Expanded HTA: Enhancing Fairness and Legitimacy

Psychedelic Science, Contemplative Practices, and Indigenous and Other Traditional Knowledge Systems: Towards Integrative Community-Based Approaches in Global Health

As individuals and communities around the world confront mounting physical, psychological, and social threats, three complimentary mind-body-spirit pathways toward health, wellbeing, and human flourishing remain underappreciated within conventional practice among the biomedical, public health, and policy communities. This paper reviews literature on psychedelic science, contemplative practices, and Indigenous and other traditional knowledge systems to make the case that combining them in integrative models of care delivered through community-based approaches backed by strong and accountable health systems could prove transformative for global health. Both contemplative practices and certain psychedelic substances reliably induce self-transcendent experiences that can generate positive effects on health, well-being, and prosocial behavior, and combining them appears to have synergistic effects. Traditional knowledge systems can be rich sources of ethnobotanical expertise and repertoires of time-tested practices. A decolonized agenda for psychedelic research and practice involves engaging with the stewards of such traditional knowledges in collaborative ways to codevelop evidence-based models of integrative care accessible to the members of these very same communities. Going forward, health systems could consider Indigenous and other traditional healers or spiritual guides as stakeholders in the design, implementation, and evaluation of community-based approaches for safely scaling up access to effective psychedelic treatments.

Eliciting Trade-Offs Between Equity and Efficiency: A Methodological Scoping Review

OBJECTIVES

To identify differences in the approaches and results of studies that elicit equity-efficiency trade-offs that can inform equity-informative cost-effectiveness analysis for healthcare resource allocation.

METHODS

We searched Ovid (Medline), EconLit, and Scopus prior to June 25, 2021. Inclusion criteria were: (1) peer-reviewed or (2) gray literature; (3) published in English; (4) survey-based; (5) parameterized a social welfare function to quantify inequality aversion or (6) elicited a trade-off in equity and efficiency characteristics of health interventions. Exclusion criteria were: (1) studies that did not conduct a trade-off or (2) theoretical studies. We abstracted details on study methods, results, and limitations. Studies were grouped by following approach: (1) social welfare function or (2) preference ranking and distributional weighting. We described findings separately for each approach category.

RESULTS

Seventy-seven papers were included, 28 parameterized social welfare functions and 49 were classified as preference ranking and distributional weighting. Study methods were heterogeneous. Studies were conducted across 29 countries. Sample sizes and composition, survey methods and question framing varied. Preferences for equity were mixed. Across both approach categories: 39 studies were classified as clear evidence of inequality aversion; 33 found mixed evidence; and 4 had no evidence of aversion. Evidence of between and within-study heterogeneity was found. Preferences for equity may differ by gender, profession, political ideology, income, and education.

CONCLUSIONS

Substantial variability in study methods limit the direct comparability of findings and their use in equity-informed cost-effectiveness analysis. Future researches using representative samples that explore within and between country heterogeneity is needed.

[Cost-effectiveness of universal childhood vaccination against hepatitis A in Spain: a dynamic approach]

OBJECTIVE

To evaluate the cost-effectiveness of infant universal vaccination against hepatitis A in Spain.

METHOD

Using a dynamic model and decision tree model, a cost-effectiveness analysis was performed to compare three vaccination strategies against hepatitis A: non-vaccination strategy versus universal childhood vaccination of hepatitis A with one or two doses. The perspective of the study was that of the National Health System (NHS) and a lifetime horizon was considered. Both costs and effects were discounted at 3% per year. Health outcomes were measured in terms of quality adjusted life years (QALY) and the cost-effectiveness measure used was the incremental cost-effectiveness ratio (ICER). In addition, deterministic sensitivity analysis by scenarios was performed.

RESULTS

In the particular case of Spain, with low endemicity for hepatitis A, the difference in health outcomes between vaccination strategies (with 1 or 2 doses) and non-vaccination are practically non-existent, terms of QALY. In addition, the ICER obtained is high, exceeding the limits of willingness to pay from Spain (€22,000-25,000/QALY). The deterministic sensitivity analysis showed that the results are sensitive to the variations of the key parameters, although in no case the vaccination strategies are cost-effective.

CONCLUSIONS

Universal infant vaccination strategy against hepatitis A would not be a cost-effective option from the NHS perspective in Spain.

Considering equity in priority setting using transmission models: Recommendations and data needs

OBJECTIVES

Disease transmission models are used in impact assessment and economic evaluations of infectious disease prevention and treatment strategies, prominently so in the COVID-19 response. These models rarely consider dimensions of equity relating to the differential health burden between individuals and groups. We describe concepts and approaches which are useful when considering equity in the priority setting process, and outline the technical choices concerning model structure, outputs, and data requirements needed to use transmission models in analyses of health equity.

METHODS

We reviewed the literature on equity concepts and approaches to their application in economic evaluation and undertook a technical consultation on how equity can be incorporated in priority setting for infectious disease control. The technical consultation brought together health economists with an interest in equity-informative economic evaluation, ethicists specialising in public health, mathematical modellers from various disease backgrounds, and representatives of global health funding and technical assistance organisations, to formulate key areas of consensus and recommendations.

RESULTS

We provide a series of recommendations for applying the Reference Case for Economic Evaluation in Global Health to infectious disease interventions, comprising guidance on 1) the specification of equity concepts; 2) choice of evaluation framework; 3) model structure; and 4) data needs. We present available conceptual and analytical choices, for example how correlation between different equity- and disease-relevant strata should be considered dependent on available data, and outline how assumptions and data limitations can be reported transparently by noting key factors for consideration.

