Can we afford it? Do we need it?
Is it any good?

Balancing efficacy and money at Montreal's biggest hospitals is the job of the unique Technical Assessment Unit. Innovation versus hospital beds

By Marcello Palmieri

In May 2002, André Bonnici, coordinator of the Pharmacy and Therapeutics Committee of the McGill University Health Centre (MUHC) faced a difficult decision. He and his colleagues needed to determine whether to replace unfractionated heparin (UFH), which has been used in anticoagulation therapy for decades, with the much more expensive low-molecular-weight heparins (LMWHs). The newer drugs were thought to offer several advantages, such as easier administration and improved safety, yet there were some perceived drawbacks.

"When a hospital decides to supply an expensive new technology or drug, it isn't given any new money. So it has to cut somewhere else," explains Dr Maurice McGregor, the chair of the Health Technology Assessment Unit (TAU), which was set up in June 2001 to help with these kinds of decisions. "The easiest way to cut is to close more hospital beds and that's the cause of the disaster we're in at the moment." TAU is staffed by experts in technology assessment whose job is to collect and analyze the best scientific evidence. Once the evidence has been compiled, it's presented to an advisory committee made up of 12 members representing administrators, nurses, technical personnel, doctors and patients who make policy recommendations. TAU's director, Dr James Brophy, then reports to the Executive Committee of the five Montreal hospitals, including the Montreal General and the Royal Victoria, that make up the MUHC.

Clearing decision bottlenecks
In the past, administrators faced with difficult decisions have relied on the doctors and information supplied by the manufacturer to guide them. Clearly this latter source can, at times, be biased or may not reflect the best interests of the hospital as a whole. "I think TAU is a great addition to hospitals. It makes information comprehensible — even for non-physicians," says pharmacologist Mr Bonnici. For his query, TAU carried out a thorough review of the literature and based their report on two well-designed meta-analyses and on two randomized controlled trials. They concluded that the LMWH was at least equivalent and perhaps slightly superior to the old UFH. The key benefit was that replacing UFH would save money in the long run by reducing the nursing workload. Based on TAU's recommendation, the Executive Committee decided to move to the new therapy. "If that report hadn't been done the way it was, we probably wouldn't have switched," says Mr Bonnici.

TAU's process is a subtle one. "We aim to make policy decisions based not only on the scientific evidence but also the subjective values of the hospital community," says Dr McGregor. Every effort is made to be fair, consistent and to ensure a transparent decision-making process. Though the committee's recommendations are not binding, they are made public. Dr McGregor is justifiably proud of TAU's record, "Each report has become hospital policy," he points out. "The score card is very good at the moment."

In addition to providing assessments of the efficacy and costs of health technology, which includes equipment, drugs and procedures, TAU also studies the legal or ethical issues that may be pertinent to its acquisition. "The most difficult step is to move from scientific analysis to actually deciding what the hospital should do," Dr McGregor asserts. "That's why the committee must be widely representative of the whole hospital community." To help ensure a 'buy in' on recommendations, senior health workers from the affected department sit in on the committee. TAU may advise against a request for funding, but at least the reasons behind the decision are fully understood.

Dr McGregor adds that the MUHC isn't the only one benefiting from the process. While at a conference in Minnesota last year, he met a local health practitioner who told him that she'd seen TAU's website and that her hospital was using some of its recommendations. Dr McGregor is pleased to think the system he had such a hand in creating for the MUHC is now helping other hospitals.