1. Outlining the Health Technology Assessment systems and structures in Ireland Máirín Ryan Director of HTA

2. Outline of presentation Some background Establishment of HIQA and its roles Current HTA structures and workplans Other HTA activity in Ireland How will HTA progress in Ireland?

3. Health Technology Assessment Health Technology Assessment (HTA) is a multidisciplinary process that summarises information about the –Medical –Social –Economic –Ethical –Medicolegal –Organisational issues related to use of a health technology in a systematic, transparent, unbiased and robust manner

4. Health Technology Assessment Objective: To inform safe and effective health policies that are patient focussed and achieve best value

5. Health Information and Quality Authority: Functions Setting Standards Monitoring Quality and Safety in Healthcare Inspecting Social Services Health Information Health Technology Assessment Driving safer better care

6. Health Technology Assessment functions The functions of the Authority are as follows…. - “To evaluate the clinical and cost-effectiveness of health technologies including drugs and provide advice arising out of the evaluation to the Minister and the Executive” - “To review and make recommendations as the Authority thinks fit in respect of the services, to ensure the best outcomes for the resources available…”

7. “rationing” HTA for consumers/patients

8. Clinicans……...a clinical purist?..or a financial realist?

9. Cost-effectiveness analysis (CEA) e.g. COST/LYG Cost-utility analysis (CUA) e.g. COST/QALY Economic evaluations are usually in the form of CEA or CUA.

10. Types of HTA Conducted in Ireland HTAs of national significance by HIQA Rapid HTA’: e.g. single technology assessment of pharmaceuticals by NCPE under HSE/IPHA agreement and guidelines in development ‘Mini-HTA’: to inform local level decision-making?

11. Types of HTA Conducted in Ireland HTAs of national significance by HIQA –broad comprehensive HTA –use of independent economic models –informs national policy (Dept of Health) and national service (Health Service Executive) decisions ‘Rapid HTA’: under HSE/IPHA agreement and guidelines in development ‘Mini-HTA’: to inform local level decision-making

12. Vaccination against HPV to prevent cervical cancer National Centre for Pharmacoeconomics commissioned to conduct HTA Adaptation of the Danish model Girls aged 12 years: ICER €17,383/LYS 2008 National Immunisation Programme approved but then …….

13. Budget impact matters – even when a technology is deemed cost effective ? Irish Times November 5 th 2008

14. Health Technology Assessment of a Population-Based Colorectal Cancer Screening Programme in Ireland

15. CRC screening HTA: Domains Clinical Effectiveness Cost-Effectiveness Ethics Resource requirements Service delivery model by NCSS

16. HTA Findings Faeco-immunochemical testing (FIT) the optimal strategy –ICER €1,696/QALY Estimated: –15% reduction in incidence (160 cases per annum) –36% reduction in mortality (275 cases per annum) Significant additional resource requirements - per annum: –12,000 to 15,000 colonoscopies –800 surgeries (but, < pre-programme requirements by year 9) Ethics: importance of an effective and comprehensive informed consent process, appropriately trained personnel, and robust quality assurance procedures in relation to the handling and communication of risks associated with screening in asymptomatic individuals

17. The challenge Conventional HTA performed; highly cost-effective Business model developed by NCSS Further issues of implementation and affordability needed to be explored to overcome a potential obstacle to adoption Could proposed new screening service be delivered within existing resources and services, without compromising their quality and safety?

18. Evaluation Findings Use current infrastructure available in 8-12 existing specialist centres, using extended working day if necessary and increased colonoscopist numbers including Advanced Nurse Practitioners Significant opportunity for developing quality assured process in this smaller number of centres Significant opportunity to use existing managerial/administrative capacity of the National Cancer Screening Service to reduce overall costs (e.g. in population register maintenance) Leveraging existing infrastructure versus new build screening centres reduced overall costs significantly, with savings from this model estimated at: Capital expenditure: from €15m to €0 Implementation costs: from €7.2m to €2.2m Running costs: €3m-€6m per annum saved

19. “Colorectal cancer screening and cervical cancer vaccine to start under Government’s Cancer Control Programme” – Minister for Health announces new details 15 January 2010

20. Types of HTA Conducted in Ireland HTAs of national significance by HIQA Rapid HTA –new pharmaceuticals on Community Drugs Schemes under agreement –May support clinical guidelines in development ‘Mini-HTA’: to inform local level decision- making

21. Scarcity means that choices must be made ! www.ncpe.ie

23. Targets to reduce expenditure across all aspects of the drugs supply chain Pharmaceutical industry Post patent price reductions & reference pricing Wholesalers Reduced margins Pharmacists Changing the reimbursement model Prescribers Generic prescribing Awareness of opportunity cost Community drugs schemes Disinvestment Patients Co-payments www.ncpe.ie

24. National Clinical Guidelines National Clinical Effectiveness Committee National guidelines –Standards set by HIQA –Mandated by the Minister –Audit versus guidelines –Licensing versus standards Rapid HTA to support evidence base: –2 nd HIV test in the third trimester –Antiretroviral therapy to prevent mother to child transmission

25. Types of HTA Conducted in Ireland HTAs of national significance by HIQA ‘Rapid HTA’ ‘Mini-HTA’: to inform local level decision- making –non-pharmaceuticals through PCCC, e.g., CF Physiotherapy Vest –technologies including drugs at local hospital level

26. HTA in 2011? National HTA Policy Framework Focus on cost containment / disinvestment Clinical Effectiveness Guidelines

27. Role of HIQA HTAs of “national significance” Guideline development Work with the health system to develop HTA capacity and methods Finalise prioritisation criteria and procedure Continue to collaborate with NCPE Work with NCEC Information resource and Horizon Scanning Strategy on stakeholder engagement in HTA Strategy on availability of cost data Ireland’s representative on international collaborations

28. International collaboration EUnetHTA Joint Action 1 –To facilitate efficient use of resources available for HTA, to create a sustainable system of HTA knowledge sharing, and to promote good practice in HTA methods and processes. –Stakeholder Forum EUnetHTA Joint Action 2 –2012 – 2014 European Directive on Cross-Border Healthcare (15.1) : –“ a voluntary network connecting national authorities or bodies responsible for health technology assessment designated by the Member States…

29. Thank You