CONCLUSIONS

Current developments in economic evaluations in global health provide a wide range of methodologies to incorporate equity into economic evaluations. Those employing infectious disease models need to use these frameworks more in priority setting to accurately represent health inequities. We provide guidance on the technical approaches to support this goal and ultimately, to achieve more equitable health policies.

Evidence-Informed Deliberative Processes for Legitimate Health Benefit Package Design - Part I: Conceptual Framework

BACKGROUND

Countries around the world are increasingly rethinking the design of their health benefit packages to achieve universal health coverage (UHC). Health technology assessment (HTA) bodies support governments in these decisions, but employ value frameworks that do not sufficiently account for the intrinsically complex and value-laden political reality of benefit package design.

METHODS

Several years ago, evidence-informed deliberative processes (EDPs) were developed to address this issue. An EDP is a practical and stepwise approach for HTA bodies to enhance legitimate health benefit package design based on deliberation between stakeholders to identify, reflect and learn about the meaning and importance of values, and to interpret available evidence on these values. We further developed the conceptual framework and initial 2019 guidance based on academic knowledge exchange, analysing practices of HTA bodies, surveying HTA bodies and experts around the globe, and implementation of EDPs in several countries around the world.

RESULTS

EDPs stem from the general concept of legitimacy, which is translated into four elements - stakeholder involvement ideally operationalised through stakeholder participation with deliberation; evidence-informed evaluation; transparency; and appeal. The 2021 practical guidance distinguishes six practical steps of a HTA process and provides recommendations on how these elements can be implemented in each of these steps.

CONCLUSION

There is an increased attention for legitimacy, deliberative processes for HTA and health benefit package design, but the development of theories and methods for such processes remain behind. The added value of EDPs lies in the operationalisation of the general concept of legitimacy into practical guidance for HTA bodies.

Integrating health technology assessment and the right to health: a qualitative content analysis of procedural values in South African judicial decisions

South Africa's move towards implementing National Health Insurance includes a commitment to establish a health technology assessment (HTA) body to inform health priority-setting decisions. This study sought to analyse health rights cases in South Africa to inform the identification of country-specific procedural values related to health priority-setting and their implementation in a South African HTA body. The focus on health rights cases is motivated in part by the fact that case law can be an important source of insight into the values of a particular country. This focus is further motivated by a desire to mitigate the potential tension between a rights-based approach to healthcare access and national efforts to set health priorities. A qualitative content analysis of eight South African court cases related to the right to health was conducted. Cases were identified through a LexisNexis search and supplemented with expert judgement. Procedural values identified from the health priority-setting literature, including those comprising Accountability for Reasonableness (A4R), structured the thematic analysis. The importance of transparency and revision-two elements of A4R-is evident in our findings, suggesting that the courts can help to enforce elements of A4R. Yet our findings also indicate that A4R is likely to be insufficient for ensuring that HTA in South Africa meets the procedural demands of a constitutional rights-based approach to healthcare access. Accordingly, we also suggest that a South African HTA body ought to consider more demanding considerations related to transparency and revisions as well as explicit considerations related to inclusivity.

Should rare diseases get special treatment?

Orphan drug policy often gives 'special treatment' to rare diseases, by giving additional priority or making exceptions to specific drugs, based on the rarity of the conditions they aim to treat. This essay argues that the goal of orphan drug policy should be to make prevalence irrelevant to funding decisions. It aims to demonstrate that it is severity, not prevalence, which drives our judgments that important claims are being overlooked when treatments for severe rare diseases are not funded. It shows that prioritising severity avoids problems caused by prioritising rarity, and that it is compatible with a range of normative frameworks. The implications of a severity-based view for drug development are then derived. The severity-based view also accounts for what is wrong with how the current system of drug development unfairly neglects common diseases that burden the developing world. Lastly, the implications of a severity-based view for current orphan drug policies are discussed.

Expectations for the Development of Health Technology Assessment in Brazil

The implementation of health technology assessment (HTA) in emerging countries depends on the characteristics of the health care system and the needs of public health care. The objective of this survey was to investigate experts' expectations for the development of HTA in Brazil and to derive measures to strengthen the impact of HTA in Brazil on health care decisions. Based on a scoping literature review, a questionnaire was developed proposing eight theses for seven domains of HTA: (i) capacity building, (ii) public involvement, (iii) role of cost-effectiveness analysis (CEA), (iv) institutional framework, (v) scope of HTA studies, (vi) methodology of HTA, and (vii) HTA as the basis for jurisdiction. Thirty experts responded in full to the survey and agreed to five of the eight theses proposed. Experts suggested several measures to promote HTA within the scope of each domain, thus addressing capacity building related to HTA, availability, and reliability of population data, and legal endowment of the HTA system. Finally, HTA processes in Brazil should also address public health issues (e.g., appraisal of interventions directed at chronic diseases).

Integration of ethical considerations into HTA reports: an analysis of integration levels using a systematic review

OBJECTIVE

To describe the type and level of ethical integration in published health technology assessment (HTA) reports and systematically identify the ethical approaches utilized.

METHODS

A literature search was conducted with the Google™ search engine using the keyword "ethic" between 1 January 2015 and 20 August 2019. Only HTA assessment reports with a section on ethics were retained and classified according to their level of ethical integration: no ethical analysis, ethical issues highlighted, assessments according to legal or social norms, and assessments from a moral or axiological perspective-using a qualitative methodology to distinguish such integration.

RESULTS

This review yielded 188 reports with a section identified as being on ethics, produced by seventeen HTA agencies in eleven countries. One hundred and thirty-six reports did not develop an ethical analysis, thirty-one highlighted ethical issues, seventeen conducted a norm-based ethical assessment using a descriptive approach grounded in social norms, and four developed an assessment grounded in a moral or axiological perspective. The bioethical "four-principles" framework was used, but mainly for presenting ethical issues and not as a moral framework.

