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PubMed2005

Use of health technology assessment in decision making: coresponsibility of users and producers?

OBJECTIVES: Health technology assessment (HTA) is a policy-oriented form of research designed to inform decision-makers on the introduction, use, and dissemination of health technology. Whereas research on knowledge transfer has focused on knowledge producers, little attention has been given to the user's perspective. This study examines how health-care provider, administrator, and patient associations across Canada use HTA reports and the limitations they encounter when accessing and using scientific knowledge. METHODS: This study draws from semistructured interviews (n=42) conducted with three types of user, located in British Columbia, Alberta, Saskatchewan, Ontario, and Quebec. Applying well-established conceptual categories in knowledge utilization research, our qualitative analyses sought to define more precisely how HTA is used by interviewees as well as the most significant barriers they encounter. RESULTS: The vast majority of users recognize the usefulness and credibility of HTA reports. Of interest, the way they use HTA takes different forms. Although administrators and health-care providers are in a better position than patient associations to act directly on HTA messages--making an instrumental use of HTA--we also found conceptual and symbolic uses across all groups. Our results also indicate that significant organizational, scientific, and material limitations hinder the use of scientific evidence. Overcoming such barriers requires a greater commitment from both HTA producers and users. CONCLUSIONS: This study argues that, to ensure better uptake of HTA, it should become a shared responsibility between HTA producers and various types of user.

Canada↗
PubMed2006

Integration of health technology assessment recommendations into organizational and clinical practice: A case study in Catalonia.

OBJECTIVES: Evaluating the impact of recommendations based upon health technology assessment (HTA) represents a challenge for both HTA agencies and healthcare policy makers. This research sought to understand factors affecting the uptake of HTA recommendations to support decision making with respect to the introduction of three health technologies. METHODS: Using a multidimensional framework, based upon a combination of theoretical models, a case study was conducted. A total of twenty-eight semistructured interviews were done with physicians from fifteen hospitals and other stakeholders in Catalonia. Interview content was analyzed iteratively and classified according to theoretical dimensions and contextual factors. RESULTS: At the sociopolitical level, factors related to the organization and financing of the health system were found to affect the utilization of HTA recommendations. At the healthcare organization level, existing collaborations between the hospital and the HTA agency favored the integration of recommendations into practices. Formalism in the organization also influenced the utilization of HTA recommendations. At the professional level, the high degree of autonomy of specialists, the importance of peers and collegial control, and the definition of professional roles and responsibilities influenced physicians' willingness to integrate HTA recommendations into their practice. CONCLUSIONS: This study offers a comprehensive framework to understand the complex dynamics that affect adoption of health technologies in organizational and professional practices. The findings suggest some avenues to promote the integration of HTA recommendations into practices and, thus, increase the utilization of scientific evidence to support decision making in health care.

Decision Making↗
PubMed2005

The impact of the Health Technology Board for Scotland's grading model on referrals to ophthalmology services.

AIM: To ascertain the impact of the Health Technology Board for Scotland's grading model on referrals to ophthalmology services. METHODS: An analysis was performed of the screening outcomes of 5575 consecutive patients, who were screened by the Grampian Diabetic Retinopathy Screening Programme between March and September 2003 according to the recommendations of the Health Technology Board and the Scottish Diabetic Retinopathy Grading Scheme 2003. RESULTS: 3066 (55%) were male. The median age was 65 years. 5.4% were passed on to the level 3 grader and 3.4% were finally referred to ophthalmology services. 2.3% required re-screening in 6 months; 85% were screened without mydriasis; 11.9% had ungradeable images despite a staged mydriasis protocol. Time to complete grading was 32 days (22-45). CONCLUSION: The impact of the Health Technology Board for Scotland's recommendations on referrals to ophthalmology services is modest and should be containable within existing resources.

Aged↗
PubMed1997

The iterative use of economic evaluation as part of the process of health technology assessment.

The economic evaluation of health care technologies has a key role within the new National Health Service health technology assessment process. There has, however, been little discussion of the best way of combining economic and clinical research. Economic evaluation should be iterative, generating progressively firmer estimates of cost-effectiveness and helping to maximise the efficiency of health care R&D. Here, four stages of economic analysis are suggested, starting with stage I when the basic clinical science is complete, and finishing with stage IV analysis to generalise the results of earlier studies to routine clinical practice.

Clinical Trials as Topic↗
PubMed1998

A training course in health technology assessment in Malaysia.

