Making EvidEncE RElEvant on ta R i o he a lt h t Ec hno logy a dv isory c omm i t t EE & t he MEdic a l a dv isory secre ta R i at

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1 Making Evidence Relevant ontario health Technology advisory Committee & the medical advisory secretariat

2 Making Evidence Relevant Ontario s Approach to Health Technology Assessment New technologies are being introduced into health care systems at an ever increasing rate, with reliable evidence about their safety and effectiveness being essential. Yet, in some jurisdictions, funding decisions are ad hoc and made in response to pressures of the day. Fortunately, for many years Ontario has had the foresight to invest in evidence to support decision-making. Led by the Medical Advisory Secretariat (MAS) and the Ontario Health Technology Advisory Committee (OHTAC), Ontario s approach to health technology assessment is generating collaboration among clinical experts in the field, shaping policy and attracting international attention. Ontario s commitment to evidence-based decision-making has been further strengthened by the Excellent Care for All Act, which came into law in June of This legislation lays the groundwork for two significant shifts in health care policy a move to evidencebased care and a new patient-based payment system along with the creation of Health Quality Ontario (HQO). As of April 4, 2011, the new organization brings under one roof the former Ontario Health Quality Council, and five other organizations and programs: MAS, OHTAC, the Ontario Health Technology Evaluation Fund, the Centre for Healthcare Quality Improvement and the Quality Improvement and Innovation Partnership. As part of the mandate of HQO and the consolidation of health care improvement work, OHTAC will become a committee of the organization s Board. Making Evidence Relevant There are many ways that MAS and OHTAC make evidence relevant for decision-makers and clinicians in Ontario. Wherever possible, MAS and its scientific collaborators ground their research in Ontario data. Broad reviews and economic policy models include comprehensive information about several technologies and interventions for a disease condition or health state and provide a common platform for prioritizing health technology investments. No other health technology assessment body has a committee like OHTAC, representing the entire spectrum of the health care community in the province, filtering MAS scientific findings through the real world lens of stakeholders and issuing recommendations that resonate with the field. The committee bridges the worlds of science and decision-making by applying evidence from around the world to the unique needs of Ontario s patients, care providers, and policy makers. Ontario s Field Evaluation Program, which is the largest of its kind internationally, funds promising technologies in clinical settings across the province while they are being evaluated, giving patients access to the technologies and providing decision-makers with Ontario-specific evidence prior to making multi-year, multi-million dollar funding commitments. About OHTAC The Ontario Health Technology Advisory Committee is an armslength committee of experts that makes recommendations to the Ministry of Health and Long-Term Care (MOHLTC) and the health system about the use and distribution of health technologies as well as the removal of obsolete technologies. The committee includes leaders from the hospital, community and long-term care sectors, nursing and medical professions, as well as experts in health economics, ethics and technology assessment. It is an application-driven committee, receiving and reviewing requests from Ontario health care providers and the MOHLTC. The committee also initiates analyses of alternative diagnostic or treatment approaches to key issues facing Ontario s patient population. The Ontario Health Technology Advisory Committee has created a forum to produce recommendations based on the unbiased analyses produced by MAS and its scientific collaborators, using a process that includes input from experts and stakeholders and grading systems to help assess the quality of the scientific evidence. Draft recommendations and related evidence are posted for public and professional comment on the OHTAC website at www. health.gov.on.ca/ohtac. After considering public and professional comments, OHTAC posts the final recommendations and reports. 2

