Co-ordinating health technology assessment in Canada: a European perspective

STAKEHOLDER INVOLVEMENT IN HEALTH TECHNOLOGY ASSESSMENT AT NATIONAL LEVEL: A STUDY FROM IRAN

OBJECTIVES

This study was carried out to evaluate the opinions of stakeholders on their roles in health technology assessment (HTA) in Iran and to determine the barriers and facilitators existing in the organizations to help increase their involvement in the HTA program.

METHODS

The study was conducted in two stages, semi-structured interviews, and "policy dialogue" with stakeholders. The data were analyzed through the framework approach.

RESULTS

The interviews were held with ten stakeholder representatives from various organizations. In addition, Twenty-one representatives participated in the policy dialogue. Based on the findings, all the stakeholder organizations considered themselves as interest groups in all the stages of the HTA process; however, their tendencies and methods of involvement differed from one another. According to the participants, the most important issue to be considered in the context of HTA was that the structures, stages, and procedures of the HTA process must be made transparent.

CONCLUSIONS

Stakeholder involvement in the HTA program cannot readily take place. Various stakeholders have different interests, responsibilities, infrastructures, and barriers. If a program does not meet these considerations, its chances of succeeding will substantially decrease. Therefore, to prevent overlooking the needs and expectations of stakeholders from the HTA process, it is essential to create opportunities in which their thoughts and ideas are taken into account.

[The introduction of technologies in health care systems: from saying to doing]

INTRODUCTION

Health technology assessment (HTA) is a tool based on scientific evidence useful for making decisions about the introduction of technological advances in healthcare systems. However, there are multiple elements that influence the actual use of the results of HTA. These elements are related both to the characteristics of HTA and to the stakeholders involved -health professionals, politicians, and society. The aim of this article was to describe the main elements that influence the applicability of HTA in practice, as well as the use of HTA in clinical practice and health policy.

METHODS

A literature search was performed in PubMed. The references retrieved, as well as additional bibliography and gray literature dealing with different aspects of HTA practice identified from the references retrieved, were reviewed. The results are presented descriptively, with analysis of the studies grouped according to the various HTA-related topics.

RESULTS

Key elements that could be improved are standardization of the evaluation process, description of the organization's mission, prioritization of the technologies to be assessed, the clarity of the presentation of results, inclusion of values other than scientific evidence, such as social and cost-effectiveness values, and increased international coordination.

CONCLUSIONS

For many people, the rationale for HTA is its explicit role in decision making, despite its problems. The immediate future of HTA would seem to include making the assessment process explicit, and the inclusion of HTA in decision making. This entails prioritization of technologies, setting limits on resource allocation and interrelation with political processes.

Diffusion and use of health technology assessment in policy making: what lessons for decentralised healthcare systems?

OBJECTIVE

The Italian National Healthcare System (NHS) is one of the most decentralised systems since the devolution reform approved in 2001. HTA is spreading as an important tool for decision-making processes both at central and local levels. The aims of this study were to review the state of the health technology assessment (HTA) programmes in Italy - with a focus on regional and central initiatives - and to discuss consequences of a multi-level structure of HTA agencies in highly regionalised healthcare systems.

METHODS

Our method combined documentary review with interviews. We reviewed scientific literature about HTA's activities in decentralised systems, legislative and administrative documents from national as well as regional authorities. Semi-structured interviews were conducted with 18 key individuals associated with HTA both at the national and regional levels. Data on HTA programmes implemented or under development in nine regions were collected and analysed according to key principles for the improved conduct of health technology assessments for resource allocation decisions.

RESULTS

HTA is in the early stage of development in Italy, although with great heterogeneity across regions. The National Agency for Health Services has certainly contributed to HTA diffusion through supporting and training activities. However, the multi-level structure of HTA in Italy has not yet provided full coordination and harmonisation of practices and outcomes across the country, with a consequent exacerbate inequality of access to services and technologies.

CONCLUSIONS

There is probably need to rethink the multi-layer organizational framework of HTA in Italy by leveraging on current knowledge and efficient redistribution of activities across regions. We would advise for different jurisdictions playing different roles while achieving similar health outcomes for their patients, rather than jurisdictions aiming at doing exactly the same things resulting in unequal access to healthcare service provision.

Moving cautiously: Public involvement and the health technology assessment community

Objectives: This study explores the factors that enhance or reduce the prospects for public involvement in the activities of health technology assessment (HTA) agencies.

Methods: The analytical framework for this study is based on the work of John W. Kingdon, which provides a comprehensive synthesis of the factors influencing governments and public organizations' agenda. The study draws insights from forty-two semistructured telephone interviews with informants involved in international HTA networks and/or in HTA agencies in Canada, Denmark, and the United Kingdom.

Results: This exploratory study suggests that the HTA community is moving toward greater public involvement. However, the HTA community remains cautious and ambivalent about the technical feasibility of public involvement, its acceptability to policy makers and practitioners, and its impacts on HTA agencies' resources and procedures.

Conclusions: The study stresses the importance of conducting rigorous and compelling evaluations to inform HTA agencies' decision to adopt, or reject, public involvement practices.

Health technology assessment in the Asia Pacific region

OBJECTIVES

Although health technology assessment (HTA) has been well established in all developed countries, it has not found a firm footing in many developing countries. This is especially true of the Asia Pacific region, which has much of the world population.

