alberta heritage foundation for medical

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Alberta Heritage Foundation

for Medical Research

Profile of an HTA programThe AHFMR Health Technology AssessmentUnit, 2002 - 2003

David Hailey

February 2004

IP-16 Information Paper

Profile of an HTA programThe AHFMR Health Technology Assessment Unit,

2002 - 2003

David Hailey

February 2004

Acknowledgment

The author wishes to thank the staff of the Health Technology Assessment Unit at the

Alberta Heritage Foundation for Medical Research for their assistance and input in the

preparation and finalization of this paper.

© Copyright Alberta Heritage Foundation for Medical Research, 2004

Comments relative to the information in this paper are welcome and should be sent to:

Director, Health Technology Assessment Unit

Alberta Heritage Foundation for Medical Research

1500 10104-103 AvenueEdmonton, AB T5J 4A7 CANADATel: (780) 423-5727 Fax: (780) 429-3501

E-mail: [email protected]

© Alberta Heritage Foundation for Medical Research, 2004

ISBN 1-896956-73-4 (Print)

ISBN 1-896956-75-0 (On-Line)

ISSN: 1706-7863

Alberta’s health technology assessment program has been established under the Health

Research Collaboration Agreement between the Alberta Heritage Foundation for

Medical Research and Alberta Health and Wellness.


Health Technology Assessment

l

Glossary

AHW: Alberta Health and Wellness

CCOHTA: Canadian Coordination Office for Health Technology Assessment

CHR: Calgary Health Region

CPG: Clinical practice guideline

EAP: Expert Advisory Panel (established by Alberta Health and Wellness)

HTA: Health technology assessment

HTAI: Health Technology Assessment Initiative

HTAU: Health Technology Assessment Unit

INAHTA: International Network of Agencies for Health Technology Assessment

IS: Information services

ISTAHC: International Society of Technology Assessment in Health Care

PTCA: Percutaneous transluminal coronary angioplasty

RCT: Randomized controlled trial

RHA: Regional Health Authority

WHO: World Health Organisation

WHO HEN: World Health Organisation Health Evidence Network


Health Technology Assessment11

Digitized by the Internet Archive

in 2016

https://archive.org/details/profileofhtaprog00hail_0

Contents

Acknowledgment i

Glossary ii

Introduction 1

Approach 3

HTAU Products 4

Formulation of HTA Questions 6

Expected timelines 9

Type of technology/topic 10

Assessment Products 12

Allocation to different series 12

Issues addressed 12

Collaborators and contractors 16

Approaches taken 16

Timelines 17

Conclusions reached in HTA products 21

Dissemination 25

Impact of HTA products 29

Areas of impact 29

Level of impact 29

Indirect impact 29

Types of decisions 30

Resource and Educational Products 41

Governance 43

Resources and Staff 44

Synthesis 45

Discussion 49

Appendix A: Publication product series produced by the HTAU 53

Appendix B: Information Collection Form 54

References 58

Alberta Heritage Foundation for Medical Research iii


Profile of an HTA Program

The AHFMR Health Technology Assessment Unit, 2002 - 2003

Tables and Figures:

Figure 1: Determinants of effectiveness 1

Figure 2: Elements of Effectiveness 49

Table 1: Assessment products April 2002 to March 2003 4

Table 2: Resource and educational products, April 2002 to March 2003 5

Table 3: Sources of requests for HTA products 6

Table 4: Specification of HTA products 7

Table 5: Expected timelines for assessment reports 10

Table 6: Issues addressed in HTA products 13

Table 7: Eventual timelines for HTA products 18

Table 8: Conclusions reached in HTA products 21

Table 9: Approaches to dissemination of HTA products 26

Table 10: Areas of impact of HTA products 31

Table 11: Level of impact of HTA products 34

Table 12: Indirect impact of HTA products 38

Table 13: Types of decisions informed by HTA products 39

Table 14: Synthesis of HTA product activity 46

Alberta Heritage Foundation for Medical Research iv


Introduction

In 2003, the HTAU at the Alberta Heritage Foundation for Medical Research (AHFMR)published a paper in its HTA Initiatives series entitled 'Elements of effectiveness for health

technology assessment programs' l. The paper was intended to provide a basis for

discussion on the components of HTA programs and approaches to measuring their

effectiveness. It gave some consideration to better defining the role played by HTAagencies and the determinants of their effectiveness. These determinants are outlined in

Figure 1. In part, the paper was seen as a self assessment tool for HTA program

managers to help achieve continual improvement of activities.

Figure 1: Determinants of effectiveness

Staffand structure

ofHTA program

formulate

: tfff*TA<q««Sti0RS

Primary

tariff Car

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Prevision

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fffteparte

teskle

local beaitb

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changes

to health care,

health outcomes

The HTAU has also been exploring ways to assess the impact of its products and has

published two recent reports on this topic which included responses to surveys of the

Unit's clients 2> 3.



This paper has been prepared to provide an overview of the outputs of the HTAU as an

aid to future management of HTA activities at the AHFMR, drawing on concepts

outlined in an earlier HTA Initiatives publication (HTAI 9 )1

. This is the first time that

this framework has been applied to an HTAU. In addition to its application to the

Alberta program, this paper forms part of an effort to help the international HTAcommunity come to grips with how HTA programs may be evaluated on a rigorous

and consistent basis. The paper is also intended to complement the previous papers on

HTA impact as a further approach to defining performance and accountability of

programs in a complex area that has still received relatively little attention.

The paper reviews the activity of the HTAU as reflected in the various products it

produced from 2002 to 2003, including the impact of these on decision makers in the

province, and identifies some areas for consideration in future management of the

HTAU.



2

Approach

The scope and other details of the project were discussed with HTAU staff in May and

June 2003 and subsequently confirmed with the Director of the HTAU. It was agreed

that the overview would be based on scrutiny of products completed from April 2002 to

March 2003 inclusive. All types of product from the Unit were considered down to

'Level D' QwikNotes or their equivalent (see Appendix A). Very brief and rapid

responses, such as "instant e-mail", were not included.

