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HTA and clinical practice guidelines as tools for knowledge translation

Health technology assessment to guide clinical practice

8th Guideline International Network Conference

29 August 2011

Dr Mabel Yap

Director (Health Services Research & Evaluation)

Ministry of Health, Singapore

Guidelines International Network

Conference 2011 “Linking Evidence, Policy, and Practice

Focus of presentation

Use of HTA/CPG methodology in

development of Integrated Care Pathways

(ICP) in Singapore

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3

Our Healthcare System

Ministry of Health Singapore

To ensure access to good and

affordable healthcare that is

appropriate to needs

To promote good health and

reduce illness

To pursue medical excellence

Championing a healthy

nation with our people

-- to live long,

live well &

with peace of mind

Our Vision Our Mission

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Primary Healthcare

- 18 Polyclinics (20%)

- Private GP Clinics (80%)

Step-down Care

- Voluntary Welfare Organizations

- Private Healthcare Organizations

Healthcare Delivery Eco-System

Secondary & Tertiary Specialist Care

- 7 Restructured Hospitals & 6 National Centers (80%)

- 16 Private Hospitals (20%)

• Supply and demand management

•Professionals, establishments, products

•Best value for healthcare resources

Policy Maker

Regulator

Purchaser

Compulsory medical savings scheme

Insurance against catastrophic illness and large medical

bills

Safety net for the needy

Medisave

MediShield

Medifund

3 “M” Financing Framework

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Compulsory savings scheme Singapore is the first country to implement medical savings account on a nationwide basis in 1984

Prior to Medisave, medical services were financed through general taxation. However, rapid healthcare cost inflation in the 1970s and evidence of ever-increasing demand for health services in developed countries showed that this was unsustainable

7% ~ 9.5% of monthly salary goes to Medisave Account

9 of 10 Singaporeans admitted to hospitals use Medisave to pay their bills

Medisave

Medisave is primarily for hospitalisation

expenses, but also covers step-down care and

certain expensive outpatient expenses

The Ministry has extended the use of Medisave

to co-pay costs of chronic disease management

programmes (CDMP) at outpatient settings, for

diabetes, hypertension, lipid disorder, stroke,

asthma, COPD, schizophrenia, major

depression .

Medisave

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Medishield Catastrophic medical insurance scheme

Protects against the very large hospital bills that Medisave may

not be sufficient to cover

Reduces the need to over-save for catastrophic (low-probability,

but high-cost) events

Opt-out scheme to encourage participation; lower

administrative and enforcement costs

More than 90% of working population subscribes to MediShield

and private Shield plans

Covers hospitalisation expenses and expensive

outpatient treatment (e.g. kidney dialysis, chemotherapy,

radiotherapy)

Endowment fund of $1.7 billion in 2009; target to

increase to $2 billion

Interest income used to help needy Singaporeans pay

for their medical expenses

Safety net for Singaporeans who cannot afford medical

expenses, even after government subsidy, Medisave

and MediShield

Ensures no Singaporean is denied access to basic

medical care because of inability to pay

Medifund

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Population growth

Demographic Challenges

2 736

3 273 3 468

3 772

311

755 798

1 305

3 047

4 028 4 266

5 077

0

1 000

2 000

3 000

4 000

5 000

6 000

1990 1995 2000 2005 2010

Po

pu

lati

on

('0

00

)

Year

SC/PR Non-Res Total

38% increase in

Singaporean

Citizens/ Permanent

Residents

67% increase in

Total Population

From 1990 - 2010

320% increase in

Non-Residents

Source: June 2011 Monthly Digest (Population), Dept of Statistics Singapore

Changing Demographics

(1980) Population 2.4 million

(2010) Population 5.1 million

Post-war baby-boomers get older

Youth base narrows as fertility rate declines

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Shift in Disease Burden : From Mortality to Morbidity

