Managing medical technology: lessons for the United States from Quebec and France

Supporting innovation in health care: A short experience in a dedicated unit of the French Ministry of Public Health

INTRODUCTION

The Delegation for Innovation in Health Care (DIES) was created by the Ministry of Solidarity and Health to centralize and support innovative health care projects. Following its dissolution, only two and a half years after its creation, the members of this delegation aimed to present the projects, which were submitted and treated by the DIES.

METHODS

All potential project leaders were free to explain the objectives of their project to our team. These projects were then classified according to their objective, their type, the medical specialty concerned, the target population and their purpose. The DIES graded the degree of innovation, advised on the need for complementary scientific evaluation and oriented the personnel in charge towards fitting financing structures.

RESULTS

Between April 2016 and December 2018, the DIES received 269 potential project leaders, almost exclusively from the national territory of France, focused on diversified medical specialties with a slight predilection for chronic diseases and disabilities. The projects were often at an economically tenuous stage of development. Less than 5% of the projects concerned drug therapy. More than a third involved medical devices, including "surgical" projects (predominately orthopedics), disability compensation methodology, vascular problems and bandages. E-health, the organization of care, and a "non-classifiable" category that included wellness projects each represented 20% of the projects. Almost 80% of these projects had some electronically (e-) based mechanism. Only 15% of all projects had the ambition to meet an unmet or poorly covered need. Only about a third of the project leaders presented a clinical or medico-economic evaluation with sufficiently rigorous methodology to assess the achievement of their objectives.

CONCLUSION

Innovative health projects are dominated by the search for improvement in the organization of the health care system and the care pathway with e-connected applications. Evaluation of the vast majority of these projects is very difficult and this situation reinforces the idea that these requests should be centralized to improve support for promoters of innovation.

Adopting and assimilating new non-pharmaceutical technologies into health care: a systematic review

OBJECTIVE

To explore what is known about organizational processes that determine whether (and the extent and rate at which) new non-pharmaceutical technologies are adopted and assimilated into routine health care.

METHODS

Electronic searching of four databases, hand searching of six journals and electronic citation tracking searches of three key research papers. A narrative synthesis was conducted.

RESULTS

Ninety-nine empirical studies and seven narrative overviews informed the findings. The majority (62%) of the studies took a deterministic approach (mainly using cross-sectional mailed questionnaires) and typically studied the impact of organizational variables - such as organizational size - on the rate of adoption of technological innovations. The remaining studies were process-based using a single- or multi-case study approach. The organizational processes that determine whether and how technological innovations are adopted and assimilated into routine health care practice are dependent upon the specific innovation concerned, the different actors involved at various points in time, and the particular organizational context in which decisions are made. It is important to see 'adoption' and 'assimilation' as part of an ongoing process rather than discrete events, and as a process that comprises both 'formal' organizational and 'informal' decisions by individual users (the latter often shaped by discussions with their peers and colleagues).

CONCLUSIONS

Further process-based studies are needed to provide a clearer evidence base for recommendations on how to facilitate the adoption and assimilation of beneficial new technologies. Three theoretical perspectives could form the basis of such studies and produce practical advice for managers and practitioners.

"We noticed that suddenly the country has become full of MRI". Policy makers' views on diffusion and use of health technologies in Iran

Objective

Uncontrolled proliferation of health technologies (HT) is one contributor to the increasing pressure on health systems to adopt new technologies. With limited resources, policy-makers encounter difficulties in fulfilling their responsibility to meet the healthcare needs of the population. The aim of this study is to explore how policy-makers' reason about the diffusion and utilization of health technologies in Iran using magnetic resonance imaging (MRI) and interferon beta as tracers.

Method

This qualitative exploration complements quantitative data generated in a research project investigating the diffusion and utilization of MRI and interferon beta in Iran. Qualitative semi-structured interviews were conducted with 13 informants in different positions and levels of authority in the Ministry of Health (MOH), University of Medical Sciences, Health Insurance Organizations, and Parliament. The data was analysed using the framework approach.

