Determining Value in Health Technology Assessment: Stay the Course or Tack Away?

The Comparison of Cost-Effectiveness Between Magnetic Resonance Spectroscopy and Provocative Discography in the Identification of Chronic Low Back Pain Surgery Candidates

Background/Context

Chronic low back pain (CLBP) is a significant US healthcare burden with millions of lumbar spine procedures annually. Diagnostic tests are essential to guide treatment but provocative discography (PD), the most common diagnostic procedure, is without robust evidence of its value. A non-invasive alternative using Magnetic Resonance Spectroscopy (MRS) offers a potential solution.

Context/Purpose

We assess cost-effectiveness of MRS with NOCISCAN diagnostic algorithm compared to PD for identifying lumbar discs requiring surgical intervention.

Study Design/Setting

We conducted cost-effectiveness analysis using modelling.

Patient Sample

We used data from a clinical study of 139 CLBP patients who met criteria for and received PD of lumbar spine and presented with an ODI score ≥40; comparing PD and MRS-based diagnostics.

Outcome Measures

We considered diagnostic costs, adverse events, surgical costs and outcomes based on a 15-point improvement on the Oswestry Disability Index.

Methods

Incremental cost-effectiveness ratios (ICERS) and probabilistic sensitivity analyses were determined. Some authors have consulted for Aclarion.

Results

Mean total cost per PD patient was $59,711, and $57,998 for MRS, demonstrating $1712 cost savings per MRS diagnosed patient. Diagnostic costs ($1950 for PD; $1450 for MRS), saved $500 per MRS patient. PD incurred adverse event costs ($57,323) for 1% of patients, which MRS eliminated. MRS-based diagnosis showed 78% surgical success, whereas PD achieved 68%. MRS was the dominant diagnostic strategy, with better clinical outcomes and cost savings. Probabilistic sensitivity analysis confirmed MRS dominance and was cost-effective across a wide range of willingness-to-pay thresholds and across 2 different scenarios which vary base-case outcomes and surgical rates.

Conclusion

This study demonstrates cost-effectiveness dominance of MRS with the Nociscan diagnostic algorithm over PD for identifying CLBP surgical candidates. MRS provides significant cost savings and leads to better surgical outcomes, making it a preferred choice for insurers and health systems.

Associations Between Lean IT Management and Financial Performance in US Hospitals

BACKGROUND AND OBJECTIVES

To understand the relationship between Lean implementation in information technology (IT) departments and hospital performance, particularly with respect to operational and financial outcomes.

METHODS

Primary data were sourced from 1222 hospitals that responded to the National Survey of Lean (NSL)/Transformational Performance Improvement, which was fielded to 4500 general medical-surgical hospitals across the United States. Secondary sources included hospital performance data from the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare & Medicaid Services (CMS). We performed 2 sets of multivariable regressions using data gathered from US hospitals, linked to AHRQ and CMS performance outcomes. We examined 10 different outcomes measuring financial performance, quality of care, and patient experience, and their associations with Lean adoption within hospital IT departments. We then focused only on those hospitals that adopted Lean in IT to identify specific practices associated with performance.

RESULTS

Controlling for other factors, adoption of Lean IT management was associated with lower length of stay ( b = -0.098, P = .018) and inpatient expense per discharge ( b = -0.112, P = .090). Specifically, use of visual management tools (eg, A3 storyboards, status sheets) was associated with lower adjusted inpatient expense per discharge ( b = -0.176, P = .034) and higher earnings before interest, taxes, depreciation, and amortization margin ( b = 0.124, P = .042). Such tools were also associated with hospital participation in bundled payment programs (odds ratio = 2.326; P = .046; 95% confidence interval, 0.979-5.527) and percentage of net revenue paid on a shared risk basis ( b = 0.188, P = .031).

CONCLUSIONS

Lean IT management was associated with positive financial performance, particularly with hospital participation in value-based payment. More detailed study is needed to understand other influential factors and types of work processes, activities, or mechanisms by which high-functioning IT can contribute to financial outcomes.