3 OHTAC s contributions to improving quality health outcomes for Ontarians has garnered international renown. Having OHTAC within the fold at Health Quality Ontario will enable the rapid deployment of evidence based changes in health care and will drive quality and sustainability improvements in health outcomes, which will benefit Ontarians and others globally. I look forward to OHTAC s continued leadership as we move forward on this transformative journey in Ontario s health care system. Saäd Rafi, Ontario Deputy Minister of Health and Long-Term Care Scientific Collaborators The fact that Ontario is a world leader in health technology assessment has only been possible due to one of the largest collaborations in our health system. Scientific partners include: Programs for Assessment of Technology in Health (PATH) Research Institute, St. Joseph s Healthcare, Hamilton Toronto Health Economics and Technology Assessment (THETA) Collaborative The Ontario Clinical Oncology Group (OCOG) Institute for Clinical Evaluative Sciences (ICES) Health Technology Safety Research Team, University Health Network Hamilton Health Sciences Centre Li Ka Shing Knowledge Institute, St. Michael s Hospital Ottawa Heart Institute The Toronto Rehabilitation Institute Centre for Health Economics and Policy Analysis, McMaster University (CHEPA) Prior to becoming part of Health Quality Ontario (HQO) in April 2011, MAS was a branch of the MOHLTC, conducting evidence-based analyses of health technologies to support decision-making by the ministry, other government agencies and health care leaders. As part of HQO, MAS will continue this important work. Comprised of clinical epidemiologists and support staff, MAS conducts systematic reviews of scientific evidence and consults with experts in the health care services community to produce the Ontario Health Technology Assessment Series. The series has been indexed in Embase and accepted for indexing by Medline considered to be the world s premier bibliographic databases. It can be accessed at The Medical Advisory Secretariat also funds scientific collaborators and has an extensive network of partners which includes academia; hospitals; community-based health services; the Ontario Medical Association; the Ontario Hospital Association; the MOHLTC; the Council of Academic Hospitals of Ontario; frontline health care workers; bioethicists; health economists; clinical epidemiologists; bioengineers; Cancer Care Ontario; the Cardiac Care Network; industry; policy decision-makers; and, many more. About MAS 3

4 In the case of insufficient clinical and cost data to make fully informed decisions, Ontario has implemented a highly innovative and relatively unique model for generating and assessing evidence. Through conditionally funded field evaluations, OHTAC funds prospective trials that compare the clinical and cost-effectiveness of non-drug technologies. The OHTAC model is one of the few international examples of clinical effectiveness research. What makes this model unique is that decision-makers control the research budget, thus making implementation of calls for research much more feasible. Drs. Kalipso Chalkidou and Gerard Anderson: Comparative Effectiveness Research: International Experiences and Implications for the United States. July 2009 Many Types of Analyses Provide Valuable Evidence for Decision-Making The Medical Advisory Secretariat (MAS) conducts single technology reviews to examine the potential impact of specific devices on Ontario s health care system. It also produces evidence updates for quick responses to questions about new or previously reviewed health technologies that do not require full reviews. Simultaneous Comparison of Multiple Interventions Increasingly, MAS has moved beyond single technology reviews to conduct broader reviews that examine and compare several, if not all, interventions for a given disease condition or health state. These mega-analyses involve establishing expert panels, conducting systematic reviews of all the evidence regarding the clinical effectiveness of the associated technologies, analyzing Ontariospecific data to provide a context for these interventions, and, if the technology is clinically effective, assessing the comparative costeffectiveness of each treatment. The work of MAS and its research partners has evolved further with the development of sophisticated policy economic modelling tools known as Ontario Decision-Analytic Models. Building on data from MAS mega-analyses, these models are created by its scientific collaborators the Toronto Health Economic and Technology Assessment (THETA) Collaborative and the Programs for Assessment of Technology in Health (PATH) Research Institute. The decision-analytic models are grounded in Ontario data, have multiple uses and provide policy-makers with a common platform for assessing and predicting the outcomes and impacts of various interventions and for prioritizing investment decisions. Several decision-analytic models have been created so far: Ontario Wound Prevention and Care Model Ontario Non-Invasive Cardiac Diagnostic Testing Economic Model Ontario Diabetes Economic Model Ontario COPD Economic Model. fast facts All OHTAC recommendations and MAS reviews are available at and From October 1, 2010 to September 30, 2011, MAS/OHTAC pages were viewed 939,626 times MAS/OHTAC websites have by far the most international readership all of sections of the MOHLTC website Every year, MAS accepts invitations from governments and medical bodies around the world to share Ontario s approach to health technology assessment 4