This article describes a 1-week training course in health technology assessment (HTA) presented in Malaysia by the Ministry of Health in 1996. Malaysia established an HTA unit in the Ministry of Health in 1995 and a National Health Technology Assessment Program in 1996. The purpose of the course was to develop HTA knowledge and skills in Malaysia, since these are largely lacking. The course consisted of didactic sessions and group work. Didactic sessions covered the principles of HTA. Group work was for the purpose of developing practical skills, and was based on reports from HTA agencies, published articles, and candidates for assessment suggested by course participants. Course participants were a mix of physicians, nurses, hospital administrators, and Ministry of Health officials. Experiences in this course may be helpful to others who wish to organize training courses in developing countries.

Developing Countries↗
PubMed2002

[Experiences with and impact of health technology assessment on the German Standing Committee of physicians and patients].

The "Bundesausschuss der Aerzte und Krankenkassen" (hereafter referred to as the "Bundesausschuss") is one of Germany's self-governing bodies in ambulatory health care. This Federal Standing Committee of Physicians and Sickness Funds has the mandate, among others, to issue directives for the ambulatory health care provided by 110,000 physicians to the approximately 70 million citizens of Germany. The Bundesausschuss' directives are legally binding and must be followed by both the physicians who provide ambulatory medical services and the sickness funds who insure these services. Although elements of evidence-based medicine were first introduced in 1990, health technology assessment (HTA) was not systematically integrated into the decision making process of the working group for medical and surgical procedures until 1998. The HTA reports of the Bundesausschuss take account of the status of the technology in other health care systems (public systems in particular) and of statements by the scientific community and interested parties, such as patient groups, and review the evidence currently available (in primary studies, systematic reviews, other assessments, etc.). These reports are prepared by representatives of the physicians and the sickness funds, in close collaboration, whenever possible, with academic experts in health technology assessment. The reports serve as a basis for the decisions made by the Bundesausschuss, which ensures their impact, and are published on the Internet at http://www.kbv.de/hta. The Bundesausschuss reports also reflect the deliberation process for each technology, in the context of the legal environment. They also explain how a decision was reached. The shortcomings of HTA process are the time and financial resources required to conduct these assessment. The advantages include the increased transparency of the decision-making process, for both the German "social" court system and for the insured. Further developments will be directed by the future framing of the legal environment by the ministry of health. A similar decision-making body has recently been installed for the hospital sector and both committees will be co-ordinated by a board, which will organize the deliberation process. It will be important to further encourage and integrate the use of evidence in the decision-making processes of these statutory bodies.

Costs and Cost Analysis↗
PubMed2000

Extracorporeal shock wave therapy in orthopedics. Assessment of an emerging health technology.

OBJECTIVE: Extracorporeal shock wave therapy (ESWT) as an emerging technology in orthopedics has been assessed in Austria with the objective to establish a scientific basis for pending and pressing health policy decisions. Despite encouraging results within some indications and the promising prospect of a noninvasive treatment for some orthopedic diseases, it seemed crucial to assess this new field of application in the light of evidence-based standards, without forgetting the reality of healthcare decisions. This article presents the results of the above mentioned assessment in the context of the policy-making process in Germany, Austria, and Switzerland. METHODS: The study is based on an overview of the already existing reviews on the effectiveness of ESWT as carried out by different actors (health insurances and orthopedists), and on an overview of additional literature covering all relevant aspects (mode of action, recommendations, economic estimates). Orthopedic societies, several institutions involved in health technology assessment, and health insurance agencies were contacted in search of further relevant literature, ongoing studies, and assessments. RESULTS: Until now, clear evidence has not been available on the effectiveness of ESWT in four currently recommended indications (tendinosis calcarea of the shoulder, epicondylopathia humeri radialis, calcaneal spur, and pseudarthrosis), although a substantial body of literature has been produced. Despite encouraging results in some indications, the lack of coherent therapy schemes and the poor quality in the design of clinical studies has been serious enough to hinder the drawing of reasonable conclusions. CONCLUSIONS: Due to the rapid diffusion of ESWT and the pressure on reimbursement agencies to prove the ineffectiveness of ESWT, the policy option of a pragmatic approach is recommended to control the diffusion of an uncertain health technology, alongside active research that would allow a more comprehensive appraisal of this potentially interesting treatment strategy in orthopedics.

Austria↗
PubMed2005

Dissemination of health technology assessments: identifying the visions guiding an evolving policy innovation in Canada.

