Around the Globe

Changing Landscape of Evidence Charting New Assessment Pathways
Q&A with Canadian Agency for Drugs and Technologies in Health (CADTH) CEO Suzanne McGurn

ealth technology assessment (HTA) is the evaluation of the clinical, economic, and humanistic value of a new product compared to existing approaches to care. In Canada, as in many other jurisdictions (such as the UK, Australia, France, and Germany), health technology reviews are used to support decisions by provincial payers about drug funding and appropriate use.

Judith Glennie, Global Forum regional editor for Canada, discusses the concept of HTA and its place in the therapeutic development of pipeline products—first on a global basis and then within the context of Canadian and other international jurisdictions—with Suzanne McGurn, president and chief executive officer of the Canadian Agency for Drugs and Technologies in Health (CADTH), in the below Q&A. CADTH is an independent not-for-profit organization responsible for providing Canada’s healthcare decision makers with objective evidence about the optimal use of drugs and medical devices, where Suzanne has served as president and CEO since July 2020.
Suzanne McGurn headshot

Suzanne McGurn
Canadian Agency for Drugs and Technologies in Health (CADTH)

Judy Glennie: Suzanne, if you had to explain it to a lay person, why would you say the work of health technology assessment agencies like CADTH is important?

Suzanne McGurn: I like to compare health technology assessments to things we’re all very familiar with. If we’re looking into which restaurant to go to, we check to see how many stars there are. If we’re looking to buy something, whether it’s a new car or appliances for our house, we look to find out how they are rated for safety or energy usage or environmental impact. How does it work? How reliable is it? What are its repair costs? All of us are very familiar with making decisions about what to buy based on using the best information available. For example, people are familiar with Consumer Reports® and how they help individuals with informing their own decisions, particularly about those large purchases. I think of HTA and the work we do like those reports: they help decision makers who face the same challenges and difficult choices that we all face with finite resources. There are competing demands on the resources that are available. People want to know that these decisions are based on the best information and not undue influence or marketing.

Agencies like CADTH help bring science, methodology, and rigor to the decision-making process. We review information similar to Consumer Reports® and make the best recommendations possible. This could be about pharmaceutical products, it could be about new cell and gene therapy, it could be about new devices, and it could be about new interventions or models of care. From my perspective, the role that CADTH plays is to lay a foundation of standardized, credible information for decision makers to use in their decision making. It’s not the only piece of information at hand, but our HTA work helps bring consistency to the process. We help decision makers, and hopefully the public, understand what the current evidence tells us and, importantly, what we don’t yet know.

JG: What is the greatest challenge that HTA bodies like CADTH face as they work to evaluate and provide advice on the use of new products?

SM: It is daunting to step into a leadership role for an organization focused on evidence in the midst of a pandemic. Less than 18 months ago, many of us didn’t know much about Scientific Tables or modeling. These are dinnertime discussions now within many households. One of the greatest challenges we face is the changing landscape of evidence and, probably for the first time, a real recognition of how fast or slow evidence evolves. And the changing nature of evidence naturally leads to lots of questions. We have drugs and products coming to us with higher uncertainty than we’ve ever seen. We see complexity, like new gene therapies or very targeted treatments, rapidly emerging in the pipeline. Just a few years ago, those seemed quite far from frontline clinical delivery, but now they’re here. So, a challenge for us is keeping pace with robust pipelines and effectively managing the increasing number of products coming through CADTH for assessment.

Another shifting paradigm: The discussion just a short time ago was centered on speed versus quality, but where we’re really moving to is more like a Triple Aim: How do we continue to be efficient, maintain quality, and ensure that effective products get to patients as quickly as possible? And coupled with that: When products arrive with limited evidence and questions remain about the benefits of treatment and patient outcomes, how do we continue to generate real-world evidence to determine if we should continue using those products or if other products should move into that space? And visa-versa: When should older “tried and true” products remain the most effective intervention rather than new, assertively marketed products? And lastly, and the one that I wouldn’t have thought about a short time ago, is our ability to continue to bring expertise and talent to the work we do at CADTH. As organizations are changing in the post-pandemic world, we’re seeing an in-demand and very mobile scientific community, so it will be important for HTA organizations to effectively support their teams while bringing in new scientific talent to support our evolving work.