5 MAS/OHTAC Evidence Review Process 1 Scoping Of Evidence 2 Conduct Evidence-Based Review 3 Develop Recommendation 4 Public and Professional Consultation 5 Assessment of public comments 6 Post Review and Recommendation MAS drafts brief overview of technology OHTAC prioritizes which technologies proceed to a full review MAS reviews evidence in consultation with -Clinical experts -Industry -Government OHTAC drafts recommendations based on evidencebased review Draft review and recommendations are posted on the MAS/OHTAC website for public and professional comment MAS reviews public and professional comment feedback OHTAC modifies recommendations as required MAS evidencebased review and OHTAC recommendations published on website and announced in e-bulletin Single HTA: average timeframe 16 weeks. Mega-analysis: average timeframe 8 months Toronto Health Economics and Technology Assessment (THETA) Collaborative Programs for Assessment of Technology in Health (PATH) Research Institute Gathering Evidence in Clinical Settings At the request of OHTAC, MAS funds and oversees field evaluations for technologies that appear promising, but for which there is inadequate evidence about their safety, clinical usefulness or cost-effectiveness. Ontario s Field Evaluation Program one of the largest of its kind globally tests new health technologies in clinical settings, in real time, to explore any uncertainty about how the technology will actually operate. These evaluations involve key stakeholders and clinicians from across the province, giving consenting patients access to the new technology while it is being evaluated. As part of Ontario s Field Evaluation Program, the Health Technology Safety Research Team at the University Health Network collects additional information about safety or human factors relevant to a technology. The team s analyses evaluate how welldesigned technologies are for health professionals and health systems. Based on its findings, the Health Technology Safety Research Team provides suggestions for reducing errors associated with the technology and explores the relative effectiveness of training approaches to overcome the limitations of technology design that could expose patients to risk. What makes OHTAC special is the broad range of expertise that is brought to bear on systematically evaluating health care technologies and translating those evaluations into recommendations that make a real difference to the people of Ontario. Tony Easty, Senior Scientist, University Health Network and the Health Technology Safety Research Team 5

6 at a glance evidence-based reviews and updates This research is produced by MAS unless indicated Single Technologies Balloon Kyphoplasty for Treatment of Painful Osteoporotic Vertebral Compression Fractures Cancer Screening With Digital Mammography for Women at Average Risk for Breast Cancer, MRI for Women at High Risk Clinical Utility of Serologic Testing for Celiac in Ontario Clinical Utility of Vitamin D Testing Endovascular Laser Treatment for Varicose Veins Extracorporeal Lung Support Technologies Bridge to Recovery and Bridge to Lung Transplantation in Adult Patients Magnetic Resonance Imaging for the Assessment of Myocardial Viability Neuroimaging for the Evaluation of Chronic Headaches Percutaneous Vertebroplasty for Treatment of Painful Osteoporotic Vertebral Compression Fractures Population-Based Strategies for Smoking Cessation Positron Emission Tomography for the Assessment of Myocardial Viability Primary Angioplasty and Thrombolysis for the Treatment of Acute ST-Segment Elevated Myocardial Infarction Robotic-Assisted Minimally Invasive Surgery for Gynaecologic and Urologic Oncology Solid Organ Transplantation for End Stage Organ Failure in Persons with HIV Stenting for Peripheral of the Lower Extremities Use of Contrast Agents with Echocardiography in Patients with Suboptimal Echocardiography Evidence Updates Endovascular Repair of Abdominal Aortic Aneurysms for Low Surgical Risk Patients (EVAR) Laparoscopic Adjustable Gastric Banding Multiple Sclerosis and Chronic Cerebrospinal Venous Insufficiency Preliminary Evidence Examination Negative Pressure Wound Therapy Mega-Analyses & Decision-Analytic Models Cardiac Diagnostic Imaging Cardiac Magnetic Resonance Imaging for the Diagnosis of Coronary Artery Computed Tomographic Angiography for the Diagnosis of Coronary Artery Stress Echocardiography for the Diagnosis of Coronary Artery Stress Echocardiography with Contrast for the Diagnosis of Coronary Artery Single Photon Emission Tomography for the Diagnosis of Coronary Artery The Relative Cost-Effectiveness of Five Non-Invasive Cardiac Imaging Technologies for Diagnosing Coronary Artery in Ontario (THETA) Ontario Non-Invasive Cardiac Diagnostic Testing Economic Model (THETA) Genetic Testing for Cancer Treatments Epidermal Growth Factor Receptor Mutation Testing for Prediction of Response to EGFR-Targeting Tyrosine Kinase Inhibitor (TKI) Drugs in Patients with Advanced Non-Small-Cell Lung Cancer Cost-Effectiveness of Epidermal Growth Factor Receptor Gene Mutation Testing for Patients with Advanced Non-Small Cell Lung Cancer Living in Ontario (THETA) Gene Expression Profiling for Guiding Adjuvant Chemotherapy Decisions in Women With Early Breast Cancer Cost-Effectiveness of Oncotype-DX Guided Treatment in Early Breast Cancer (THETA) KRAS Testing for Anti-EGFR Therapy in Advanced Colorectal Cancer Cost-effectiveness of KRAS Genetic Testing for Anti-EGFR Therapy in Metastatic Colorectal Cancer (THETA) Field Evaluations Evaluation of Effective Smart Pump Design and Education Strategies* Multiple Intravenous Infusions: Phase 1a: Situation Scan Summary Report* Ontario Multidetector Computed Tomographic Coronary Angiography Study (OMCAS): Economic Evaluation Legend * Health Technology Safety Research Team Programs for Assessment of Technology in Health (PATH) Research Institute Toronto Health Economics and Technology Assessment (THETA) Collaborative Ontario Clinical Oncology Group (OCOG) Institute for Clinical Evaluative Sciences (ICES) 6

