There and Back Again: An HTA Analyst’s Tale of

Evidence-Informed Decision Making

Daniel Grigat, MA

HTA Analyst, Knowledge Translation

Research, Innovation, and Analytics

Alberta Health Services

CADTH, April 2014

2

Presentation Objectives

HTA in the Alberta Context

Stories of success

and challenges

3

4

11.21

8.73

7.68

5.92

4.29

5.53

0

2

4

6

8

10

12

South Zone Calgary Zone Central Zone Edmonton Zone North Zone Best Large RHA/Zone (Central West LHIN,

ONT)

Ris

k-A

dju

ste

d R

ate

(p

er

1,0

00

)

Source = CIHI CHRP

5-Day In-Hospital Mortality Following Major Surgery - 2010/11

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Presentation Objectives

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Strategic Clinical Networks

• Multidisciplinary (Researchers, Clinicians, Support Units,

Policy-Makers, Patients)

• Evidence-Based

• Strategic and Innovative

• Accessibility (reduce variation in care)

• Sustainability (Choosing Wisely)

7

Strategic Clinical Networks 1. Addiction & Mental Health

2. Obesity, Diabetes and Nutrition

3. Emergency

4. Cancer

5. Cardiovascular and Stroke

6. Bone & Joint Health

7. Seniors Health

8. Critical Care

9. Surgery

10. Respiratory

11. Primary Care and Chronic Disease

12. Maternal, Newborn and Youth Health

13. Kidney

HTA Partners (IHE, UofA, UofC)

From Micro to Macro: The Alberta Health

Technologies Decision Process

Alberta Advisory

Committee on

Health Technologies

AHW Health Technologies

Policy Unit

Screening

Sub-Committee

Executive

Team/

Minister

AHS

AH

Strategic

Clinical

Networks

Assessing System Needs Assessing Technology and Policy Development Decision/implementation

From Alberta Health

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Evidence-Based Decision Making

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Knowledge to Action Cycle

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Clinical Opportunity Identification

Evidence Synthesis

Evidence-informed Decision Making

Implementation and Evaluation

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Clinical Opportunity Identification

Evidence Synthesis

Frequent Users of Emergency Medical Services

Complex High Needs Users

Rapid Reviews: Patient Profiles, Case Management

Lack of: clarity, clear intervention, coordination with other

efforts or agencies, cost benefits

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Clinical Opportunity Identification

Evidence Synthesis

Edmonton Inner City Health Research & Education Network

Multi-disciplinary Case Management for inner-city persons

Evidence: existing RR, update SR, new RR

Next Steps: Funding, Implementation and Evaluation

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Evidence Synthesis

Policy

Diabetic Foot Care Pathway

How do we prevent, identify, and treat diabetic foot ulcers?

PICO (wound care, orthopaedics, contact casting)

Policy Implications: uninsured services

Barrier: clinical independence, comfort with orthopaedics, fear

of policy process

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Evidence Synthesis

Policy

Repetitive Transcranial Magnetic Stimulation

Treatment Resistant Major Depressive Disorder

ECT: invasive (safety, access), stigmatized (acceptability)

Promising evidence but unanswered questions on optimal use

Next Steps: Policy, Implementation, Evaluation

Barriers: Time Frame

16

Bariatric Surgery

HTA: treatments for obesity, surgery 5-10 year outcomes

Current provision of service 0.5%.

Barriers: funding, OR management, surgeon support / late

engagement, HTA didn’t answer clinical optimization questions

Next Steps: Surgery SCN, answer optimization questions

Evidence-informed Decision Making

Implementation and Evaluation

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Enhanced Recovery After Surgery

Evidence-based CPGs.

Barriers: resistance to practice change (e.g. anaesthesiology)

KT: Leadership Support, Clinical Champions, Clinical

Informatics, Targeted Training Programs, Robust Evaluation

Next Steps: Scale Up, Test Implementation Strategies

Evidence-informed Decision Making

Implementation and Evaluation

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Lessons Learned

Stakeholders must be engaged from the public to the front

lines to universities to the Minister

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Lessons Learned

Translation is continuous and iterative: Clinical Need ->

Research Question(s) -> Policy Implications -> Operational

Options -> Clinical Need

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Lessons Learned

Problems require a lot of definition before solutions are

sought

If I had one hour to save the

world I would spend fifty-five

minutes defining the problem

and only five minutes finding

the solution.

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Lessons Learned

Funding frameworks tend to drive the conceptualization of

problems (from Dens to HTR to PRIHS)

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Lessons Learned

Time Matters – evidence is often sought too late in the

process, more structured planning is required, clinical time

and policy time are out of sync

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Lessons Learned

Consideration of policy options should include clinical

experts, research experts, and the persons who will be tasked

with implementing directives

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Lessons Learned

Knowledge Translation and change management is hard

work. Change does not happen by emailing CPGs or issuing

directives.

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Acknowledgements Dr. Ulrich Wolfaardt, Dr. Don Juzwishin, Barbara

Hughes, Rosmin Esmail

Strategic Clinical Networks: Obesity Diabetes

Nutrition; Addiction and Mental Health;

Emergency; Cancer

Ministry of Alberta Health

Dr. Gabrielle Zimmerman and CADTH

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Questions and Comments?

Clinical Opportunity Identification

Evidence Synthesis

Evidence-informed

Decision Making

Implementation and Evaluation