Reflections on the evolution of health technology assessment in Europe

A realist synthesis to develop an explanatory model of how policy instruments impact child and maternal health outcomes

BACKGROUND

Child and maternal health, a key marker of overall health system performance, is a policy priority area by the World Health Organization and the United Nations, including the Sustainable Development Goals. Previous realist work has linked child and maternal health outcomes to globalization, political tradition, and the welfare state. It is important to explore the role of other key policy-related factors. This paper presents a realist synthesis, categorising policy instruments according to the established NATO model, to develop an explanatory model of how policy instruments impact child and maternal health outcomes.

METHODS

A systematic literature search was conducted to identify studies assessing the relationships between policy instruments and child and maternal health outcomes. Data were analysed using a realist framework. The first stage of the realist analysis process was to generate micro-theoretical initial programme theories for use in the theory adjudication process. Proposed theories were then adjudicated iteratively to produce a set of final programme theories.

FINDINGS

From a total of 43,415 unique records, 632 records proceeded to full-text screening and 138 papers were included in the review. Evidence from 132 studies was available to address this research question. Studies were published from 1995 to 2021; 76% assessed a single country, and 81% analysed data at the ecological level. Eighty-eight initial candidate programme theories were generated. Following theory adjudication, five final programme theories were supported. According to the NATO model, these were related to treasure, organisation, authority-treasure, and treasure-organisation instrument types.

CONCLUSIONS

This paper presents a realist synthesis to develop an explanatory model of how policy instruments impact child and maternal health outcomes from a large, systematically identified international body of evidence. Five final programme theories were supported, showing how policy instruments play an important yet context-dependent role in influencing child and maternal health outcomes.

A Value Framework to Assess Patient-Facing Digital Health Technologies That Aim to Improve Chronic Disease Management: A Delphi Approach

OBJECTIVES

Digital health technologies (DHTs) can optimise healthcare costs and improve quality and efficiency of care. However, the fast-paced rate of innovation and varying evidence standards can make it difficult for decision-makers to assess these technologies in an efficient and evidence-based manner. We sought to develop a comprehensive framework to assess the value of novel patient-facing DHTs used to manage chronic diseases by eliciting stakeholder value preferences.

METHODS

Literature review and primary data collection from a three-round web-Delphi exercise was utilized. 79 participants from 5 stakeholder groups (patients, physicians, industry, decision makers, and influencers) and 3 countries (United States of America, United Kingdom, and Germany) took part. Likert scale data were statistically analyzed to determine intergroup differences in both country and stakeholder groups, stability of results, and overall consensus.

RESULTS

The resulting co-created framework comprised 33 stable indicators with consensus from quantitative value judgments across domains: health inequalities, data rights and governance, technical and security, economic characteristics, clinical characteristics, and user preferences. Lack of stakeholder consensus was observed on the importance of value-based care models, optimizing resources for sustainable systems, and stakeholder involvement in DHT design, development, and implementation; however, this was because of high rates of neutrality and not negative judgments. Supply-side actors and academic experts were the most unstable stakeholder groups.

CONCLUSION

Stakeholder value judgments revealed a need for a coordinated regulatory and health technology assessment policy response that updates laws to meet technological innovations, offers a pragmatic approach to evidence standards to assess DHTs, and involves stakeholders to understand and meet their needs.

Hospital-based health technology assessment of innovative medical devices: insights from a nationwide survey in France

OBJECTIVES

To better understand the process of hospital acquisition of innovative medical devices (MDs) and the hospital-based health technology assessment (HB-HTA) pathways in France, an in-depth study based on a quantitative approach is needed. The aim of the present study was to assess through a national survey how HB-HTA is currently implemented in French hospitals and to identify its level of formalization.

METHODS

A quantitative online survey was conducted among hospitals performing HB-HTA in France, with a focus on the acquisition of innovative MDs for individual use. The survey, conducted between March and June 2022, was developed by a scientific board composed of members of the French-speaking Society for HB-HTA.

RESULTS

Sixty-seven out of 131 surveyed hospitals with HB-HTA activities responded, including 29 university hospitals, 24 nonprofit private hospitals, and 14 local hospitals. Sixty-one respondents (91 percent) reported the existence of a process dedicated to evaluating innovative MDs; of these, 16 declared that their hospitals had a formalized unit with HB-HTA activity. These units were more frequently found in larger hospitals with more than 500 inpatient beds (n = 16, p = 0.0160) and in university hospitals (n = 12, p = 0.0158). No hospital reported any collaboration with HAS, the French national HTA agency.