CONCLUSIONS

The majority of reports featuring a section on ethics mention ethical considerations without ethical analysis. Ethical issues are grouped with legal, social, and organizational issues and treated as contextual considerations that decision makers should be aware of. When reports present systematic norm-based ethical assessments from a descriptive perspective or ethical assessment based on a moral or axiological perspective, there is a tendency to ground these analyses in frameworks created for the purpose and reliant on a concept of ethics supporting them.

Examining Equity Effects of Health Interventions in Cost-Effectiveness Analysis: A Systematic Review

OBJECTIVE

This systematic review aims to catalogue and describe published applications of equity-informative cost-effectiveness analysis (CEAs).

METHODS

Following PRISMA guidelines, we searched Medline for English-language, peer-reviewed CEAs published on or before August 2019. We included CEAs that evaluated 2 or more alternatives; explicitly mentioned equity as a consideration or decision-making principle; and applied an equity-informative CEA method to analyze or examine at least 1 equity criterion in an applied CEA. We extracted data on selected characteristics and analyzed reporting quality using the CHEERS checklist.

RESULTS

Fifty-four articles identified through a search and bibliography reviews met the inclusion criteria. All articles were published on or after 2010, with 80% published after 2015. Most studies evaluated primary prevention interventions in disease areas such as cancer, infectious diseases, and cardiovascular disease. Equity impact analysis alone was the most common equity-informative CEA (56%), followed by equity impact analysis with financial protection effects (30%). At least 11 different equity criteria have been used in equity-informative CEAs; socioeconomic status and race/ethnicity were used most frequently. Seventy-eight percent of studies reported finding "greater value" in an intervention after examining its distributional effects.

CONCLUSION

The number of equity-informative CEAs is increasing, and the wide range of equity criteria, diseases, interventions, settings, and populations represented suggests that broad application of these methods is feasible but will require further refinement. Inclusion of equity into CEAs may shift the value of evaluated interventions and can provide crucial additional information for decision makers.

WICID framework version 1.0: criteria and considerations to guide evidence-informed decision-making on non-pharmacological interventions targeting COVID-19

Introduction

Public health decision-making requires the balancing of numerous, often conflicting factors. However, participatory, evidence-informed decision-making processes to identify and weigh these factors are often not possible- especially, in the context of the SARS-CoV-2 pandemic. While evidence-to-decision frameworks are not able or intended to replace stakeholder participation, they can serve as a tool to approach relevancy and comprehensiveness of the criteria considered.

Objective

To develop a decision-making framework adapted to the challenges of decision-making on non-pharmacological interventions to contain the global SARS-CoV-2 pandemic.

Methods

We employed the ‘best fit’ framework synthesis technique and used the WHO-INTEGRATE framework as a starting point. First, we adapted the framework through brainstorming exercises and application to case studies. Next, we conducted a content analysis of comprehensive strategy documents intended to guide policymakers on the phasing out of applied lockdown measures in Germany. Based on factors and criteria identified in this process, we developed the WICID (WHO-INTEGRATE COVID-19) framework version 1.0.

Results

Twelve comprehensive strategy documents were analysed. The revised framework consists of 11+1 criteria, supported by 48 aspects, and embraces a complex systems perspective. The criteria cover implications for the health of individuals and populations due to and beyond COVID-19, infringement on liberties and fundamental human rights, acceptability and equity considerations, societal, environmental and economic implications, as well as implementation, resource and feasibility considerations.

Discussion

The proposed framework will be expanded through a comprehensive document analysis focusing on key stakeholder groups across the society. The WICID framework can be a tool to support comprehensive evidence-informed decision-making processes.

Around the Tables - Contextual Factors in Healthcare Coverage Decisions Across Western Europe

Background: Across Western Europe, procedures and formalised criteria for taking decisions on the coverage (inclusion in the benefits basket or equivalent) of healthcare technologies vary substantially. In the decision documents, which display the justification of, the rationale for, these decisions, national healthcare institutes may employ ‘contextual factors,’ defined here as situation-specific considerations. Little is known about how the use of such contextual factors compares across countries. We describe and compare contextual factors as used in coverage decisions generally and 4 decision documents specifically in Belgium, England, Germany, and the Netherlands.

Methods: Four group interviews with 3 experts from the national healthcare institute of each country, document and web site analysis, and a workshop with 1 to 2 of these experts per country were followed by the examination of the documents of 4 specific decisions taken in each of the 4 countries, sampled to vary widely in type of technology and decision outcome.

Results: From the available decision documents, we conclude that in every country studied, contextual factors are established ‘around the table,’ ie, in deliberation. All documents examined feature contextual factors, with similar contextual factor patterns leading to similar decisions in different countries. The Dutch decisions employ the widest variety of factors, with the exception of the societal functioning of the patient, which is relatively common in Belgium, England, and Germany. Half of the final decisions were taken in another setting, with the consequence that no documentation was retrievable for 2 decisions.

Conclusion: First, we conclude that in these countries, contextual factors are actively integrated in the decision document, and that this is achieved in deliberation. Conceptualising contextual factors as both situation-specific and actively-integrated affords insight into practices of contextualisation and provides an encouragement for exchange between decision-makers on more qualitative aspects of decisions. Second, the decisions that lacked a publicly accessible justification of the final decision document raised questions on the decisions’ legitimacy. Further research could address patterning of contextual factors, elucidate why some factors may remain implicit, and how decisions without a publicly available decision document may enable or restrain decision-making practice.