JG: Given that we live in a global environment, what do you see other HTA agencies doing that might be worth considering at CADTH?

SM: When I attended international HTA meetings over the past year, I expected a greater diversity in our post-pandemic challenges, but in fact many of the same conversations are happening around the world. We are all focusing on capturing what we’ve learned throughout the pandemic and understanding what it means for our future directions. It’s always hard to find silver linings in the midst of something as tragic as what we’ve all been experiencing, but there have been a few.

We’ve been learning about the democratization of evidence: How do we get more evidence and more context to decision makers, but also to the public and clinicians?

We’ve learned the value of aligning our processes. We’ve seen what can happen when regulatory agencies, industry, HTA bodies, and the payers work together, particularly in difficult times.

We’ve also seen an increasing level of trust. Trust comes from having the opportunity to work with other people, and the pandemic has created an environment for us to engage with each other far more frequently than we did in the pre-pandemic world.

I also see more opportunities for international cooperation, certainly in the pharmaceutical space. We’re all benefitting and learning from the work that’s being led under Project Orbis. CADTH works with NICE on an early scientific advice program, and that provides helpful global insight. In the real-world evidence space, we’ve been harnessing international collaboration and learning how other HTA bodies are assessing products that we anticipate may come through our pipelines. We’re also partnering where we can and looking for additional collaboration; in particular, looking at how we advance assessments of digital health technologies that have a lot of potential value to bring our health system in a post-pandemic world. We see real opportunity to partner with other large HTA organizations in the area of evaluating digital technologies. We’re finding both small and large opportunities by just having regular and ongoing conversations with people.

I think the pandemic has taught us that no one has the capacity to do everything all the time, so there will need to be a right-sizing, or a resizing, of what we do individually and what we can do jointly or collectively. We need to learn from one another and build on work that’s been done elsewhere. Where is the best value proposition for HTA? What type of technology or product do we bring the greatest value to? You might not look at a Consumer Report® for everything you buy, but you certainly do look at them for big-ticket items and investments you’re making over the longer term.

JG: As you mentioned, using real-world evidence, or RWE, for decision making in various phases of a product’s lifecycle is a very quickly evolving area of science. Many agencies are taking steps to more systematically and transparently integrate this kind of information into their processes. What is the future of RWE at CADTH?

SM: I’d say the future of RWE at CADTH is very bright. There’s been a lot of work done in RWE, but the nomenclature of RWE, I think, has scared some people off and made it feel more daunting than it needs to. During COVID, products were brought forward earlier, with less mature data, stemming from a desire for earlier access to treatment. There is no place to go but “two feet first” into the real-world evidence future.

At CADTH, we’ve brought on a lead for RWE and in their early interactions, nationally and internationally, they have been asking, “Where are others in RWE? How can we leverage existing work? What kinds of questions does RWE answer most effectively, and how do we engage stakeholders in this important work?”

Before the pandemic, we established an RWE Core Action Team to move this forward in a more systematic and transparent way. Like everything, I don’t think there’s one size that fits all. RWE is going to be varied and during this period of time, we’ll all continue to learn as we go. What works in some circumstances probably doesn’t work in other circumstances. CADTH will use the next 12 to 24 months as a real learning period. We’ll partner with others to try things and see what we can learn. It’s important for us not to be slowed down by trying to get it perfect, or to go so fast that we miss opportunities to improve on things that others have learned. With a pipeline full of products with uncertainty in the rare disease pharmaceutical space, and with our ability to conduct traditional randomized controlled trials in these populations more limited, we must figure out how to do this well and bring it to scale in a way that allows us to respond effectively and make sure that patients have the opportunity to benefit from these emerging products.

JG: What can we expect to see in the coming years at CADTH or in the HTA world in general?

SM: A priority for me is making sure we take forward our learnings from the pandemic. I think there are ways we can all work together in a more rapid way across the continuum of health technology management. What can be shared when? How much earlier can it be shared? Can we make decisions sooner? Can decision makers get information in their hands that helps them with their decisions in a timely fashion?