A Review on the Usability, Flexibility, Affinity, and Affordability of Virtual Technology for Rehabilitation Training of Upper Limb Amputees

(1) Background: Prosthetic rehabilitation is essential for upper limb amputees to regain their ability to work. However, the abandonment rate of prosthetics is higher than 50% due to the high cost of rehabilitation. Virtual technology shows potential for improving the availability and cost-effectiveness of prosthetic rehabilitation. This article systematically reviews the application of virtual technology for the prosthetic rehabilitation of upper limb amputees. (2) Methods: We followed PRISMA review guidance, STROBE, and CASP to evaluate the included articles. Finally, 17 articles were screened from 22,609 articles. (3) Results: This study reviews the possible benefits of using virtual technology from four aspects: usability, flexibility, psychological affinity, and long-term affordability. Three significant challenges are also discussed: realism, closed-loop control, and multi-modality integration. (4) Conclusions: Virtual technology allows for flexible and configurable control rehabilitation, both during hospital admissions and after discharge, at a relatively low cost. The technology shows promise in addressing the critical barrier of current prosthetic training issues, potentially improving the practical availability of prosthesis techniques for upper limb amputees.

Reconstructing the value puzzle in health technology assessment: a pragmatic review to determine which modelling methods can account for additional value elements

Health technology assessment (HTA) has traditionally relied on cost-effectiveness analysis (CEA) as a cornerstone of evaluation of new therapies, assessing the clinical validity and utility, the efficacy, and the cost-effectiveness of new interventions. The current format of cost-effectiveness analysis, however, does not allow for inclusion of more holistic aspects of health and, therefore, value elements for new technologies such as the impact on patients and society beyond its pure clinical and economic value. This study aimed to review the recent modelling attempts to expand the traditional cost-effectiveness analysis approach by incorporating additional elements of value in health technology assessment. A pragmatic literature review was conducted for articles published between 2012 and 2022 reporting cost-effectiveness analysis including value aspects beyond the clinical and cost-effectiveness estimates; searches identified 13 articles that were eligible for inclusion. These expanded modelling approaches mainly focused on integrating the impact of societal values and health equity in cost-effectiveness analysis, both of which were championed as important aspects of health technology assessment that should be incorporated into future technology assessments. The reviewed cost-effectiveness analysis methods included modification of the current cost-effectiveness analysis methodology (distributional cost-effectiveness analysis, augmented cost-effectiveness analysis, extended cost-effectiveness analysis) or the use of multi-criteria decision analysis. Of these approaches, augmented cost-effectiveness analysis appears to have the most potential by expanding traditional aspects of value, as it uses techniques already familiar to health technology assessment agencies but also allows space for incorporation of qualitative aspects of a product's value. This review showcases that methods to unravel additional value elements for technology assessment exist, therefore, patient access to promising technologies can be improved by moving the discussion from "if" to "how" additional value elements can inform decision-making.

Health Technology Assessment-Informed Decision Making by the Federal Joint Committee/Institute for Quality and Efficiency in Health Care in Germany and the National Institute for Health and Care Excellence in England: The Role of Budget Impact

OBJECTIVES

This study aimed to test (official) evaluation criteria including the potential role of budget impact (BI) on health technology assessment (HTA) outcomes published by the Federal Joint Committee (Gemeinsamer Bundesausschuss [GBA]) and the Institute for Quality and Efficiency in Health Care (Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen [IQWiG]) in Germany as well as the National Institute for Health and Care Excellence (NICE) in England.

METHODS

Data were extracted from all publicly available GBA decisions and IQWiG assessments as well as NICE single technology appraisals between January 2011 and June 2018, and information with regard to evaluation criteria used by these agencies was collected. Data were analyzed using logistic regression to estimate the effect of the BI on the HTA outcomes while controlling for criteria used by GBA/IQWiG and NICE.

RESULTS

NICE recommendations are largely driven by the incremental cost-effectiveness ratio and, if applicable, by end-of-life criteria (P < .01). While IQWiG assessments are significantly affected by the availability of randomized controlled trials and patient-relevant endpoints (P < .01), GBA appraisals primarily focus on endpoints (P < .01). The BI correlated with NICE single technology appraisals (inverted-U relationship, P < .1) and IQWiG recommendations (increasing linear relationship, P < .05), but not with GBA decisions (P > .1). Nevertheless, given that IQWiG assessments seem to be more rigorous than GBA appraisals regarding the consideration of evidence-based evaluation criteria, decisions by GBA might be negatively associated with the BI.

CONCLUSIONS

Results reveal that GBA/IQWiG and NICE follow their official evaluation criteria consistently. After controlling for all significant variables, the BI seems to have an (independent) effect on HTA outcomes as well.