7 2011 Single Technologies Clinical Utility of Serologic Testing for Celiac in Asymptomatic Patients Constraint Induced Movement Therapy for Rehabilitation of Arm Dysfunction after Stroke in Adults Continuous Glucose Monitoring for Patients with Diabetes Corneal Collagen Cross-Linking Using Riboflavin and Ultraviolet-A for Corneal Thinning Disorders Diurnal Tension Curves for Assessing the Development or Progression of Glaucoma Endovascular Radiofrequency Ablation for Varicose Veins Internet-Based Device-Assisted Remote Monitoring of Cardiovascular Implantable Electronic Devices 2011 (In Progress) Transcatheter Aortic Valve Implantation for Treatment of Aortic Valve Stenosis. 24-Hour Ambulatory Blood Pressure Monitoring Evidence Updates Update on Multiple Sclerosis and Chronic Cerebrospinal Venous Insufficiency Preliminary Evidence Examination Screening Mammography 2011 (In Progress) Genetic Testing for Dilated Cardiomyopathy Mega-Analyses & Decision-Analytic Models Chronic Obstructive Pulmonary Chronic Obstructive Pulmonary (COPD) Evidentiary Framework Community-Based Multidisciplinary Care for Patients with Stable Chronic Obstructive Pulmonary Home Telehealth for Patients with Chronic Obstructive Pulmonary : Hospital-at-Home Programs for Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Influenza and Pneumococcal Vaccinations for Patients with Chronic Obstructive Pulmonary Long-Term Oxygen Therapy for Patients with Chronic Obstructive Pulmonary Non-Invasive Positive Pressure Ventilation for Acute Respiratory Failure Patients with Chronic Obstructive Pulmonary Non-invasive Positive Pressure Ventilation for Chronic Respiratory Failure Patients with Stable Chronic Obstructive Pulmonary Pulmonary Rehabilitation for Patients with Chronic Obstructive Pulmonary Smoking Cessation for Patients with Chronic Obstructive Pulmonary Ontario COPD Economic Model (PATH) 2011 (In Progress) Intermediate Care Field Evaluations Cost-Effectiveness of Heart Failure Multidisciplinary Clinics in Ontario Neurosurgical Evaluation of Children and Adolescents with Drug Refractory Epilepsy and the Role of Magnetoencephalography Ontario Multidetector Computed Tomographic Coronary Angiography Study (OMCAS): An Evaluation of Diagnostic Accuracy Photoselective Vapourization of the Prostate Specialized Multidisciplinary Community- Based Clinics for Chronic Wounds 2011 (In Progress) Diabetes Education Centres in Ontario: Impact on Care Effectiveness and Long-term Cost Utility of an Interactive Computer-Assisted Technology in Chronic Management Hyperbaric Oxygen Treatment (HBOT) for Diabetic Ulcers Investigating the Leaks of Chemotherapeutic Agents in Ontario Treatment Centres* Laparoscopic Adjustable Gastric Banding Mitigating Risks Associated with Multiple Intravenous Infusions* Oncotype-DX for Guiding Adjuvant Chemotherapy for Early Breast Cancer Ontario Policy and Economic Model in Rheumatoid Arthritis Pre-hospital Evaluation and Economic Analysis of Different Coronary Syndrome Treatment Strategies PREDICT Pressure Ulcer Multidisciplinary Teams via Telemedicine PUMTT Robotic-Assisted Minimally Invasive Surgery for Gynecologic and Urologic Oncology Turning for Ulcer ReductioN TURN 7

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