Which HTA Product Do I Need?
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This document outlines the development of a decision guide for policy makers to determine which type of health technology assessment (HTA) product is needed. It describes 3 core objectives: 1) an inventory of HTA products, 2) criteria for selecting product types, and 3) a framework for using HTA products. It also provides examples of how the framework has been applied to specific policy questions on radiofrequency ablation and hysteroscopic tubal sterilization. The framework is intended to provide consistency, define the appropriate scope and balance of information needed, and aid discussions between HTA partners and policy makers.
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Which HTA Product Do I Need?
- 1. Which HTA Product Do I Need? Developing a Decision Guide for Policy Makers Ann Scott1, Christa Harstall2, Joan Berezanski3 1 Research Associate, Institute of Health Economics, 2Director of Health Technology Assessment, Institute of Health Economics, 3 Executive Director, Clinical Advisory and Research Branch, Primary Health Care Division, Alberta Health Alberta, Canada 1
- 2. The Alberta Health Technologies Decision Process (Decision Process) • Mandate to develop policy regarding public provision of non-pharmaceutical health technologies and services using robust scientific methods • STEP analyses – Social and Systems Demographic – Technological – Economic – Policy • Begins with selection and prioritization of technologies or services • Guided by a Project Charter for each review 2
- 3. HTA Products • Institute of Health Economics (IHE), Edmonton, Alberta – http://www.ihe.ca/ • Three Core Objectives 1. Inventory of HTA products offered by HTA agencies 2. Inventory of criteria used to determine which HTA product type is requested for a given policy question 3. Framework for using various HTA products in the Decision Process 3
- 4. Outline of Methods • Inventory of HTA products (objective 1) – SRs, HTAs, or narrative reviews - information used to benchmark the IHE product line • Inventory of criteria used for selecting product types (objective 2) – Articles detailing criteria used to determine which HTA product type to use for a particular question – SRs, HTAs, or narrative reviews detailing the criteria used to set priorities for HTA research • Framework for using HTA products (objective 3) – Use information from objectives 1 and 2 to design a decision matrix or questionnaire 4
- 5. Levels of HTA • Levels of HTA products developed • Scoping Report – Limited search, brief synthesis • Level 1 – Limited in scope, focused on certain main questions • Level 2 – Broader scope of questions, may involve administrative data • Level 3 – Most comprehensive – Economic modeling – Least bias 5
- 6. Interface Questionnaire • Is there more than one condition being considered? • Is there any relevant Alberta data regarding the technology? • Required components of economic evaluation – Budget impact – Model-based evaluation – Cost attribution • Timeframe 6
- 7. Case Example: Radiofrequency Ablation (RFA) for low back pain • Policy Question: should RFA continue to be publicly provided for patients with low back pain in Alberta? If so, what is the most appropriate population? • Technological: does it work? • Economics: is it cost effective? • Social: what is the demand and modes of provision in Alberta? • The HTA will include a comprehensive analysis of the intervention 7
- 8. Case Example: Hysteroscopic Tubal Sterilization (HTS) • Policy Question: Should HTS be publicly funded in Alberta as an option for patients seeking permanent sterilization? • Even though the Social and System Demographics was not the major focus of this evidence review, a comprehensive review was required for the other two components 8
- 9. Advantages • Provides a comprehensive framework to aid discussions – Helps in addressing the right questions – Identifies and focuses efforts on the gaps in information for policy development – Identifies issues that will not likely drive policy decisions • Helps define balance in information/time tradeoff • Consistency between HTA partners – Clear expectations • Objective questionnaire – Clear questions to aid in translation between policy needs and HTA tools 9
- 10. Challenges • Early days – Some lessons won’t be learned until the projects are finished • Not always easy to translate responses on the interface questionnaire to the appropriate level of HTA – Every policy question is different • Conflict between comprehensiveness and timelines – Often, a policy question that is large in scope and is of particular political interest also requires a response in a short timeframe 10
Editor's Notes
- Thank you. For decision makers, it is a challenge to have the right information within the right timeframe. What is the right amount and type of information required to support evidence-informed decision making? What is the appropriate product to provide the information needed when it is needed? We believe that marrying the product with the policy decision can help address these questions and we want to share with you a project conducted by the Institute of Health Economics to address the need for diverse types of HTA products for government decision making on health technologies and services. I’m presenting our project to you today, but the key experts that performed the work, Christa Harstall and Ann Scott are in the audience today.
- While Canada is governed at the federal and provincial levels, most healthcare-related decision making is within the jurisdiction of individual provincial governments. Alberta is one of 3 provinces in Canada that has a well established and robust process for using evidence to inform policy development for health technologies and services. The Alberta Health Technologies Decision Process involves the use of comprehensive health technology assessments, performed by internationally recognized HTA producers in Alberta, to inform decisions on health technologies and services. These HTAs are known as STE reviews and contain information on the social and systems demographic (S section), technological (T section) and economic (E section) considerations of health technologies; the Ministry then analyzes the ethical and legal aspects during policy development. Each STE review is guided by a specific Project Charter that lists the policy issues of particular interest to the Ministry. The Charter includes research-oriented questions for the STE review developed in consultation with the HTA Partner organization and an Expert Advisory Group. For the Decision Process to remain efficient, responsive and timely, it is essential to use our available HTA resources appropriately. Therefore, we needed a framework to help us choose which type of review is best suited to inform particular policy questions. Essentially, in some cases, a rapid review of lesser depth of analysis may be sufficient to address policy needs.