How to create value with constrained budgets in oncological care? A narrative review

INTRODUCTION

As a result of an increasing focus on patient-centered care within oncology and more pressure on the sustainability of health-care systems, the discussion on what exactly constitutes value re-appears. Policymakers seek to improve patient values; however, funding all values is not sustainable.

AREAS COVERED

We collect available evidence from scientific literature and reflect on the concept of value, the possible incorporation of a wide spectrum of values in reimbursement decisions, and alternative strategies to increase value in oncological care.

EXPERT OPINION

We state that value holds many different aspects. For reimbursement decisions, we argue that it is simply not feasible to incorporate all patient values because of the need for efficient resource allocation. We argue that we should shift the value debate from the individual perspective of patients to creating value for the cancer population at large. The different strategies we address are as follows: (1) shared decision-making; (2) biomarkers and molecular diagnostics; (3) appropriate evaluation, payment and use of drugs; (4) supportive care; (5) cancer prevention and screening; (6) monitoring late effect; (7) concentration of care and oncological networking; and (8) management of comorbidities. Important preconditions to support these strategies are strategic planning, consistent cancer policies and data availability.

Cancer treatments touch a wide range of values that count for patients and other stakeholders: What are the implications for decision-making?

BACKGROUND

Cancer rates and expenditures are increasing, resulting in debates on the exact value of this care. Perspectives on what exactly constitutes worthwhile values differ. This study aims to explore all values-elements regarding new oncological treatments for patients with cancer and all stakeholders involved and to assess their implications in different decision-making procedures.

METHOD

Thirty-one individual in-depth interviews were conducted with different stakeholders to identify values within oncology. A focus group with seven experts was performed to explore its possible implications in decision-making procedures.

RESULTS

The overarching themes of values identified were impact on daily life and future, costs for patients and loved ones, quality of life, impact on loved ones, societal impact and quality of treatments. The expert panel revealed that the extended exploration of values that matter to patients is deemed useful in patient-level decision-making, information provision, patient empowerment and support during and after treatment. For national reimbursement decisions, implications for the broad range of values seems less clear.

CONCLUSION

Clinical values are not the only ones that matter to oncological patients and the stakeholders in the field. We found a much broader range of values. Proper recognition of values that count might add to patient-level decision-making, but implications for reimbursement decisions are less clear. The results could be useful to guide clinicians and policymakers when it comes to decision-making in oncology. Making more explicit which values counts for whom guarantees a more systematic approach to decision-making on all levels.

Malthusian Trajectory for Heart Failure and Novel Translational Ambulatory Technologies

INTRODUCTION

It has been estimated that congestive heart failure (CHF) will reach epidemic proportions and contribute to large unsustainable impacts on health budgets for any cardiovascular condition. Against other major trends in cardiovascular outcomes, readmission and disease burden continue to rise as the demographics shift.

METHODS

The rise in heart failure with preserved ejection fraction (HFpEF) among elderly women will present new challenges. Gold standard care delivers sustainable and cost-effective health improvements using organised care programs. When coordinated with large hospitals, this can be replicated universally.

RESULTS

A gradient of outcomes and ambulatory care needs to be shifted from established institutions and shared with clients and community health services, being a sizeable proportion of CHF care.

CONCLUSION

In this review, we explore health technologies as an emerging opportunity to address gaps in CHF management.

Supply-Side Cost-Effectiveness Thresholds: Questions for Evidence-Based Policy

There is growing interest in cost-effectiveness thresholds as a tool to inform resource allocation decisions in health care. Studies from several countries have sought to estimate health system opportunity costs, which supply-side cost-effectiveness thresholds are intended to represent. In this paper, we consider the role of empirical estimates of supply-side thresholds in policy-making. Recent studies estimate the cost per unit of health based on average displacement or outcome elasticity. We distinguish the types of point estimates reported in empirical work, including marginal productivity, average displacement, and outcome elasticity. Using this classification, we summarise the limitations of current approaches to threshold estimation in terms of theory, methods, and data. We highlight the questions that arise from alternative interpretations of thresholds and provide recommendations to policymakers seeking to use a supply-side threshold where the evidence base is emerging or incomplete. We recommend that: (1) policymakers must clearly define the scope of the application of a threshold, and the theoretical basis for empirical estimates should be consistent with that scope; (2) a process for the assessment of new evidence and for determining changes in the threshold to be applied in policy-making should be created; (3) decision-making processes should retain flexibility in the application of a threshold; and (4) policymakers should provide support for decision-makers relating to the use of thresholds and the implementation of decisions stemming from their application.