An information collection form was developed with input from HTAU staff (Appendix

B). Unit staff then used the form to provide details of the products for which they had

been responsible. Two rounds of follow-up requests for further information were

undertaken to clarify various points, including summaries of the conclusions reached in

assessments. Staff had the opportunity to correct and update material entered on the

information collection form.

The information was then used to provide summaries of various areas related to the

preparation and use of the products. Most of the details in the paper relate to

Formulation of HTA questions, HTA products. Dissemination, and Impact of HTA,which were 'Assessment Stream' issues identified in HTAI 9. Some consideration is

also given to Governance, Resources, Staff and Structure as well as Collaborative and

Contractual Inputs.

The Unit's products included both assessments and resource/educational publications.

These categories are discussed separately since the issues related to them are somewhatdifferent.



HTAU Products

The nineteen assessment products completed from April 2002 to March 2003 are listed

by category in Table 1. Four of these were in the HTA series. There were also five

TechNotes, two HTA Initiatives reports, two Information Papers, two QwikNotes, and

four reviews that fell outside the regular HTAU series. The latter had a substantial

influence on the workload and operation of the Unit. One of the Initiatives reports was

prepared at the University of Alberta and published by the AHFMR in an effort to

further links with the Department of Public Health Sciences and raise the profile of

HTA in the province.

Table 2 lists the three educational/resource products completed during this period - the

latest update of an Information Paper and two publications in the HTA Initiatives

series.

Table 1: Assessment products April 2002 to March 2003

Health Technology Assessments

01 Brooks L, Leggett Tait P, Harstall C. Acupuncture: evidence from systematic reviews and meta-

analyses, May 2002

02 Ospina M, Harstall C. Prevalence of chronic pain: an overview, December 2002

03 Ospina M, Harstall C. Multidisciplinary pain programs for chronic pain: evidence from systematic

reviews, January 2003

04 Guo B, Scott A, Bowker S. Suicide prevention strategies: evidence from systematic reviews,

February 2003

TechNotes

05 Ospina M. Cryosurgery for prostate cancer, May 2002

06 Guo B. Intracoronary brachtherapy for the treatment of in-stent restenosis, May 2002

07 Guo B. Osteogenic protein-1 for fracture healing, November 2002

08 Scott A. Trigger point injections for non-malignant chronic pain, March 2003

09 Scott A. Treatment of thoracic insufficiency syndrome with the vertical expandable prosthetic

titanium rib, December 2002

HTA Initiatives

10 Hailey D. Minimally invasive hip arthroplasty, March 2003

1 1 Yoon P. Emergency department fast-track system, March 2003





Table 1: Assessment products April 2002 to March 2003 (cont’d)

Information Papers

12 Hailey D. Stereotactic radiosurgery: an update, May 2002

13 Hailey D. Hyperbaric oxygen therapy - recent findings on evidence for its effectiveness, March

2003

QwikNotes

14 Guo B. Effectiveness of computerized physician order entry systems in reducing medication

errors, April 2002

15 Corabian P. Prolotherapy, June 2002

‘Customized Responses’ - reviews undertaken outside regular HTAU series

16 HTAU . A selected inventory of abstracts of Cochrane reviews on physiotherapy/physical therapy,

October 2002

17 HTAU. A selected inventory of abstracts of systematic reviews on chiropractic services, October

2002

18 HTAU . A selected inventory of abstracts of systematic reviews on podiatry services, October

2002

19 HTAU . A selected inventory of abstracts of systematic reviews on optometric sen/ices, October2002

Table 2: Resource and educational products, April 2002 to March 2003

20 Chan L, Topfer LA. Health technology assessment on the Net: a guide to internet sources of

information, June 2002 (Information Paper)

21 Hailey D. Local health technology assessment: a guide for health authorities, December 2002(HTA Initiative)

22 Hailey D. Elements of effectiveness of health technology assessment programs, March 2003(HTA Initiative)



Formulation of HTA Questions

Sources of requests for assessments are shown in Table 3. The pattern is similar to those

for previous years, with most products being developed in response to requests from

AHW and/or RHAs. All the HTA products were aimed at decision-makers within the

province. Two of them were also prepared with the aim of furthering HTA in Alberta.

Table 3: Sources of requests for HTA products

AHW RHAsa AHW +RHAs

OtherHTAb

Professional

body0University'

lift 1 ililllll

HTA report 1 3

TechNote 2 2 1

HTA initiatives 1 1

Information Paper 1 1

QwikNote 1 1

Customized Response 4

Totals 8 4

a. Includes the Alberta Mental Health Board

4 1 1 1

b. Calgary Health Technology Implementation Unit

c. College of Physicians and Surgeons of Alberta

d. University of Alberta, Department of Public Health Sciences

Information on the specification of the assessment products, including details of the

issues that were to be addressed, are given in Table 4. The responses provided by

HTAU staff indicated that project specifications were addressed mostly in terms of the

question or issue raised by the organization requesting the HTA. In all cases there was

discussion to confirm or clarify the nature of the request (often face to face, also by

telephone and e-mail). Most of the questions were framed in terms of evidence of

effectiveness or current status of various technologies, sometimes in association with

safety issues. Cost or access issues were mentioned less often. This is similar to the

pattern for other HTAU products in previous years.

In several cases, the product was a follow up to a previous assessment undertaken by

the HTAU or was intended as a precursor to further work on a topic.



6



Table 4: Specification of HTA products

Product Question/issue


01 Acupuncture:

evidence from

systematic reviews

and meta-analyses

Current scientific evidence over the last five

years addressing the question ‘for which

conditions acupuncture has scientific support’

(effectiveness, for whom, by whom)

02 Prevalence of chronic

pain: an overview

What is the best available evidence on

prevalence estimates for pain not related to

cancer?