Integrating public preferences into national reimbursement decisions: a descriptive comparison of approaches in Belgium and New Zealand

Background

Public health care payer organizations face increasing pressures to make transparent and sustainable coverage decisions about ever more expensive prescription drugs, suggesting a need for public engagement in coverage decisions. However, little is known about countries’ approaches to integrating public preferences in existing funding decisions. The aim of this study was to describe how Belgium and New Zealand used deliberative processes to engage the public and to identify lessons learned from these countries’ approaches.

Methods

To describe two countries’ deliberative processes, we first reviewed key country policy documents and then conducted semi-structured interviews with five leaders of the processes from Belgium and New Zealand. We assessed each country’s rationales for and approaches to engaging the public in pharmaceutical coverage decisions and identified lessons learned. We used qualitative content analysis of the interviews to describe key themes and subthemes.

Results

In both countries, the national public payer organization initiated and led the process of integrating public preferences into national coverage decision making. Reimbursement criteria considered outdated and changing societal expectations prompted the change. Both countries chose a deliberative process of public engagement with a multi-year commitment of many stakeholders to develop new reimbursement processes. Both countries’ new reimbursement processes put a stronger emphasis on quality of life, the separation of individual versus societal perspectives, and the importance of final reimbursement decisions being taken in context rather than based largely on cost-effectiveness thresholds.

Conclusions

To face the growing financial pressure of sustainable funding of medicines, Belgium’s and New Zealand’s public payers have developed processes to engage the public in defining the reimbursement system’s priorities. Although these countries differ in context and geographic location, they came up with overlapping lessons learnt which include the need for 1) political commitment to initiate change, 2) broad involvement of all stakeholders, and 3) commitment of all to engage in a long-term process. To evaluate these changes, further research is required to understand how coverage decisions in systems with and without public engagement differ.

A systems perspective on the importance of global health strategy developments for accomplishing today's Sustainable Development Goals

Priority setting within health systems has not led to accountable, fair and sustainable solutions to improving population health. Providers, users and other stakeholders each have their own health and service priorities based on selected evidence, own values, expertise and preferences. Based on a historical account, this article analyses if contemporary health systems are appropriate to optimize population health within the framework of cross cutting targets of the Sustainable Development Goals (SDGs). We applied a scoping review approach to identify and review literature of scientific databases and other programmatic web and library-based documents on historical and contemporary health systems policies and strategies at the global level. Early literature supported the 1977 launching of the global target of Health for All by the year 2000. Reviewed literature was used to provide a historical overview of systems components of global health strategies through describing the conceptualizations of health determinants, user involvement and mechanisms of priority setting over time, and analysing the importance of historical developments on barriers and opportunities to accomplish the SDGs. Definitions, scope and application of health systems-associated priority setting fluctuated and main health determinants and user influence on global health systems and priority setting remained limited. In exploring reasons for the identified lack of SDG-associated health systems and priority setting processes, we discuss issues of accountability, vested interests, ethics and democratic legitimacy as conditional for future sustainability of population health. To accomplish the SDGs health systems must engage beyond their own sector boundary. New approaches to Health in All Policies and One Health may be conducive for scaling up more democratic and inclusive priority setting processes based on proper process guidelines from successful pilots. Sustainable development depends on population preferences supported by technical and managerial expertise.

Expanding HTA – Correcting a Misattribution, Clarifying the Scope of HTA and CEA Comment on "Ethics in HTA: Examining the ‘Need for Expansion’"

Abrishami, Oortwijn, and Hofman (AOH) attribute to me a position I do not hold and an argument I did not make. The purpose of this note is make clear what my position actually is and to clarify the main differences between health technology assessment (HTA) and cost-effectiveness analysis (CEA).

Hospital staff perspectives towards health technology assessment: data from a multidisciplinary survey

BACKGROUND

Technology adoption in hospitals is usually based on cost-effectiveness analysis, feasibility and potential success. Different countries have embraced a range of principles to accomplish an effective comprehensive process of health technology assessment (HTA). The aim of the study was to analyse the viewpoints and relative weight of technology-oriented hospital staff members toward the clinical, social, technological and economic aspects of HTA.

METHODS

Using a structured questionnaire, a survey was conducted among different professionals in an 850-bed hospital.

RESULTS

We revealed a range of viewpoints among hospital staff members according to their personal characteristics and professional standpoints. The clinical aspects of HTA were considered 'highly important' (HI) by most participants, especially the 'lifesaving' parameter. Similarly, the 'lack of effective alternative technology' was ranked HI by a high percentage of participants, independent of their profession. Economic aspects were ranked HI only by half of the participants, while social and technological aspects were ranked HI only by a relatively low percentage. Nurses added 'improving quality of life', 'increasing teamwork efficiency' and 'improving medical standards'. Allied health professionals focused on 'lack of effective alternative technologies' as a main argument for adoption of HTA, alongside increasing efficiency, budget savings and contribution to hospital reputation. Engineers emphasised the requirement of significant investment in infrastructure and increasing efficiency. Administrators ranked patient experience as HI. Interestingly, the high ranking of social aspects correlated with older responders, while junior staff ranked safety significantly higher.

CONCLUSIONS

A multi-perspective multidisciplinary approach would be beneficial for policy-makers at hospitals and even on a national scale in Israel.

Moving Towards Accountability for Reasonableness - A Systematic Exploration of the Features of Legitimate Healthcare Coverage Decision-Making Processes Using Rare Diseases and Regenerative Therapies as a Case Study

Background: The accountability for reasonableness (A4R) framework defines 4 conditions for legitimate healthcare coverage decision processes: Relevance, Publicity, Appeals, and Enforcement. The aim of this study was to reflect on how the diverse features of decision-making processes can be aligned with A4R conditions to guide decision-making towards legitimacy. Rare disease and regenerative therapies (RDRTs) pose special decision-making challenges and offer therefore a useful case study.

