Hospital-based Health Technology Assessment Research Articles

Effects and repercussions of local/hospital-based health technology assessment (HTA): a systematic review.

BackgroundHealth technology assessment (HTA) is increasingly performed at the local or hospital level where the costs, impacts, and benefits of health technologies can be directly assessed. Although local/hospital-based HTA has been implemented for more than two decades in some jurisdictions, little is known about its effects and impact on hospital budget, clinical practices, and patient outcomes. We conducted a mixed-methods systematic review that aimed to synthesize current evidence regarding the effects and impact of local/hospital-based HTA.MethodsWe identified articles through PubMed and Embase and by citation tracking of included studies. We selected qualitative, quantitative, or mixed-methods studies with empirical data about the effects or impact of local/hospital-based HTA on decision-making, budget, or perceptions of stakeholders. We extracted the following information from included studies: country, methodological approach, and use of conceptual framework; local/hospital HTA approach and activities described; reported effects and impacts of local/hospital-based HTA; factors facilitating/hampering the use of hospital-based HTA recommendations; and perceptions of stakeholders concerning local/hospital HTA. Due to the great heterogeneity among studies, we conducted a narrative synthesis of their results.ResultsA total of 18 studies met the inclusion criteria. We reported the results according to the four approaches for performing HTA proposed by the Hospital Based HTA Interest Sub-Group: ambassador model, mini-HTA, internal committee, and HTA unit. Results showed that each of these approaches for performing HTA corresponds to specific needs and structures and has its strengths and limitations. Overall, studies showed positive impacts related to local/hospital-based HTA on hospital decisions and budgets, as well as positive perceptions from managers and clinicians.ConclusionsLocal/hospital-based HTA could influence decision-making on several aspects. It is difficult to evaluate the real impacts of local HTA at the different levels of health care given the relatively small number of evaluations with quantitative data and the lack of clear comparators. Further research is necessary to explore the conditions under which local/hospital-based HTA results and recommendations can impact hospital policies, clinical decisions, and quality of care and optimize the use of scarce resources.

Hospital-based health technology assessment: insights from New Zealand.

The paper by Assistant Prof. Gagnon, published in this issue of PharmacoEconomics [1], succinctly summarizes the current status of hospital-based, health technology assessment activities around the world. Such a summary is timely given the multiplicity of new health technologies clambering for a place in our public hospitals, which are often inundated in red ink. How is it possible to maintain the dual goals of optimal patient care and fiscal prudence? Apart from the ever-elusive ‘Wisdom of Solomon’, one practical tool is the appropriate use of health technology assessment ‘at the coalface’, as it were. Here in New Zealand, as elsewhere, that coalface is often the tertiary hospital where caring and eager clinicians are enthusiastic protagonists of novel cutting-edge technology. Where those innovations can potentially improve outcomes whilst reducing costs, they are greeted with open arms. Sadly, a much more common scenario is one where the innovation is an improvement over current therapies but whilst the improvements might be measurable and real (with reduced morbidity and/or mortality rates), the costs are often eye watering when compared with the quantum of improvement. The metric for this, in health technology terms, is the incremental cost-effectiveness ratio (ICER) and it is not uncommon for new technologies to be presented with tentative ICERs of tens of thousands of dollars for every added quality-adjusted life-year. When healthcare dollars are in short supply, as they have been since the global financial crisis of 2008, it makes novel health technologies seem like desirable but unaffordable luxury cars. Ernest Rutherford, that great Nobel prizewinner from New Zealand, was a master of bluntness when he accurately stated the New Zealand stance on technological matters:

Hospital-based health technology assessment: developments to date.

Health technology assessment (HTA) uses a multidisciplinary approach to answer relevant questions regarding the safety, efficacy, effectiveness and cost-effectiveness of health technologies. There is growing interest in implementing HTA methods at the hospital level because it could facilitate decision-making regarding acquisition, implementation or discontinuation of technologies or interventions within the hospital. First, this article provides an overview of current international experiences and knowledge of hospital-based HTA. Then, it presents the different types of hospital-based HTA, providing examples of each of these models, as well as their strengths and limitations. Finally, it proposes a set of emerging issues that could help inform decision-makers who consider implementing hospital-based HTA, or other stakeholders interested in the field.