CONCLUSION

A diverse range of HB-HTA organizations with different structural levels exist in France for MD procurement linked to the category of hospitals. The study highlights the need for recognition of HB-HTA activity at the regulatory level in France and for direct collaboration between HTA activities performed at local and national levels.

Accelerated epigenetic aging in older adults with HIV disease: associations with serostatus, HIV clinical factors, and health literacy

The prevalence of older persons with HIV (PWH) disease has increased considerably in the last 20 years, but our understanding of biological factors of aging and their clinical correlates among PWH remains limited. Study participants were 149 persons aged 50 and older, including 107 PWH and 42 seronegatives. All participants completed a blood draw, research medical evaluation, structured psychiatric interview, neurocognitive assessment, questionnaires, and measures of health literacy. Four epigenetic clocks were generated from stored blood samples using standardized laboratory methods. In regression models adjusting for sex and smoking status, PWH had significantly higher epigenetic aging acceleration values than seronegatives on all four indicators. Within the PWH sample, higher levels of epigenetic aging acceleration were moderately associated with lower current CD4 count, AIDS diagnoses, higher scores on the Veterans Aging Cohort Study Index, and lower telomere values. Higher epigenetic aging acceleration indices were also associated with lower health literacy among PWH. PWH experience accelerated aging as measured by a series of epigenetic clocks, which may be linked to immune compromise and risk of all-cause mortality. Health literacy may be a modifiable target for mitigating the risk of accelerated aging among older PWH.

Time From Marketing Authorization to Reimbursement of Medicines in Greece After the Introduction of the Health Technology Assessment Process From July 2018 to April 2022

OBJECTIVES

This study aimed to quantify the median time from marketing authorization (MA) to the inclusion of medicines in the reimbursement list after the introduction of the health technology assessment process in Greece.

METHODS

From July 2018 to April 2022, the Ministerial Decisions (MDs) and reimbursement lists, posted on the website of the Ministry of Health, were reviewed. The following information was collected for the medicines: the date that MDs and positive reimbursement lists were issued, the MA date, the date of the official price publication, and the type of the health technology assessment application. The time from MA to listing was calculated as the difference between the MA date and the date that the relevant reimbursement list was issued.

RESULTS

During the study period, 93 MDs were issued, from which 79 (85%) were positive and 14 (15%) were negative. Focusing on medicines included in the positive list for the first time, the median time from MA to listing for the new molecules was found to be 34.8 (interquartile range 25.7-41.3) months. This time was statistically significantly shortened for fixed dose combinations (20.9 [15.3-45.4] months, P = .008), and biosimilars (23 [16.6-28.2] months, P = .001). For generics was 17.6 (interquartile range 10-30) months, statistically significantly lower than that of new molecules (P < .001).

CONCLUSIONS

The time from MA to the inclusion of medicines in the reimbursement list in Greece is significantly long, especially for innovative medicines. Thus, policy makers should consider this point to optimize and improve patients' subsidized access.

Spending, Utilization, and Price Trends for Immune Checkpoint Inhibitors in US Medicaid Programs: An Empirical Analysis from 2011 to 2021

BACKGROUND AND OBJECTIVE

Immune checkpoint inhibitors (ICIs) have become a cornerstone in cancer treatment. With high treatment costs and an increasing number of young and low-income patients with cancer, there is a need to determine the current spending and utilization of ICIs in a real-world population. The objective of this study was to outline the drug spending, utilization, and price trends of ICIs for US Medicaid programs from 2011 to 2021.

METHODS

A retrospective descriptive analysis was conducted using the Medicaid State Drug Utilization pharmacy summary files managed by the Centers for Medicare and Medicaid Services. Six ICIs for this study include ipilimumab, pembrolizumab, nivolumab, atezolizumab, avelumab, and cemiplimab. Yearly reimbursement and prescription numbers were calculated for six ICIs billed through Medicaid between 2011 and 2021. The average spending per prescription was calculated as a proxy for drug prices.

RESULTS

Overall spending and utilization on ICIs have risen exponentially over the past decade. Between 2011 and 2021, expenditures increased from $2.8 million to $4.1 billion. Utilization increased from 94 prescriptions to 462,049 prescriptions in 2021 with six ICIs. The average spending per prescription, or average drug price, decreased 70%, from $29,795.88 in 2011 to $8914.69 in 2021.

CONCLUSIONS

Spending on and utilization of ICIs have increased dramatically over the past decade. These findings shed new light on the impact of ICIs on state Medicaid programs and may provide insight into potential cost drivers that need to be addressed through policy.

