Health Technology Assessment (HTA) has been a concept in the field of health care since the 1980s, when one witnessed a rapid growth of new medical technologies in relation to limited health budgets. The HTA is a multiscientific and interdisciplinary activity delivering input for priorities and decisions in the health care system in relation to prevention, diagnostics, treatment and rehabilitation.
Decisions on the use of technology are made at all levels in the health care system. They often include a unification of complicated medical, patient-related, organisational and economic information in a context where there may also be ethical problems. Providing input for the decision-makers is highly dependent of interaction, division of labour and cooperation between professionals of the health care system, the research environment and the political decision-makers and their officials. Decisions must be made on an evidence-based foundation where all relevant circumstances and conse- quences are systematically illustrated by means of scientific methods.
HTA is relevant in connection with complex problems prior to the establishment of a policy. This may be the establishment of a policy for treatment of e.g. inguinal hernia or a joint procedure for treatment of diabetes in general practice or in regional hospi- tals. It may also be health-political decisions on treatment and screening offers, with consequences for the whole country.
HTA does not make complexity disappear but offers a structure for the multifaceted basis for decisions. It is important to emphasise that the decision situation itself is beyond HTA. Besides input from HTA, many other components may form part of decision-making, for instance regarding other patients or other circumstances in the health care system and in society.
What is HTA?
HTA is a research-based, usage-orientated assessment of relevant available knowledge about problems in connection with the use of technology in relation to health and diseases. By virtue of its methods, which are based on research, but also in terms of its aiming at decision-making, HTA is related to planning, administration and manage- ment.
HTA may therefore be considered as bridging between two domains: a decision- making domain and a research domain (2), cf. Figure 1.1. In order to fulfil such a purpose, the problems in focus of an HTA must be based on the need of the decision- makers (and their advisers) for a documented basis for decisions about the use of health technology.
HTA is thus defined in terms of its purpose and not as a specific method (4). At a more specific level, HTA is a comprehensive, systematic assessment of the precondi- tions for and the consequences of using health technology. In an HTA context, health technology is defined broadly as procedures and methods of prevention, diagnostics, treatment, care and rehabilitation, including equipment and medical drugs (5). Supportive systems and organisation within the health care system may furthermore be regarded as health technology. HTA comprises analysis and assessment of various areas where the use of health technology may have consequences. These areas may be grouped under four main elements in order to ease the overview: the technology, the patient, the organisation and the economy. The main elements are overlapping to a certain extent. Ethics, which is traditionally attributed to the patient element, cannot for instance be separated from the technology analysis, just as ethics may constitute the framework for analysis across the elements (6). Also legal issues may be included transversally to the elements.
Evidence and HTA
It is important to remember that even though HTA is intended for practical use, it must be on the basis of scientific methods. For many years, “evidence” has been a key word in HTA. The concept of evidence was introduced in connection with “evidence- based medicine” which is a clinical discipline integrating the best scientific results from systematic research in clinical work (7,8). It dates back to the clinicians in Paris in the nineteenth century, and the line goes via the critical clinical school from the 1960s to evidence-based medicine (9).
Connected to evidence-based medicine, the Cochrane cooperation was developed in parallel. Its products are international well-reputed literature overviews. The pivotal point in Cochrane reviews is an evidence assessment of clinical studies according to a pre-determined method. In connection with HTA, systematic Cochrane reviews con- stitute an important basis of documentation for the assessment of the effects and side effects of technologies (10).
In the mid-1990s the concept of evidence was broadened, leading to the development of an “evidence-based health care system”. This indicates that an effort should be made to acquire a rational, well-documented basis for decisions in the health care system in general – not just in a clinical context, but also concerning prioritisation, planning, regulation, management and practice at all levels (9). At the same time, this shows the close relationship between evidence and HTA.
In connection with non-clinical decisions, it will not always be possible to maintain the rational evidence-based approach. This has led to the formation of the modified concept: evidence-informed decision-making. This concept implies that one looks at evidence and includes it, but at the same time accepts that there is room for other important factors to be part of decision-making.