Findings

Although policy-makers appeared to be positive to health technology assessment (HTA), the processes of policy-making described by the interviewees did not seem to be based on a full understanding of this (discipline). Several obstacles to applying knowledge about HT and HTA were described. The current official plan for MRI adoption and diffusion in the country was said not to be followed, and no such plan was described for interferon beta. Instead, market forces such as advertising, and physician and consumer demand, appear to have strong influence on HT diffusion and use. Dual practice may have increased the induced demand and also reduced the supervision of the private sector by the MOH.

Conclusion

Management instability and lack of coordination in the MOH were found to be important obstacles to accumulation of knowledge and experience which, in turn, could have led to suboptimal managerial and policy-making processes. Furthermore marketing should be controlled in order to avoid creating unnecessary patient demands and negative influences on physicians' behavior.

U.S. pharmacy policy: a public health perspective on safety and cost

A public health perspective based on social justice and a population health point of view emphasizes pharmacy policy innovations regarding safety and costs. Such policies that effectively reduce costs include controlling profits, establishing profit targets, extending prescription providers, revising prescription classification schemes, emphasizing generic medications, and establishing formularies. Public education and universal programs may reduce costs, but co-pays and "cost-sharing" do not. Switching medications to over-the-counter (OTC) status, pill splitting, and importing medication from abroad are poor substitutes for authentic public health pharmacy policy. Where policy changes yield savings, public health insists that these savings should be used to increase access and improve population health. In the future, pharmacy policies may emphasize public health accountability more than individual liberty because of potential cost savings to society. Fear of litigation, as an informal mechanism of focusing manufacturer's attention on safety, is inefficient; public health pharmacy policy regarding safety looks toward a more active regulatory role on the part of government. A case study of direct-to-consumer advertising illustrates the complexity of public health pharmacy policy.

Economic evaluation of interactive teledermatology compared with conventional care

Teledermatology offers a means of providing specialist care to underserved patients. The objectives of this study were to compare the costs of interactive teledermatology with conventional care, and to evaluate from a healthcare provider perspective whether interactive teledermatology is economically viable in the northeastern region of the United States. We studied the interactive teledermatology practice at Nantucket Cottage Hospital on Nantucket Island and the ambulatory clinics at the Massachusetts General Hospital in Boston, Massachusetts. The cost-minimization analysis compared the costs of an interactive teledermatology practice with that of a face-to-face dermatology clinic. One-way sensitivity analyses examined the effect of varying the costs of technology, physician compensation, or clinic space on the overall cost of interactive teledermatology. We also assessed the economic viability of the interactive teledermatology practice by comparing the operating costs with reimbursements. The total hourly operating costs for the interactive teledermatology practice on Nantucket Island and the face-to-face clinic in Boston were $274 and $346, respectively. Three separate one-way sensitivity analyses showed that, for the cost of the teledermatology practice to equal that of the conventional clinic, the cost of teledermatology technology could increase by 9.3-fold, dermatologists working at the teledermatology practice could be compensated up to $197 an hour, or the cost of teledermatology clinic space could reach $57 an hour. Our analysis also showed that the hourly reimbursement for the teledermatology practice was $487, which exceeded its hourly operating cost of $274. The cost of operating an interactive teledermatology practice in a remote region may be less than that of a conventional clinic in a nearby urban center in the northeastern area of the United States. From a healthcare provider perspective, interactive teledermatology can be an economically viable means of providing dermatological care to remote regions.

Geographical variation in surveillance strategies after curative-intent surgery for upper aerodigestive tract cancer

BACKGROUND

Analysis of geographical variation in utilization of medical resources is often used to identify regions of overutilization or underutilization.

METHODS

We surveyed the membership of the American Head and Neck Society regarding their recommended frequency of office visits and 13 imaging studies and blood tests for their patients after potentially curative therapy for upper aerodigestive tract cancers.