I spend a lot of time thinking about how CADTH can help decision makers manage uncertainty. I can’t imagine what is more uncertain than our last 18 months, but we’re learning to live with it and to remain flexible and responsive to change.

I think the new Alzheimer’s drug is topical in every pharmaceutical conversation right now both in terms of its potential impact and its potential cost. It reminds me of the period of time leading up to the launch of the hepatitis C drugs. And in that situation the products showed very high efficacy, but we still couldn’t imagine how we would work through the cost of bringing those products to the people who needed them. However, through understanding the evidence and working creatively together we were successful. With new products coming to market that will treat both rare diseases and very common diseases, what could be more exciting than figuring out how we distill the promise of those drugs and bringing those treatments that hold the greatest promise to the patients who are most likely to benefit in a timely way? The HTA process is about providing people with information to decide whether and what to buy, and sometimes it’s also about helping them prioritize who should get what and when, and thinking about the sequencing considerations for treatments.

Recently, a number of Canadian and world events have really shaken our social fiber. The issue of equity has always underpinned the societal considerations for HTA. But we really need to reexamine traditional beliefs, our unconscious biases, and our approaches to make sure that we don’t inadvertently leave groups out or leave them behind. Perhaps we’ve learned that some things aren’t appropriate for large populations but are appropriate for some populations because of the specific characteristics of these populations. There may be things that different people need to use differently. And we need to get better at understanding, identifying, and articulating that.

From a CADTH perspective, I hope that you will see greater collaboration, greater engagement, and greater awareness in jurisdictions about our capacity and expertise beyond pharmaceuticals. I think a lot of people still only know CADTH as a pharmaceutical HTA body. But as we look at the digital future, the devices and the virtual care that helped sustain our healthcare systems during the pandemic will not disappear. And CADTH is well-positioned to help bridge the evidence gap for things like connected devices and other digital health technologies. And you’ll likely see more from us in the area of horizon scanning, helping health system leaders “see around the corner” and anticipate the innovation that may be on their doorstep very soon.

JG: We’ve discussed topical issues in the health technology assessment environment, but are there other considerations you’d like to share as CADTH develops its new strategic plan?

SM: There’s nothing like a strategic plan to challenge you to think about the future. People can hardly imagine, after the pandemic, trying to plan for five years, so we’re looking forward for the next three years. Some things we’ve already talked about will be top of mind: keeping pace with change, harnessing real-world evidence, and a more cohesive approach to health technology management not just at the beginning for access but throughout the lifecycle. We put a lot of emphasis at the beginning of the process right now, but part of our opportunity lies in following some of these products through their lifecycle to either decommission them when they’re no longer appropriate or to identify whether they’re being used appropriately or even underutilized. The importance of earlier stakeholder engagement and trying to understand the landscape from more perspectives is certainly key to our thinking. Sometimes, an answer seems very logical from where you’re sitting—but when you genuinely look at that same issue from a 360-degree perspective, it can look very different.

Throughout the pandemic, we have all had to think deeply about our relationships—with industry, with jurisdictional health systems, and with the parts of those health systems that get less attention, like long-term care homes or home care. In some instances, it’s our differences that garner the most attention, but I truly believe that healthcare stakeholders have so much more in common than we realize. If each of us periodically gets out of our respective chairs and talks about the principles of what we want to achieve, I think we can make a lot of progress. A principle-focused conversation at the outset makes all the other downstream conversations that much easier because it puts us on the same page from the very beginning.

I truly believe that it’s a great time to be in HTA, and the work we do will be essential to health policy decisions in the months and years to come. There will be difficult conversations ahead as governments struggle with the pandemic from a health system perspective, from a life sciences industry perspective, from an economic perspective, and from a budgetary perspective. There are many competing demands on our public resources, and HTA can serve as a real intersection to help with making those decisions. I’m excited to be here and I’m certainly looking forward to the next couple of years to see how much our world changes, or how much stays the same, after the past 18 months.