Toward Public Health Resilience in the Eastern Mediterranean Region: Findings From the Seventh Eastern Mediterranean Public Health Network Regional Conference

The resilience of public health in the Eastern Mediterranean Region (EMR) varies from country to country, mostly based on the governmental and financial situation of the countries. With the theme of Towards Public Health Resilience in the EMR: Breaking Barriers, the seventh Eastern Mediterranean Public Health Network regional conference, held from November 14 to 18, 2021, was dedicated to exploring ways for achieving public health resilience. A total of 101 oral presentations and 13 poster presentations were presented on various public health topics. The conference included 6 keynote sessions, 10 roundtable sessions, and 5 preconference workshops. The preconference workshops were conducted on border health; the mobilization of Field Epidemiology Training Program (FETP) residents and graduates and rapid responders in EMR countries; continuous professional development for the public health workforce; brucellosis surveillance using the "One Health" approach; and strategies to integrate and use noncommunicable diseases data sources. The roundtable sessions included discussions on the following topics: the role of FETPs in responding to COVID-19, institutionalization of rapid response to public health emergencies, health systems resilience, integration of early warning and response with event-based and indicator-based surveillance, sustaining international health regulations, strengthening the "One Health" approach, the anticipated future of public health in the post COVID-19 era, supporting public health research capacity in a diverse region, and COVID-19 vaccines and routine immunization synergies and drawbacks. The keynote speaker sessions covered topics on essential public health functions and the universal health coverage challenge in the EMR, lessons from the US COVID-19 public health response, learning from COVID-19, reshaping public health after the pandemic era, COVID-19 resilient primary health care, and the cohesion of society during and after a pandemic. The conference sessions provided highly promising opportunities to explore ways to achieve such goals in the EMR and shed light on the latest scientific findings, important lessons learned, and discussions on the ways in which current barriers can be broken down through coordination and collaboration.

The Value of New: Consideration of Product Novelty in Health Technology Assessments of Pharmaceuticals

BACKGROUND

Efforts to understand how treatments affect patients and society have broadened the criteria that health technology assessment (HTA) organizations apply to value assessments. We examined whether HTA agencies in eight countries consider treatment novelty in methods and deliberations.

METHODS

We defined a novel pharmaceutical product to be one that offers a new approach to treatment (e.g., new mechanism of action), addresses an unmet need (e.g., targets a rare condition without effective treatments), or has a broader impact beyond what is typically measured in an HTA. We reviewed peer-reviewed publications and technical guidance materials from HTA organizations in Australia, Canada, England, France, The Netherlands, Norway, Sweden, and the United States (US). In addition, we explored how HTA organizations integrated novelty considerations into deliberations and recommendations related to two newer therapies-voretigene neparvovec for an inherited retinal disorder and ocrelizumab for multiple sclerosis.

RESULTS

None of the HTA organizations acknowledge treatment novelty as an explicit value criterion in their assessments of pharmaceutical products. However, drugs that have novel characteristics are given special consideration, particularly when they address an unmet need. Several organizations document a willingness to expend more resources and accept greater evidence uncertainty for such treatments. Qualitative deliberations about the additional unquantified potential benefits of treatment may also influence HTA recommendations.

CONCLUSION

Major HTA organizations do not recognize novelty as an explicit value criterion, although drugs with novel characteristics may receive special consideration. There is an opportunity for organizations to codify their approach to evaluating novelty in value assessment.

The long process by which HTA became a paradigm: A longitudinal conceptual structure analysis

This study maps the conceptual structure of health technology assessment (HTA) research with the aim of contributing to a better understanding of this research stream. A bibliometric analysis of 1,198 HTA articles retrieved from the Web of Science database was conducted. The analysis of descriptive performance indicators identified the main traits of the scientific debate about the HTA in terms of publications, productive countries, and sources. A co-word analysis was performed by adopting social network analysis tools to map the conceptual structure of the dataset. The results highlight the growing academic interest in the research topic, especially in recent years. The results revealed that HTA is a widely known term and represents the reference paradigm for assessment in healthcare technologies. This paper contributes to the field by providing an examination of the current state of the art of HTA research and identifying possible future research directions. This study differs from existing studies because it involved a conceptual analysis of the scientific literature using macro keywords.

