“Whether something cool is good enough”: The role of evidence, sales representatives and nurses' expertise in hospital purchasing decisions

Evolving Use of Health Technology Assessment in Medical Device Procurement-Global Systematic Review: An ISPOR Special Interest Group Report

OBJECTIVES

To review the current academic evidence describing how data from health technology assessments (HTAs) informs procurement decisions for medical devices.

METHODS

A systematic literature review was performed to identify relevant studies and criteria used in medical device purchasing or procurement decisions. Included articles were screened for relevancy and risk of bias. The included studies were summarized qualitatively.

RESULTS

A total of 292 studies were screened, of which 11 matched the inclusion criteria. Included studies' geographies and HTA maturity varied. Some studies described hospital-level HTA processes, whereas others focused on national-level recommendations. Criteria for procurement decisions included standard HTA factors, such as efficacy, cost, cost-effectiveness, and budget impact; broader issues were also noted, including impact on the organization, ethical aspects, staff workload, and volume. There was little consideration of device-specific characteristics, such as life cycle, learning curve, or incremental technical innovation. Few decisions referred to HTA reports as part of the procurement decision; similarly, few HTA reports included a procurement perspective to help guide the procurement bodies.

CONCLUSIONS

There is minimal evidence that notes HTA influencing medical device procurement. Procurement bodies and hospitals may not be incentivized to publish their work and transparency could be improved; further research would better describe the link between HTA and procurement. Such research would enable the HTA agencies to meaningfully assess devices to target procurement bodies and allow device sponsors to prioritize evidence. This could limit redundancy, improve evidence, and ultimately promote savings to healthcare systems and expand access.

Outsourcing practice-based education: The role of industry representatives and implications for clinical expertise

In an era of significant human and fiscal constraints, hospitals increasingly rely on industry representatives to fill gaps related to practice-based education. Given their dual sales and support functions, the extent to which education and support functions are, or ought to be, fulfilled by industry representatives is unclear. We conducted an interpretive qualitative study at a large, academic medical centre in Ontario, Canada, during 2021-2022, interviewing 36 participants across the organization with direct and varied experiences with industry-delivered education. We found that ongoing fiscal and human resource challenges prompted hospital leaders to outsource practice-based education to industry representatives, which created an expanded role for industry beyond initial product rollouts. Outsourcing, however, generated downstream costs to the organization and undermined the goals of practice-based education. To attract and retain clinicians, participants advocated for re-investment in practice-based education in-house, with a limited and supervised role for industry representatives.

Purchasing high-cost medical devices and equipment in hospitals: a systematic review

OBJECTIVES

To systematically review academic literature for studies on any processes, procedures, methods or approaches to purchasing high-cost medical devices and equipment within hospitals in high-income countries.

METHODS

On 13 August 2020, we searched the following from inception: Cost-Effectiveness Analysis Registry, EconLit and ProQuest Dissertations & Theses A&I via ProQuest, Embase, MEDLINE, and MEDLINE in Process via Ovid SP, Google and Google Scholar, Health Management and Policy Database via Ovid SP, IEEE Xplore Digital Library, International HTA Database, NHS EED via CRD Web, Science Citation Index-Expanded, Conference Proceedings Citation Index-Science, and Emerging Sources Citation Index via Web of Science, Scopus, and Zetoc conference search. Studies were included if they described the approach to purchasing (also known as procurement or acquisition) of high-cost medical devices and/or equipment conducted within hospitals in high-income countries between 2000 and 2020. Studies were screened, data extracted and results summarised in tables under themes identified.

RESULTS

Of 9437 records, 24 were included, based in 12 different countries and covering equipment types including surgical robots, medical imaging equipment, defibrillators and orthopaedic implants. We found heterogeneity in methods and approaches; including descriptions of processes taking place within or across hospitals (n=14), out of which three reported cost savings; empirical studies in which hospital records or participant data were analysed (n=8), and evaluations or pilots of proposed purchasing processes (n=2). Studies emphasise the importance of balancing technical, financial, safety and clinical requirements for device selection through multidisciplinary involvement (especially clinical engineers and clinicians) in decision-making, and the potential of increasing evidence-based purchasing decisions using approaches such as hospital-based health technology assessments, ergonomics and device 'user trials'.