Should We Consider Including a Value for "Hope" as an Additional Benefit Within Health Technology Assessment?

Health technology assessment (HTA) typically uses average health-related quality of life gain as its main measure of benefit used in economic evaluation. Nevertheless, there have been calls to consider novel aspects of benefit including the "value of hope," defined as a patients' potential preferences for a wider distribution of treatment benefit with a positive skew, in the hope that they will be one of the lucky ones. The value of hope may also derive from feeling hopeful as a positive mental state, which may be missing from current measures of health-related quality of life. The value attributed to feeling hopeful could be related to, or additional to, the value derived from possible risk-seeking preferences. Here, we reflect upon the strength of the case for the inclusion of the "value of hope" taking a critical look at the commonly referenced evidence for including the "value of hope" as risk-seeking preferences. We also draw attention to other conceptions of hope-as an emotion, a cognitive process, or a combination of both-and reflect upon the potential of including these broader notions of hope into HTA. The case for the inclusion of the "value of hope" based on risk-seeking preferences is weak. We suggest research questions that could give further evidence on whether hope is an important missing value from HTA.

Extended Reality "X-Reality" for Prosthesis Training of Upper-Limb Amputees: A Review on Current and Future Clinical Potential

The rejection rates of upper-limb prosthetic devices in adults are high, currently averaging 26% and 23% for body-powered and electric devices, respectively. While many factors influence acceptance, prosthesis training methods relying on novel virtual reality systems have been cited as a critical factor capable of increasing the likelihood of long-term, full-time use. Despite that, these implementations have not yet garnered widespread traction in the clinical setting, and their use remains immaterial. This review aims to explore the reasons behind this situation by identifying trends in existing research that seek to advance Extended Reality "X-Reality" systems for the sake of upper-limb prosthesis rehabilitation and, secondly, analyzing barriers and presenting potential pathways to deployment for successful adoption in the future. The search yielded 42 research papers that were divided into two categories. The first category included articles that focused on the technical aspect of virtual prosthesis training. Articles in the second category utilize user evaluation procedures to ensure applicability in a clinical environment. The review showed that 75% of articles that conducted whole system testing experimented with non-immersive virtual systems. Furthermore, there is a shortage of experiments performed with amputee subjects. From the large-scale studies analyzed, 71% of those recruited solely able-bodied participants. This paper shows that X-Reality technologies for prosthesis rehabilitation of upper-limb amputees carry significant benefits. Nevertheless, much still must be done so that the technology reaches widespread clinical use.

A Structured Pathway Toward Disruption: A Novel HealthTec Innovation Design Curriculum With Entrepreneurship in Mind

The typical curriculum of training and educating future clinicians, biomedical engineers, health IT, and artificial intelligence experts lacks needed twenty first-century skills like problem-solving, stakeholder empathy, curiosity stimulation, entrepreneurship, and health economics, which are essential generators and are pre-requirements for creating intentional disruptive innovations. Moreover, the translation from research to a valuable and affordable product/process innovation is not formalized by the current teachings that focus on short-term rather than long-term developments, leading to inaccurate and incremental forecasting on the future of healthcare and longevity. The Stanford Biodesign approach of unmet clinical need detection would be an excellent starting methodology for health-related innovation work, although unfortunately not widely taught yet. We have developed a novel lecture titled HealthTec Innovation Design (HTID) offered in an interdisciplinary setup to medical students and biomedical engineers. It teaches a future-oriented view and the application and effects of exponential trends. We implemented a novel approach using the Purpose Launchpad meta-methodology combined with other innovation generation tools to define, experiment, and validate existing project ideas. As part of the process of defining the novel curriculum, we used experimentation methods, like a global science fiction event to create a comic book with Future Health stories and an Innovation Think Tank Certification Program of a large medical technology company that is focused on identifying future health opportunities. We conducted before and after surveys and concluded that the proposed initiatives were impactful in developing an innovative design thinking approach. Participants' awareness and enthusiasm were raised, including their willingness to implement taught skills, values, and methods in their working projects. We conclude that a new curriculum based on HTID is essential and needed to move the needle of healthcare activities from treating sickness to maintaining health.

