Health Technology Assessment Contributes to Changed Practice
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So, with the support of his region and his SEARCH Canada faculty mentor, and using connections made through SEARCH Canada, he approached the Institute of Health Economics (IHE) for assistance in completing a health technology assessment on the use of inhaled Nitric Oxide (iNO) in the adult intensive care patient population.
“Over the past year and a half, the cost of administering this therapy has increased 10 fold in Canada, almost doubling the daily cost of caring for a patient in the ICU,” he says. “In addition, the clinical benefits remain unclear. Despite the increasing cost and lack of evidence supporting a clear-cut benefit of this experimental therapy over conventional management, the use of iNO to treat patients with Acute Respiratory Distress Syndrome (ARDS) has remained relatively static. My goal was to provide a foundation to support more selective use of this therapy within our region, initially, and since the report is applicable all across Canada, in other health regions as well.”
Patients suffer from inflammation and injury to the lung, due to a number of causes. The syndrome results in low levels of oxygen in the blood, which can cause further injury and dysfunction in other organs. These are some of the most acutely ill and highly unstable patients cared for in an adult intensive care unit. While improvements in general treatment strategies have resulted in better outcomes for these people over the past 20 to 30 years, the limitations associated with the various conventional management strategies often force clinicians to consider the use of other, non-conventional strategies to improve oxygen delivery.
The use of iNO is one such strategy, used most often as a last resort therapy in ARDS. When inhaled, it can produce changes in the lung that reduce blood pressure and help improve the amount of oxygen transferred to the blood. The degree of improvement depends on a number of factors. In about 40 per cent of patients, this therapy produces no response at all.
“With this technology, we see some improvement in oxygenation in about 60 per cent of patients,” Greg says, “but this is typically short-lived and, in some cases, actually causes the patient to deteriorate when it is discontinued. This report tries to answer many clinically relevant questions regarding optimal use of this therapy, including the modification of existing protocols and policy to be used more selectively; to discontinue the therapy earlier when we don’t see a response, and to reconsider using it at all in situations with a low probability of success.”
Greg is now working to disseminate his results and share his experiences - both within and external to the region. “One Attending Physician has suggested I present the report to the ICU Executive Committee – to make the clinical leaders in the region more aware of the cost increase and evidence related to efficacy. The next step will be to roll these recommendations out as a change in our guidelines and policy.”
As for Greg, personally, he is grateful for all the support he received along the way and for the experience gained in conducting this health technology assessment.