03 Multidisciplinary pain

programs for chronic

pain: evidence from

systematic reviews

Evidence on the efficacy/effectiveness/

efficiency of multidisciplinary pain programs

for non-malignant chronic pain and how do weestablish provincial needs for a multidiscipline

pain program?

04 Suicide prevention What suicide prevention strategy is effective?

strategies: evidence

from systematic

reviews

05 Cryosurgery for

prostate cancer

06 Intracoronary

brachytherapy

TechNotes

What is the status of cryosurgery for the

treatment of prostate cancer?

The current status of the use of intracoronary

brachytherapy for patients with in-stent

restenosis after PTCA

07 Osteogenic protein-1 Regulatory status in Canada and the US for

for fracture healing patient groups; current practice in Canada;and evidence supporting its use and on

adverse effects

08 Trigger point Is trigger point injection effective for treating

injections for non- chronic pain? What is the feasibility of

malignant chronic pain delivering this procedure to patients in

regional communities?

Related HTAUproducts

Overview of the regulation

of acupuncture in Alberta

May 2001 - Information

Paper

One of two reports on the

suicide prevention project

QwikNote - February 2002TechNote - May 1998

Related to the HTA reports

on chronic pain



7


The AHFMR Health Technology Assessment Unit, 2002 2003

Table 4: Specification of HTA products (cont’d)109 Treatment of thoracic

insufficiency syndrome

with the prosthetic

titanium rib

Question/issue

TechNotes (cont’d)

Safety and efficacy/effectiveness of using a

vertical expandable prosthetic rib implant to

treat patients with thoracic insufficiency

syndrome. Is the procedure considered

experimental? What patient conditions are

eligible for this treatment and how manysurgeries/hospitalizations are needed over the

course of the treatment?

Related HTAU:

:

10 Minimally invasive hip

arthroplasty

11 Emergencydepartment fast-track

system

12 Stereotactic

radiosurgery: an

update

13 Hyperbaric oxygen

therapy - recent

findings

14 Effectiveness of

computerized

physician order entry

systems

15 Prolotherapy

HTA Initiatives

Proposed introduction of a new surgical

technique into CHR; interest in data on safety,

efficacy, cost

What does the literature say about the

effectiveness of emergency department fast-

track systems?

Information Papers

Current evidence on the effectiveness of

radiosurgery issues on out of province

referral, other indications for radiosurgery

Request from the College of Physicians and

Surgeons in relation to approvals given for

treatments by the private hyperbaric oxygentherapy service in Calgary. The College

wanted updated advice to take account of

recent studies reported in the literature.

QwikNotes

Is there any research evidence to show that

computerized physician order entry systems

reduce medication errors?

Proposed first stage in a

more extensive

assessment to be

coordinated by Calgary

Health Technology

Implementation Unit

Two previous HTAreports, one TechNoteand two Techscans(briefs), all used by AHW

Previous HTA on

hyperbaric oxygen

therapy in relation to

facilities in Alberta

The current status of prolotherapy TechNote March 1996

Update [brief] May 1998



8



Table 4: Specification of HTA products (cont’d)

Product Question/issue Related HTAUproducts

Customized Responses

16 Physiotherapy/

physical therapy

Is there any evidence of effectiveness of

community physical therapy/physiotherapy?

17 Chiropractic services Is there any evidence of effectiveness of

chiropractic services?

18 Podiatry services

19 Optometric services

What is the evidence regarding the

effectiveness of podiatry?

Is there any evidence of effectiveness of

optometric services?

Expected timelines

Expected timelines for the various products are shown in Table 5. The four HTAreports were each expected to take a year, as might be expected for reports that

incorporate major reviews. The timelines for the TechNotes varied from one to three

months, continuing the pattern for this type of product, though the initial timeline for

the cryosurgery publication was less than a month. As has been discussed elsewhere 4,

providing considered responses over such short time frames puts pressure on the

evaluation process. Requestors of TechNotes should provide very good justification for

expecting urgent responses. Both QwikNotes, as expected, had very short timelines.

The first HTA Initiative product was given a long timeline because of the expected

collaboration with the Calgary HTA program and the need to negotiate details.

Timelines for the second HTA Initiative refers to editing, review, and formatting of a

report that had already been prepared outside the Unit. A timeline of six months for

the first Information Paper was based on expected time needed to update previous

HTA reports on the topic in question. The similar timeline for the second paper

reflected the comparatively non-urgent nature of the request.

The reviews undertaken as customized responses all had a timeline of two months.

This was extremely demanding on the Unit's work program and resources.

Acceptability of very short timelines for urgent requests needs to be kept under review

so that the Unit does not become exposed to unreasonable demands. On the other

hand, the Unit has established an impressive record over the years in handling urgent

requests, and such activity has contributed substantially to its reputation.



9



Type of technology/topic

A wide range of topics was addressed, both in terms of technologies and diseases/

conditions, continuing the pattern of a broadly-based HTA agenda, though with a focus

on non-pharmaceutical technologies.

Table 5: Expected timelines for assessment reports

Product Ex|

tin


01 Acupuncture: evidence from systematic reviews and meta-analyses

02 Prevalence of chronic pain: an overview

Length,

months

03 Multidisciplinary pain programs for chronic pain: evidence from

systematic reviews.