CONCLUSIONS

We highlight the need for more empirical work that evaluates purchasing approaches or interventions, and greater specificity in study reporting (eg, equipment type, evaluation outcomes) to build the evidence base required to influence policy and practice for medical equipment purchasing.

PROTOCOL REGISTRATION

This review was registered in Open Science Framework: Shokraneh F, Hinrichs-Krapels S, Chalkidou A et al. Purchasing high-cost medical equipment in hospitals in OECD countries: A systematic review. Open Science Framework 2021; doi:10.17605/OSF.IO/GTXN8. Available at: https://osf.io/gtxn8/ (accessed 12 February 2022).

Modes of coordination for health technology adoption: Health Technology Assessment agencies and Group Procurement Organizations in a polycentric regulatory regime

The challenge of novel and high cost health technologies has encouraged the growth of regulatory agencies such as Health Technology Assessment (HTA) organizations and Group Procurement Organizations (GPO). Yet the existence of several agencies in the same polycentric regulatory regime raises questions about whether and how their work can be coordinated. Drawing on a case study of GPOs and HTA agencies across four provinces in Canada, involving document review and key informant interviews (n = 44) conducted between 2013 and 2016, we explore the separate evolution of these agencies, emerging connections between them for non-drug technologies, and the organizational processes and evaluative judgments that underpin coordination efforts. HTA agencies and GPOs developed separately; connections emerged recently in three provinces and suggest four modes of coordination. One mode aligns most closely with that recommended by health economists and HTA practitioners, whereby HTA precedes procurement, with coverage decisions informing technology acquisition. The second mode is a version of the first, where procurement refers cases to HTA for coverage or technology management support; unlike the first, it recognizes procurement's evaluative strengths. Yet both the first and second modes focus on exceptional cases and will be infrequent. The third mode is more systemic, reflecting a generalized complementary of purpose as public agencies. HTA could support GPOs in contested technology acquisition efforts through timely and responsive input, while procurement could expand HTA's impact and inform HTA's growing interest in responsible innovation and environmental sustainability. The final mode is non-coordination, reflecting the potential for agencies to occupy quite distinct regulatory niches within the same regime. We conclude that consistency and convergence around a single model of resource allocation is not inevitable; nor is it necessary for coordinated effort. Thus, where differences in regulatory practice and epistemology persist, mutual accommodation and shared learning may prove most productive.

Constructing a problem and marketing solutions: A critical content analysis of the nature and function of industry-authored oral health educational materials

AIMS AND OBJECTIVES

To document the nature of industry-authored educational materials focused on oral health; and analyse how they construct the relationships between nurses and industry.

BACKGROUND

Nurses frequently rely on pharmaceutical and medical device companies for continuing education. However, industry-sponsored education is a key aspect of multi-faceted promotional campaigns and may introduce bias into clinical decision-making.

DESIGN

Critical qualitative content analysis reported according to the COREQ checklist.

METHODS

We purposively sampled educational documents from the websites of 4 major manufacturers of oral health products for acute care. Two researchers analysed each document using an open-ended coding form. We conducted an interpretive analysis using inductive coding methods.

RESULTS

We included 63 documents that emphasised the importance of education in the form of training, expert guidance, evidence syntheses and protocols to support oral care practices. Industry promoted its relationship with nursing as an oral health authority through three dominant messages: (1) Pneumonia is a source of morbidity, mortality and treatment costs, which informed nurses about a critical problem; (2) Comprehensive oral care reduces pneumonia risk, which instructed nurses about product-oriented solutions; and (3) Frequent oral care is important, which emphasised compliance to standardised protocols. These messages formed an accountability logic that prompted clinicians to address a problem for which the company's products served as a solution. In doing so, industry validated dominant administrative concerns including compliance, while promoting product uptake.

