Comparative Effectiveness in Orthopaedics: Stakeholder Perspectives

Kevin J. Bozic, MD, MBA

Associate Professor and Vice Chair

UCSF Department of Orthopaedic Surgery and Philip R. Lee Institute for Health Policy Studies

Disclosures/Conflicts of Interest

External Advisory Role:

AAOS (HCSC, GTOC)

AAHKS (Education, Health Policy, EBPC)

COA (Executive Committee)

CMS (MedCAC)

UCSF Medical Center (HTAP)

United Health Care, BCBSA, Integrated Healthcare Association, Pacific Business Group on Health

Research Support:

OREF, AHRQ, NIH

Objectives

1. To identify considerations in the decision making process for the adoption of new technologies in orthopaedics

2. To understand the strengths and limitations of comparative effectiveness research

3. To develop an algorithm for evaluating and adopting new technologies in an orthopaedic practice

Technology in Orthopaedics

ImplantFactors

SurgeonFactors

PatientFactors

HospitalFactors

What Factors Influence Patient Outcomes?

Benefits of Technology

Technology: Unintended consequences

Technology: Cost Implications

• “The general consensus among health economists is that growth in real health care spending over the past 4 decades was principally the result of the emergence of new medical technologies and their adoption and widespread diffusion by the U.S. health care system.”

-CBO Report, “Technological Change and the Growth of Health Care Spending”, Feb, 2008

•“…however, the benefit of many of these new technologies has not yet been rigorously demonstrated.”

Comparative Effectiveness: Value

1.5-2X

4-6X

2-3X

Cost Value?

??

??

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Evaluating Technologies: Perspective Surgeons

“Evidence standard”

Adequacy of evidence

Magnitude of benefit

Relationships with industry

Peers

Hospitals/payers Short-term cost-containment

Patients Internet, friends, family

DTCA

Policymakers Comparative Effectiveness

Clinician Perspective

Level of Evidence (I-V)

Efficacy The extent to which medical

interventions achieve health improvements under ideal circumstances

Effectiveness The extent to which medical

interventions achieve health improvements in real practice settings

Effectiveness: Registry Data

Effectiveness: Registry Data

Hospital Perspective

1990’s 2000’s

UCSF Healthcare Technology Assessment Program (HTAP)

“HTA is the bridge between the world of research and the world of clinical decision making”

Alan Garber, Health Affairs, 2004

Considerations

Patient population

Surgeon experience

Relationships with vendor, hospital

Price

Service

Programmatic needs

Patient Perspective: DTCA

DTCA: Policy Implications

DTCA

$$

$$ $$

Policy Maker Perspective: Comparative Effectiveness?

Comparative Effectiveness Research

“As applied in the health care sector, an analysis of comparative effectiveness is simply a rigorous evaluation of the impact of different options that are available for treating a given medical condition for a particular set of patients.”

Congressional Budget Office, 2007

See: http://www.cbo.gov/ftpdocs/88xx/doc8891/12-18-ComparativeEffectiveness.pdf

Evolutionary or Revolutionary?

Trends in Orthopaedic Implant Costs in the U.S.

“Overshooting” the Needs of our Patients

“The functionality of today’s healthcare technologies, although impressive, often outstrips the ability of consumers to absorb it”

Impact of Technology on Surgeon “Value”

“Take hip replacement surgery for example. Here much of the cost and “skill”, as it were, have moved from the surgeon to the device.”

Considerations in Technology Decisions Is there a clinical need?

Patient population

Results with existing technology

Use data whenever possible

Factors influencing decision Device company

Peers

Hospital

Patients

Impact on Patient outcomes

Hospital margins

O.R. Efficiency

My Algorithm

Versatility of product line

Service

Price

Benefits vs. Risks of switching

Potential improvement in clinical outcomes

Uncertainty in patient outcomes

Impact on efficiency

Price

Summary Explosion of new technologies

in orthopaedics

Consumerism

Increased scrutiny, transparency regarding costs, clinical effectiveness

Questions:

Comparative effectiveness:

Clinical effectiveness vs. gold-standard?

Cost-effectiveness?

Impact on clinical, shared decision making

“Newer” Is Not Always “Better”

“Novelty cannot necessarily be equated with benefit, and an intervention or device’s value resides not in it’s newness but rather in its ability to improve patient outcomes, reduce morbidity, and/or reduce the overall cost of care. “

Emanuel EJ, Fuchs VR, Garber AM. Essential elements of a technology and outcomes assessment initiative. JAMA. Sep 19 2007;298(11):1323-1325.

Thank You!!!