- The Institute of Health Economics was asked to develop such a framework on responsive and timely HTA products. The Institute of Health Economics is a not-for-profit organization with key competencies in health economics, health technology assessment, decision analytic modeling, and dissemination of findings from research. They are one of three HTA partners in Alberta that have the capacity to produce these STE reviews. The three core objectives of the project were to establish an inventory of HTA products available worldwide; create an inventory of criteria for determining which HTA product is the most appropriate for answering a particular policy question; and create a framework for using the various HTA products in the Decision Process. While the framework was developed for use within the Alberta context and with the local HTA partners, the underlying concepts may be applicable to other jurisdictions and HTA agencies.
- A systematic literature search was conducted up to March 2011. For objective 1, IHE looked for systematic reviews, HTAs, or narrative reviews detailing the types of products produced by HTA agencies worldwide. For objective 2, IHE looked for publications that detailed criteria or questions used to determine which HTA product type is used by healthcare decision makers to inform a given policy question or to set priorities for HTA research, because there is a potential overlap between the two sets of criteria. We found there wasn’t a significant body of published literature on the number or types of HTA products other agencies use, or detailed criteria used in the selection of HTA products. For objective 3, IHE used the information obtained from the literature searches to define a framework that could be used to guide the choice of an HTA product.
- IHE developed a product line that defined what each available report type looks like methodologically, as well as the depth and type of information provided within each report. Multiple levels of HTA products were developed from short scoping reports to larger scale efforts that delve into grey literature and include comprehensive economic analyses. The HTA products were designed to vary in terms of comprehensiveness of component analyses and the timelines expected from the Ministry, without sacrificing quality. As this menu of research or HTA products was generated from the researcher’s perspective, to be useful it had to be converted into something that reflected the decision maker’s viewpoint.
- The result was a questionnaire designed to serve as an interface between the evidence needs of policy makers and the menu of products available from HTA producers within the Decision Process. Its purpose is to facilitate discussion between policy makers and HTA producers on what type of HTA product should be commissioned to answer policy questions identified by the government. The questionnaire is quite comprehensive, but some examples: Whether more than one clinical condition applies If Alberta-specific administrative data is available How in-depth the economic analysis needs to be And importantly, what timeframe is required The aim is to open a detailed discussion regarding the policy needs for a particular health service, and embark on an HTA that strikes a balance between comprehensiveness and responsiveness.
- I want to go over a couple of examples of how we’ve piloted the use of the questionnaire. Radiofrequency Ablation (RFA) is a service that is already being publicly provided in Alberta and involves the use of an RFA probe to disrupt nerves in the lower back to treat chronic pain. There is more demand for this service than is currently met; however, there are also concerns about the appropriateness of the population receiving the service. The policy question is whether or not it should continue. Does the evidence support its continued use? And if so, what’s the most appropriate population? Using the interface questionnaire to guide our discussions, it became apparent that an HTA that covered all three areas of consideration; social and system demographics, technological effectiveness and economic evaluation was needed. In terms of technology, we needed to understand what the evidence said about effectiveness. In terms of economics, we needed to understand if the treatment is cost-effective. We also needed to understand what demand there is in Alberta and how is it being provided currently.
- Another example is hysteroscopic tubal sterilization; a non-surgical alternative to open or laparoscopic tubal ligation. The question was: Should hysteroscopic tubal sterilization (HTS) be publicly funded in Alberta as an option for patients seeking permanent sterilization? The questionnaire identified that the focus was mainly on the effectiveness/safety and economical aspects of the technology but not the social and system demographics. This meant a comprehensive systematic review of the technological safety and effectiveness evidence and a comprehensive economic analysis – budget impact and model-based evaluation, but a less in-depth summary of social and system demographics information. This is a great example where the questionnaire lead to discussions that focused our efforts and resources in informing policy.
- As we continue to refine the process we have found : It helps us interact with our HTA partners and ensure we’re asking the right questions during the initiation phase of a project. It also helps the HTA partner define what are the most important pieces that deserve the most effort. The discussion guided by the interface questionnaire really allows us to get at the heart of the policy issue. Just as importantly, it helps us identify which issues can be addressed by a less in-depth analysis. It also shows us what information may be missing in the final HTA and identifies upfront the opportunity cost of tradeoffs made between comprehensiveness and timeliness. And it has the potential to create some level of consistency between the HTA partners in terms of comprehensiveness. Even if methodology varies between HTA partners, identifying the issues ahead of time helps clarify the expectations on both sides. Finally, the interface questionnaire is also clear and concise. This supports dialogue between policy-makers and researchers.
- As we improve the framework and questionnaire we will continue piloting the framework. And of course, some lessons can only be learned after these trial projects are finished and we can look back and see if the final product met the policy-maker’s needs. The questionnaire has been tailored to the specific needs of the Alberta Decision Process, so it is unclear how applicable it may be to other contexts. One aspect we’re working on is the link between the interface questionnaire and the HTA product level required. Projects don’t always fit neatly within one of the HTA product levels. So it’s important to keep in mind the interface questionnaire is meant to catalyze that discussion, and not necessarily serve as a set of rigid rules. Policy issues are unique to each policy. Every project is different. Overall, there remain challenges to be addressed between the balance of quality and comprehensiveness with timeliness. Often, it is the hot button issue that a government must address with new policy that is needed in a short timeframe, but requires comprehensive research to back it up. This framework helps us in these discussions and gets us on track in making sure an appropriate HTA is performed for the policy issue at hand. It has provided a new way of navigating the gulf between the needs of policy makers and the realities of research.