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Hospital-based technology assessment : a case study involving laser treatment of BPH Bassett, Ken; Kazanjian, Arminee, 1947- Jun 30, 1996

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Centre for Health Servicesand Policy ResearchHOSPITAL-BASED TECHNOLOGY ASSESSMENT:A Case Study Involving Laser Treatment of BPHKen BassettArminee KazanjianBCOHTA 96:6C JUNE 1996B.C. Office of Health Technology AssessmentDiscussion Paper SeriesTHE UNIVERSITY OF BRITISH COLUMBIAHOSPITAL..BASED TECHNOLOGY ASSESSMENT:A CASE STUDY INVOLVING LASER TREATMENT OF BPHKen BassettArminee Kazanjian1STAHC '96 PresentationSanFranciscoJune 24th , 1996B.C. Office of Health Technology AssessmentCentre for Health Services & Policy Research5-184 Koerner Pavilion, 2211 Wesbrook MallThe University of British ColumbiaVancouver, B.C.Canada V6T 1Z3Ph: (604) 822-7049Fax: (604) 822-7975HOSPITAL-BASED TECHNOLOGY ASSESSMENT:A CASE STUDY INVOLVING LASER TREATMENT OF BPHHospitals in British Columbia seldom use formal health technology assessment (HTA)lprocesses to assist in capital acquisition decisions, to organize health services, or toinfluence clinical care.The Greater Victoria Hospital Society (GVHS)2 in contrast, has an establishedTechnology Assessment Committee (TAC), project-specific Working Groups, and arigorous, explicit HTA process that requires input from both hospital administrators andclinical care providers.The TAC, which began in 1990, is a joint medical staff/administrative committee thatreports directly to the Hospital Executive Committee. All new technologies are broughtto the Committee, prioritized and, where necessary, delegated to a TA Working Group(TAWG). TAWGs' examine a technology in detail following an explicit process. Thereview involves considering the technology and its potential application, as well as hospitaland community needs.Until 1994, the TAWGs' considered technology without critical appraisal' of clinicalefficacy and effectiveness evidence. During 1994, a member of the British ColumbiaOffice of Health Technology Assessment(BCOHTA),4 who regularly attends TACmeetings, began to informally contribute critical appraisal to the HTA projects. The LaserTreatment of Benign Prostatic Hyperplasia (BPH) project, which began at this time, wasthe first project in which BCOHTA contributed a systematic and explicit critical appraisalof the literature on the effectiveness of such a device.Neither the laser treatment of BPH, nor its proponents, are singled out for criticism.Rather, the explicit purpose of this HTA project was to examine some of the wider issuesrelevant to health care reform. Of particular interest were the costs and benefits ofintegrating an appraisal of effectiveness evidence into an TAC project, as this directlychallenged the expert opinion of the clinicians involved.The TAC laser project brought together, into one venue, representatives from fourdisparate groups: GVHS urologists and GVHS administrators, the device industry, andresearchers from the BCOHTA. Although the TAC brought the groups together, it didnot bring about consensus, as each group entered into, and largely maintained, a differentconceptual framework, value system, and practical agenda, with:• the laser industry arguing 'the need for progress'• the GVHS urologists and administrators arguing 'the need to compete withother hospitals'• BCOHTA arguing 'the need for research and evaluation'.Be Office of Health Technology Assessment Hospital-based technology assessment:a case study involving laser treatment ofBPHJune 24, 1996Page 1...adding a critical appraisal oftheeffectiveness evidence had the moresubtle and potentially far reachingeffect ofopening up clinicaleffectiveness claims to systematicreview and debate.Several debates about efficacy and effectiveness evidence ensued. Of importance wasnot so much the contents of the debates, although there were interesting differences in theevaluation methods and presentational strategies used by the local urologist, the BCOHTArepresentative and the device industry. Rather, of importance was the circumstance inwhich clinicians and industry representatives faced an unprecedented systematic challengeto their professional authority and their responses to that challenge.This HTA project was largely unsuccessful in the narrow sense of determining whichtechnology to purchase for the surgical treatment of BPH, because rapid technologicalevolution continually results in outdated clinicaltrial evidence. However, several lessons werelearned. First, building an evidence-basedmedicine infrastructure in the hospital settingrequires an appreciable amount of hospitalresources