓ ✓ ✓ 69 continued
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From page 70... ...
AHRQ EPCs have reviewed 5 of the 20 topics listed (ambulatory blood pressure monitoring, CT angiography, proteomic testing for ovarian cancer, spinal fusion for low back pain, and uterine fibroids)
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From page 71... ...
. Methods Used to Identify High-Priority Topics Selection Criteria Many organizations report using the same general criteria to gauge the potential impact that an evidence assessment might have on clinical care and patient outcomes (Table 3-5)
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From page 72... ...
. Although AHRQ has handled a relatively small volume of nominations, it has considerable experience managing topic nominations for its effectiveness programs.
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From page 73... ...
There are few, if any, empirical data to suggest the optimal frequency for setting priorities or updating previous assessments. The Cochrane Collaboration recommends that systematic reviews be updated every two years and review groups send reminders and results of new literatures searches to prompt the authors (Higgins and Green, 2006)
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From page 74... ...
Five of the eight principles have particular salience for the Program's priority setting process and are described in Table 3-7. Key Program Challenges PSAC Membership The PSAC would be an active body with ongoing responsibility for reviewing topic nominations, horizon scanning, and advising the Program on topics that merit priority systematic review.
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From page 75... ...
unnecessary duplication Objectivity -- evidence based The process is developed by a broadly representative and without bias; conflict of group selected to ensure a balanced membership and interest is minimized minimal bias due to conflicts of interest. Responsiveness -- addresses the The process cultivates input from key decision makers, information needs of decision particularly patients, clinicians, and guideline developers, makers and ensures up-to-date information.
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From page 76... ...
; community-based interventions such as immunization initiatives or programs to encourage smoking cessation; and research methods and data sources for the analysis of comparative effectiveness. Identifying Potential Topics There should be an open and inclusive topic nomination process that cultivates input from the key end users, such as the developers of guidelines and quality measures, patients, clinicians, and payers.
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From page 77... ...
2006. Solicitation for nominations for new primary and secondary health topics to be considered for review by the United States Preventive Services Task Force.
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From page 78... ...
. BCBSA TEC (Blue Cross and Blue Shield Association Technology Evaluation Center)
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From page 79... ...
1992. Setting priorities for health technologies assessment: A model process.
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From page 80... ...
2003. Setting priorities for the evaluation of health interventions: When theory does not meet practice.
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