RESULTS

Of the 1322 members surveyed, 610 (46%) responded: 420 responses (32%) were assessable. Responses were compared by US Census Region, Metropolitan Statistical Area, and managed care organization penetration rate. Overseas members (16% of assessable responses) comprised a separate category for the regional analysis. There were statistically significant variations in practice patterns among Census Regions for office visits, complete blood count, computed tomography of the head, sonography, and esophagoscopy. Non-US members recommended significantly more blood tests, imaging studies, and endoscopy than US members for routine cancer surveillance. Only the frequency of office visits differed significantly among Metropolitan Statistical Areas. Surprisingly, the penetration rate of managed care organizations had no significant effect on posttreatment surveillance intensity.

CONCLUSIONS

This analysis indicates that only a small portion of the wide variation in observed follow-up practice patterns can be explained by geographical determinants.

Cost-effectiveness analysis of strategies introducing FDG-PET into the mediastinal staging of non-small-cell lung cancer from the French healthcare system perspective

AIM

To determine the most cost-effective strategy using PET for mediastinal staging of potentially operable non-small-cell lung cancer (NSCLC).

METHODS

Four decision strategies based on French NSCLC work-up practices for the selection of potential surgical candidates were compared, comprising CT only, PET for negative CT, PET for all with anatomical CT, and CT and PET for all cases. The medical literature was surveyed to obtain values for all variables of interest. Costs were assessed with reimbursements from the French healthcare insurance for the year 1999. Expected cost and life expectancy were calculated for all possible outcomes of each strategy. Sensitivity analysis was performed to determine the effects of changing variables on the expected cost and life expectancy.

RESULTS

Compared with the CT only strategy, CT and PET for all resulted in a relative reduction of 70% of surgery for persons with mediastinal lymph node metastasis. PET for all with anatomical CT was shown to be a cost-effective alternative to the CT only, with life expectancy increased by 0.10 years and expected cost savings of 61 euros. This strategy was more favourable than PET for negative CT. Overall, sensitivity analyses showed the robustness of the results.

CONCLUSION

The introduction of thoracic PET for NSCLC staging is potentially cost-effective in France. Further clinical investigation might help to validate this result.

Geographic variation in posttreatment surveillance intensity for patients with cutaneous melanoma

BACKGROUND

We investigated whether geographic determinants could account for variation in posttreatment melanoma surveillance intensity among plastic surgeons.

METHODS

A custom-designed questionnaire was mailed to U.S. and non-U.S. members of the American Society of Plastic and Reconstructive Surgeons (ASPRS). Subjects were asked how they use 14 specific follow-up modalities during years 1 to 5 and 10 following primary treatment for patients with cutaneous melanoma. Repeated-measures analysis of variance was used to compare practice patterns by TNM stage, year postsurgery, U.S. census region, metropolitan statistical area (MSA), and managed care organization (MCO) penetration rate.

RESULTS

Of the 1,142 respondents, 395 were evaluable. Those who did not perform melanoma surgery or follow-up were excluded. Correlation analysis showed that mean follow-up intensity for the modalities surveyed was highly correlated across TNM stages and years postsurgery. Within MSAs, only chest radiograph utilization varied significantly. The pattern of testing varied significantly by geographic region for seven modalities (office visit, computed tomography scan of the brain and chest/abdomen, alpha-fetoprotein level, 5S-cysteinyl dopa level, abdominal ultrasonogram, bone scan); in each of these, utilization by non-U.S. surgeons exceeded utilization in any U.S. census region. The pattern of testing varied significantly by MCO penetration rate for chest radiograph (greater utilization in the lowest MCO penetration rate areas) and 5S-cysteinyl dopa level (greater utilization in the highest MCO penetration rate areas).

CONCLUSIONS

The intensity of posttreatment surveillance recommended by ASPRS members caring for patients with cutaneous melanoma varies markedly. This analysis provides the first evidence that geographic factors significantly affect the surveillance strategies of clinicians following patients with cutaneous melanoma. Variation by census region was most prominent, although the size of detected differences was small.