Health Technology Assessment and Its’

Methods:Should we use it? Can we use it? How to use it?

J.L. (Hans) Severens PhD

Professor of Evaluation in Health Care

Institute of Health Policy & Management

& iMTA, Institute of Medical Technology Assessment

Erasmus University Rotterdam, The Netherlands

1637Descartes paradigmof modern science

Period 1Slow accumulation ofmedical knowledge:- knowledge of anatomy- classification of diseases- description of relation betweenillness, autopsy and pathology

Period 2Rapid development of knowledge:-microscope, stethoscope, bloodpressurecuff, x-ray- Pasteur, vaccines, desinfectans, narcotics,morphine, penecillin- intravenous, subcutanous drug delivery

Before ancient Greeks

Early 1900s

Period 3Biological revolution:- mass production of medicine- DNA and biotechnology- lab tests- imaging techniques- organ transplants

A short history of medicine

A history on HTA

• Three decades of HTA

• 1980’s

• Informing decision on health insurance coverage

• HTAi, INAHTA, EU, World Bank, WHO

• National HTA capacity

Banta and Jonsson, Int J Techn Assessm Health Care 2009; 25 Suppl 1: 1-6.

Why HTA?

• rapid development of medical technological possibilities

• limitations of human resources

• budget constraints; (unlimited) rise of health care costs

Thus: choices have to be made (in case a health care

system is considered to be a ‘ public property’)

WHO-report Health Systems Financing; the path to universal

coverage:

• promoting efficiency and eliminating waist

• ‘more health for money’

Clinical effectiven

essSocial

aspects

Costs andfinancing

Organisatio-nal

aspects

Ethical conse-quences

Medical & biological knowledge

EpidemiologyHTA

Based on Habbema et al., 1989

Health Technology Assessment

• What is a health technology?

• What is health technology assessment?

– systematic evaluation

– properties, effects, impacts of health technology

– intended or unintended consequences

– to provide structured, evidence based input to decision

making

– to promote safe, effective, cost-effective patient-

focused health policies

Clinical effectiven

essSocial

aspects

Costs and financing

Organisatio-nal

aspects

Ethicalconse-quences

Medical & biological knowledge

EpidemiologyHTA

Based on Habbema et al., 1989

Components of economic evaluation (Torrance, 1986)

Intangible

benefits

Indirect

benefits

(prod. gains)

Economic

benefits

direct

Economic

benefits

Value of

health

improvement

per se

Ad hoc

numeric

scales

Willingness

to pay

Utilities

(Qaly’s)

Resources

consumed

(costs)

Direct

costs

Indirect

costs

(prod. Loss)

Intangible

cost

Health care

programme

Health

improvement

(consequences)

mortality

Health

effects

morbidity

1st ed 1987

Economic Evaluations

Intervention A Consequences A Cost A

Cost B

Difference

in costs?

Consequences BIntervention B

Difference in

consequences?

Relationship?

Quality Adjusted Life Year

0

1

Health state value or utility

Life expectancy 9 years

4 * 0.9 = 3.6

3 * 0.7 = 2.1

2 * 0.2 = 0.4

Total QALY: 6.3

11 years

5 * 1.0 = 5.0

2 * 0.8 = 1.6

4 * 0.2 = 0.8

7.4

Negative

consequences

Positive

consequences

More expensive

Less expensive

• Should we use it?

• Can we use it?

• How to use it?

Scheen AJ et al., Lancet 2008; 372: 1197-8

Drug development

for treatment of type 2 diabetes

Why HTA?

• Endografts for aortic

aneurysm

• Weights loss drugs

• Radical mastectomy for

breast cancer

• Should we use it?

• Can we use it?

• How to use it?

To inform decision making?

Decision making levels:

1) national/regional decision making

2) institutional/profession decision making

3) individual doctor-patient decision making

0

50

100

150

200

250

Co

st

per

life

ye

ar

gain

ed

in

Au

s$

Recommended at price Recommended at lower price Rejected

George et al. Center for Health Program Evaluation, Australia 1999

The relation between reimbursement of

pharmaceuticals and cost effectiveness

• Objective: to evaluate impact of cost-effectiveness information

on clinical decision making

• Methods:

• Discrete choice experiment (3x2x3)

• Italian cardiologists (N=129, 1143 observations)

• Choices between paired scenarios:

• Quality of evidence: high – moderate – low

• Health gain: high – moderate

• Cost-effectiveness: favorable - moderate – unfavorable

Results

• All three dimensions had a significant impact on a

clinicians’ decision on the use of an innovative drug

• Marginal effects:

– of high quality evidence larger than medium quality

evidence

– of favorable cost-effectiveness larger than moderate

cost-effectiveness

• Relative importance of favorable cost-effectiveness higher

that evidence quality and health gain

• Heterogeneity of preferences:

– Age <45yr

– Good knowledge of economic evaluations

Torbica & Fattore, Soc Sci Med 2010; 70: 1536-1543

Total degree of influence of economic

evaluation on actual decision making

Degree of

influence

Macro

(n=11)

Meso

(n=11)

Micro

(n=3)

1 Unknown 11,1% 9,1% -

2 Big 5,6% 27,3% 33,3%

3 Moderate 11,1% 9,1% 33,3%

4 Small/No 66,7% 54,6% 33,3%

Van Velden et al., PharmacoEconomics 2005; 23: 1075-1082

Barriers and limitations to use of EE

Decision maker-related factors

– access and time constraints

– poor understanding of concepts, principles, and methods

– ethical and value-based concerns

Context-related factors

– organizational, budgetary, political, and social factors

– levels of decision making differ in

structure, objectives, responsibilities

Economic evaluation-related factors

– complexity of studies

– generalizability and relevance to context

– concerns QALY modelBrousselle and Lessard, Soc Sci Med 2011; 72: 832-839

So, can we use it?

• (pharmaco-) economic evaluation is potentially useful to

inform decision making

• decision makers should be trained in research methods

• HTA ≠ (pharmaco-) economic evaluation

• HTA is context-specific

• HTA is evidence based decision making

• Should we use it?

• Can we use it?

• How to use it?

Follow NICE?

National (regional) HTA essential

• health care situation is local

• comparison is local

• decision making context is local

International HTA

• do not follow foreign decisions automatically, but assess

critically

• be ware of using foreign evidence and data

• use a transferability assessment tool

• core HTA?

How to organise HTA

Roles:

• coordination of assessments and appraisals

• providing evidence

• conducting assessment

• advising

• decision making

Parties involved:

• assessment agencies and/or academia

• advisory bodies

• regulatory bodies

• stakeholders: policy makers, health care

providers, industry, patients

Stages in HTA

Assessment:

• clinical effectiveness

• evaluation cost and consequences

• review of available evidence

• mostly quantitative research

Appraisal:

• interpretation and consideration

• stakeholder involvement

• Increasing patient involvement

Sorrenson, Euro Observer 2009; 11: 1-4

TAIL:

‘Technology Assessment’ Iterative Loop

1. Burden of illness

2. Aetiology or causation

3. Efficacy andcommunity

effectiveness

4. Efficiency

5. Synthesis and implementation

6. Monitoring

7. Reassessment

Based on Tugwell et al., J Chron Dis 1986; 4: 339-351

HTA needs transparency

• what subjects need priority

• what decision needs to be made

• distinguish assessment and appraisal

• assessment without conflict of interest

• double check the assessment

• include stakeholders in the appraisal

• who decides

• learning by doing

• continuity

In conclusion

HTA and the strive for ‘More health for money’

• Can we use it?

• Should we use it?

• How to use it?