Diabetes Mellitus

Mental Disorders

Neurological, vision & hearing

disorders

Cardiovascular diseases

Cancers

Others Total

Cardiovascular

Cancers

Diabetes

Neurological, vision & hearing

Mental

BURDEN OF DISEASE BY BROAD CAUSE GROUP SINGAPORE (2007)

YLL YLD

Top 5 Diseases by DALYs

Neurological, vision & hearing disorders, Mental disorders, and Diabetes – make up 35% of BoD

> 50% of total Disability-Adjusted Life-Years (DALYs) due to living with ill health or disability (YLD)

Need for Integration of Care

Rehab

CentresFamily

Physician

Polyclinic

Palliative

Care

Screening

&

Prevention

Nursing

Homes

Community

Hospital

Restructured

Hospital

Home

Episodic Care

Silos

SYSTEMS

Prevention and Early Diagnosis

Primary Care Secondary/

Tertiary Care (Outpatient)

Secondary/ Tertiary Care (Inpatient)

Step Down Care

End-of-Life Care

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Rehab Centres

Family Physician

Polyclinic

Palliative Care

Screening & Prevention

Nursing Homes

Community Hospital

Restructured Hospital

Home

Integration- Provider to provider journey

Integrate Public, Private and People sector

Centred around the

patient

2a. Right-site rehab and

subacute care in

Community Hospitals to

reduce stay in RHs

5. Day rehab &

care services

INTERMEDIATE CARE LONG-TERM CARE

6. Community

nursing services

7. Caregiver

training

PRIMARY CARE

12. “One Family

Physician for

Every

Singaporean”

1. Aged Care

Assessment

Services to triage

elderly patients and

develop discharge

plan

4. Comprehensive Care

Needs Assessment to

recommend services

needed to maintain

elderly at home 3. Transitional Post-

Acute Home Care to

reduce stay in RH and

enable early

discharge to home

11. Integrated

Screening and

Prevention Programme

8. Fall

prevention

9. Care Coordination

and Case Management

Home

10. Information and

Referral

Integrated Clinical Pathways

National Electronic Health Records

2b. Patients with

serious acute

conditions

escalated to AMCs

13. Primary Care Networks and

Disease Management Units

DEVELOPING NEW SERVICES

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5 Integrated Care Pathways

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Stroke

Diabetes

Acute Heart

Syndrome

Hip Fracture

Chronic Obstructive

Lung Disease

Rehab

Implementation RHS Team #1

1.RHS Dr, Nurses, AHP 2.AIC Rep 3.MOH Rep

Implementation Teams (Customised to each Regional Health System)

etc

Clinical Team (National) (Development of care elements)

Each ICP workgroup consists of :

Implementation RHS Team #2

1.RHS Dr, Nurses, AHP 2.AIC Rep 3.MOH Rep

Implementation RHS Team #3

1.RHS Dr, Nurses, AHP 2.AIC Rep 3.MOH Rep

Integrated Care Pathways Project

Role of HTA

• To provide the evidence-base for safe and effective

interventions for various care pathways

Deliverables:

a. Develop framework for integrated care pathways

b. Prioritise interventions for inclusion in ICP

c. Identify gaps where more research can be done

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Identify Problem

Identify, Review,

Select Knowledge

Monitor

Knowledge

Use

Sustain

Knowledge

Use

Evaluate

Outcomes

Adapt

Knowledge

to Local Context

Assess Barriers/

Supports to

Knowledge Use

Select, Tailor,

Implement

Interventions

Products/

Tools

Synthesis

Knowledge

Inquiry

KNOWLEDGE CREATION

Graham et al (2006): Lost in Knowledge

Translation: Time for a Map?

