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Developing a disinvestment methodology to review Australian medical services - ‘ophthalmology’ as a test case.
1. Adelaide Health Technology Assessment (AHTA)
Tuesday, June 26, 2012
KEEPING AN ‘EYE’ ON THE PROBLEM:
Developing a disinvestment methodology to
review Australian medical services -
‘ophthalmology’ as a test case
Tracy Merlin and Jackie Street
Life Impact | The University of Adelaide
2. Background
2009-2010:
• Government funding put aside to develop an evidence
based method of managing the Medicare Benefits
Schedule into the future. » MBS Quality Framework
Broad aims:
• Maximise health outcomes - safe, effective, appropriately
used
• Promote efficient use of limited health care resources -
could we get better outcomes using our health
dollar elsewhere?
3. What is the Medicare Benefits Schedule?
• List of services performed primarily by clinicians
that are subsidised by the Government
https://www.chf.org.au/pdfs/chf/What-is-the-MBS.pdf
4. Demonstration Whole-of-Specialty
Review: ophthalmology
Participants
– Adelaide Health Technology Assessment , University of Adelaide –
consultants (responsible for the methodology, identification,
analysis and synthesis of evidence)
– Clinical Working Group – experts in the field of ophthalmology
– Australian Government Department of Health and Ageing
– Consumer representation
– Policy advisors – Medical Services Advisory Committee
Guiding principles
– Evidence based
– Fit for purpose
– Consult key stakeholders
5. Challenge 1:
What is the service?
• MBS descriptors are non-descriptive
Item 42809 RETINA, photocoagulation of,
not being a service associated with photodynamic therapy with verteporfin
WHAT IS IT? WHY IT IS DONE?
• Direct photocoagulation • Retinal detachment
• Perifovial photocolagulation • Diabetic retinopathy
• Macular grid photocoagulation • Choroidal neovascularisation
• Pan-retinal photocolagualtion associated with pathologic myopia
• Continuous wave vs pulsed in micro, nano, • Macular oedema
pico or femto seconds • Age-related macular degeneration
• Argon, YAG, Krypton, YLF, HeNe, Diode • Macular holes
• 350nm to 750nm wavelength • Retinoblastoma
• Laser power levels from 1.5 to 8 Watts
• Optically pumped semiconductor lasers
based on near-infrared-pumped quantum-
well structures
6. Challenge 2: How to evaluate established
services?
• Thin evidence base
– Reimbursed on basis of expert opinion
– Data collection ↓ after technology adoption
– Services often difficult to evaluate in trials ie
consultations , number of follow-up tests/re-treatments
• Lack of comparator
– How to determine comparative effectiveness and safety
when technology/service being reviewed is the
benchmark (rightly or wrongly)?
• Level of entrenchment
– Consumer expectations / preferences
– Stakeholder beliefs / income
– Practice variation / usage
8. MBS data analysis
• Pattern of claims consistent with
disease burden and patient
demographics?
• Regional variation in practice?
• Rural vs urban uptake?
• Pattern of services used together?
9. Guideline concordance
• Appropriate clinical practice guidelines identified for each
item
• AGREE appraisal instrument used to rate quality of
guideline.
– Recommendations in those guidelines with high AGREE
rating were given more credence than lower rated
guidelines
• Judgement made whether MBS item descriptor was similar
to recommendations in guideline or whether it did not
reflect evidence-based “best practice”
10. Mini-HTA - optimisation
• Research questions:
– Are there particular populations or settings where the
technology works better than others?
– Are there particular forms of the technology that are
more effective?
• Pre-defined PICO (Population, Intervention, Comparator,
Outcomes) criteria → study eligibility
• Databases: Cochrane Library, Embase/Medline, EconLit.
