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In a healthcare environment brimming with competing priorities, the need to underpin policy decisions with evidence is becoming more important. Paul Mulholland examines the health technology assessments (HTAs) conducted by HIQA and how it is coping with the increasing number of assessment requests made to the Authority
Recently, HIQA commenced a national public consultation on a draft health technology assessment (HTA) of C-reactive protein point-of-care testing (CRP POCT) to guide antibiotic prescribing for acute respiratory tract infections in primary care settings.
The objective of CRP POCT is to assist clinicians in ruling out serious bacterial infection. In this way, the test can support a decision not to prescribe an antibiotic to those who are unlikely to benefit from treatment. The assessment will inform a decision as to whether the test should be used to support antibiotic prescribing in primary care for patients presenting with symptoms of acute respiratory tract infection.
The assessment also considers the organisational implications associated with introducing CRP POCT in primary care. HIQA’s draft report found that the use of CRP POCT to inform antibiotic prescribing in primary care for acute respiratory tract infections leads to a significant reduction in antibiotic prescribing without compromising patient safety. While there is evidence that CRP POCT has a short-term effect on antibiotic prescribing, it is unclear whether that effect is sustained over the longer term, according to the Authority. Like all HTAs, the clinical and cost-effectiveness of the test were assessed.
The assessments are being requested with increasing frequency to ascertain the evidence-base of a particular treatment. In a resource-tight environment, they also provide important information on costing of a particular intervention. Most HTAs in Ireland are conducted by the National Centre for Pharmacoeconomics (NCPE), which assesses medicines for reimbursement. These assessments receive a lot of media attention in comparison to those conducted by HIQA, which is responsible for assessments of non-drug interventions.
While HIQA does not assess individual drugs for reimbursement, it does consider medicines in the context of national programmes.
HIQA is also responsible for HTA guidelines and standards, which are updated regularly. Although the Authority’s work in the area does not receive the same focus, its advice is key to determining what new interventions are introduced into the Irish healthcare system. In this feature, we examine how well-braced HIQA is to carry out this work, and whether Ireland is getting the balance right in terms of what HTAs are conducted.
The NCPE conducts mainly more HTAs than HIQA. Since 2015, HIQA has published 11 HTAs (see panel below). Last year alone, the NCPE conducted 23 HTAs and in 2017, the number was 16. It also completed 47 rapid reviews in 2018 and 64 in 2017. A rapid review is usually completed within four-to-six weeks, whereas a full HTA takes in the region of three months for the NCPE.
Speaking to the Medical Independent (MI), HIQA’s Deputy Chief Executive and Director of Health Technology Assessment, Dr Máirín Ryan, PhD, said the Authority has to restrict the amount of HTAs it conducts due to limited capacity.
Only six technical staff work on HTAs in HIQA, which is the same number since the Authority began doing the assessments. This is despite the fact an increasing number of requests for assessments are being sent to HIQA.
“The demand for HTA outstrips our capacity to provide it,” according to Dr Ryan.
“So our capacity is to do three-to-four HTAs of national programmes or to inform national service decisions each year. And the last time we did a call for topics, we got 26 proposals from the Department of Health and from the HSE. And then we had to prioritise those.”
By comparison, the NCPE had 8.5 whole-time equivalents (WTEs) in 2017, 10.5 WTEs in 2018 and aims to have 17.5 WTEs by the end of 2019. All NCPE staff members play a role in HTA assessments.
In 2015, HIQA implemented a HTA topic prioritisation process to select topics for inclusion in the HTA workplan for approval by the Authority’s board. Prioritisation criteria include clinical impact, budget impact, link to imminent decision and link to national health policy. Due to the fixed capacity to undertake HTAs, a limited number of topics can be included in each workplan. Topics which were not included in the HTA workplan or which could not be undertaken within the relevant timeframe include: HTA of domiciliary invasive ventilation (IV) in the management of motor neuron disease/amyotrophic lateral sclerosis; HTA of cancer genomics in all patients diagnosed with cancer; HTA of immunoablation followed by autologous haematopoetic stem cell transplant in relapsing-remitting multiple sclerosis; and a HTA of monitored dosage systems in primary care. In total, since 2015, HIQA has been unable to include eight proposed HTAs in its workplan or undertake the HTA within the relevant timeframe.