Methods: Features operationalizing each A4R condition as well as three different approaches to address these features (cost-per-QALY-focused and multicriteria-based) were defined and organized into a matrix. Seven experts explored these features during a panel run under the Chatham House Rule and provided general and RDRT-specific recommendations. Responses were analyzed to identify converging and diverging recommendations.

Results: Regarding Relevance, recommendations included supporting deliberation, stakeholder participation and grounding coverage decision criteria in normative and societal objectives. Thirteen of 17 proposed decision criteria were recommended by a majority of panelists. The usefulness of universal cost-effectiveness thresholds to inform allocative efficiency was challenged, particularly in the RDRT context. RDRTs raise specific issues that need to be considered; however, rarity should be viewed in relation to other aspects, such as disease severity and budget impact. Regarding Publicity, panelists recommended transparency about the values underlying a decision and value judgements used in selecting evidence. For Appeals, recommendations included a life-cycle approach with clear provisions for re-evaluations. For Enforcement, external quality reviews of decisions were recommended.

Conclusion: Moving coverage decision-making processes towards enhanced legitimacy in general and in the RDRT context involves designing and refining approaches to support participation and deliberation, enhancing transparency, and allowing explicit consideration of multiple decision criteria that reflect normative and societal objectives.

Defining priority medical devices for cancer management: a WHO initiative

Medical devices are indispensable for cancer management across the entire cancer care continuum, yet many existing medical interventions are not equally accessible to the global population, contributing to disparate mortality rates between countries with different income levels. Improved access to priority medical technologies is required to implement universal health coverage and deliver high-quality cancer care. However, the selection of appropriate medical devices at all income and hospital levels has been difficult because of the extremely large number of devices needed for the full spectrum of cancer care; the wide variety of options within the medical device sector, ranging from small inexpensive disposable devices to sophisticated diagnostic imaging and treatment units; and insufficient in-country expertise, in many countries, to prioritise cancer interventions and to determine associated technologies. In this Policy Review, we describe the methods, process, and outcome of a WHO initiative to define a list of priority medical devices for cancer management. The methods, approved by the WHO Guidelines Review Committee, can be used as a model approach for future endeavours to define and select medical devices for disease management. The resulting list provides ready-to-use guidance for the selection of devices to establish, maintain, and operate necessary clinical units within the continuum of care for six cancer types, with the goal of promoting efficient resource allocation and increasing access to priority medical devices, particularly in low-income and middle-income countries.

[Ethics in health technology assessment. Review]

INTRODUCTION

Bioethics and the health technologies assessment emerged to help make decisions. The objective of the work was to know, with respect to the health technologies assessment, the scientific production on its ethical issues, the degree of incorporation of these in practice, the inclusion of the values in the deliberative processes and the most relevant approaches to ethical analysis.

METHODOLOGY

A narrative review was made, based on a systematic search of literature in both natural and hierarchical language, using the terms technology assessment biomedical, ethics and deliberation (and its related terms). All types of papers published between May 2007 and April 2017 in Spanish, French, English or Italian that included both ethical aspects and health technology assessment were included. The PUBMED, OVID-Medline, Scopus databases and secondary searches were explored from the identified works. The information was extracted by a single researcher and managed with Mendeley and EPIINFO 7.2.

RESULTS

A total of 141 papers were identified, including 85 after revision by title and summary, with the following characteristics: 29 reviews (5 systematic), 16 frameworks, 18 methodological works and 29 with description of experiences. Multiple frameworks, approaches and methods in ethical analysis were identified.

CONCLUSION

The health technologies assessment has an approach excessively mechanistic, and can be improved by incorporating the values of the stakeholder, through deliberative processes. The methods of ethical analysis that seem most suitable are the axiological ones and those developed specifically for the health technologies assessment.

Can reflective multicriteria be the new paradigm for healthcare decision-making? The EVIDEM journey

Background

Multiple technologies, procedures and programs call for fairly-based decisions for prioritization of healthcare interventions. There is a diversity of perspectives of what constitutes a legitimate decision, which depends on both the process and the reasoning applied. Current approaches focus on technical aspects while methods to support alignment of decisions with the compassionate impetus of healthcare systems is lacking.

Methods

The framework was developed based on an analysis of the foundations of healthcare systems, the reasoning underlying decisions and fair processes. The concept of reflective multicriteria was created: it assumes that decisionmakers guided by a generic interpretative frame rooted in the compassionate impetus of healthcare systems, can sharpen their reasoning, raise awareness of their motivation and increase legitimacy of decisions. The initial framework was made available through a not for profit organization (the EVIDEM Collaboration, 2006–2017) to stimulate its development with thought leaders and stakeholders in an open source philosophy. Development was tailored to the real-life needs of decisionmakers and drew on several domains of knowledge including healthcare ethics, evidenced-based medicine, health economics, health technology assessment and multicriteria approaches.

Results

The 10th edition framework builds on four dimensions: (1) the universal impetus of healthcare systems, (2) reasoning, values and ethics, (3) evidence and knowledge on interventions, and (4) a transformative process. Mathematical aspects of the framework are designed to help clarify, express and share individual reasoning; this non-conventional use of numbers requires a cultural change and needs to be phased in slowly. The framework includes four tools for easy adaptation and operationalization: (a) concepts and operationalization, (b) adapt and pilot, (c) evidence matrix, (d) mathematical representation of reasoning. Application is useful throughout all types of healthcare interventions, for all levels of decision, and across the globe.