04 Suicide prevention strategies: evidence from systematic reviews.

TechNotes;

05 Cryosurgery for prostate cancer

06 Intracoronary brachytherapy

07 Osteogenic protein-1 for fracture healing

08 Trigger Point Injections for non-malignant chronic pain

09 Treatment of thoracic insufficiency syndrome with the prosthetic

titanium rib

10/00 - 10/01

5/01 - 5/02

5/01 - 5/02

2/01 - 2/02

1 /02 - 2/02,

extended to 4/02

4/02 - 5/02

10/02 - 12/02

10/02 - 12/02

10/02 - 12/02

HiHTA Initiatives

10 Minimally invasive hip arthroplasty 6/02 - late 02

1 1 Emergency department fast-track system 01/03 - 4/03

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12 Stereotactic radiosurgery: an update 10/01 - 4/02

1 3 Hyperbaric oxygen therapy - recent findings 1 0/02 - 4/03

12

12

12

12

1,3

1

2

2

2

5-6

3

6

6



10

Table 5: Expected timelines for assessment reports (cont’d)

Product

QwikNotes

Expected Length,

timeline months

14 Effectiveness of computerized physician order entry systems 4/02 - 4/02 <1

15 Prolotherapy 5/02 - 6/02 1

Customized Responses

16 Physiotherapy/physical therapy 10/02- 1/03 2

17 Chiropractic services 10/02-1/03 2

18 Podiatry services 10/02-1/03 2

19 Optometric services 10/02-1/03 2

Alberta Heritage Foundation for Medical ResearchHealth Technology Assessment

11

Assessment Products

Allocation to different series

Decisions to develop reports in the HTA, TechNote, and QwikNote series were

consistent with the expected complexity of the longer assessments and the perceived

urgency of advice for requestors of non-refereed reports. Two reports were published

in the HTA Initiatives series because of a wish to raise the profile of HTA in the

province and to document particular collaborative arrangements. One of the

Information Papers was a lengthy assessment report, following two previous HTAreports on the same topic. The other Information Paper was a brief review of findings

from recent HTA reports and reviews. The Customized Responses were made available

on the AHFMR web site as a non-standard group of reviews.

Some thought needs to be given to the allocation of reports to the particular series. The

products for 2002/2003 were spread over four printed series, for various reasons. This

might be confusing for users of HTAU products and unhelpful for dissemination.

Issues addressed

Issues addressed in HTAU products are indicated in Table 6. As in previous years,

safety, efficacy, and effectiveness were the most common topic areas. Eight products

made some reference to economic issues, though there were none that included

economic analysis. Four considered access issues; four Customized responses referred

to practice guidelines, and one HTA report was concerned with prevalence rates.

Unlike some assessments in previous years, there was no consideration of social or

ethical issues, though the HTA report on suicide prevention programs made somereference to social aspects.

Issues addressed in HTA products will of course depend on the questions that are being

asked. However, with some of the topics considered in the 2002/2003 products there

might have been an opportunity to broaden their scope by incorporating commentaryand perspective on social matters.



12

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Collaborators and contractors

The HTA report on acupuncture was co-authored by a contractor who provided

important support in bringing this project to a conclusion. The products on chronic

pain were supported by input from an information sharing group that included

representation from AHW, CHR, and Capital Health Region. With the suicide

prevention program assessment, contact with Alberta Mental Health Board

representatives was related to formulation of the HTA question rather than to

collaboration. The HTA Initiatives report on the emergency department fast-track

system was written by a physician from the University of Alberta who had been a

participant in the Technology Assessment for Health Care course offered by the

Department of Public Health Sciences.

With the Customized Responses products, contracts were made with the College of

Physical Therapists of Alberta, the Alberta College of Optometrists, individuals from

the Associated Foot Clinic, and the College of Chiropractors of Alberta. The contractors

were used to review the selected abstracts. This was a useful approach to obtain

expertise in the subject areas and to assist the HTAU with its workload.

A librarian from the University of Calgary provided IS support for the project on

minimally invasive hip arthroplasty because of pressure on existing AHFMRarrangements and the collaboration with the Calgary HTA program. All reports in the

HTA Initiatives series were formatted and edited by an external contractor, maintaining

continuity in the production of this type of publication.

Approaches taken

Systematic reviews were undertaken for all the Health Technology Assessment reports.

One of these also had a narrative review component and in another there was analysis

of administrative and survey data. Systematic review with narrative commentary on

cost data was used for the Information Paper on radiosurgery.

Two of the TechNotes were said to be based on systematic review, two on narrative

review, and one on a mix of both approaches. Narrative review was used for the two

HTA Initiative products and the second Information Paper.

The approaches taken appear to have been appropriate and there are no obvious areas

of concern. The distinction between systematic and narrative review may not always be

entirely clear - even with the narrative reviews used for some products there wouldhave been careful consideration of selection criteria and appraisal of quality. A point

that deserves continuing attention is the depth of review and analysis needed to

appropriately answer the question that an HTA is addressing.





With the Customized Responses, the approach was to review selected abstracts of

systematic reviews on the different topics. This was a pragmatic approach adopted to

meet the time and scope pressures associated with these products. Abstract review wasalso used for the two QwikNotes.

There was external review of all HTA series reports, one Information Paper, the HTAInitiatives report on hip arthroplasty, and two TechNotes. With the four Customized

Responses there was external review of the articles selected. The number of reviewers

used varied from product to product. Detailed internal review by HTAU staff wasundertaken for all products.

Timelines

Table 7 gives details of actual timelines for the assessment products. Targets were metfor all the urgently required products (TechNotes, QwikNotes, and Customized

Responses). This was an impressive level of performance by the HTAU.

All of the HTA series reports took longer than expected. With the two on chronic pain,

delay was in part associated with the necessity to interact with an external group andwith time taken to define some aspects of the project. The project on acupuncture wasused as a Teaming experience' for a person on a short-term placement with the HTAU,and there were overheads associated with necessary mentoring. Protracted

negotiations with the client were needed with the project on suicide prevention

strategies.

It is not uncommon for more complex HTA projects to run over time; management of

factors contributing to delay will be an ongoing task. Provision of interim advice to

clients, as was undertaken for the products referred to here, may be helpful. However,an area that may need attention is the time taken for review and publication of longer

reports, which ran to five months for three of the HTA products.

The remaining products were completed as expected, other than a small overrun caused

by delay in starting the Information Paper on radiosurgery.



Table

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timelines

for

HTA

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Conclusions reached in HTA products

Table 8 lists brief summaries of the conclusions reached in the various HTA products as

well as the questions or issues that they addressed. In most cases, the conclusions

reached appeared to match the questions asked, though occasionally some points were

not covered or additional issues were mentioned.