CONCLUSIONS

Industry-authored educational materials may promote industry interests, rather than nursing or patient agendas. Dependence on industry's information and product solutions may have unintended, negative consequences for nursing practice.

RELEVANCE TO CLINICAL PRACTICE

Though industry's educational materials present as convenient, helpful and evidence-based, they may serve to redirect care processes in ways that reinforce company goals rather than clinical priorities. Nurses should seek independent sources of continuing education where possible.

Factors affecting procurement of wound care products: a qualitative study of hospital managers and clinicians

Objective To identify factors that influence procurement and disinvestment decisions for wound care products in the acute care setting. Methods A qualitative descriptive study was undertaken. Eighteen face-to-face semi-structured interviews were conducted with purposively sampled senior clinical and non-clinical managers from three Australian acute care hospitals with responsibility for consumables procurement and disinvestment decisions. Data were coded and analysed thematically. Results Three main themes (Systems and triggers, Evidence-free zone, Getting the governance right) with sub-themes were identified that reflect that: (1) procurement processes were often ad hoc and workarounds common. Disinvestment was poorly understood and opportunities were missed to reduce use of low value products ; (2) product selection was commonly based on clinician preference, contractual obligations and information from industry representatives; and (3) improved evidence-based governance and processes are needed to connect procurement and disinvestment decisions and to minimise the influences of clinician preference and industry representatives on product selection. Conclusions Systematic and evidence-based approaches are needed to strengthen procurement and disinvestment decisions related to consumables such as wound care products and to minimise the purchasing of low-value products Decision-making frameworks should consider cost and clinical effectiveness and enable the identification of opportunities to disinvest from low-value products. What is known about the topic? High volume-low unit cost healthcare consumables such as wound care products are a major component of healthcare expenditure. Disinvestment from low-value wound care products has potential to improve patient outcomes and optimise health resources. What does this paper add? Disinvestment was poorly understood and considered in isolation from procurement decisions. Procurement decisions were rarely informed by research evidence, with clinicians exercising considerable freedom to make purchasing decisions based on product preference and industry information. Frameworks and guidelines are needed to guide procurement and disinvestment decision-making for wound care products. What are the implications for practitioners? New models for procurement and disinvestment decision-making for wound care products could help to strengthen decision-making processes, facilitate evidence-based product choices and also prompt consideration of removal of low-value products.

Device representatives in hospitals: are commercial imperatives driving clinical decision-making?

Despite concerns about the relationships between health professionals and the medical device industry, the issue has received relatively little attention. Prevalence data are lacking; however, qualitative and survey research suggest device industry representatives, who are commonly present in clinical settings, play a key role in these relationships. Representatives, who are technical product specialists and not necessarily medically trained, may attend surgeries on a daily basis and be available to health professionals 24 hours a day, 7 days a week, to provide advice. However, device representatives have a dual role: functioning as commissioned sales representatives at the same time as providing advice on approaches to treatment. This duality raises the concern that clinical decision-making may be unduly influenced by commercial imperatives. In this paper, we identify three key ethical concerns raised by the relationship between device representatives and health professionals: (1) impacts on healthcare costs, (2) the outsourcing of expertise and (3) issues of accountability and informed consent. These ethical concerns can be addressed in part through clarifying the boundary between the support and sales aspects of the roles of device representatives and developing clear guidelines for device representatives providing support in clinical spaces. We suggest several policy options including hospital provision of expert support, formalising clinician conduct to eschew receipt of meals and payments from industry and establishing device registries.

They Know How to Work It, That’s Their Focus in Life: The Complex Role of Industry Representatives in Surgical Innovation

Relationships between health care providers and industry can generate conflicts of interest with their attendant harms. However, the types of relationships that involve conflicts of interest have often been understood narrowly as material ones between individual clinicians and industry. In research we undertook with surgical teams, we found the role of industry representatives has become normalized in the context of surgical innovation. In this article, we report the findings of our study and unpack the features of both surgery and innovation which contribute to the scope and normalization of industry involvement. We argue that these relationships generate significant ethical challenges and conclude by commenting on how our conceptualization of the situation might inform change.