Similarities and Differences in Health Technology Assessment Systems and Implications for Coverage Decisions: Evidence from 32 Countries

Health technology assessment (HTA) systems across countries vary in the way they are set up, according to their role and based on how funding decisions are reached. Our objective was to study the characteristics of these systems and their likely impact on the funding of technologies undergoing HTA. Based on a literature review, we created a conceptual framework that captures key operating features of HTA systems. We used this framework to map current HTA activities across 32 countries in the European Union, the UK, Canada and Australia. Evidence was collected through a systematic search of competent authority websites and grey literature sources. Primary data collection through expert consultation validated our findings and further complemented the analysis. Sixty-three HTA bodies were identified. Most have a national scope (76%), are independent (73%), have an advisory role (52%), evaluate pharmaceuticals predominantly or exclusively (76%), assess health technologies based on their clinical and cost-effectiveness (73%) and involve various stakeholders as members of the HTA committee (94%) and/or through external consultation (76%). The majority of HTA outcomes are not legally binding (81%). Although all study countries implement HTA, the way it fits into decision-making, negotiation processes, and coverage and funding decisions differs significantly across countries. HTA is a dynamic and transformative process and there is a need for transparency to investigate whether evidence-based information influences coverage decisions.

Topic selection process in health technology assessment agencies around the world: a systematic review

Objective

The purpose of this study was to systematically review the process for topic selection by health technology assessment (HTA) agencies around the world to provide the knowledge base for the improvement of topic selection frameworks in HTA agencies.

Methods

A systematic search was conducted in PubMed and EMBASE to identify papers up to February 2019. Gray literature was identified by screening the Web sites of HTA agencies on the nonprofit member list of the International Network of Agencies for Health Technology Assessment (INAHTA). Data were extracted for each HTA agency and synthesized, with issues including general contextual information about each agency and the process of topic selection.

Results

Out of forty-nine nonprofit members of INAHTA, a total of seventeen HTA agencies with a framework for topic selection were identified from twenty-two included papers/documents. Multiple criteria were used for topic selection in all frameworks and agencies undertook multiple steps, which could include the specification of criteria for topic selection, identification of topics, short listing of potential topics, scoping of potential topics, scoring and ranking of potential topics, and deliberation and decision on final topics for HTA. Shortcomings were found in relation to methods of scoring and ranking as well as lack of monitoring and the evaluation of the process.

Conclusions

Our study provides insights into the current practice of topic selection in HTA agencies. Multiple criteria decision analysis methodology appears highly relevant to these processes. A consensus approach for the development of methods of topic selection would be valuable for the HTA community.

Health technology assessment (HTA) in England, France and Germany: what do matched drug pairs tell us about recommendations by national HTA agencies?

Aims: To explore health technology assessment (HTA) outcomes of matched drug pairs by national agencies in Germany (Gemeinsamer Bundesausschuss, GBA), France (Haute Autorité de Santé, HAS) and England and Wales (NICE). Methods: We considered published GBA decisions, HAS reports and NICE guidance from January 2011 to June 2018. HTAs of matched pairs were compared overall, and for non-cancer and cancer drugs separately. We further analyzed the role of additional attributes related to cancer therapies. Results: Matched pairs show higher concordance for GBA/HAS than for GBA/NICE and HAS/NICE. Overall, NICE evaluated technologies more favorably than GBA and HAS. GBA appraisals of cancer drugs, however, tended to be more positive than cancer-related recommendations by NICE and HAS. Conclusion: The findings indicate substantial variations in HTAs, although cancer-related outcomes seem to diverge less than non-cancer results.

Common Pharmaceutical Price and Cost Controls in the United Kingdom, France, and Germany: Lessons for the United States

To identify pharmaceutical spending-control options for the United States, we analyzed the policies of the United Kingdom, France, and Germany, which encourage drugmakers to undertake innovations that improve health while controlling spending. Their main strategies today include: using legislation to set default rules that increase the insurer's bargaining position, employing health technology assessment that measures cost-effectiveness or comparative effectiveness and caps the purchase or reimbursement price, setting a single maximum price for similar drugs (reference group pricing), capping prices near prices in other European countries (external reference pricing), prohibiting price increases, contracting to obtain discounts as sales volume rises, procuring drugs through competitive bids, and requiring manufacturers to pay rebates when spending exceeds a global budget. Each strategy addresses a distinct cause of high spending and supports overall goals. Most recent US reform proposals recommend incremental changes that would not address the major sources of high and increasing pharmaceutical prices. However, some US reform proposals resemble certain European strategies and could bring more significant change. US policymakers should consider adopting each of the strategies employed in these countries.

