Article
The definition and functions of HTA are described.
The five case study technologies taken under consideration were: positron emission tomography, hepatitis C genotyping and viral load testing, telemedicine, prostate cancer screening and stroke technologies.
Useful insights into the production of HTA in survey countries were obtained but care needs to be taken before generalising the results.
The OECD initiated the Health Project in 2001 to address some of the
key challenges policy makers face in improving their country’
health systems.
Health care is an important economic, scientific and social endeavour
for all OECD countries. It has contributed to the extension of human
life and reduction of pain, disease risk, and disability. However, in
recent decades health-related activities have been consuming growing
proportions of GDP. In 1990, the average rate of health care spending
in OECD countries was 7.3% of GDP. By 2001, this average had risen to
8.4% - representing an increase of 15% over and above GDP growth (OECD
20021).
In the context of lower economic growth, the ageing of the population
and the rise in health care prices and utilisation, many OECD governments
are concerned about the sustainability of public health care financing.
A desire for real progress and recognition of important gaps in the
information needed to undertake change led to political commitment and
support across countries for a focused cross-national effort. The three-year
initiative provided member countries with multiple opportunities to
participate in and learn from component studies focused on pressing
health policy issues and to benefit from the information and exchanges
that occurred.
The final report2 published by the OECD at the occasion of the meeting
of the OECD Health Ministers held at Paris, 13 – 14 May 2004 begins
by investigating the potential for further improvements through disease
prevention and health-care quality improvement. It next considers approaches
for resolving outstanding problems in fostering adequate access to care.
The report then explores avenues for increasing the responsiveness of
health systems. The cost and financing dilemma and the prospects for
increasing efficiency are also considered.
As part of the OECD Health Project, a study on health-related technologies
(see box 1 for a definition of health technology) was launched due to
observations reported by some authors regarding the fact that technology
is a driver of health care costs, e.g. Aaron3(1991) and Newhouse4 (1992)
report that approximately 50% of the rise in health care spending can
be attributed to technological change. Furthermore, a study by Fuch5
(1996) indicates that this proposition has become a dominant view amongst
health economists. However, other economists argue that there is little
direct evidence on the role of technological change in cost growth (Cutler
and McClellan, 1996)6.
| What
is a health technology? |
| Health
technologies are means to improve health outcomes at the population
or individual levels. They may include processes, expertise, systems,
or artefacts. Drugs, an MRI scanner, a patient recall system for
population cervical screening, a stent, minimally invasive approaches
to surgery, and a patient records management system, are all health
technologies in this sense. Of course, drugs, capital equipment
and devices tend to be the technologies that get the most attention
from most of the stakeholders. |
The OECD’s project on health related
technologies
The OECD’s project on health related technologies, conducted under
the guidance of experts drawn together from government, academia, health
technology assessors and industry, has aimed to provide evidence on
how countries can improve the integration of health care technologies.
Its focus has been on the transition from Health Technology Assessment
(HTA) to decision making and decision implementation. It examined the
production of evidence, primarily in the form of HTA, and the use of
evidence in decision making. It has also examined features of the decision
making process and the policy tools used to implement decisions. Fundamentally,
the project has asked two questions:
How can the use of evidence be improved in health care decision making?
How can the decision making and implementation processes be improved
to deliver better health system performance?
The project sought to survey current practice in decision making and
implementation, and the use of HTA; to identify and consider the key
challenges in decisionmaking
and using HTA in reaching decisions; and to discuss and validate the
results in an expert wor shop.
This paper presents a description of Health Technology assessment; its
principal functions and some selected results of the survey. For the
overall description of the project see ref.7
Health Technology Assessment: the technology
of decision making
Health Technology Assessment is best understood as a set of methods
for the systematic organisation and appraisal of information around
health technologies. There is a large international community involved
in HTA and supported by various cross-country projects and associations,
including Health Technology International, (HTAi)8 (under the auspices
of which is published the International Journal of Technology Assessment
in Health Care), and the International Network of Agencies for Health
Technology Assessment (INAHTA)9, membership of which is comprised of
organisations that are majority-funded by governments.
