What Decision-Makers Want and What They Have Been Getting

Abstract

I believe we would all agree that the only reason we produce health technology assessments (HTAs) is to inform health policy decisions, and when they fail to do so they are a waste of time and effort. Nevertheless, at the present time it seems that HTAs often have little impact [1–4]. My first objective will be to consider some of the factors that cause HTAs to fail to influence policy. My second will be to report on an ongoing experiment in HTA development that attempts to minimize these factors, and has resulted in an extremely high impact of HTA reports on health policy decisions. Before I start, I have two caveats. First, my remarks are not evidence-based. They are reflections resulting from my reading and my personal experience both as an HTA producer and as a health-care decision-maker. Second, my experience is mostly Canadian, so some of my reflections may not be completely relevant to other countries. Furthermore, the decision-makers I will be referring to are the meso-level policymakers, the people who make technology acquisition decisions at the hospital or regional level. In our Canadian system of universal health insurance, top-level policy, such as decisions on what programs will be funded, are taken at government level. Increasing the impact of HTAs on such decisions has been discussed elsewhere [5]. But hospitals or regions mostly take meso-decisions, such as those on the acquisition and use of new technologies. These organizations are usually given a capped budget and expected to conform to the Canada Health Act, according to which they must to give all “necessary” treatments to all Canadians, a feat that clearly requires careful prioritization. Sound prioritization decisions require well-prepared, objective evidence such as is found in HTAs. So if HTAs are not influencing these decisions it is urgent that we consider what to do about it. Our options are limited. I believe the UK solution to this problem is not an option for us in Canada. In the UK the final path of all HTAs is the National Institute of Clinical Excellence (NICE), and their policy “recommendations” are now virtually mandatory, and Regional Authorities are required to follow them. North America is probably too big and regional differences too great for such a solution to be accepted. So we must consider the other option. We must ask why many HTAs lack impact and what we can do about it.