Health technology assessment and judicial deference to priority-setting decisions in healthcare: Quasi-experimental analysis of right-to-health litigation in Brazil

The constitutional right to health in Brazil has entitled patients to litigate against the government-funded national health system (SUS), claiming access to various health treatments including those excluded from the health system's benefits package. Courts have tended to rely on a single medical prescription to judge these cases in favor of individual patients and against the health system. The large volume of cases has had a substantial financial impact on the government's health budget and has created unfairness in accessing healthcare. To change courts' behavior, a new health technology assessment (HTA) body - CONITEC - was created in 2011. Its creation was accompanied by an administrative procedure that made decisions about the health system's benefits package more transparent, accountable, participative and evidence-informed. It was expected that this HTA system would bring more legitimacy to the government's priority-setting decisions and promote deference from the courts. This study tests whether Brazil's new HTA system succeeded in encouraging judicial deference by analyzing a stratified random sample of 13,263 court decisions for whether the existence of a CONITEC report resulted in less frequent court orders to provide treatment for individual litigants. The results show that the creation of CONITEC did not change courts' behavior; courts still decide in favor of patients in most cases. Indeed, even when there was a CONITEC report recommending against government funding for a particular healthcare treatment, the vast majority of the relatively few patients who were unsuccessful in obtaining a health benefit at their first court hearing later obtained a favorable decision after appealing to a higher court. This finding was confirmed through an interrupted time-series analysis that did not find an impact of having a CONITEC report on courts' willingness to override a government priority-setting decision. In fact, CONITEC was rarely cited in court decisions, even when litigants mentioned the existence of a CONITEC report.

The impact of drug quality ratings from health technology assessments on the adoption of new drugs by physicians in Germany

Payers are increasingly calling for the value of new drugs to be measured explicitly. We analyze how the availability of drug quality ratings by health technology assessment (HTA) agencies affects the adoption of new drugs by physicians in Germany. We combine data from drug quality ratings, promotional spending, and a physician panel. In a latent utility model, time to adoption is specified as a function of quality rating, promotional spending by manufacturers, and physician-specific variables. As expected, drugs with a positive rating were adopted faster (p < 0.001) than those without. However, our results suggest that it was the publication of the quality rating itself that affected adoption. Indeed, before a quality rating was published, drugs that went on to receive a positive quality rating were not adopted significantly faster than drugs that went on to receive a negative quality rating. In contrast, after the publication of the HTA quality rating, drugs with a positive rating were adopted significantly faster than those without (p < 0.05). The per physician value of a positive quality rating was EUR 393.50. Our results suggest that there are returns from HTAs beyond their use in price negotiations.

What do we need to know? Data sources to support evidence-based decisions using health technology assessment in Ghana

BACKGROUND

Evidence-based decision-making for prioritising health is assisted by health technology assessment (HTA) to integrate data on effectiveness, costs and equity to support transparent decisions. Ghana is moving towards universal health coverage, facilitated mainly by the National Health Insurance Scheme (NHIS) established in 2003. The Government of Ghana is committed to institutionalising HTA for priority-setting. We aimed to identify and describe the sources of accessible data to support HTA in Ghana.

METHODS

We identified and described data sources encompassing six main domains using an existing framework. The domains were epidemiology, clinical efficacy, costs, health service use and consumption, quality of life, and equity. We used existing knowledge, views of stakeholders, and searches of the literature and internet.

RESULTS

The data sources for each of the six domains vary in extent and quality. Ghana has several large data sources to support HTA (e.g. Demographic Health Surveys) that have rigorous quality assurance processes. Few accessible data sources were available for costs and resource utilisation. The NHIS is a potentially rich source of data on resource use and costs but there are some limits on access. There are some data on equity but data on quality of life are limited.

CONCLUSIONS

A small number of quality data sources are available in Ghana but there are some gaps with respect to HTA based on greater use of local and contextualised information. Although more data are becoming available for monitoring, challenges remain in terms of their usefulness for HTA, and some information may not be available in disaggregated form to enable specific analyses. We support recent initiatives for the routine collection of comprehensive and reliable data that is easily accessible for HTA users. A commitment to HTA will require concerted efforts to leverage existing data sources, for example, from the NHIS, and develop and maintain new data (e.g. local health utility estimates). It will be critical that an overarching strategic and mandatory approach to the collection and use of health information is developed for Ghana in parallel to, and informed by, the development of HTA approaches to support resource allocation decisions. The key to HTA is to use the best available data while being open about its limitations and the impact on uncertainty.

The knowledge and attitude of Ghanaian decision-makers and researchers towards health technology assessment

Although health technology assessment (HTA) is intended to provide policymakers with objective information, the likelihood that a health decision-maker (HDM) will use this information is associated with their knowledge, role and perception of the HTA process. In Ghana, policymakers are working towards formalising the use of HTA, but HDM knowledge of and attitude towards HTA are not known. Between March and May 2016, we conducted in-depth interviews and used inductive thematic analysis to explore Ghanaian HDMs (n = 23) and researchers' (n = 4) perceptions of and barriers to HTA and identify ways to promote HTA. We compare our findings with those reported in previous studies conducted in low-and-middle-income countries. Common themes were that resources, political and cultural factors act as barriers to HTA use. Recommendations made in previous studies which were also identified in this study included the need for the development of both human and data capacity, allocating funds to HTA and stakeholder involvement in HTA processes. Specific recommendations made by Ghanaian HDMs and researchers in this study focused on the establishment of an HTA body: its location, the constitution of the appraisal team, the type of evidence to appraise and who makes the final decision. The findings provide important information in the context of current planning to institutionalise HTA in Ghana. Addressing the identified barriers will enable policymakers to maximise the chances of realising the expected benefits of HTA, as participants who are potential producers and end-users are likely to use what they have contributed to.