Health technology assessment (HTA) has received increasing support over the past twenty years in both North America and Europe. The justification for this field of policy-oriented research is that evidence about the efficacy, safety, and cost-effectiveness of technology should contribute to decision and policy making. However, concerns about the ability of HTA producers to increase the use of their findings by decision makers have been expressed. Although HTA practitioners have recognized that dissemination activities need to be intensified, why and how particular approaches should be adopted is still under debate. Using an institutional theory perspective, this article examines HTA as a means of implementing knowledge-based change within health care systems. It presents the results of a case study on the dissemination strategies of six Canadian HTA agencies. Chief executive officers and executives (n = 11), evaluators (n = 19), and communications staff (n = 10) from these agencies were interviewed. Our results indicate that the target audience of HTA is frequently limited to policy makers, that three conflicting visions of HTA dissemination coexist, that active dissemination strategies have only occasionally been applied, and that little attention has been paid to the management of diverging views about the value of health technology. Our discussion explores the strengths, limitations, and trade-offs associated with the three visions. Further efforts should be deployed within agencies to better articulate a shared vision and to devise dissemination strategies that are consistent with this vision.

Canada↗
PubMed1997

The status of health technology assessment worldwide. Results of an international survey.

Health technology assessment (HTA) has increasingly become a valuable tool to examine effectiveness, quality of care, patient outcomes, and cost-effectiveness of health care technologies. In 1994 and 1995, a survey was conducted to document the scope of worldwide HTA activities; 103 organizations from 24 countries responded. This paper summarizes the results of this international survey, including a description of each country's program, types of technologies assessed, methodologies used, and dissemination approaches. Results for Canada, the United States, and European and other countries are presented separately.

Canada↗
PubMedDate not supplied

[Use of probabilistic methods in economic evaluation of health technologies].

The present article illustrates the advantages of probabilistic methods in health technology assessment. Using probabilistic distributions for parameters, these methods represent parameter uncertainty more effectively than deterministic models. The results of this simulation process represent the joint distribution of cost and effects in the cost-effective plane. More precisely, the cost-effectiveness ratio of each simulation is used to determine whether the ratio is cost effective in relation to the ceiling ratio. This kind of information is represented in the cost-effectiveness acceptability curve, which indicates the probability of a health technology being cost-effective for a particular quality-adjusted life year value.

Biomedical Technology↗
PubMed2000

Health technology assessment in Europe. Improving clarity and performance.

This paper discusses the challenges facing health technology assessment (HTA) in Europe, based on an explicit analysis of the characteristics of an "optimal" HTA system. It has three objectives: a) to elaborate an explicit system of policy goals and the characteristics of an optimal HTA system that facilitates the achievement of these goals; b) to identify the general institutional incentive barriers (government and market failures) that prevent the attainment of an optimal HTA system in Europe; and c) to argue that evaluation of the implications of health technologies for equity and inequality in health is an essential part of this optimal system and a considerable challenge for HTA decision makers, especially as national governments realign policy toward equity goals.

Europe↗
PubMed2004

A consumer involvement model for health technology assessment in Canada.

Similar to other health policy initiatives, there is a growing movement to involve consumers in decisions affecting their treatment options. Access to treatments can be impacted by decisions made during a health technology assessment (HTA), i.e., the rigorous assessment of medical interventions such as drugs, vaccines, devices, materials, medical and surgical procedures and systems. The purpose of this paper was to empirically assess the interest and potential mechanisms for consumer involvement in HTA by identifying what health consumer organizations consider meaningful involvement, examining current practices internationally and developing a model for involvement based on identified priorities and needs. Canadian health consumer groups representing the largest disease or illness conditions reported a desire for involvement in HTA and provided feedback on mechanisms for facilitating their involvement.

Biomedical Technology↗
PubMed1999

Domiciliary midwifery support in high-risk pregnancy incorporating telephonic fetal heart rate monitoring: a health technology randomized assessment.