Hospital-based health technology assessment on the use of mitral clips in the treatment of mitral regurgitation

This study, carried out at the Florence Teaching Hospital Careggi (AOUC), reports the technological evaluation, through the use of Health Technology Assessment (HTA), on the application of mitral clips in the treatment of mitral insufficiency. The assessment, carried out by analyzing the clinical, technological, social, procedural, safety and economic elements, sought to answer the following research questions: Evaluation of the general technological status of the mitral clips in the treatment process of mitral regurgitation, with particular reference to traditional methods; and contextualisation of the analyses within the hospital structure, by identifying criticality issues and improvements. The methodology was based on the following steps: technological description; areas of evaluation and the selection of Key Performance Indicators; research of scientific facts and the collection of expert opinions; evaluation and reporting of findings. The results are based on an analysis which included a total of 50 indicators, effectively evaluating 86.5% of them, from the least from the clinical sector (80%) to the most in the areas of procedure, safety and social (100%). Traditional surgery (repair or valve replacement) still represents the gold standard for the treatment of mitral regurgitation due to its maturity both on a technological and clinical level. The minimally invasive procedures which use the mitral clips present interesting opportunities both on a social level (minimum stay in hospital and no post-operative rehabilitation) and clinical level, especially as an alternative to medication, even if they are still at an emergent level (the long-term results are unknown) and complex to use. From the clinical point of view they show some interesting findings related to immediate and post-operative mortality (none during the operation and a minor and equal amount 30 days and 12 months later in comparison to traditional methods) whilst economically, despite the fact that the cost of the device is greater than those used in traditional interventions, the cost-refund relationship does not show significant differences compared to the traditional types of treatment. The HTA evaluation of minimally invasive technologies that use clips for the treatment of mitral regurgitation shows, in the hospital setting, very interesting results, particularly for inoperable patients, where the clinical and social improvements are significant compared to pharmacological treatments, whilst for 'operable' patients, the traditional techniques are still the most appropriate.

068 Integrating guidelines into local clinical practice and policy using hospital-based health technology assessment

BackgroundMost existing centres for health technology assessment (HTA) are associated with payers or government agencies, and review and analyse emerging and costly technologies. Yet, such centres can exist within individual...

HOSPITAL-BASED HEALTH TECHNOLOGY ASSESSMENT FOR INNOVATIVE MEDICAL DEVICES IN UNIVERSITY HOSPITALS AND THE ROLE OF HOSPITAL PHARMACISTS: LEARNING FROM INTERNATIONAL EXPERIENCE

Several models of hospital-based health technology assessment (HTA) have been developed worldwide, for the introduction of innovative medical devices and support evidence-based decision making in hospitals. Two such models, the HTA unit and mini-HTA models, are widespread in university hospitals and involve various stakeholders. The purpose of this work was to highlight the potential role of hospital pharmacists in hospital-based HTA activities. We searched for articles, reviews, and letters relating to hospital-based HTA, as defined by the Hospital-Based Health Technology Assessment Worldwide Survey published by the Health Technology Assessment International (HTAi) Society, in the Health Technology Assessment database, MEDLINE, EMBASE, and hospital pharmacy journals. The number of university hospitals performing hospital-based HTA has increased since the 2008 Hospital-Based Health Technology Assessment Worldwide Survey. Our own experience and international findings show that hospital pharmacists already contribute to hospital-based HTA activities and have developed study interpretation skills and a knowledge of medical devices. Promoting multidisciplinary approaches is one of the key success factors in hospital-based HTA. Hospital pharmacists occupy a position between hospital managers, clinicians, health economists, biomedical engineers, and patients and can provide a new perspective. In the future, hospital pharmacists are likely to become increasingly involved in hospital-based HTA activities.

Clinical studies of innovative medical devices: what level of evidence for hospital‐based health technology assessment?