METHODS

The beginnings of HTA in this region go back to the work of Dr. David Banta in China and the establishment of the Asian HTA Network. The Network embarked on increasing awareness and building capacity among personnel from the region. Attempts were made to introduce HTA in countries where it did not exist, as well as to strengthen existing HTA programs. The Network had regular meetings, and also carried out a study on the diffusion and utilization of magnetic resonance imaging in the region. In an attempt to boost the efforts of the Network, the author spearheaded the organization of the Asian Regional HTA Conferences in Kuala Lumpur in 2000 and 2003, and in Manila, Philippines, in 2004. In addition, the author carried out a survey on HTA in the region. There are two broad categories of countries in the region: Australia, Malaysia, Singapore, New Zealand, China, Philippines, Korea, Thailand, and Taiwan, which have formal HTA programs, and others for which informal mechanisms or related activities exist, which include Bangladesh, Bhutan, Brunei, Cambodia, India, Indonesia, Laos, Maldives, Mongolia, Nepal, Pakistan, Sri Lanka, and Vietnam.

RESULTS

It is important that once HTA is established, it is used effectively. Perseverance and dedication is needed to ensure the success of an HTA program.

CONCLUSION

Some countries in the region have effective HTA programs, whereas in some, efforts are being made to establish HTA, or HTA-related activities are being carried out in the absence of a formal HTA program.

Evidence-informed health policy 3 - interviews with the directors of organizations that support the use of research evidence

Background

Only a small number of previous efforts to describe the experiences of organizations that produce clinical practice guidelines (CPGs), undertake health technology assessments (HTAs), or directly support the use of research evidence in developing health policy (i.e., government support units, or GSUs) have relied on interviews and then only with HTA agencies. Interviews offer the potential for capturing experiences in great depth, particularly the experiences of organizations that may be under-represented in surveys.

Methods

We purposively sampled organizations from among those who completed a questionnaire in the first phase of our three-phase study, developed and piloted a semi-structured interview guide, and conducted the interviews by telephone, audio-taped them, and took notes simultaneously. Binary or categorical responses to more structured questions were counted when possible. Themes were identified from among responses to semi-structured questions using a constant comparative method of analysis. Illustrative quotations were identified to supplement the narrative description of the themes.

Results

We interviewed the director (or his or her nominee) in 25 organizations, of which 12 were GSUs. Using rigorous methods that are systematic and transparent (sometimes shortened to 'being evidence-based') was the most commonly cited strength among all organizations. GSUs more consistently described their close links with policymakers as a strength, whereas organizations producing CPGs, HTAs, or both had conflicting viewpoints about such close links. With few exceptions, all types of organizations tended to focus largely on weaknesses in implementation, rather than strengths. The advice offered to those trying to establish similar organizations include: 1) collaborate with other organizations; 2) establish strong links with policymakers and stakeholders; 3) be independent and manage conflicts of interest; 4) build capacity; 5) use good methods and be transparent; 6) start small and address important questions; and 7) be attentive to implementation considerations. The advice offered to the World Health Organization (WHO) and other international organizations and networks was to foster collaborations across organizations.

Conclusion

The findings from our interview study, the most broadly based of its kind, extend to both CPG-producing organizations and GSUs the applicability of the messages arising from previous interview studies of HTA agencies, such as to collaborate with other organizations and to be attentive to implementation considerations. Our interview study also provides a rich description of organizations supporting the use of research evidence, which can be drawn upon by those establishing or leading similar organizations in LMICs.

Harmonization of evidence requirements for health technology assessment in reimbursement decision making

As more countries use HTA to inform decisions on the reimbursement of health technologies, harmonization of evidence requirements between jurisdictions has been proposed, mainly on the grounds of improved efficiency. Harmonization has the potential to avoid duplication of effort for both manufacturers and HTA bodies involved in preparing and reviewing HTA submissions for innovative technologies. However, it also carries risks of loss of local control over decisions, the application of general data standards which are not universally accepted and slowing the rate of development of innovation in the analytical disciplines supporting HTA. This study reviews the issues associated with harmonization taking into account the perspectives of the multiple stakeholders. This study draws on experiences from recent initiatives intended to promote the harmonization of HTA and experience from related fields, particularly regulatory approval of new medical technologies.

Redefining health technology assessment in Canada: diversification of products and contextualization of findings

OBJECTIVES

While strategies for enhancing the dissemination and impact of Health Technology Assessment (HTA) are now being increasingly examined, the characteristics of HTA production have received less attention.

METHODS

This study presents the results of a content analysis of the HTA documents (n = 187) produced by six Canadian agencies from 1995 to 2001, supplemented by interviews with chief executive officers and researchers (n = 40). The goal of this analysis was to characterize the agencies' portfolios and to analyze the challenges these agencies face in responding to the increased demand for HTA.

RESULTS

On average, thirty HTA products were issued annually by the agencies. While the bulk of documents produced were full HTA reports (76 percent), two agencies showed significant diversification in their products. Three agencies in particular actively supported the publication of results in scientific journals. Three agencies showed evidence of adapting to different institutional environments by specializing in certain areas (drugs, health services). Overall, a significant portion of the agencies' HTAs contained data on costs (37 percent) and effectiveness (48 percent), whereas ethical and social issues were rarely addressed (17 percent). Most agencies addressed issues and outcomes that did not strictly fall under the typical definition of HTA but that increased the "contextualization" of their findings.

CONCLUSIONS

Our discussion highlights four paradoxes and reflects further on challenges raised by the coordination of HTA within large countries and among European states. This study concludes that HTA is being redefined in Canada as HTA agencies offer a more contextualized informational basis, an approach that may prove more compatible with the increased demand for HTA.