Paradigms in operation: explaining pharmaceutical benefit assessment outcomes in England and Germany

Health technology assessments (HTAs) are used as a policy tool to appraise the clinical value, or cost effectiveness, of new medicines to inform reimbursement decisions in health care. As HTA organisations have been established in different countries, it has become clear that the outcomes of medicine appraisals can vary from country to country, even though the same scientific evidence in the form of randomised controlled trials is available. The extant literature explains such variations with reference to institutional variables and administrative rules. However, little research has been conducted to advance the theoretical understanding of how variations in HTA outcomes might be explained. This paper compares cases of HTA in England and Germany using insights from Kuhn (1962, The Structure of Scientific Revolutions, 2nd edn. Chicago: The University of Chicago Press) and Hall (1993, Policy paradigms, social learning, and the state: the case of economic policymaking in Britain. Comparative Politics 25, 275-296) to demonstrate how policy paradigms can explain the outcomes of HTA processes. The paper finds that HTA outcomes are influenced by a combination of logical issues that require reasoning within a paradigm, and institutional and political issues that speak to the interaction between ideational and interest-based variables. It sets out an approach that advances the theoretical explanation of divergent HTA outcomes, and offers an analytical basis on which to assess current and future policy changes in HTA.

Pre-reimbursement: early assessment for coverage decisions

Background

In the past decade, the Ludwig Boltzmann Institute for Health Technology Assessment (LBI-HTA) has introduced two programs: “Horizon Scanning in Oncology” (HSO) and extra medical services (“MELs”), which are to facilitate coverage decisions based on early assessments. This article aims to outline the general process and methods within these two programs.

Methods

A narrative-descriptive synthesis of the literature was performed to outline the general and LBI-HTA-specific processes and methods of early assessments.

Results

In total, 79 HSO assessments (2009–2018) and 95 MELs (2008–2018) have been conducted by the LBI-HTA. Recently, additional methods that contribute to European applicability have been introduced into these programs.

Conclusions

Overall, pre-coverage decisions based on early assessment reports are dependent on the existing evidence. However, the organisation of the health care system and the cross-linking between decision-makers and HTA institutions can have an impact.

Is the National Institute for Health and Care Excellence (NICE) in England more 'innovation-friendly' than the Federal Joint Committee (G-BA) in Germany?

Objectives: Our study explores whether, and how, different methodological choices are associated with different health technology assessment (HTA) outcomes. We focus on the Federal Joint Committee (Gemeinsamer Bundesausschuss, G-BA) in Germany and the National Institute for Health and Care Excellence (NICE) in England. Both agencies may be considered as exemplars for the application of the principles of evidence-based medicine and the logic of cost-effectiveness, respectively. Methods: We extracted data from all publically available G-BA appraisals until April 2015, as well as all NICE single technology appraisals completed during this period. We compared HTA results for matched condition-intervention pairs by G-BA and NICE, and explored other factors including therapeutic area, clinical effectiveness and cost-effectiveness. Results: NICE issued guidance for 88 technologies (125 subgroups) and recommended 67/88 technologies (99/125 subgroups). G-BA completed 105 appraisals (226 subgroups) and determined additional benefit for 64/105 appraisals (90/226 subgroups). We identified 37 matched pairs; for 24/37 drugs, evaluations diverged. NICE recommended 78% (29/37) of technologies appraised, whereas G-BA confirmed additional benefit for 57% (21/37) only (p < 0.05). Conclusions: NICE evaluates new drugs more favorably than G-BA. However, our analysis suggests differences by therapeutic area. Results indicate that different methods are associated with systematic differences in HTA outcomes.

Comparing Use of Health Technology Assessment in Pharmaceutical Policy among Earlier and More Recent Adopters in the European Union

OBJECTIVES

To examine and compare the use of health technology assessment (HTA) for the reimbursement of new medicines in selected European Union member states with decades of experience in the use of HTA and in countries that have used it regularly since 2000.