The HTA process comprises two stages. First there is the systematic
review of evidence which includes:
Identification of a research question, for example, “what is the
additional benefit of polymerase chain reaction over cytogenetics in
diagnosis of haematological malignancy?”, or “what is the
optimal strategy for management of lower back pain?”, and development
of a research strategy to answer these questions.
Systematic retrieval of scientific evidence.
Analysis, critical review and summary of the evidence, including comment
on the validity and strength of the evidence.
Though it is strictly not ‘review’, this component of HTA
may also include modelling, especially to support economic analysis.
The second stage is appraisal. That is, forming judgements about the
meaning of the evidence obtained by systematic review and the formation
of views as to the value of a technology in the health care system.
The evidence and its appraisal then inform the decision making process10.
At minimum, HTA directed to particular technologies addresses safety
and effectiveness of those technologies; that is, what risks obtain
to patients and whether they are justified given the possible health
gains; and whether the technologies provide beneficial health outcomes
and how those health outcomes compare with alternative technologies.
Very frequently HTA includes economic evaluation, typically in the form
of cost-effectiveness analysis (CEA). It is important to note that CEA
asks a different question from cost-benefit analysis (CBA). CBA and
CEA ask a similar question in the general terms, “are the costs
of an investment justified by its costs? “ Unlike CBA, CEA measures
outcomes in natural units of health benefit rather than in monetary
terms. Ideally these measures are a multi-dimensional unit such as quality-adjusted
life years, or a unit of life years saved; or less ideally, units such
as numbers of events of morbidities avoided (for example, cost per acute
myocardial infarction avoided).
The specific question for CEA tends to be: “if a technology will
provide net health gains for the community, and if the technology costs
more than the alternatives (and they usually do), what is the cost per
unit of health gain and is that a worthwhile investment for the community?”
HTA Functions
The principal functions of HTA have been defined by the members of the
International Network of Health Care Technology Agencies (INAHTA) as:
Technology Safety: To assess the potential adverse effects of diagnostic
and therapeutic technologies.
Efficacy and Effectiveness: To assess the capacity of technologies to
produce beneficial effects, both in ideal and real situations.
Efficiency (economic evaluation): Once the effectiveness of the technology
has been tested, it is necessary to evaluate its efficient application
in the system.
Social consequences (intended and unintended): It is then necessary
to assess the social consequences of the application of the technology.
This includes the assessment of equity, as well as the opportunity cost
associated with the use of technology.
Ethical implications: To consider the ethical implications of decisions
about the incorporation of new technologies (e.g. cloning).
Acceptability, availability, accessibility, and utilisation indications:
This final step includes the assessment of operative issues about the
incorporation and use of medical technology.
Survey on how some OECD countries integrate Health Technologies and
the use of HTA
The survey focused on past and present decision-making processes and
production of HTA, seeking information on: How decisions about health
technologies are made; how evidence, and in particular HTA, was used
in that decision; how HTA was conducted and how decisions were implemented
within health care systems.
The survey examined three types of decision making (i) pre-marketing
decisions: the decision to allow a product/service to be used in the
health care system; (ii) funding/coverage decisions: the decision to
fund/cover a product or service on either private or public insurance
schemes; and (iii) investing/planning: the decision to invest in a technology,
including health care planning decisions. The survey analysis primarily
focused on funding/coverage and investing/planning decisions.
To enable collection of comparative information the survey collected
information for five case study technologies11: positron emission tomography,
hepatitis C genotyping and viral load testing, telemedicine, prostate
cancer screening and stroke technologies. These technologies were selected
by the Expert Group based on an agreed set of criteria. These criteria
aimed to ensure that the selection of case study technologies would
reflect the diversity of uses (e.g. use of technology in screening,
diagnosis, treatment, and management) and settings (e.g. ambulatory
care, hospital care). Together, the set of case study technologies illustrate
decision making in various parts of the health care system.