Table 8: Conclusions reached in HTA products

Product Question/Issue Conclusions “In a word”

01 Acupuncture:

evidence from

systematic

reviews and

meta-analyses

‘For which conditions

acupuncture has

scientific support’

(effectiveness, for

whom, by whom).

Acupuncture appears effective for Conditional

dental and temporomandibular support, somepain and antiemesis. For all other applications.

indications it is no more effective

than the standard of care or the

evidence is too weak to drawconclusions.

02 Prevalence of

chronic pain: an

overview

Best available

evidence on

prevalence estimates

for pain not related to

cancer.

Reported chronic pain prevalence Limited useful

estimates vary widely (10.1% to evidence, need

55.2%) and severe chronic pain local data,

prevalence is 8% in children and11% in adults. Prospective

epidemiological studies should be

conducted to estimate the chronic

pain prevalence in Alberta.

03 Multidisciplinary

pain programs for

chronic pain:

evidence from

systematic

reviews

Evidence on the

efficacy/effectiveness/

efficiency of

multidisciplinary pain

programs for non-

malignant chronic pain

and how do weestablish provincial

needs for a

multidiscipline pain

program?

f1

Unclear which treatment (within

the multidisciplinary pain

programs) is responsible for the

observed improvements in chronic

pain patients or which kind of

patients do best under a particular

individualized treatment plan.

RHAs providing management of

chronic pain must establish

appropriate data collection

systems and assess both clinical

effectiveness of intervention

strategies and their efficiency.

Effectiveness

not established,

local studies

needed.

04 Suicide

prevention

strategies:

evidence from

systematic

reviews.

What suicide

prevention strategy is

effective?

No single strategy is effective in

reducing suicide rate. Thestrongest evidence indicated that

some prevention strategies,

including school-based suicide

prevention programs for high risk

students and psychological/

pharmacological treatment for

suicide attempters, appear

promising.

Limited

effectiveness for

some strategies,

efficacy not

established for

others.





Table 8: Conclusions reached in HTA products (cont’d)

05 Cryosurgery for

prostate cancer

06 Intracoronary

brachytherapy

07 Osteogenic

protein-1 for

fracture healing

08 Trigger point

injections for

non-malignant

chronic pain

09 Treatment of

thoracic

insufficiency

syndrome with

the prosthetic

titanium rib

Question/issue

What is the status of

cryosurgery for the

treatment of prostate

cancer?

The current status of

the use of

intracoronary

brachtherapy for

patients with in-stent

restenosis after PTCA.

Regulatory status in

Canada and the US for

patient groups; current

practice in Canada;

and evidence

supporting its use and

on adverse effects.

The efficacy/effectiveness of

cryosurgery in the management of

prostate cancer is still not

established.

Evidence from six RCTs suggests

that the technology is feasible and

safe as an adjunct to treatment of

in-stent restenosis, and reduces

short term restenosis rates.

However, late thrombosis mayminimize the long-term benefits.

Evidence from one RCTsuggested osteogenic protein-1

was safe and success rates whenused in conjunction with

intramedullary rod fixation were

comparable with those achieved

with autograft for the treatment of

tibial non-unions. It is indicated for

use in recalcitrant long bone non

unions where autograft is

unfeasible and alternative

treatment has failed.

Is trigger point injection

effective for treating

chronic pain? What is

the feasibility of

delivering this

procedure to patients

in regional

communities?

No definitive proof that trigger

point injection is more effective

than acupuncture or placebo. Not

known whether a lack of multi-

disciplinary pain managementprograms in regional areas limits

or encourages its use, or what

type of provider would achieve

best results.

Safety and efficacy/

effectiveness to treat

patients with thoracic

insufficiency

syndrome; whether

procedure is

experimental; patient

conditions eligible for

this treatment; numberof surgeries/

hospitalizations

needed during the

treatment.

No major safety issues were

I

identified; early efficacy outcomes

suggest that it may be a viable

treatment option for children with

thoracic insufficiency. However,

the procedure is costly and

requires frequent hospital visits for

extension and eventual

replacement of the device. Its

effect on pain and quality of life is

unknown.

Efficacy not

established.

Short term

safety andefficacy

established,

long term

efficacy unclear.

Appears to besafe and

effective

technology.

;

Efficacy not

established.

Emergingpromising

technology,

efficacy not

established.



22




Product Question/Issue Conclusions

10 Minimally

invasive hip

arthroplasty

Proposed

introduction of a newsurgical technique;

interest in data on

safety, efficacy,

cost.

Offers the promise of lower

morbidity, shorter hospital stay,

cost savings, faster recovery.

However, further studies andexperience will be necessary to

establish its place in routine care.

11 Emergencydepartment fast-

track system

12 Stereotactic

radiosurgery: an

update

Effectiveness of

emergencydepartment fast-

track system.

Current evidence on

the effectiveness of

radiosurgery, taking

into consideration

out of province

referral and newerindications for SRS.

I

|

1

13 Hyperbaric

oxygen therapy -

recent findings

Updated advice oneffectiveness of

hyperbaric oxygentherapy in different

applications, to take

account of recent

studies reported in

the literature.

Emergency department fast-track

system, as an adjunct to

emergency departments, appears

to be efficient, cost-effective, safe

and satisfactory to patients. It

should incorporate timely andaccurate reporting of visits to

patients’ primary care physicians.

SRS should continue to be madeavailable to appropriately selected

patients with metastatic disease,

arteriovenous malformations andacoustic neuroma; it should not

be offered for treatment of

Parkinson’s disease, trigeminal

neuralgia or epilepsy. Anyreferral of patients for SRS should

be to centres of excellence, taking

account of other appropriate

treatment options.

There is support for use of

hyperbaric oxygen therapy for

decompression sickness, gasembolism, gas gangrene, carbon

monoxide poisoning,

osteoradionecrosis, diabetic

wounds, and necrotising soft

tissue infections. There is no

consensus on support for its usein osteomyelitis, thermal burns,

soft tissue radionecrosis,

compromised skin grafts, andmany other conditions.