and a wide range of personnel. Second,systematically examining, as in this instance,clinical efficacy and effectiveness evidence acts asa direct challenge to the clinical experts involved,as those clinicians expect to hold the exclusiveright to determine the state of evidence regarding clinical care. Directly challenging theexpert opinion of clinicians requires rigorous research, credibility and confidence. Third,incorporating a systematic examination of the clinical efficacy and effectiveness literatureadds a very powerful tool to a hospital TAC committee: a tool that allows it, for the firsttime, to formally challenge the opinions of clinical experts. Fourth, while adding criticalappraisal expertise to hospital committees gives the committees a powerful means ofchallenging the opinions of clinical experts, the ultimate objective is that of improvingpatient care. As the introduction of HTA to hospital decision-making is a newphenomenon, its impact on this long-term objective remains unquantified. In the interim,the focus should be on the efficacy and effectiveness of the intervention and not the debateitself.The key issue remaining is to what extent and in what role should a hospital utilize criticalappraisal expertise. Is this expertise best kept in the background in the form of writtenreports, or should there be a direct exchange, as described in the report, between theclinical expert providing clinical care and the critical appraisal expert interpreting theefficacy and effectiveness of clinical care? The problem with a confrontational exchange isthat too much rests on its public display; that is, on style rather than content. In addition,a clinical care provider, who may have otherwise supported the idea of evidence-basedmedicine, could become potentially lost to the evidence-based medicine movement.In summary, integrating an appraisal of the efficacy and effectiveness evidence into the TAprocess, while helping to clarify the state of knowledge for laser treatment of BPH, didnot solve the problem of deciding which technology to purchase for treatment of BPH.Rather, adding a critical appraisal of the effectiveness evidence had the more subtle andBe Office of Health TechnologyAssessment Hospital-basedtechnologyassessment:a case study involving laser treatment ofBPHJune 24, 1996Page 2potentially far reaching effect of opening up clinical effectiveness claims to systematicreview and debate.Several recommendations concerning evidence-based medicine in hospital settings seemappropriate:• Clinicians need far more training in, and better opportunities for, adequatelyexamining the state of efficacy and effectiveness evidence.• Hospitals need to establish ongoing contexts, such as the TAC described inthe report, in which to critically examine efficacy and effectiveness evidence.• Public policy makers and funding agencies, that is, the BC Ministry of Healthand its relevant programs, need to identify and to financially support hospitalsmaking systematic efforts to deal with areas of clinical uncertainty, such asthat for the surgical treatment of BPH.NOTESI Health technology assessment is defmed as "any process of examining and reportingproperties of a medical technology used in health care, such as safety, efficacy, feasibility,and indications for its use, cost, and cost-effectiveness, as well as social, economic andethical consequences, whether intended or unintended" [Source: Institute of Med.Division of Health Sciences Policy, Division of Health Promotion and Disease Prevention.Committee for Evaluating Medical Technologies in Clinical Use. Assessing MedicalTechnologies. Washington, D.C.: National Academy Press, 1985.]2 The GVHS consists of three facilities with 800 acute and 700 extended, long term, andpsychiatric care beds. These hospitals serve Victoria itself, and act as a referral centerfor southern Vancouver Island.3 Critical appraisal, following a systematic review, involves applying strict criteria inassessing the validity of knowledge for a given device, drug, or procedure. Its goals areto highlight knowledge strengths and to direct further research towards knowledge gaps.Critical appraisal, therefore, evaluates rather than simply reviews the state of knowledge.4 The BCOHTA is a government-funded, university-based, provincial TA program ofresearch which began in 1990. Among other activities, it has contributed written andoral presentations to a wide range of local and national clinical effectiveness debates.Be Office of Health Technology Assessment Hospital-based technology assessment:a case study involv ing laser treatment ofBPHJune 24,1996Page 3

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