Recent global shortages in the supply of the medical isotope prompted Health Canada to request that CADTH produce national guidance on the optimal use of 99mTc. While there are a number of strategies that can be taken to optimize the use of the isotope — many of which were employed during the last supply disruption — the focus of our work is optimal allocation through prioritization in the event that the supply of 99mTc is scarce.
Working with a multi-disciplinary committee comprising experts in research methodology, health economics, institutional and regional representatives from health professions (nuclear medicine physicians, radiologists, technologists, cardiologists, a medical oncologist, a radiopharmacist, a medical ethicist), administrators from ministries of health, and members of the public, we developed a framework using a multi-criteria– based approach by which relevant factors to be considered when allocating 99mTc can be combined to create a priority ranking of clinical uses of the isotope.
The ultimate result of the process is a prioritized list of clinical uses of 99mTc that is backed by an explicit methodology that organizes all relevant information. Since the process is explicit, results can be explained, or adjusted to allow for changes in the relevant information (e.g., acquisition of new equipment or changes to wait times for imaging procedures). When the available supply of 99mTc is reduced, the isotope would be allocated first to high-priority clinical uses.
The list of clinical uses that require 99mTc-based imaging is not exhaustive. Its intent is to assist health care practitioners and decision-makers in managing a large proportion of the work they would see within their institution(s) during a time of reduced supply. Importantly, uses of 99mTc for which no reliable alternative exists were not formally included in the prioritization process because they should be allocated 99mTc, if available.
We strove to include the most relevant alternatives to 99mTc-based imaging, which typically included other radioisotopes, CT, MRI, PET, and U/S. We did not include modalities or approaches that were under investigation. In some jurisdictions, select alternative imaging modalities may be unavailable. In addition, wait times for imaging modalities in some jurisdictions may already be long, or there may be restrictions on the ordering of some of these modalities by family physicians. Institutions, health authorities, and jurisdictions may wish to consider measures to increase access to these imaging modalities, such as an extension to the hours the scanners are in operation or changes to ordering privileges.
The output of this project, the national guidance, has become the foundation for a flexible web-based tool that can be customized for local use. Ideally, users of the web-based tool will work collaboratively with key decision-makers at their level to create a customized priority ranking that is reflective of their local setting – be it a hospital, a health authority, or a jurisdiction, and consistent across the country.
Canadian Agency for Drugs and Technologies in Health, Ottawa (ON)
Mujoomdar M, Russell E, Dionne F, et al. Optimizing Health System Use of Medical Isotopes and Other Imaging Modalities [Internet]. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2012. CONCLUSIONS AND IMPLICATIONS FOR DECISION-MAKING.