|Implemented in this survey?|
A health district in NSW has recently developed a process to undertake Health Technology Assessments at the local level. The process is designed to cover new procedures, programs, devices and equipment. The aim is to ensure that decisions regarding the introduction of new technologies and cessation of ineffective technologies are guided by evidence of effectiveness, safety and cost effectiveness, as well as provide an understanding of the organisational impacts of the technologies.
In an attempt to develop a more consistent approach to Health Technology Assessment (HTA) across local Area Health Services, the State Department of Health issued a Model Policy for the introduction of new interventional procedures into clinical practice. The purpose of the Model Policy is to guide AHS in their development of a standard process to introduce those procedures that are supported by evidence of efficacy, safety and are an effective use of resources within current budgetary constraints. (1) The Model Policy provides guidance but is not prescriptive on how Areas should implement such a process. Indeed, the document stresses the need for Areas to adopt a model that reflects local needs and context.
Following the release of the Model Policy, a local health region (the Northern Sydney Central Coast Area Health Service - NSCCAHS) in the state of New South Wales (NSW) developed the Health Technology Assessment initiative. The NSCCAHS HTA initiative is a system for assessing new health technologies to inform decisions about if, how and where they will be adopted. Proposed technologies are being assessed for effectiveness, safety, cost-effectiveness and impact on workforce, training needs, patient volumes, service provision and support services. The definition for technologies covered by the HTA initiative is broad and includes any new procedures, programs, devices and equipment but excludes drugs (due to the fact that local processes are already in place for decisions on the introduction of pharmaceuticals).
The procedure commences once a clinical department makes an application. The Department provides some initial information on the type of technology and its proposed use. The application is then assessed by the local HTA team who will utilise HTAs done by other agencies in Australia and elsewhere, where they exist. Where they do not exist, a literature review (and consultation) will be undertaken. The NSCCAHS process then applies this information and undertakes further analysis of local population, organisational, patient factors to determine the safety, effectiveness and efficiency of local uptake, and implementation requirements. The assessment is presented to the local HTA Committee who makes a recommendation to the local Area executive. The final decision rests with the Area's executive. In the event of a positive recommendation of the technology, funding needs to be met by existing department resources.
The HTA Initiative at the NSCCAHS aims to shift funding to technologies that provide health benefit and away from those technologies that do not provide as much benefit. Furthermore, the HTA initiative seeks to ensure that decision making processes are fair, equitable and transparent and that they do not favour any particular discipline or service.
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
Given the dearth of HTA activity outside of the national Pharmaceutical Benefits Scheme and Medicare, this local initiative could have an impact on the way this Area adopts and diffuses health technologies. It explicitly incorporates a cost-effectiveness criterion as part of its assessment and this is rather innovative at the local level.
However, the policy impact will be limited by the degree to which providers participate in the process and abide by the recommendations made. The process has no funding attached to its decisions and therefore has limited powers to enforce its decisions (i.e. funding must come from the budgets of clinical departments). The policy has not received any media attention although some of the issues it is trying to address receive widespread attention. The policy will have some relevance in countries where local decisions makers are empowered to make resource allocation decisions.
In NSW, local health regions are responsible for delivering health services to the general population residing in their catchment area. Under existing arrangements, funding is provided directly by the NSW State Government under mechanisms which impose budget caps. The acquisition and use of new medical technologies is usually funded from existing Area resources although there are some notable exceptions for big-ticket items such as radiotherapy equipment. These arrangements inevitably lead to financial pressures and highlight the need for priority setting at the local Area level.
NSW Health Model Policy
|Implemented in this survey?|
Whilst Australia was one of the first countries to formally incorporate HTA in decision making at a national level, it has recently been recognised that Australian HTA efforts are fragmented and uncoordinated. Most critically, there is a lack of assessment for a range of technologies used, with procedural and coverage gaps, in particular for those technologies frequently used in the public hospital sector.(2) In Australia both state and federal governments are responding to this situation by establishing new bodies to asses a broader range of technologies. For example, the Victorian Department of Human Services (Department) has established the Victorian Policy Advisory Committee on Clinical Practice and Technology (VPACT) and the NSW Department of Health issued a Model Policy for the introduction of new interventional procedures in 2003.(1)
The development and implementation of the HTA initiative at the NSCCAHS has largely been ignored by the media and the general public. However, from the preliminary work conducted by the NSCCAHS we are able to glean the position of clinicians and other medical professionals working in the Area. A series of interviews with key Area personnel revealed that decision making processes prior to the introduction of the new policy were regarded as unsatisfactorily. Budgetary impact and costs were seen to be the major deciding factor in whether the new technology is actually introduced, but decisions rarely included simultaneous consideration of costs and consequences. Stakeholders expressed the view that the new health technology evaluation initiative should include a broad range of stakeholders and effectively communicate new procedures as well as keeping staff informed of decision outcomes. The interviews also revealed a willingness to accept change provided the new policy was clinician-led and created minimum administrative burdens.(3)
|NSW Department of Health||very supportive||strongly opposed|
|Health care professional at the AHS||very supportive||strongly opposed|
|NSW Department of Health||very strong||none|
|Health care professional at the AHS||very strong||none|
The HTA Initiative was implemented in 2006. The Area has established the NSCCAHS Health Technology Assessment Committee chaired by an independent person with a health economics background. During the first fifteen months since its inception, the Committee has received 14 applications. Of these, nine were recommended (with caveats), two are awaiting outcome of trials, one application was withdrawn after preliminary discussion (not sufficient evidence), and two were not recommended.
The intiative is designed to pre-empt and plan for processes to be put in place, to enable the smooth transition to new technologies, and monitoring of outcomes once the technologies are in place. For example, a new technology may require staffing changes, staff training and credentialing, redesign of work practices, infrastructure changes, changes to partner services, and a system for tracking utilisation and outcomes.
The Area has also measured baseline perceptions about decision-making processes amongst staff and aims to monitor changes in perceptions over time. There is also the possibility that the impact of the assessment process will be evaluated alongside a broader study of other Area initiatives in this field.
No evaluation completed
The new Health Technology Assessment initiative is intended to inform decisions about if, how and where new technologies will be adopted within NSCCAHS. It also aims to identify the health technologies to be replaced or reduced by new technologies. The initiative aims to shift funding to technologies that provide health benefit and away from those technologies that do not provide as much benefit. Furthermore, the initiative seeks to ensure that the decision making process is fair, equitable and transparent and that it does not favour any particular discipline or service.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
One of the important objectives of this initiative is to not only assess the safety of a technology but determine whether diffusion is appropriate in the context of the local health region. For example, are staff adequately trained to undertake the new procedure? Such an assessment is an important contribution to the health system's ability to diffuse technology safely. As part of the assessment, cost-effectiveness is also taken into account and the initiative has the capacity to broaden local decisions to incorporate notions of both costs and benefits. Whilst the potential is there for a policy such as this to have an impact, there are two major risks associated with its success:
1. New South Wales Health Department. Model policy for the safe introduction of new interventional procedures into clinical practice: a model policy for area health services and other public health organisations. 2003.
Available from: www.health.nsw.gov.au/archive/cib/circulars/2003/cir2003-84.pdf
2. Australian Productivity Commission. Impacts of advances in medical technology in Australia: Productivity Commission research report. 2005.
3. Gallego G, Fowler S, van Gool K. Decision makers' perceptions of health technology decision making and priority setting at the institutional level. Australian Health Review. 2008; (In Press).
Gallego, Gisselle and Kees van Gool