Focus on New Technology:
Winter 2001/Vol. 5 No.1
Permanente Physicians Determine Use of New Technology: Kaiser Permanente's Interregional New Technologies Committee
By Mitchell Sugarman
One of these cases--a class action lawsuit in which $40 million in damages was assessed against the KP Northern California Region--ensued after the Region decided to delay coverage of in vitro fertilization (IVF) for about two years after reasonable scientific evidence had shown IVF to be safe and effective for treating certain types of infertility. The court found that the decision to designate IVF as "experimental"--thus delaying coverage for the procedure--was not based on sound scientific evidence and did not result from a well-documented process of evaluation.
In the other case (in the former KP Texas Region), the parents of twins with severe congenital liver disease requested liver transplantation for the infants. The request was denied on the grounds that the procedure was experimental in infants. At the time, liver transplantation in adults was still new and was widely considered experimental; liver transplantation in infants had not yet been done. Nonetheless, a media storm of bad publicity attended the Region's denial, and a settlement of $5 million was awarded to the family of the twins. Both twins received liver transplantation, and both ultimately died.
The KP INTC today considers many topics in addition to infertility treatment and organ transplantation. Recent and upcoming clinical topics for INTC discussion include cervical cancer screening technologies, transmyocardial revascularization, photodynamic therapy (PDT) for treatment of esophageal cancer, PDT for age-related macular degeneration, percutaneous vertebroplasty, and melanoma vaccines.
Formation of KP Interregional
Initially established by the late Paul Lairson, MD, who served as Physician Liaison (the predecessor position to the Executive Director of The Permanente Federation), the Committee began by examining issues such as heart transplantation, lung transplantation, gastric stapling, and radial keratotomy. Given this history, we may reasonably say that Kaiser Permanente has been practicing evidence-based medicine since long before this concept entered the medical vernacular.
The Committee is currently chaired by Dr Jed Weissberg, Associate Executive Director of The Permanente Federation, and is managed by Mitchell Sugarman, Director of Medical Technology Assessment in The Permanente Federation (Table 1). Through these members, the Committee gains access to Permanente specialists throughout the KP Program so that the evidence supporting use of a specific technology for a given medical condition can be evaluated by physicians who regularly treat that condition.
Committee Evaluative Process
When sufficient information is available, the Committee compares the safety, efficacy, and relative utility of the new medical technology with current medical practice. In some instances, a new medical technology stands alone as a completely new innovation, making comparison difficult. In this situation, the safety, efficacy, and utility of the technology must be evaluated without any comparison.
Agenda items for the INTC come from a variety of sources. An individual Permanente physician may inquire if the INTC has data or a report on the technology that the physician can use to make a decision about a patient. A Health Plan benefits manager at KP may simply want to know if the technology is included in Health Plan coverage. These inquiries may not require extensive review by the INTC, because relevant data may already exist. Through the INTC's contacts, physicians in one KP Region can easily be connected with physicians in another KP Region who may have the experience sought by the first physician. However, when a question does not have a simple answer or when the technology prompts divergent views, the topic is likely to be placed on the INTC's agenda. After the INTC makes a recommendation, the recommendation is disseminated throughout the Program, primarily through the recorded minutes of the INTC meeting.
KP Regional Committees
Decision making and Controversies
As might be expected from the nature of this developmental activity, the process has also been filled with controversy. Medicine is not an exact science, and evidence is sometimes not conclusive; therefore, a degree of judgment always accompanies the INTC's recommendations. This situation is exemplified by bone marrow transplantation for breast cancer--a topic that has been placed on the INTC agenda 11 times since 1991. Most of the early Committee meetings resulted in recommendations that did not support bone marrow transplantation for breast cancer; later, in light of mounting pressure from advocacy groups, from news media, from legal challenges, and from legislative mandates, the INTC recommended bone marrow transplantation for breast cancer as a "medically appropriate alternative treatment in carefully selected patients." In 1999, however, more definitive evidence was presented (at American Society for Clinical Oncology meetings in Atlanta, Georgia) to show that this approach to treating breast cancer is more dangerous and no more effective than conventional care. (Notwithstanding this evidence, however, a federal mandate still requires that federal employees receive coverage of bone marrow transplantation for breast cancer!)
Obtaining Further Information
About the INTC
The Committee is a national model for evaluating potential solutions in an environment constantly challenged with new technology and rising health care costs.
Suggested Further Readings