On the prioritisation process, Dr Ryan said: “When it comes to HTA, what you are trying to ensure [is] that we provide a robust evidence base that answers all the questions that the decision-makers have… We scope up each topic and work out what exactly the decision-maker needs to know. And we present each scope in terms of what is the link to decision-making.”
HIQA has a prioritisation advisory group, which compromises representatives from the Department of Health and HSE. Through the group, a ranked work programme is developed, which lists topics in terms of importance against the assessment criteria, such as clinical and budget impact. HTA topics that were not included in the workplan are kept under review and considered again when HIQA next undertakes “prioritisation” if the requester confirms that the investment decision could still benefit from an assessment.
“And we start to work on topics that are at the top of the programme,” according to Dr Ryan.
“So other topics that are considered to be important, they are still on the work programme but unfortunately they may be scheduled for two years’ time, with the delay in decision-making, so by the time we come to the point that we have them in the work programme, the HTA may not be as useful anymore. Because either the decision has already been made, or the other consequence is, you have delayed access to that particular technology for people who could have benefitted from it in the meantime. So sometimes, you find you are asked to do a HTA but you can’t actually commit to do it for up to two years. That is what the difficulty is; it’s our response time, if you like. And also then, something might come in as an urgent priority that has to be dealt with quickly, which pushes other things further down the line again.”
In a statement to this newspaper, the Irish Cancer Society expressed its disappointment about the fact that requested HTAs on cancer genomics have not yet been undertaken by HIQA.
“The National Cancer Strategy recognises the role that cancer genomics has in improving outcomes for people with cancer,” according to the statement. “Without first undertaking a health technology assessment that seeks to understand the potential costs and benefits of cancer genomics, outcomes for Irish patients will not improve at the same pace as other countries. The Irish Cancer Society urges additional resources be directed to HIQA so that it can complete assessments that are urgently needed.
Getting the balance right
Dr James O’Mahony, PhD, is a health economist in Trinity College Dublin, who has undertaken research into the HTA process in Ireland. For Dr O’Mahony, there is too much policy emphasis on conducting assessments on drugs, rather than non-drug interventions. Dr O’Mahony said this emphasis leads to waste within health spending, as drugs are significantly more expensive than the type of interventions which HIQA assesses, or those that seek to improve elective care.
Indeed, Dr O’Mahony said a much greater focus on improving current services should be undertaken, rather than the approval of new interventions. Dr O’Mahony said that a more “joined-up” policy perspective would see priority given to reducing elective waiting lists rather than spending on new drugs.
“We shouldn’t be spending the money in the way we do,” Dr O’Mahony told MI.
“A lot of people don’t want to reflect on this because it’s inconvenient. But there is a deep ethical problem about the way we are spending money at the moment, just because we are not spending money in the right place… I think a big problem in Ireland is that most of the experts who do cost-effectiveness analysis are in the drugs area, and they don’t have to apply the same logic to the other interventions.”
A study Dr O’Mahony was involved in last year (Chen et al, Value in Health, 2018) surveyed the cost-effectiveness of procedures with the largest waiting lists in the Irish public health system to inform a reconsideration of Ireland’s current cost-effectiveness threshold of €45,000/quality-adjusted life-years (QALY). Waiting list data for inpatient and day case procedures in the Irish public health system were obtained from the National Treatment Purchase Fund (NTPF). The 20 interventions with the largest number of individuals waiting for inpatient and day case care were identified. The academic literature was searched to obtain cost-effectiveness estimates from Ireland and other high-income countries. Cost-effectiveness estimates from foreign studies were adjusted for differences in currency, purchasing power parity, and inflation.
Of the top 20 waiting list procedures, 17 had incremental cost-effectiveness ratios (ICERs) lower than €45,000/QALY, 14 fell below €20,000/QALY, and 10 fell below €10,000/QALY. Only one procedure had an ICER higher than the current threshold. Two procedures had ICERs reported for different patient and indication groups that lay on either side of the threshold.
According to the authors, the analysis demonstrated that most interventions with the largest inpatient and day case waiting lists for public health services in Ireland are more cost-effective than the current threshold. This suggests that a fairer and more efficient allocation of resources could be achieved by reducing the threshold to divert funding from new interventions to the currently “constrained services”. The conclusion stated that “policy-makers should take note of the manifest inconsistency”.