Conclusion

By clarifying their reasoning while keeping decisionmakers aware of the impetus of healthcare systems, reflective multicriteria provides an effective approach to increase the legitimacy of decisions. Beyond a tool, reflective multicriteria pioneered by EVIDEM is geared to transform our vision of the value of healthcare interventions and how they might contribute to relevant, equitable and sustainable healthcare systems.

Electronic supplementary material

The online version of this article (10.1186/s12962-018-0116-9) contains supplementary material, which is available to authorized users.

MCDA from a health economics perspective: opportunities and pitfalls of extending economic evaluation to incorporate broader outcomes

BACKGROUND

Multi-criteria decision analysis (MCDA) is a structured decision-making process that offers greater flexibility to incorporate multiple objectives than cost-effectiveness analysis or benefit-cost analysis.

CONCLUSIONS

The flexibility of MCDA requires careful consideration of its methodological underpinnings, analytical forms and cognitive biases that may arise in eliciting trade-off. The methodology of MCDA should ideally incorporate both deliberative and technical processes.

Gains in health utility associated with urinary catheter innovations

Purpose

To estimate gains in health utility for two different catheter features and a support service related to urinary catheters used for intermittent catheterization.

Patients and methods

Two internet-based time trade-off (TTO) surveys were undertaken to value vignettes describing two innovative catheter features and a support service. The first TTO survey “Size and Service” included catheters with compact design and the availability of a support service for users; the second TTO survey “Phthalates” included avoidance of potentially harmful phthalates in the material of the catheters. All participants were from the UK; they traded health states against a time horizon that matched their total life expectancy. Sensitivity analyses were done to estimate the impact of extreme values on disutilities.

Results

The participants (n=890) estimated the incremental value of 0.031 (95% CI: 0.024–0.039), 0.009 (95% CI: 0.003–0.015), and 0.037 (95% CI: 0.027–0.046), respectively, for catheters with compact design, availability of support service, and catheters not containing phthalates.

Conclusions

Participants valued all three improvements in catheter design. To capture the impact of such design improvements on quality of life and utilities, vignette-based approaches can be a useful supplement to the conventional, generic tools.

ETHICS IN HEALTH TECHNOLOGY ASSESSMENT: A SYSTEMATIC REVIEW

OBJECTIVES

Integration of ethics into health technology assessment (HTA) remains challenging for HTA practitioners. We conducted a systematic review on social and methodological issues related to ethical analysis in HTA. We examined: (1) reasons for integrating ethics (social needs); (2) obstacles to ethical integration; (3) concepts and processes deployed in ethical evaluation (more specifically value judgments) and critical analyses of formal experimentations of ethical evaluation in HTA.

METHODS

Search criteria included "ethic," "technology assessment," and "HTA". The literature search was done in Medline/Ovid, SCOPUS, CINAHL, PsycINFO, and the international HTA Database. Screening of citations, full-text screening, and data extraction were performed by two subgroups of two independent reviewers. Data extracted from articles were grouped into categories using a general inductive method.

RESULTS

A list of 1,646 citations remained after the removal of duplicates. Of these, 132 were fully reviewed, yielding 67 eligible articles for analysis. The social need most often reported was to inform policy decision making. The absence of shared standard models for ethical analysis was the obstacle to integration most often mentioned. Fairness and Equity and values embedded in Principlism were the values most often mentioned in relation to ethical evaluation.

CONCLUSIONS

Compared with the scientific experimental paradigm, there are no settled proceedings for ethics in HTA nor consensus on the role of ethical theory and ethical expertise hindering its integration. Our findings enable us to hypothesize that there exists interdependence between the three issues studied in this work and that value judgments could be their linking concept.

The values and ethical commitments of doctors engaging in macroallocation: a qualitative and evaluative analysis

BACKGROUND

In most socialised health systems there are formal processes that manage resource scarcity and determine the allocation of funds to health services in accordance with their priority. In this analysis, part of a larger qualitative study examining the ethical issues entailed in doctors' participation as technical experts in priority setting, we describe the values and ethical commitments of doctors who engage in priority setting and make an empirically derived contribution towards the identification of an ethical framework for doctors' macroallocation work.

METHOD

We conducted semi-structured interviews with 20 doctors, each of whom participated in macroallocation at one or more levels of the Australian health system. Our sampling, data-collection, and analysis strategies were closely modelled on grounded moral analysis, an iterative empirical bioethics methodology that employs contemporaneous interchange between the ethical and empirical to support normative claims grounded in practice.

RESULTS

The values held in common by the doctors in our sample related to the domains of personal ethics ('taking responsibility' and 'persistence, patience, and loyalty to a cause'), justice ('engaging in distributive justice', 'equity', and 'confidence in institutions'), and practices of argumentation ('moderation' and 'data and evidence'). Applying the principles of grounded moral analysis, we identified that our participants' ideas of the good in macroallocation and their normative insights into the practice were strongly aligned with the three levels of Paul Ricoeur's 'little ethics': 'aiming at the "good life" lived with and for others in just institutions'.

CONCLUSIONS

Our findings suggest new ways of understanding how doctors' values might have procedural and substantive impacts on macroallocation, and challenge the prevailing assumption that doctors in this milieu are motivated primarily by deontological considerations. Our empirical bioethics approach enabled us to identify an ethical framework for medical work in macroallocation that was grounded in the values and ethical intuitions of doctors engaged in actions of distributive justice. The concordance between Ricoeur's 'little ethics' and macroallocation practitioners' experiences, and its embrace of mutuality, suggest that it has the potential to guide practice, support ethical reflection, and harmonise deliberative practices amongst actors in macroallocation generally.