“In a word”

Emergingpromising

technology, not

yet established.

Effective

technology

Conditional

support, someapplications.

Conditional

support, someapplications.






Question/Issue

14 Effectiveness of

computerized

physician order

entry systems

(CPOE)

Is there any

research evidence

to show that

computerized

physician order

entry systemsreduce medication

errors?

Evidence from three RCTsindicated that medical errors

decreased after implementation of

CPOE system. CPOE systemsare likely most effective when part

of an electronic medical record

system allowing full access to a

patient’s clinical information.

Effective

technology.

15 Prolotherapy The current status of

prolotherapy.

Results of abstracts of three

RCTs noted - no conclusions

provided.

Ineffective

technology.

16 Physiotherapy/

physical therapy

17 Chiropractic

services

18 Podiatry services

19 Optometric services

Is there anyevidence of

effectiveness of

these services?

No overall conclusions,

documents summarized findings/

conclusions in reviewed

abstracts. However, available

data indicate that there is such

evidence.

;| ’

1

;

;

Widely usedhealth services,

essential in

numerousapplications.



24

Dissemination

Brief details of approaches taken to dissemination of HTA products are given in Table 9.

Paper copies of all products were sent to the primary targets and electronic copies of all

but three were e-mailed. There seemed to be direct discussion with the primary target

in relatively few cases. Discussion was ongoing for the chronic pain products and the

suicide prevention programs report, providing some offset against the long time

needed to complete the publications. A presentation was made on one of the

QwikNotes and there was some discussion with AHW regarding the Information Paper

on radiosurgery. Potentially this is an area that could be improved, with more active

follow-up, though it is appreciated that this is not always easy to arrange and that it

places further demands on resources.

Wider dissemination was carried out via the standard HTAU circulation list, the

AHFMR web site, the HTA database, and the INAHTA web site in many cases. There

were also several conference presentations and in some cases secondary circulation of

products by other organizations. The invitation to publish the chronic pain prevalence

report in the International Association for the Study of Pain Clinical Updates was useful

for the dissemination process. Requests for publications and citations in other agencies'

reports give an indication of visibility (and potential secondary impact).

In just one case - the report on the emergency department fast-track system - more

elaborate short-term dissemination arrangements were made, including involvement of

the AHFMR Communications, a news release to print and electronic media, and a

media interview. The opportunity for supporting dissemination of other HTA products

is an issue that merits discussion.



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Product

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Impact of HTA products

Tables 10 to 13 give information related to the impact of the various assessment

products. For the most part, the information reflects the direct experience of HTAUstaff in managing individual projects, and in a number of cases there is also supporting

information through documents from clients and other organizations. The data

therefore give an important "snapshot" of the impact of the HTA program, but it

should be borne in mind that there is no detailed study, for example using survey

methodology, to substantiate all the information and opinion given here.

Areas of impact

Table 10 outlines the areas of impact of HTA studies, using the categories adopted for a

project on reporting the impact of HTA reports that is currently being undertaken by

INAHTA. Only one product had no apparent impact (though this was reviewed by an

external information group). All other products were at least considered by decision

makers. In six cases, conclusions or recommendations were accepted. Material from

five products was incorporated into policy documents and 14 assessments were used as

reference material. One HTA report was linked to changes in practice and six products

had other impacts, including input to future research on the technologies considered

and expectations of future collaborations with the HTAU.

Level of impact

Table 11 includes opinions of HTAU staff on the level of impact associated with the

HTA products and gives some supporting details. Two TechNotes on cryosurgery and

intracoronary brachytherapy were thought to have had major impact on subsequent

decisions on these technologies. A further fifteen products were considered to have

provided some input to decisions. Possibly this is a conservative view, as in several

cases there appeared to have been significant developments that flowed directly from

work done on the assessment products. In one case, the product received someconsideration by a decision maker and in one the impact was minimal. The details in

the table give an indication of action taken and use of the products by different

stakeholders in the province.

Indirect impact

Table 12 gives information on indirect impacts of eight HTA products. With four of

these there was some influence on other targets within Alberta, with likely influence onfuture policy or administrative decisions. Six products were accessed by organizations

outside Alberta and provided some input to HTA activities undertaken by other

agencies.





Types of decisions

Table 13 gives an indication of the types of decisions that were informed by the various

HTA products, using categories from the current INAHTA project. This draws on all

available information and does not necessarily reflect the exact questions or issues that

the HTA products were required to address. Coverage decisions were the most

common, related to 10 and possibly 11 products. In four cases there were capital

funding decisions, referral for treatment in two (possibly three), program operation in

seven, guideline formulation in two, influence on routine practice in three (possibly

four), and indications for further research in five. This summary reflects the range of

issues addressed by products from the HTAU.

Overall, the picture that emerges from this summary of impacts is encouraging. While

detail was sometimes limited, it seems clear that products from the HTAU had a useful

impact in most cases, and that often this was achieved by products with very tight

deadlines.



30

Considered

Conclusions/

Technology

HT

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material

HTA

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Profile

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Resource and Educational Products

1. The first of the three publications in this group was the latest version of"Health

technology assessment on the net", which was first published in 1999 and has been

updated annually since then.

This is a widely known publication that has proved to be a useful resource for those

working in HTA. It has been made available through the AHFMR web site and

through hard copy and numerous other outlets. These include conference

presentations (ISTAHC and the Canadian Health Libraries Association), the HTAcourse at the University of Alberta, the National Library of Medicine's Etext on

Health Technology Assessment Information Resources (links to the guide), and

through several other web sites, for example, the NeLH (National Electronic Library

of Health), ScHARR, DACEHTA (Denmark), VATAP (USA), and the Evidence-

Based Medicine group (Italy). The authors have been responsible for dissemination.

