Health technology assessment: lessons learned from around the world--an overview.

Few recent issues in drug development and health systems management have generated more commentary, and more controversy, than health technology assessment (HTA). The keen interest in HTA stems from the high stakes involved. For regardless of differences in definition and application, it is clear that HTA brings together public and private interests in a process in which there are potentially winners and losers, and the perception of outcome is highly contingent on each party’s point of view. Critics charge that HTA has been used simply to restrict access to new health-care technology, whereas advocates underscore use of HTA to promote efficient resource allocation and to advance population-based health. Any contemporary body of work on HTA needs to reconcile, by definition, the relationship between HTA [a form of policy research that examines shortand long-term consequences of the application of a health-care technology] and evidence-based medicine (EBM) [clinical evidence analysis for individual decision-making practice guideline, and policy decisionmaking]. Underlying these concepts is the demand for information on the comparative effectiveness (CE) of health-care interventions when used in actual practice. With this Value in Health Special Issue, we seek to inform this ongoing debate on the nature and role of HTA by bringing together leading academicians and practitioners from around the world to offer their perspectives on HTA in their country and to identify lessons learned. In Article 2, “Health Technology Assessment and Evidence Based Medicine: What Are We Talking About?” the relationship between HTA and EBM are presented as well as an overview of HTA as a process. In Articles 3 to 7 (“Nasty or Nice? A Perspective on the Use of Health Technology Assessment in the United Kingdom”; “Health Technology Assessment in Canada: 20 Years Strong?”; Health Technology Assessment: A Perspective from Germany”; “Health Technology Assessment: Reflections from the Antipodes”; and “Health Technology Assessment in Health-Care Decisions in the United States”), we asked contributors from the United Kingdom, Canada, Germany, Australia, and the United States to describe the health-care organizations involved in HTA, their processes, and the use of HTA in healthcare decisions of their respective countries, and to assess their HTA processes across a range of important attributes: transparency of information and process, independence of, and participation in the assessment and appraisal, use of QALY thresholds, methods to deal with uncertainty, and the role of “real-world” data. We further asked contributors to elicit how HTA function in practice care across a range of equity, efficiency and access dimensions, effects on patient and provider choice and access, effects on health-care budgets and health outcomes, and the role of politics in the process. Some contributors addressed all of these attributes and practical considerations, whereas others only addressed attributes and practical considerations deemed relevant in their country. Article 8—“Lessons for Health Technology Assessment: It Is Not Only about the Evidence”—emphasizes the similarity of country-specific HTA systems and processes and presents future direction. Although the country-specific HTA health organizations and processes presented in this Special Issue may vary, we see emerging from these articles a set of common issues about the role of HTA in society, its effects on public health and access to care, its effects on innovation, and on the integrity and viability of publicly financed health care in general. We see HTA at the focal point of an ongoing struggle across a range of countries attempting to come to terms with expanding expenditures for health care, the availability of remarkable new innovations in healthcare technology, and constrained budgets. Although this Special Issue will not resolve these concerns, it is hoped that by articulating, comparing, and contrasting HTA systems and processes, it enriches the discourse and helps build the common ground needed to seek meaningful solutions; and that the lessons learned can inform the development of HTA in societies confronting the challenges of supporting economic growth and providing basic health care. The last article in this Special Issue, “Editorial: Pursing Efficiency: A Dead End for HTA?” is provided by a guest editor. Guest editors are selected by the Value in Health editor-in-chief to critique this Special Issue to ensure that a broad range of views are expressed. We hope that you will find this Value in Health Special Issue on HTA both informative and engaging as we grapple with the HTA challenges ahead.