“Now, that it is not to say that I wouldn’t support all high-tech drugs, but they would have to be at a price to justify spending money on them instead of addressing those waiting lists,” according to Dr O’Mahony.
“But there is going to be a big problem with that though, in that the health system, spending on drugs, for want of a better word, is kind of ‘sexy’. It is the high-tech way of treating people, and clearing waiting lists is about the grind of organisation, making sure your systems work properly, making sure you have enough experts to provide the services and it is unglamorous.
“And I also think a big part of what is going on there is that the patient population has come to accept that elective care is poor. We are just used to that. So there is this paradox where we accept waiting lists that go on for years; we have to remember some of these waiting lists go on for years for simple procedures.”
Dr O’Mahony would like to see HIQA instigate HTAs rather than simply respond to requests from the Department of Health and the HSE, which it has done up until now. HIQA is not prohibited from initiating a HTA. However, one of HIQA’s key principles for maximising the value of the HTA function is to ensure that the assessment is linked to an imminent decision and that the decision-maker intends to use the HTA to inform the decision. Therefore, to date, HIQA has conducted HTAs in response to requests from the Minister for Health or the HSE where there is a commitment that the decision will be informed by the HTA and will be taken within the timeframe of that advice.
The Chief Executive of IPPOSI (Irish Platform for Patient Organisations, Science and Industry) Dr Derick Mitchell, PhD, would also like to see HIQA conduct more HTAs.
“We have a good relationship with HIQA for HTA; in terms of the process in HIQA, it is open and there is stakeholder engagement,” according to Dr Mitchell.
“They don’t perform an awful lot of HTAs — that would tell us that there is a limited enough capacity within HIQA to perform a greater amount of HTAs and the introduction of new innovations into the system. From the point of view of changes, we would like to see from that perspective… obviously, we would like to see more HTAs being performed, but in a standardised way that HIQA supports.”
Dr Mitchell stressed the need for HTAs to be more “patient-focused”. IPPOSI recently launched a patient charter with regard to drug HTAs, and Dr Mitchell stressed the importance of HTAs examining the patient experience as well as examining budget and clinical impact.
On the European front, the European Commission has put forward a proposal to boost co-operation among EU member states for assessing health technology (see panel on left). International co-operation has worked on a purely voluntary basis up until now. The new regulation is intended to provide the basis for more permanent and sustainable co-operation in the area of HTA when the current arrangement expires in 2020. Joint clinical assessments should make HIQA’s processes more efficient on topics falling within the scope of the proposed regulation.
Dr Ryan said HIQA has recently started work on its corporate plan for the next three years. One of the priorities highlighted in the corporate plan is to expand and consolidate the Authority’s HTA capacity.
Also, Dr Ryan pointed out that HIQA established a new function last year called HRB-CICER. The Health Research Board (HRB) is funding the Collaboration in Ireland for Clinical Effectiveness Reviews (CICER), which is hosted by HIQA. Following a competitive process, HIQA was awarded research funding spanning the five-year period from 2017 to 2022 to produce the evidence to support the development of national clinical guidelines.
In addition, last year the Department of Health asked HIQA to develop capacity to work on evidence around supporting particular policy decisions. On the basis of the request, HIQA established a policy team, which is also funded through the HRB. The two projects the Authority has been asked to look at are: The national review of cardiac services; and the economic costs around antimicrobial resistance. The team consists of three individuals, separate from the main HTA team, which has not been bolstered.
Dr Ryan said that the increase in the number of HTA requests is due to a “growing awareness of the importance of having an evidence-base to underpin substantial investment decisions”.
“The key thing here is the economic issue of the opportunity cost,” according to Dr Ryan.
“Because if we invest in one health programme, then we don’t have money for something else. So for example, you invest in a particular vaccination programme; that means you don’t have money for something else. And there are lots of voices about what we can invest in. So it is trying to ensure that when we are trying to make those big investment decisions, that those decisions, that it supports, if you like, evidence-based, sustainable and also equitable choices when it comes to healthcare and health technologies. For example, I think Sláintecare is a good example where there is an increased focus over time on the need to have evidence underpinning key decisions.”