METHODS

The selected countries were categorized into "earlier" adopters (group A: England, Germany, France, and Sweden) and more "recent" adopters (group B: Poland, Bulgaria, Hungary, and Romania). A systematic review of published literature was performed. The analysis and comparison of HTA procedures were done by using an analytical framework.

RESULTS

In all countries, the assessment criteria used include effectiveness, safety, relative effectiveness, and economic data. In group A countries, the main objectives are improving quality of care, ensuring equal access, and efficient use of resources. Group B countries have established HTA organizations with official guidelines but often seek the decisions of other developed countries. They place considerable emphasis on the budget impact of new therapies, and HTA is also used as a cost estimation tool for state budgets.

CONCLUSIONS

HTA organizations have been developed dynamically not only in high-income countries but also in countries with limited resources. The experience and evolution of both can be used by countries that are in the dawn of creating an HTA organization.

Identification of publicly available data sources to inform the conduct of Health Technology Assessment in India

Background: Health technology assessment (HTA) provides a globally-accepted and structured approach to synthesising evidence for cost and clinical effectiveness alongside ethical and equity considerations to inform evidence-based priorities. India is one of the most recent countries to formally commit to institutionalising HTA as an integral component of the heath resource allocation decision-making process. The effective conduct of HTA depends on the availability of reliable data.   Methods: We draw from our experience of collecting, synthesizing, and analysing health-related datasets in India and internationally, to highlight the complex requirements for undertaking HTA, and explore the availability of such data in India. We first outlined each of the core data components required for the conduct of HTA, and their availability in India, drawing attention to where data can be accessed, and different ways in which researchers can overcome the challenges of missing or low quality data. Results: We grouped data into the following categories: clinical efficacy; cost; epidemiology; quality of life; service use/consumption; and equity. We identified numerous large local data sources containing epidemiological information. There was a marked absence of other locally-collected data necessary for informing HTA, particularly data relating to cost, service use, and quality of life. Conclusions: The introduction of HTA into the health policy space in India provides an opportunity to comprehensively assess the availability and quality of health data capture across the country. While epidemiological information is routinely collected across India, other data inputs necessary for HTA are not readily available. This poses a significant bottleneck to the efficient generation and deployment of HTA into the health decision space. Overcoming these data gaps by strengthening the routine collection of comprehensive and verifiable health data will have important implications not only for embedding economic analyses into the priority setting process, but for strengthening the health system as a whole.

Identification of publicly available data sources to inform the conduct of Health Technology Assessment in India

Background: Health technology assessment (HTA) provides a globally-accepted and structured approach to synthesising evidence for cost and clinical effectiveness alongside ethical and equity considerations to inform evidence-based priorities. India is one of the most recent countries to formally commit to institutionalising HTA as an integral component of the heath resource allocation decision-making process. The effective conduct of HTA depends on the availability of reliable data.   Methods: We draw from our experience of collecting, synthesizing, and analysing health-related datasets in India and internationally, to highlight the complex requirements for undertaking HTA, and explore the availability of such data in India. We first outlined each of the core data components required for the conduct of HTA, and their availability in India, drawing attention to where data can be accessed, and different ways in which researchers can overcome the challenges of missing or low quality data. Results: We grouped data into the following categories: clinical efficacy; cost; epidemiology; quality of life; service use/consumption; and equity. We identified numerous large local data sources containing epidemiological information. There was a marked absence of other locally-collected data necessary for informing HTA, particularly data relating to cost, service use, and quality of life. Conclusions: The introduction of HTA into the health policy space in India provides an opportunity to comprehensively assess the availability and quality of health data capture across the country. While epidemiological information is routinely collected across India, other data inputs necessary for HTA are not readily available. This poses a significant bottleneck to the efficient generation and deployment of HTA into the health decision space. Overcoming these data gaps by strengthening the routine collection of comprehensive and verifiable health data will have important implications not only for embedding economic analyses into the priority setting process, but for strengthening the health system as a whole.

Who’s afraid of institutionalizing health technology assessment (HTA)?: Interests and policy positions on HTA in the Czech Republic

This article identifies the interests and policy positions of key health policy stakeholders regarding the creation of a health technology assessment (HTA) agency in the Czech Republic, and what considerations influenced them. Vested interests have been suggested as a factor mitigating the diffusion of HTA bodies internationally. The Czech Republic recently considered and discarded establishing an HTA agency, making it a good case for studying actors’ policy positions throughout the policy debates. Findings are based on in-depth, semi-structured expert and elite interviews with 34 key Czech health policy actors, supported by document analysis and extensive triangulation. Findings show that the HTA epistemic community of ‘aspiring agents’ was the only actor strongly in favor of an HTA body. Payers and the medical device and diagnostics industry were against it; patients and clinicians had no clear preferences. Original decision-makers were in favor but a new minister of health opted for a simpler policy alternative to solve his need for expertise. Existing institutions, policy alternatives and the institutional design of a future HTA body influence domestic actors’ preferences for or against an HTA agency. Domestic and international proponents of HTA should give serious thought to their concerns when advocating for HTA bodies.