A Health Economics Approach to US Value Assessment Frameworks-Introduction: An ISPOR Special Task Force Report [1]

Concerns about rising spending on prescription drugs and other areas of health care have led to multiple initiatives in the United States designed to measure and communicate the value of pharmaceuticals and other technologies for decision making. In this section we introduce the work of the International Society for Pharmacoeconomics and Outcomes Research Special Task Force on US Value Assessment Frameworks formed to review relevant perspectives and appropriate approaches and methods to support the definition and use of high-quality value frameworks. The Special Task Force was part of the International Society for Pharmacoeconomics and Outcomes Research Initiative on US Value Assessment Frameworks, which enlisted the expertise of leading health economists, concentrating on what the field of health economics can provide to help inform the development and use of value assessment frameworks. We focus on five value framework initiatives: the American College of Cardiology/American Heart Association, the American Society of Clinical Oncology, the Institute for Clinical and Economic Review, the Memorial Sloan Kettering Cancer Center, and the National Comprehensive Cancer Network. These entities differ in their missions, scope of activities, and methodological approaches. Because they are gaining visibility and some traction in the United States, it is essential to scrutinize whether the frameworks use approaches that are transparent as well as conceptually and methodologically sound. Our objectives were to describe the conceptual bases for value and its use in decision making, critically examine existing value frameworks, discuss the importance of sound conceptual underpinning, identify key elements of value relevant to specific decision contexts, and recommend good practice in value definition and implementation as well as areas for further research.

Preventing type 2 diabetes: systematic review of studies of cost-effectiveness of lifestyle programmes and metformin, with and without screening, for pre-diabetes

OBJECTIVE

Explore the cost-effectiveness of lifestyle interventions and metformin in reducing subsequent incidence of type 2 diabetes, both alone and in combination with a screening programme to identify high-risk individuals.

DESIGN

Systematic review of economic evaluations.

DATA SOURCES AND ELIGIBILITY CRITERIA

Database searches (Embase, Medline, PreMedline, NHS EED) and citation tracking identified economic evaluations of lifestyle interventions or metformin alone or in combination with screening programmes in people at high risk of developing diabetes. The International Society for Pharmaco-economics and Outcomes Research's Questionnaire to Assess Relevance and Credibility of Modelling Studies for Informing Healthcare Decision Making was used to assess study quality.

RESULTS

27 studies were included; all had evaluated lifestyle interventions and 12 also evaluated metformin. Primary studies exhibited considerable heterogeneity in definitions of pre-diabetes and intensity and duration of lifestyle programmes. Lifestyle programmes and metformin appeared to be cost effective in preventing diabetes in high-risk individuals (median incremental cost-effectiveness ratios of £7490/quality-adjusted life-year (QALY) and £8428/QALY, respectively) but economic estimates varied widely between studies. Intervention-only programmes were in general more cost effective than programmes that also included a screening component. The longer the period evaluated, the more cost-effective interventions appeared. In the few studies that evaluated other economic considerations, budget impact of prevention programmes was moderate (0.13%-0.2% of total healthcare budget), financial payoffs were delayed (by 9-14 years) and impact on incident cases of diabetes was limited (0.1%-1.6% reduction). There was insufficient evidence to answer the question of (1) whether lifestyle programmes are more cost effective than metformin or (2) whether low-intensity lifestyle interventions are more cost effective than the more intensive lifestyle programmes that were tested in trials.

CONCLUSIONS

The economics of preventing diabetes are complex. There is some evidence that diabetes prevention programmes are cost effective, but the evidence base to date provides few clear answers regarding design of prevention programmes because of differences in denominator populations, definitions, interventions and modelling assumptions.

Health technology assessment process of a cardiovascular medical device in four different settings

AIM

Health technology assessment (HTA) is a tool to help the decision-making process. The aim is to describe methods and processes used in the reimbursement decision making for drug-eluting stents (DES) in four different settings.

METHODS

DES as a technology under study was selected according to different criteria, all of them agreed by a working group. A survey of key informants was designed.

RESULTS

DES was evaluated following well-structured HTA processes. Nonetheless, scope for improvement was observed in relation to the data considered for the final decision, the transparency and inclusiveness of the process as well as in the methods employed.

CONCLUSION

An attempt to describe the HTA processes of a well-known medical device.

EXPLORING VALUES OF HEALTH TECHNOLOGY ASSESSMENT AGENCIES USING REFLECTIVE MULTICRITERIA AND RARE DISEASE CASE

Objectives: Tackling ethical dilemmas faced by reimbursement decision makers requires deeper understanding of values on which health technology assessment (HTA) agencies are founded and how trade-offs are made. This was explored in this study including the case of rare disease.

Methods: Representatives from eight HTA explored values on which institutions are founded using a narrative approach and reflective multicriteria (developed from EVIDEM, criteria derived from ethical imperatives of health care). Trade-offs between criteria and the impact of incorporating defined priorities (including for rare diseases) were explored through a quantitative values elicitation exercise.

Results: Participants reported a diversity of substantive and procedural values with a common emphasis on scientific excellence, stakeholder involvement, independence, and transparency. Examining the ethical imperatives behind EVIDEM criteria was found to be useful to further explore substantive values. Most criteria were deemed to reflect institutions’ values, while 70 percent of the criteria were reported by at least half of participants to be considered formally by their institutions. The quantitative values elicitation highlighted the difficulty to balance imperatives of “alleviating or preventing patient suffering,” “serving the whole population equitably,” “upholding healthcare system sustainability,” and “making decisions informed by evidence and context” but may help share the ethical reasoning behind decisions. Incorporating “Priorities” (including for rare diseases) helped reveal trade-offs from other criteria and their underlying ethical imperatives.

Conclusions: Reflective multicriteria are useful to explore substantive values of HTAs, reflect how these values and their ethical underpinnings can be operationalized into criteria, and explore the ethical reasoning at the heart of the healthcare debate.