Integrated Care Pathways Project Methodology

• Discussion with policy makers and Expert workgroup

Identify Outcomes of Interest

• Potential relevant interventions identified

Review of available Guidelines

• Expert workgroup prioritise key elements of care

Identify key elements of care

• Team conduct intensive search and critical appraisal of current evidence

Literature search for current evidence

• Includes quantification of effect size + economic evaluation where possible

Construct evidence matrix

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CASE STUDY Integrated Care Pathways for Stroke

8 outcomes identified

1. Mortality 2. Symptom-to-Needle Time 3. Recurrent Vascular Events 4. Length of Stay 5. Functional Outcome 6. Complications 7. Depression 8. Stroke Misdiagnosis

• Discussion with policy makers and Expert workgroup on outcomes of interest for management of Acute Stroke

Identify Outcomes of

Interest

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Searched for and reviewed clinical practice guidelines to identify expert consensus on interventions Clinical practice guidelines appraised with AGREE instrument: 12 guidelines considered to be “recommended”

• Potential relevant interventions identified

Review of available

Guidelines

Interventions recommended in guidelines extracted and presented to expert workgroup

Expert workgroup identified four interventions as potential key elements of ICP:

1. Acute Stroke Service 2. Early Specialist Assessment for TIA 3. Early Administration of IV Alteplase 4. Stroke Rehabiliation

• Expert workgroup prioritise key elements of care

Identify key elements of care

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- PubMed (MEDLINE)

- EMBASE

- US National Guideline Clearinghouse (NGC)

- Canadian Medical Association (CMA) Infobase

- Scottish Intercollegiate Guidelines Network (SIGN) website

- UK National Institute for Health and Clinical Excellence (NICE) website

- Australian National Health and Medical Research Council (NHMRC) website

• Team conduct intensive search and critical appraisal of current evidence

Literature search for current evidence

- Critically appraised articles, applying SIGN levels of evidence - Summarised and quantified effect size of outcome measures

• Team conduct intensive search and critical appraisal of current evidence

Literature search for current evidence

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Graphic presentation of clinical benefits

• Includes quantification of effect size + economic evaluation where possible

Construct evidence matrix

So What?

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Identify Problem

Identify, Review,

Select Knowledge

Monitor

Knowledge

Use

Sustain

Knowledge

Use

Evaluate

Outcomes

Adapt

Knowledge

to Local Context

Assess Barriers/

Supports to

Knowledge Use

Select, Tailor,

Implement

Interventions

Products/

Tools

Synthesis

Knowledge

Inquiry

KNOWLEDGE CREATION

Graham et al (2006): Lost in Knowledge

Translation: Time for a Map?

MOH took necessary

actions to make

changes to relevant

health policies.

Funding provided to

one RHS to pilot the

recommendations

Programme

monitoring, data

collection

Programme

evaluation through

KPIs and targets

Key elements to be

incorporated into the

standards of care for

RHS

Other ICPs in Singapore

• Hip Fracture: – Similar methodology looking across the whole

spectrum of care from pre-hospitalisation, acute

phase, rehabilitation and community.

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• Diabetes Mellitus: – Focused HTA reviews on certain aspects of DM care

that the expert workgroup feels need more evidence

for:

1. Universal screening of diabetes

2. Effectiveness of hospital glucose teams

3. Discharge care plans for hospitalised DM

patients

4. Frequency of scheduled glucose monitoring

5. Influenza vaccination for people with DM

• Chronic Obstructive Pulmonary Disease: – Reviews of economic evaluations on identified

treatment modalities for COPD which will contribute

towards expert workgroup’s recommendations

Cost-Effective

Not cost-

effective

Insufficient

Evidence

Inhaled

Corticosteroids Triple therapy Indacaterol

Seretide Roflumilast

Symbicort Endobronchial

valves

Spiriva Pulmonary

rehabilitation

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In conclusion

• Evidence-based approach adopted for policy

and programme development by MOH

• HTA methodology applied to develop

integrated care pathways

• Developing the pathway alone is insufficient

for implementation. Important to include

knowledge translation processes.

Policy

Impact

Thanks to ICP Project Team,

especially Drs KH Pwee and Jeff Loke