Requests for the document have been received from all over the world. For

example, NZHTA (New Zealand) has used the guide in their training; the Health

Council of the Netherlands has recommended the guide to their staff; the Singapore

Ministry of Health has requested copies; and the Newfoundland Ministry of Health

requested copies for staff members. In Alberta, the guide has been used by

librarians at the University of Alberta John Scott Health Sciences Library and

included in their Evidence-Based Healthcare Information Resources web page.

This is a useful, ongoing activity for the HTA program that requires only limited

resources to maintain. Overall, impact would be hard to assess but certainly

AHFMR is well known as a useful source of information in this area.

2. The first of the HTA Initiatives products "Local health technology assessment: a guidefor

health authorities" was developed to assist in building HTA capacity and competence

at the local level in Alberta. Staff in RHAs were the main target. The request for the

product came from the Director of HTA, with the report seen as being

complementary to other publications in this series. It was completed in 2002 (start

July, review November, published December).

This is a guideline covering elements of HTA, based on narrative review and

commentary. Dissemination was through standard circulation procedures plus

discussion by the author with staff at Foothills Hospital, Calgary and at a workshop.

Impact of this product is hard to assess. There was interest in the document from

the CHR, with verbal advice from the Department of Surgery that it had been

helpful in considering approaches to new technologies. There has also been interest

from individuals in Italy and the Philippines, via conference contacts. It is unclear,



Profile of fin HTA Program


from the information available, whether there has been any additional impact within

RHAs in Alberta, which were the main target for this product.

3. The suggestion for development of the final product, "Elements of effectiveness for

health technology assessment programs" came from discussion between the author and

the Director of HTA, and followed earlier work in this area at the Department of

Public Health Sciences, University of Alberta, which had been presented at an

ISTAHC meeting. The issue addressed is the factors that define and contribute to

the effectiveness of HTA programs. It was seen as a contribution to building HTAcompetence.

The project was started in September 2002 and published in March 2003. It is an

extended commentary with a focus on HTA program effectiveness. Drafts were

given to a number of HTA contacts in Canada and elsewhere but there was no

feedback during preparation.

The primary target for this work was really the HTAU, and the immediate

consequence is the present paper. In addition to dissemination through standard

circulation methods, the work has been presented at seminars and conferences.

General interest in the approach has been expressed by agencies in Canada, the

Netherlands, and Singapore, but there is as yet no specific indication of impact.



42

Governance

Little information on governance was provided in the responses from HTAU staff, and

issues in this area can be dealt with only to a limited extent in a project of this sort. Amore direct and detailed approach would be needed to explore relevant issues.

With all HTA products and activities of the HTAU, reports are prepared and submitted

to the Chief Executive Officer and the Trustees on a regular basis. Regular updates are

provided to the AHFMR Health Advisory Committee and Health Research Advisory

Committee. The committees also provide advice for future opportunities and activities.

With the Customized Responses, information provided indicated that the Chief

Executive Officer and Trustees of the AHFMR were informed of the initiation and

progress of the project. Their feedback/ directive was to proceed with the project but

with the understanding that other projects would be delayed.

A positive aspect was that the need for transparency and accountability was clearly

communicated between the AHFMR and the client. It was made clear that reports

prepared by HTAU would be released at some point in the future.

The only other area related to governance was a delay in finalizing a contract associated

with the project on radiosurgery.



Resources and Staff

Detailed discussion of resources and staff issues are beyond the scope of this paper and

would require detailed local input and analysis. However, some points arise from the

information made available.

There were ten authors for the assessment products, six of whom were on short-term

placements or external to the HTAU. In general, assessors were involved with a range

of topics and most had a role in preparation of longer term products. The four

permanent assessors in the HTAU were all involved in the preparation of the

Customized Responses, which would have required a substantial commitment of their

time. The HTA Resource products had three authors.

IS support was provided by the AHFMR Librarian for 10 products and by other persons

for 12. These statistics reflect the continuing requirements of the HTA program and the

limited IS support directly available from the AHFMR. One person provided other

support, which included formatting and editing of draft reports, for all the Unit's

products. This is a situation that has been with the HTAU for some time and was an

issue raised in HTAI #9 ("Is there sufficient support to provide an efficient HTA program?")1

. A contractor provided formatting and design services for four products in the HTAInitiatives series, an arrangement that worked well.

This summary takes no account of the staff resources used in internal review and

technical editing of HTA products. This is a demanding area that forms part of the

routine operation of the HTAU and contributes considerably to the quality of its output.



44

Synthesis

Table 14 brings together information given previously on issues addressed, policy

areas, HTA findings, and opinion on impact, to give some synthesis of overall activity.

These details give a general picture of the HTA products and their impact. There is an

overall indication of questions that were addressed and assessment findings, and the

use made of these, giving assurance of appropriate activity for the HTAU use of

assessment to inform policy decisions.



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Discussion

This paper brings together many details of the performance of the HTAU at the

AHFMR as reflected in the products that were completed from April 2002 to March

2003, though it is only a partial overview. The data and commentary are based on the

information provided by HTAU staff, the publication record, and impressions obtained

by the author through periodic contact with the Unit. Further information, for example

on resources, would be needed to give a comprehensive profile and would require

additional input from within the AHFMR. There has been no detailed review of the

individual products. Nor has there been any discussion of other HTAU activities, such

as presentations at seminars and conferences.

The available information shows that there was good performance from the HTAU,with particular strengths in some of the literature reviews and in responses to urgent

requests. Output of normal types of HTA products by core staff, particularly longer

term projects, was influenced by the work on the Customized Responses.

In HTAI #9 it was suggested that important elements for an HTA program, which

contribute to its continuity, are Need for HTA, Governance, Efficiency, Quality,

Coverage, and Impact (see Figure 2).

Figure 2: Elements of Effectiveness

Efficiency Governance

)

QualityContiunity Need for

Survival HTA

Coverage Impact



49

The information available on the HTAU for its 2002/2003 products is encouraging on

these elements:

Needfor HTA: The services of the HTAU clearly continue to be in demand from

decision makers in Alberta health care. The Customized Responses provided a

diversion from expected HTA activities.