Health economic evaluations of medical tests: Translating laboratory information into value - A case study example

Health-care providers and funders are focused on identifying value in all their services and that includes laboratories. This means that in order to gain a share of scarce resources, laboratory professionals must also understand and assess the value of tests and that includes their economic impact. This can be assessed using health economic modelling tools which, when used in conjunction with a detailed value proposition for the test, can translate laboratory information into value. While a variety of health economic assessment tools are available, this review will focus on the use of decision analytic models which essentially compare the outcomes from pathways with and without the new test, the value of which is being assessed. A step-by-step framework is provided to guide laboratory professionals through the essential steps of conducting the evaluation. Initial steps include mapping the clinical pathway, understanding the goal of the evaluation, identifying the key stakeholders and their needs and determining a suitable analytical model. Following collection of the actual data, the validity of the model must be checked, and the robustness of the outcomes tested through sensitivity analysis. The last step is to translate the findings into measures of value which can then inform appropriate decisions by the stakeholders. This review of basic health economic modelling should enable laboratory professionals to have an understanding of how modelling can be applied to tests in their own environment and help deliver their potential value.

Future of Data Analytics in the Era of the General Data Protection Regulation in Europe

The development of evidence to demonstrate 'value for money' is regarded as an important step in facilitating the search for the optimal allocation of limited resources and has become an essential component in healthcare decision making. Real-world evidence collected from de-identified individuals throughout the continuum of healthcare represents the most valuable source in technology evaluation. However, in the European Union, the value assessment based on real-world data has become challenging as individuals have recently been given the right to have their personal data erased in the case of consent withdrawal or when the data are regarded as being no longer necessary. This act may limit the usefulness of data in the future as it may introduce information bias. Among healthcare stakeholders, this has become an important topic of discussion because it relates to the importance of data on one side and to the need for personal data protection on the other side, especially when it comes to "personal data related to the physical or mental health of a natural person, including the provision of health care services, which reveals information about his or her health status". At the forefront of these discussions are data protection issues as well as the population's trust in digital services. It seems that the new era has begun, where citizens and patients will have the ability to manage their personal or self-generated data. The European Commission has laid the groundwork for this paradigm shift that will steadily emerge in the coming years. To prepare for this change, we believe attention should be given to data security and other rules of data privacy. It has become increasingly important to ensure that individuals are properly introduced into complex environments with multiple sources of Big Data for clinical and behavioral purposes to provide an optimal balance between societal and individual benefits. In this article, a number of issues are considered and discussed, based upon the authors' experience, with the aim of helping the reader better understand the implications of the use of Big Data and the importance of data protection in the coming years.

Creeping Through the Backdoor: Disruption in Medicine and Health

Can disruption happen when no one notices? Disruptive technologies and processes are fundamentally starting to up-end how medicines and health systems benefit patients but the question is whether health systems are ready for them. This paper will briefly review the business strategy and management literature on topics such as disruption and “black swan” theories of change, before turning to discuss some of the areas where change is affecting medicine and healthcare. Such areas include the emergence of cell and gene therapies, the economics of cures, digital technologies, mobile apps, social media, supply chain technologies such as drones and online distribution, universal health coverage and funding, and consumerisation of healthcare. The question to be asked is whether these sorts of changes are “disruptive” or whether they were coming for a long time and it is just that health systems are slow to change. It could be argued that while perhaps unexpected by day-to-day practitioners in healthcare, in fact, many of the changes now starting to affect the health and medicines sector have been affecting other sectors such as technology, finance and communications for decades.

Health technology assessment (HTA) and economic evaluation: efficiency or fairness first

The economic evaluation which supports Health Technology Assessment (HTA) should inform policy makers of the value to society conferred by a given allocation of resources. However, neither the theory nor practise of economic evaluation satisfactorily reflect social values. Both are primarily concerned with efficiency, commonly conceptualised as the maximisation of utility or quality adjusted life years (QALYs). The focus is upon the service and the benefits obtained from it. This has resulted in an evaluation methodology which discriminates against groups and treatments which the population would like to prioritise. This includes high cost treatments for patients with rare diseases. In contrast with prevailing methods, there is increasing evidence that the public would prefer a fairness-focused framework in which the service was removed from centre stage and replaced by the patient. However methods for achieving fairness are ad hoc and under-developed. The article initially reviews the theory of economic evaluation and argues that its focus upon individual utility and efficiency as defined by the theory omits potentially important social values. Some empirical evidence relating to population values is presented and four studies by the first author are reviewed. These indicate that when people adopt the social perspective of a citizen they have a preference for sharing the health budget in a way which does not exclude patients who require services that are not cost effective, such as orphan medicinal products (OMP's) and treatments for patients with ultra-rare diseases (URD's).