Like health technology assessment (HTA) agencies, hospitals are faced with requests for innovative and costly medical devices. However, local decision makers are frequently confronted with a lack of high-quality clinical data when assessing the effectiveness of innovative medical devices. The aim of this study was to quantify the level of evidence available for innovative medical devices in the context of hospital-based HTA. We searched the Medline, Embase and Cochrane Library databases for articles, letters and reports relating to 32 innovative medical devices requested at our hospital between January 2008 and March 2012. All clinical studies retrieved were screened and classified according to the Sackett 5-point level-of-evidence scale. We screened and classified 217 studies: 215 clinical trials and 2 cost-effectiveness studies. Only 47 of the 215 clinical studies (22%) provided high-level clinical evidence (levels 1-2); 33 (15%) were randomized controlled trials (RCTs). More than half of the 215 studies (52.1%) included fewer than 30 patients. Only 14 of the 47 high-quality studies reported the amount of missing data. For implantable medical devices, 84 (71.8%) studies specified the follow-up period and the mean follow-up period was 18.9 months. Finally, methodological quality did not increase with the risk level of the medical device. Our findings confirm that only a few studies of innovative medical devices provide high-level clinical evidence. Nevertheless, RCT may be the 'gold standard' for drugs, but it is not always appropriate for medical devices. Changes to the European regulation of medical devices, with the requirement for a demonstration of clinical efficacy and safety before release onto the European market, have raised expectations.

Integrating local data into hospital-based healthcare technology assessment: Two case studies

Health technology assessment (HTA) programs influence practice on a broad scale through reimbursement decisions or national guidelines. Hospital-based HTA programs inform clinical decisions at the local level. Typically, they do this by adapting general HTA to their local setting, or by creating new HTA. However, unlike payer-based HTA organizations, hospital-based HTA organizations can also integrate local data into their reports. We describe two examples of local data integrated into hospital-based HTA. In the first, qualitative data were used to select a new cardiac catheterization lab. In the second, quantitative data was used to inform a decision on whether to continue telemedicine services to critical care units. Local evidence sources included equipment service records, and interviews with physicians, technicians, and administrative staff in the first example, and the hospital's administrative and claims databases in the second example. In each case, there was little evidence from the peer-reviewed literature that could be applied to the decision. In the first example, staffing patterns and local preferences had considerable bearing on technology choices. In the second example, local outcomes data from administrative records were decisive. Hospital-based HTA using local data can fill gaps in the published evidence, and also improve the generalizability of evidence to the local setting. To take advantage of local evidence, health systems should encourage the development of hospital-based HTA centers, seek out local preference data, and maintain databases of patient outcomes and utilization of services.

Health technology assessment in Italy

The aim of this study was to review the history of health technology assessment (HTA) in Italy. Founded in 1978, the Italian National Health Service (NHS) has been strongly regionalized mainly after a constitutional reform, which started a devolution process. HTA started in the 1980s at the National Institute of Health and in a few University Hospitals, with a focus on big ticket technology: that process was driven by clinical engineers. In recent years, HTA is becoming an important tool for decision-making processes at central, regional, and local levels. In particular, the National Agency for Regional Health Services (AGENAS) and five regions (of twenty-one) are strongly committed to develop HTA initiatives connected with the planning process. At the local level, the hospital-based HTA activity is probably the most important peculiarity of the country and the real driver of the HTA movement.

Hospital-based Health Technology Assessment: the experience of Agostino Gemelli University Hospital’s HTA Unit

The Italian National Health Care Service, as many other industrialised countries’, has to cope with increasinghealth care needs in spite of the limited resources available.Therefore, it is necessary to assess diagnostic-therapeutic procedures, technologies and organizationalstandards, in order to allocate the available resources appropriately.Methodologies developed by the area of research known as Health Technology Assessment, provide scien-tific support for the policies that all countries have adopted in order to rationalize, and sometimes to ration,health care services.Within this context Health Technology Assessment plays a key role in establishing appropriate health carepolicy decisions.If in the past Health Technology Assessment’s areas of applications have involved mainly macro health carepolicies, HTA’s methods are now becoming imperative also on an organizational level, as a valuable tool tosupport managerial decisions.This article outlines the 4 year - experience of A. Gemelli University Hospital of applying HTA methodologies.