We conducted a health technology assessment of the care of women with high-risk pregnancies in the South Wales valleys. Women in the control arm were intended to receive conventional care with standard midwifery visits. Women in the intervention arm received additional or longer visits and domiciliary fetal heart rate telemonitoring. Eighty-one mothers were randomized. There were significant differences in midwifery intervention resources between domiciliary and control groups, with the former receiving a mean of 3.7 visits lasting 33.5 min, compared with 1.4 visits lasting 12.8 min for the latter. There were slightly more spontaneous labours and fewer Caesarean sections in the domiciliary group. Maternal satisfaction and anxiety were high in both groups. Domiciliary care increased the service costs by 21.02 Pounds per woman in terms of extra midwife travel and visiting time, and by a further 18.38 Pounds per woman in home monitoring equipment costs. This, however, was more than offset by health service savings from fewer clinic visits (35.60 Pounds) and fewer clinic ultrasound scans (9.01 Pounds). Adding the reductions in lost productivity to women and their partners (34.51 Pounds) suggests that domiciliary care was cheaper than conventional care, even if it did not greatly reduce inpatient days (a reduction nonetheless saving 184.24 Pounds). While clinical processes were similar in both groups, there were useful practical advantages and savings for patients and the health service from the domiciliary intervention.

Anxiety↗
PubMed2000

Assessment of the learning curve in health technologies. A systematic review.

OBJECTIVE: We reviewed and appraised the methods by which the issue of the learning curve has been addressed during health technology assessment in the past. METHOD: We performed a systematic review of papers in clinical databases (BIOSIS, CINAHL, Cochrane Library, EMBASE, HealthSTAR, MEDLINE, Science Citation Index, and Social Science Citation Index) using the search term "learning curve." RESULTS: The clinical search retrieved 4,571 abstracts for assessment, of which 559 (12%) published articles were eligible for review. Of these, 272 were judged to have formally assessed a learning curve. The procedures assessed were minimal access (51%), other surgical (41%), and diagnostic (8%). The majority of the studies were case series (95%). Some 47% of studies addressed only individual operator performance and 52% addressed institutional performance. The data were collected prospectively in 40%, retrospectively in 26%, and the method was unclear for 31%. The statistical methods used were simple graphs (44%), splitting the data chronologically and performing a t test or chi-squared test (60%), curve fitting (12%), and other model fitting (5%). CONCLUSIONS: Learning curves are rarely considered formally in health technology assessment. Where they are, the reporting of the studies and the statistical methods used are weak. As a minimum, reporting of learning should include the number and experience of the operators and a detailed description of data collection. Improved statistical methods would enhance the assessment of health technologies that require learning.

Biomedical Technology↗
PubMed2000

Health technology assessment in Portugal.

The Portuguese healthcare system is often portrayed as a National Health Service (NHS) model, characterized by universal coverage, comprehensive benefits, nearly free services, national tax financing, and public ownership or control of the factors of production. However, in reality the system fails to accomplish these features in a complete way. There coexist a number of occupation-related health insurance schemes that were originally intended to be integrated into the NHS. In addition, in key areas the NHS does not provide the wide range of services it promises. The public sector has a predominant role in the provision of hospital stays and general practitioner consultations, but the private sector provides a major portion of specialist consultations, dental consultations, and diagnostic services. Major problems in the system led to health reforms in the 1990s. New reform proposals include some specific steps concerning health technology, including standards for medical equipment based on quality, geographic distribution, sustainability, and cost-effectiveness. A new National Plan of Health Equipment was completed in 1998, aimed at improving the distribution of equipment. Despite reforms, healthcare expenditures continue to rise. There is general agreement that gains in efficiency could be made. This situation is beginning to encourage interest in health technology assessment (HTA) in Portugal, although these activities are not yet very developed. Recently, legislation requiring presentation of economic evaluations for new pharmaceutical products was enacted. Present plans also call for the creation in the future of a national agency for HTA.

Delivery of Health Care↗
PubMed2000

Implementing the findings of health technology assessments. If the CAT got out of the bag, can the TAIL wag the dog?

OBJECTIVE: To explore whether more could be done to increase the implementation of health technology assessment (HTA) findings. METHODS: A literature review was undertaken to identify the main barriers to implementation, the mechanisms that influence the diffusion and use of health technologies, and evidence of the successful implementation of findings. RESULTS: Numerous barriers to the implementation of HTA findings exist at the public policy, healthcare professional, and general public levels. Several mechanisms for influencing the use of health technologies exist, and there are some examples of findings being implemented through these mechanisms. However, there are also concerns about the aggressive implementation of findings. A balanced approach to the implementation of HTAs is required. CONCLUSION: The main elements of a successful implementation strategy are: a) defining a clear policy question; b) defining a clear research question; c) making recommendations commensurate with the evidence; d) identifying the implementation mechanism; e) paying attention to incentives and disincentives; and f) clarifying the roles and responsibilities of the various parties. Further research is also required into several aspects of implementation.

Cost-Benefit Analysis↗