Internationalization of HTA
In light of the development of HTA, practitioners of such all over the world have organised a number of networks, each of which is strengthening the HTA effort via cooperation and knowledge sharing. Four international organisations, three global and one European, are outlined briefly in the following:
European Network for HTA (EUnetHTA) is a three-year project aimed at establishing a formal European HTA network. EUnetHTA was initiated by the EU and was launched in 2005 with its secretariat function in the Danish National Board of Health. The project comprises 27 European countries of which 24 countries are members of the EU. EUnetHTA is intended to ensure a more efficient utilization of the resources that are used for the assessment of new health technologies, and to enhance the quality and validity of decisions on the application of technologies. These objectives are to be achieved through increased coordination, division of labour and knowledge sharing at a European level. Models and method development aimed at utilizing common know- ledge and reducing duplication in relation to specific HTA projects are applied. The work of EUnetHTA is structured in eight “work packages” each of which involves several participant countries. The network is expected to be made permanent at the end of the project in 2008.
Health Technology Assessment International (HTAi) is an international society for the promotion of HTA based on individual membership. HTAi serves to promote the development of HTA in terms of methods, expertise, quality and application. The task is sought to be approached by an interdisciplinary, international effort, in which timely and effective presentation of international HTA results has high priority. Other core focus areas are support for HTA education and research. HTAi hosts an annual inter- national conference (HTAi Annual Meeting) and is responsible for the publication of the International Journal for Technology Assessment in Health Care (IJTAHC). From 1990 until the establishment of HTAi in 2003 these tasks were handled by a similar society with the name International Society of Technology Assessment in Health Care (ISTAHC).
International Network of Agencies for HTA (INAHTA) was established in 1993 and is presently (2007) a cooperation of 45 HTA organisations in 23 countries. The purpose of INAHTA is to create a forum for exchange of information and cooperation focusing on the joint interests of the member organisations. Together with NHS Centre for Reviews and Dissemination INAHTA is the host for a comprehensive international HTA database, located in York, UK. The database comprises information about com- pleted and ongoing HTA projects, HTA publications as well as articles about HTA. For more information about the database, please visit HTA Database.
International Information Network on New and Changing Health Technologies (EuroScan) has existed since 1997 and is a cooperation between 15 HTA organisations from 9 European and 3 non-European countries about early warning of new technologies. The cooperation concerns the identification and prioritising of new technologies. For the purpose of mutual exchange of technology EuroScan hosts a database with information about new and potentially interesting technologies and overviews of published “tech- nology warnings” to which all member countries contribute to and make use of.
(1) Health Technology Assessment Committee of the Danish National Board of Health. National strategy for health technology assessment. Copenhagen: National Board of Health; 1996.
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(6) Andersen S. Etiske aspekter ved MTV [Ethical Aspects of HTA]. In: Kristensen FB, Sigmund H (eds.): MTV, sundhedstjemesteforskning og klinisk praksis. [HTA, health science research and clinical practice.] Copenhagen: Danish Health Science Research Board and Danish Institute for Health Technology Assessment; 2000. p. 51- 57.
(7) Evidence-based medicine. A new approach to teaching the practice of medicine. Evidence-Based Medicine Working Group. JAMA 1992 Nov 4;268(17):2420-2425.
(8) Kleijnen J, Chalmers I. How to practice and teach evidence-based medicine: role of the Cochrane Colaboration. Acta Anaesthesiol Scand Suppl 1997;111:231-233.
(9) Kristensen FB, Sigmund H, editors. Evidensbaseret sundhedsvæsen. Rapport fra et symposium om evidensbaseret medicin, planlægning og ledelse. Rapport fra et sympo- sium om evidensbaseret sundhedsvæsen. [HTA, health service research and clinical practice. Report from a symposium on evidence-based health service.] Copenhagen: DSI-Institute for Health Services Research;1997. DSI-report 97.02.
(10) Bhatti Y, Hansen HF, Rieper O. Evidensbevægelsen udvikling, organisering og arbejdsform. En kortlægningsrapport. [Development of the evidence movement, organisation and work method. A mapping report.] Copenhagen: AKF-Forlag; 2006.
Source:Health Technology Assessment Handbook
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