Governance: Values appear to have been upheld. The nature and degree of interaction

of governance with the HTA program is not clear from the information available.

Continued support to ensure that requests from government are reasonable and

realistic 1 appears essential in view of pressures on the HTAU that arose during this

period.

Efficiency: Efficiency in terms of handling short-term requests was high. Efficiency

with longer term activities is less easy to assess, in part because of the involvement of

other agencies. Overall output was a product every 2.4 weeks, an HTA product every 3

weeks, and a longer HTA product every 7.4 weeks. These rates seem very acceptable.

Quality: Quality of products was not considered in any detail for this paper. Quality of

reviews appeared to be very good. Ongoing consideration on the relationship of HTAproduct content to formulation of HTA questions would be useful.

Coverage: A broad range of topics was addressed in the Unit's products, continuing the

pattern from previous years. The balance between follow-up assessments and newtopics will continue to be an issue to monitor.

Impact: Many products had a useful impact on decision making.

Some areas that deserve consideration in future management of the HTAU are listed

below. Several of them are issues that have been around for some time and may need

ongoing management rather than definitive resolution.

• Balance of long-term and short-term projects. Most of the products for 2002/2003 were

either long-term assessments or responses to urgent requests. There was not muchmiddle ground.

• Allocation to series. HTA products were spread over four printed series, for various

reasons. This might be confusing for users of HTAU products.

• Acceptability of very short timelines for "urgent" requests needs to be kept under

review so that the Unit does not become exposed to unreasonable demands.

• The time taken for review and printing of longer reports should be monitored.

• The levels of analysis needed in assessment products to appropriately address the

questions or issues raised should be kept under review.



50

• There may be an opportunity to usefully broaden the scope of assessment activities,

for example through consideration of social issues.

• The resource products are a useful component of the Unit's output, but it is hard to

judge their overall impact.

• The limited support from within the AHFMR for dissemination activities is an issue

that requires discussion.

• Support staff resources for the HTAU are modest. This appears to be an area of

vulnerability.



Profile of an HTA ProgramThe AHFMR Health Technology Assessment Unit, 2002 - 2003

Appendices

Appendix A: Publication product series produced by the

HTAU

Health Technology Assessments: Comprehensive appraisals of health technologies;

providing a synthesis of data from the literature or reporting on empirical studies.

Subject to external review.

TechNotes: Brief responses to requests for rapid advice, with limited analysis. These

are not subject to external review.

Information Papers: Publications providing information on health technology topics.

No assessments.

Health Technology Assessment Initiatives: Publications with the primary aim of

introducing and integrating an applied HTA process into a RHA's program operations.

QwikNotes: Very rapid responses to urgent requests, with limited assessment,

provided electronically.



Appendix B: Information Collection Form

HTAU profile, 2003

Title: AHFMR contact:

Origin of request:

FORMULATION OF THE QUESTION

Date of request:

What was the question/issue?

Expected timeline:

Was there discussion to

confirm issue/approach?

Any relationship to other

reports (AHFMR or other?)

HTA PRODUCT

Type (series) Reason for this type of report?

Authors:

Any external collaboration?

IS support: Other support:

(indicate who, why, role)

Was collaboration through contract, other agency, free advice/

input, other?

Start date: Review date: Publication date:

Approach [tick one or more]:

- systematic review

- narrative review

- admin, data analysis

- cost/economic analysis

Issues addressed [tick one or Reviewers:

more]:

- safety

- efficacy

- effectiveness

- survey- economic impact

- other- access

- social

- ethical

- other

Alberta Heritage Foundation for Medical Research 54Health Technology Assessment



Report title

DISSEMINATION

Approach for primary target: Mail paper copy

Approaches for wider

dissemination

E-mail

Face to face discussion

Longer dialog

Other

Standard circulation list,

newsletter, web site

HTA database

INAHTA web site

Media release/conference

Meeting/seminar

Conference presentation

Other

Persons involved in

dissemination

Author(s) (Details)

Other HTAU

Other AHFMR

External to AHFMR

GOVERNANCE, RESOURCES, STAFF & STRUCTURE

Any information or issues regarding this HTA related to Governance (e.g. CEO, Board of Trustees,

Minister), Resources, Staff and Structure of HTAU?



55



Report title

General opinion on impact

(GIVE DATE FOR THISENTRY)

What were main indications of

impact?

Were there any indications of

impact on other organizations

or individuals?

Have there been any requests

for follow up HTA work on this

topic?

IMPACT

1 . Minimal Was there any impact on the maintarget?

2. Some consideration of

HTA

3. Some input to decisions

4. Major influence ondecisions

[Tick one or more] (Details)

1 . No apparent impact

2. HTA considered bydecision - maker

3. HTA recommendations/

conclusions accepted

4. HTA demonstrated that

technology met specific

program requirements

5. HTA material incorporated

into policy or administrative

documents

6. HTA information used as

reference material

7. HTA linked to changes in

practice

8. Other [please specify]

(Details)



56

References

References

1. Hailey D. Elements ofeffectiveness for Health Technology Assessment programs.

Edmonton: Alberta Heritage Foundation for Medical Research. HTA Initiative #9,

March 2003.

2. TurnKey Management Consulting. A study of the impact of 2000-2001 HTA products.

Edmonton: Alberta Heritage Foundation for Medical Research. Information Paper

IP-11, January 2002.

3. Howard Research and Instructional Systems Inc. A Study of the impact of2001-2002

Health Technology Assessment products. Tinal Report. Edmonton: Alberta Heritage

Foundation for Medical Research. Information Paper IP-15, June 2003.

4. Hailey D, Corabian P, Harstall C, Schneider W. The use and impact of rapid

health technology assessments. International Journal of Technology Assessment in

Health Care 2000; 16(2):651-56.



Bibliotheque nationale du Canada

alberta heritage foundation for medical

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