implementation of new technologies dr keith cooper southampton health technology assessments centre...
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Implementation of new technologies
Dr Keith CooperSouthampton Health
Technology Assessments Centre
University of Southampton
Structure of talk
• Introduction• Background to evidence based
decision making for implementing new technologies
• Example: Machine perfusion preservation vs. cold storage in kidney transplantation
Introduction
• Within health care systems there is limited resources and increasing demand on services
• Choices need to be made in a fair and equitable manner
Choice B
Choice A
HTA modelling• Health Technology Assessment aims to
evaluate health technologies by investigating:– whether the technology works – for whom – at what cost – how it compares with the alternatives
• A health technology can be any intervention that improves health and includes – medications, devices, hospital procedures, health
promotion activities and diagnostic tests• Health Technology Assessment in the UK is
overseen by the NIHR HTA programme – Provides Technology Assessment Reports for NICE
NICE (National Institute for Health and Clinical Excellence)
• Provides guidance to NHS on new technologies, promote clinical excellence and the effective use of resources within the NHS.
• Recommendations are based upon – Clinical evidence: systematic review, meta analyses– Economic evidence: cost effectiveness models
• Bases decision-making on Technology Assessment Reports (TARs) and manufacturer submissions
• TARs produced by university departments, such as Southampton Health Technology Assessments Centre (SHTAC)
• New technologies are most often more effective and more costly – is it good value for money to adopt?
NICE decision making – Cost effectiveness
• Costs and health benefits are estimated for patients on alternative treatments
• Health benefits are in term of Quality Adjusted Life Years– Life expectancy + Quality of life
• Compare new treatment with existing treatment(s)
• NICE is more likely to recommend a treatment if its cost effectiveness is lower than CE threshold (£30,000 per QALY)
Machine perfusion systems and cold static storage of kidneys from deceased donors
• NICE technology appraisal guidance [TA165] Published date: January 2009
• Assessment group report by PenTAG, university of Exeter– (Bond, Pitt, Akoh,
Moxham, Hoyle, Anderson)
What is the best method of preservation for kidneys for
transplantation?• Cold storage solutions
– the kidney is flushed through with a sterile preservation solution and is kept on ice in a box before transplantation
– Marshall's hypertonic citrate (Soltran, Baxter Healthcare) and Belzer UW (Viaspan, Bristol Myers Squibb)
• Machine perfusion systems– Machine perfusion systems continuously
pump cold preservation solution through the kidney
– The LifePortTM kidney transporter (Organ Recovery Systems), RM3 renal preservation system (Waters Medical Systems)
Clinical evidenceMachine Preservation Trial (Moers, 2008)
PPART study (Watson 2010)
Cold storage (Viaspan)N= 336
Machine perfusion (Lifeport)N = 336
Cold storageN = 45
Machine perfusion (Lifeport)N = 45
Proportion of delayed graft function following transplant
26.5% 20.8% 56% 58%
Proportion of primary non function
4.8% 2.1% 0% 2%
Graft survival at 1 year 90% 94% 98% 93.3%
Other model parameters (costs)
Parameter Value
Storage cost per Kidney:
Cold storage (ViaSpan) £262.33
Machine perfusion (LifePort) £736.55
Other costs
Transplant cost £16,413
Dialysis cost (per month) £2052
Post transplant cost (month 1-3) £2463
Post transplant cost (month 4-12)
£1385
Other model parameters (QALY)
• Quality of life values (age 50 years)
• Transplant state: 0.75• Dialysis state: 0.63
Cost effectiveness results
Results using MPT data (Moers 2008)
Costs per patient
Health benefits (QALYs)
Preferred technology
Cold storage (ViaSpan) £142,805 9.58
Machine perfusion (LifePort)
£139,110 9.79
Difference £-3695 0.22 Machine perfusionResults using PPART data
(Watson 2010)Costs per patient
Health benefits (QALYs)
Preferred technology
Cold storage (ViaSpan) £139,205 9.19
Machine perfusion (LifePort)
£141,319 9.13
Difference £2114 -0.06 Cold storage
NICE recommendations
• The overall costs and benefits associated with kidney transplantation using either machine perfusion or cold static storage were similar.
• The Committee recommended that the LifePort kidney transporter be considered as an alternative to cold static storage solutions.
• The choice of which to use would depend on clinical and logistical factors within both the retrieval team and transplant centres.
NICE – recommendations further research
• The Committee considered that it was important for transplant centres to collect standardised and comprehensive data that follow up the outcomes for kidneys stored using different methods.
Conclusions
• Unclear from current data (2009), whether machine perfusion preferable to cold storage– Depends upon trial data used
• Difficult to show difference in clinical outcomes– Large RCT is needed which may not be practical
• Other more recent studies have come to different conclusions
• Gomez et al 2012 – MP is cost effective• Groen et al 2012 – MP cost saving• Jochmans 2015 (Transplant International)
provides excellent overview of current evidence
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