Gary Culliton reports on HIQA’s Health Technology Assessment Directorate, which is charged with establising the cost-effectiveness of new public initiatives.
A Health Technology Assessment (HTA) is about more than deciding whether a programme is cost-effective. HIQA’s cervical cancer HTA recently concluded that vaccinating all 12-year-old girls against HPV, would cost about €12m per year.
The broader objective of any HTA though, is to get the best outcome in terms of patient survival and quality of life. A range of preventative medicine programmes is high on Health Minister Harney’s agenda.
The BreastCheck programme has begun to be rolled out and the cervical cancer screening programme will be implemented soon. A programme of colorectal cancer screening is next on the agenda and a HIQA HTA on this is underway.
h4, Compare the effects
First the HTA will compare the effects of a screening programme with no screening programme, said Dr Máirín Ryan, HIQA’s Director for Health Technology Assessment. Then the alternative technologies will be assessed. Fecal Occult Blood Testing may be guaiac-based (a chemical test) or immunoassay-based. This involves taking a sample of the stool to see if there is blood in it (this would be an indication that the patient should go for a colonoscopy).
Flexible Sigmoidoscopy and CT colonography – where the colon is examined to see if there are polyps or pre-cancerous cells there – are the other screening options which are being evaluated. The population cohort to be screened would probably be over 55s but this would be defined by the HTA. Different types of screening programmes require different resources in terms of trained personnel, for example. Before you ask whether you can get these people, it has to be established how many would be needed.
h4. Cancers detected earlier
A colorectal screening programme will mean more cancers will be detected earlier. This will mean improved survival and improved quality of life. It would however, have an impact on the numbers of trained gastroenterologists Ireland will need. The HTA also evaluates issues such as this.
The HTA for a national colorectal cancer screening programme is being carried out by HIQA on behalf of the National Cancer Screening Service Board. It has a much broader remit that did the HTA on HPV vaccines. The clinical effectiveness, the cost-effectiveness, organisational impact (on budget, resources etc.) as well as the ethical aspects of such a programme are being examined. This HTA will thus take longer for this reason.
Most European countries have a HTA agency, which judges whether a technology is effective and cost-effective, in a given patient group.
h4. Colorectal screening
HIQA can project-manage a HTA and ensure its quality, as happened with its first two assessments. Expert Advisory Groups are typically constituted, made up of all the broad stakeholders, including clinic-ians involved in the diagnosis and care of patients. HIQA’s HTA Directorate has contracted out work on the HTA for colorectal screening.
In this instance, the National Cancer Registry (which has a research wing) has partnered with the National Pharmacoeconomic Centre in St James’s Hospital, the School of Nursing DCU and the University of Sheffield (which did a model in the UK setting). Overall a team of ten people will generate the HTA.
This is one part of the evidence that informs a policy decision. It is also about what is the best way to deliver it. The HTA on colorectal screening is expected to be completed by the start of next year and four technologies will be examined.
If you introduce a cancer screening programme, you are going to identify more cancers. Thus more costs will be incurred in managing early cancers. However you will avoid people turning up with (more expensive) end-stage cancers or requiring palliative care.
h4. Fewer advanced cases
Therefore, the cost of the screening programme plus the cost of treating more acute early-stage cases, is balanced against the savings from fewer advanced or palliative cases, where there will be decreased burden. The effectiveness and cost-effectiveness is dependent on the incidence of the disease in the population. The National Cancer Registry manage the data on colorectal cancer. Data on how effective the screening programme is at picking up cases is taken from randomised control trials in the international literature.
h4. Evidence-based process
A HTA is an evidence-based process that is about presenting the information a decision-maker needs, in order to make an investment decision. In regard to preventative medicine, the Minister also gets policy advice from the National Immunisation Advisory Committee and from the National Cancer Screening Service. When it has its full staffing, HIQA will continue to commission some work out from the academic centres. It will then do some work in-house.
The first report (on HPV vaccines) was confined to cost-effectiveness in the Irish setting. The Expert Advisory Group provided oversight and ensured the quality of the process. It gave expert opinion on how the HTA should be conducted. The National Pharmacoeconomic Centre (NPC) did the technical report (this Centre has looked at re-imbursement for new drugs coming on the market since 2006).
Other domains which may be considered in HTAs include clinical effectiveness, safety, social impact (what factors influence whether a patient will avail of a screening programme or not), budget and organisational impact, ethical and medico-legal effects (in future stem cell technologies may have such implications).
h4. Completed in six months
The NPC partnered with the Danish HTA Agency, (which had worked with universities there to come up with an economic model for Denmark). This link meant the Irish HTA could be completed in six months (it would have taken 18 months otherwise).
Once the policy decision is made, it is then up to the immunisation office in the HSE to choose between the two HPV vaccines which have been assessed.
‘Life years gained’ is the metric in the HTA model concerned with costings. This calculates the difference in the cost of having a vaccination programme, compared to the cost of having no vaccination programme, divided by the average difference in survival (in years) across the population at which you are looking. This metric allows one technology to be compared with another.
h4. €45,000 per life year gained
There is always uncertainty in modelling what will happen in the future. Thus the impact of varying the data is also assessed. For example, the cost-effectiveness ratio of the HPV vaccination programme came out at €17,383 per life year gained.
Dr Ryan considers that if the cost per quality-adjusted life-year gained goes above €45,000, there is uncertainty about the technology’s cost-effectiveness: it is not considered good value for money (in terms of improved survival and good quality of life), compared to investing in other things.
The figure is also used by the National Pharmacoeconomics Centre (the UK uses a threshold of Stg. £30,000).
h4. Clinical background
There are currently three people working in HIQA’s HTA directorate. This is expected to rise to 15, mostly technical people. Some of these staff will be from a clinical background. There will also be health economists and statisticians. Recruitment is expected to commence shortly.
The HTA will make a best estimate of what the expected cost of a programme is. There might, however, be increases in the cost of direct medical cancer care, for example. A sensitivity analysis will be carried out, which varies the costs by plus or minus 20 per cent and evaluates whether the screening programme is still cost-effective or not.
In the future, other technologies which the HTA Directorate could evaluate include drugs, medical devices, diagnostics (including radiology), surgical procedures, care pathways (shifting care from hospitals to the community) and public health interventions (such as health promotion campaigns).