Twelve countries participated in the survey. These were: Australia,
Austria, Canada, France, Germany, Ireland, Japan, Mexico, The Netherlands,
Norway, Spain and Switzerland. Survey respondents were identified by
members of the Expert Group and nominated on the basis of their expertise
in either the decision making process and/or the production of HTA for
any of the five case study technologies. Survey respondents included
departmental officials, health technology assessors, health care and
hospital administrators, clinicians and researchers.
The production of health technology assessment : an analysis of survey
results
The following results are based on health technology assessments carried
out on a sample of case study technologies. Whereas they provide useful
insights into the production of HTA in survey countries, care needs
to be taken before generalising the results.
Who undertakes HTA?
Chart 1 shows that the most common practitioners of HTA were not-for-profit
agencies who conducted 27% of all HTAs in this sample (n=26). It also
shows that joint assessments were common. Joint assessment always included
a not-for-profit agency together with a professional body and/or government.
(Chart 1)
 |
What is inside HTA?
The OECD survey found that the content of HTA varied quite significantly
for the five case study technologies. Table 1 demonstrates that while
almost all HTAs included evidence of effectiveness (with only one exception
in telemedicine), there were far fewer assessments that considered psychological,
social and ethical factors. Cost-effectiveness was also reported widely,
but additional costs or cost savings less so. Fewer HTAs reported taking
R&D issues into consideration.
What led to HTA being conducted?
The OECD survey asked respondents to identify the reasons for carrying
out a HTA. Table 2 shows that in this survey the most common reason
for undertaking an HTA was that it was part of an existing HTA programme.
However, there is some interesting variation between technologies. For
example, the primary reason for an assessment of costly technology such
as Position Emission Tomography was a direct request from the government
or insurer. However an assessment of telemedicine was more likely to
have been conducted as part of a HTA programme. The other reasons for
undertaking HTA included political pressure and priority for a national
research or HTA programme.
Click
here to see the Table 2
Who and what is the HTA for?
Different OECD countries have different purposes for HTA. Some countries
have instigated (or are in the process of instigating) formal consideration
of economic evidence in decision making, particularly for pharmaceutical
reimbursement decisions (Dickson, Hurst and Jacobzone, 200312).
Beyond pharmaceutical technologies, the survey found that for the five
case studies, the most commonly envisioned role for the HTA was to inform
providers, closely followed by the role of informing investment decisions.
As demonstrated in Chart 2, 8% of respondents sited other roles for
the HTA, which mainly involved health services planning.
(Chart 2)
 |
The timing and resources required for
HTA
The survey asked respondents to estimate the time it took to complete
the HTA. The results from 19 different HTAs show that some HTAs take
less than a month while others take up to four years. Table 3 reports
the percentage of HTAs in the survey by the amount of time taken.
(Table 3)
Click here to see
the Table 3
Marketing HTA activities
The survey received 16 responses to the question of how HTA results
were disseminated. Chart 3 shows that most HTA practitioners use multiple
means of distributing the results of HTA. The most common forms of dissemination
were: widely distributing reports or newsletters, website publication,
and conferences and meetings.
A number of respondents mentioned that they used different methods of
dissemination to target various audiences.
That is, they established a portfolio approach to dissemination depending
on the key messages of the HTA and who the decision makers were.
Chart 3. Methods of disseminating HTA
 |
Conclusions
Health technologies can convey enormous benefits to health, but may
account for up to half of the increased costs in health care. Health
care decision makers face the challenging task of harnessing the opportunities
created by health technologies and at the same time ensuring that the
health care system remains sustainable and equitable. Adding to this
challenge are the sometimes conflicting pressures and demands from patients
(and tax payers), health professionals, the producers of new technologies,
and a range of other pressure groups.
Objective evidence is of crucial importance in helping to resolve conflicting
demands to reach transparent agreement on the optimal paths forward.
Without evidence, the uptake and diffusion of technologies are more
likely to be influenced by a whole range of social, financial, professional
and institutional factors, and may not produce optimum levels of health
outcomes.
HTA is a form of assessment which considers not only the effectiveness
of technologies but also their wider impacts, including legal and social
issues and efficiency. The role of HTA is highly valued by decision
makers and is playing an increasing role in many OECD countries.