11. Mini-HTA - optimisation
• Search limits: English language, humans, publ 2005-2011
• Hierarchical literature selection by study design:
– Limit 1 – SRs
– Limit 2 – controlled clinical trials, RCTs or
meta-analyses
– Limit 3 - any articles + progressive
retrospective 5 year time periods
• Critical appraisal + narrative synthesis (NHMRC body of
evidence matrix)
12. Ascertainment of consumer preferences
• Qualitative literature search – Embase.com, Scopus
• Analysis of weblogs – identified through Google advanced
domain search. Commercial blogs excluded
• Literature imported into NVivo – thematic coding and analysis
Styes...One became big and bad enough that I was prompted to
see an eye doctor in Lapeer- not knowing he was going to
remove it right there in his office- I was in for a huge surprise-
They froze it- felt like they pulled my eyelid back and tied it to my
ponytail- took the stye out- and left me with a huge bruise and a
patch to cover it. That wont [sic] happen again- I assure you. I
have since had styes- but use over the counter stye medication
which seems to be doing a good job.
(TJ, United States, November 13, 2003).
14. Review Process
• Protocol for Stage 1 drafted and released for public
consultation – Dec 2010
• Stage 1: Review of 61 Medicare items undertaken using
mixed methods approach
– Tailored approach; not all items received all analyses
– Oct 2011: released for public consultation
– Review recommendations – only 20 / 61 services escaped
change
– March 2012: recommendations provided to MSAC →
MSAC provided advice to Minister
• Stage 2: Review of remaining 23 Medicare items is underway
16. Policy outcomes of
demonstration review
• 2011-2012 Budget Comprehensive Management
Framework for the MBS:
– Commitment to rolling reviews of the appropriateness,
clinical quality, safety and fee levels of existing MBS
items
– Aim is to maximise health outcomes for patients and
be cost neutral
– Methodology feasible and accepted.
» template for all subsequent whole-of-specialty
reviews
17. • Co-author – Jackie Street (consumer preferences)
• Researchers applying methodology – David Tamblyn, Linda
Mundy, Edith Reddin, Ben Ellery, Vineet Juneja, Sophie
Hennessy, Sophia Scrimgeour
• Feedback from Eliza Hazlett, Amy Lambert, Kelly Cameron,
Alex Hunyor, Guy D’Mellow, Russell Bach, Mark Daniell
• Funded by – Australian Government Department of Health &
Ageing.
tracy.merlin@adelaide.edu.au
The Medicare Benefits Schedule is a list of attendances or procedures performed primarily by clinicians or medical practitioners that are subsidised by the Government. It covers everything from hip replacements, surgery for appendicitis and delivering babies to an annual diabetes check, genetic counselling and the common visit to the GP to get a sick certificate.
All well and good but how do we do a whole-of-specialty review?? Several challenges.Stakeholder beliefs re effective service. Income from subsidised service.How to address all of these challenges??
Need to use different data sources. Use multiple sources to provide a holistic view of the technology’s worth.Level of entrenchment explored through analysis of claims data, consumer perspective, stakeholder negotiation.Guidelines concordance and mini-HTA supplement each other ie evidence and expert opinion when evidence is lacking. Also establishes benchmark practice and delivery of a service.
Level of entrenchment
Analysis of the concordance between clinical practice guideline recommendations and MBS item descriptors (outlining eligible patient indications for the service).
Qualitative analysis of patient/consumer literature on values and preferences concerning specific ophthalmology services;
And negotiation with stakeholders on minor wording amendments to item descriptorsie terminology
Implications for the health system: A framework for reviewing the public funding of established technologies has been developed. This methodology is now standard for ‘whole-of-specialty’ reviews of established medical services in Australia and may be a suitable model for other health systems.
It turns out that, for our friend photocoagulation of the retina, there was a range of evidence available depending upon its use. It ranged from poor quality to not so poor quality. Few studies to swaths of systematic reviews. Though often the evidence was some years old – which meant that direct photocoagulation of choroidal neovascularisation with microsecond pulsed Argon lasers had long since been replaced with continuous wave grid photocoagulation with diode lasers and therefore the evidence had applicability issues to a present day clinical setting.However, a mixed methods approach mitigated, in some cases, the lack of evidence able to be derived from a single source.