What has health technology assessment ever done for us?

Health technology assessment (HTA) has over the past three decades become a well-established part of decisions about allocation of resources in many countries. Despite this, little is known about HTA’s impact on health systems. Few studies have evaluated the benefits of HTA for health outcomes, for access to care or for public budgets. In contrast, HTA has relatively clear upfront costs, which could potentially discourage policy-makers from establishing HTA agencies, especially in low income countries with restricted resources. It may be premature, though, to dismiss this approach altogether, as less tangible modernizing goals are still significant.

Health technology assessment (HTA) organizations: dimensions of the institutional and political framework

Health technology assessment (HTA) is consolidated as a scientific and technological practice. The aim of this study is to identify HTA organizations from different settings and analyze their relevant dimensions in terms of effectiveness/impact, in order to address the challenges they face in Brazil. Narrative literature review based on data and websites of HTA organizations. There are well-established activity development processes in all organizations. These activities have specific features in their profile, in the process of technology assessment, decision and implementation of technologies that influence their potential impact on health systems. Agencies share in common the challenges of ranking the technologies to be assessed, and the implementation of their recommendations. Technical and political strengthening of the institutionalization of HTA in Brazil may foster scientific, technological and innovation policies, effectively impacting health policies. Resumo: A avaliação de tecnologias em saúde (ATS) está consolidada enquanto prática científica e tecnológica. O objetivo do estudo é identificar organizações de ATS de diferentes contextos e analisá-las de acordo com dimensões relevantes na avaliação de sua efetividade/impacto, buscando contribuir com os desafios enfrentados no contexto nacional. Revisão narrativa da literatura, realizada em bases de dados e web sites de organizações de ATS. Existem processos de desenvolvimento das atividades bem estabelecidos em todas as organizações. Elas apresentam particularidades no seu perfil, nos processos de avaliação, decisão e implementação das tecnologias que influenciam o seu impacto potencial sobre os sistemas de saúde. As agências compartilham os desafios de priorização das tecnologias a serem avaliadas e implementação das suas recomendações. O fortalecimento técnico e político do processo de institucionalização da ATS no contexto nacional poderá contribuir com as políticas científicas, tecnológicas e de inovação, impactando de forma efetiva as políticas de saúde.

[Health technology assessment (HTA). Developments in healthcare and potential for radiology]

CLINICAL/METHODICAL ISSUE

Cost-intensive measures and procedures, such as also employed in radiology, have far-reaching economic implications in respect to increasing expenditure with limited resources.

STANDARD RADIOLOGICAL METHODS

Health technology assessment (HTA) describes the systematic evaluation of medical procedures and technologies which in recent years has been introduced by many countries into healthcare politics.

ASSESSMENT

In many cases HTA analyses can be directly implemented into practice as shown by the examples given in this article; however, in the current form of HTA the practical implementation for radiology often presents the problem that the cost-benefit ratio does not yet have a comprehensive view in the HTA report but is limited to a subsection, e.g. current costs versus sensitivity of a method. Since its inception radiology has had a high power of innovation and new developments will also substantially determine the future years. These procedures must not only be evaluated with respect to feasibility but also in the sense of the HTA in the total concept.

PRACTICAL RECOMMENDATIONS

In radiology there are also a large number of possibilities for radiologists not only as passive consumers of HTA reports but also to become active participants in this process, an opportunity which should be taken advantage of.

Health-related quality of life and productivity losses in patients with depression and anxiety disorders

OBJECTIVES

To assess the explanatory power of disease severity and health-related quality of life (HRQOL) on absenteeism and presenteeism in a working population suffering from depression and/or anxiety disorders.

METHODS

We used data of a large, multicenter, randomized trial (n = 644). Pearson chi-squared tests, analysis of variance, and multinomial logistic regression analyses were performed to explore associations of the type of the disorder and HRQOL with different types of productivity losses. Multivariate regression analyses were performed to assess associations with the duration of absenteeism.

RESULTS

The type of the disorder, disease severity, and HRQOL were associated with different types of productivity losses. Health-related quality of life and age were significantly associated with the duration of absenteeism.

CONCLUSIONS

Our findings indicate that HRQOL may significantly explain the type of productivity loss as well as the duration of absenteeism.