Ethics in HTA: Examining the "Need for Expansion"

The article by Daniels and colleagues on expanding the scope of health technology assessment (HTA) to embrace ethical analysis has received endorsement and criticism from commentators in this journal. Referring to this debate, we examine in this article the extent and locus of ethical analysis in HTA processes. An expansion/no-expansion framing of HTA is, in our view, not very fruitful. We argue that meaningfulness and relevance to the needs of the population are what should determine the extent of ethics in HTA. Once ‘relevance’ is the guiding principle, engaging in ethical analysis becomes inevitable as values are all over the place in HTA, also in how assessors frame research questions. We also challenge dividing the locus of ethical analysis into assessment and appraisal as this would detach HTA from its purpose, ie, supporting legitimate decision-making. Ethical analysis should therefore be considered integral to the HTA process.

Towards Integrated Health Technology Assessment for Improving Decision Making in Selected Countries

OBJECTIVES

To assess the level of comprehensiveness of health technology assessment (HTA) practices around the globe and to formulate recommendations for enhancing legitimacy and fairness of related decision-making processes.

METHODS

To identify best practices, we developed an evaluation framework consisting of 13 criteria on the basis of the INTEGRATE-HTA model (integrative perspective on assessing health technologies) and the Accountability for Reasonableness framework (deliberative appraisal process). We examined different HTA systems in middle-income countries (Argentina, Brazil, and Thailand) and high-income countries (Australia, Canada, England, France, Germany, Scotland, and South Korea). For this purpose, desk research and structured interviews with relevant key stakeholders (N = 32) in the selected countries were conducted.

RESULTS

HTA systems in Canada, England, and Scotland appear relatively well aligned with our framework, followed by Australia, Germany, and France. Argentina and South Korea are at an early stage, whereas Brazil and Thailand are at an intermediate level. Both desk research and interviews revealed that scoping is often not part of the HTA process. In contrast, providing evidence reports for assessment is well established. Indirect and unintended outcomes are increasingly considered, but there is room for improvement. Monitoring and evaluation of the HTA process is not well established across countries. Finally, adopting transparent and robust processes, including stakeholder consultation, takes time.

CONCLUSIONS

This study presents a framework for assessing the level of comprehensiveness of the HTA process in a country. On the basis of applying the framework, we formulate recommendations on how the HTA community can move toward a more integrated decision-making process using HTA.

Equity in HTA: what doesn't get measured, gets marginalised

When making recommendations about the public funding of new health technologies, policy makers typically pay close attention to quantitative evidence about the comparative effectiveness, cost effectiveness and budget impact of those technologies – what we might call “efficiency” criteria. Less attention is paid, however, to quantitative evidence about who gains and who loses from these public expenditure decisions, and whether those who gain are better or worse off than the rest of the population in terms of their health – what we might call “equity” criteria. Two studies recently published in this journal by Shmueli and colleagues suggest that this efficiency-oriented imbalance in the use of quantitative evidence may have unfortunate consequences – as the old adage goes: “what gets measured, gets done”. The first study, by Shmueli, Golan, Paolucci and Mentzakis, found that health policy makers in Israel think equity considerations are just as important as efficiency considerations – at least when it comes to making hypothetical technology funding decisions in a survey. By contrast, the second study – by Shmueli alone – found that efficiency rules the roost when it comes to making real decisions about health technology funding in Israel. Both studies have limitations and potential biases, and more research is needed using qualitative methods and more nuanced survey designs to determine precisely which kinds of equity consideration decision makers think are most important and why these considerations do not appear to be given much weight in decision making. However, the basic overall finding from the two studies seems plausible and important. It suggests that health technology funding bodies need to pay closer attention to equity considerations, and to start making equity a quantitative endpoint of health technology assessment using the methods of equity-informative economic evaluation that are now available.

Cost-effectiveness of implementing computed tomography screening for lung cancer in Taiwan

BACKGROUND

A screening program for lung cancer requires more empirical evidence. Based on the experience of the National Lung Screening Trial (NLST), we developed a method to adjust lead-time bias and quality-of-life changes for estimating the cost-effectiveness of implementing computed tomography (CT) screening in Taiwan.

METHODS

The target population was high-risk (≥30 pack-years) smokers between 55 and 75 years of age. From a nation-wide, 13-year follow-up cohort, we estimated quality-adjusted life expectancy (QALE), loss-of-QALE, and lifetime healthcare expenditures per case of lung cancer stratified by pathology and stage. Cumulative stage distributions for CT-screening and no-screening were assumed equal to those for CT-screening and radiography-screening in the NLST to estimate the savings of loss-of-QALE and additional costs of lifetime healthcare expenditures after CT screening. Costs attributable to screen-negative subjects, false-positive cases and radiation-induced lung cancer were included to obtain the incremental cost-effectiveness ratio from the public payer's perspective.

RESULTS

The incremental costs were US$22,755 per person. After dividing this by savings of loss-of-QALE (1.16 quality-adjusted life year (QALY)), the incremental cost-effectiveness ratio was US$19,683 per QALY. This ratio would fall to US$10,947 per QALY if the stage distribution for CT-screening was the same as that of screen-detected cancers in the NELSON trial.

CONCLUSIONS

Low-dose CT screening for lung cancer among high-risk smokers would be cost-effective in Taiwan. As only about 5% of our women are smokers, future research is necessary to identify the high-risk groups among non-smokers and increase the coverage.

The Need for Global Application of the Accountability for Reasonableness Approach to Support Sustainable Outcomes Comment on "Expanded HTA: Enhancing Fairness and Legitimacy"

The accountability for reasonableness (AFR) concept has been developed and discussed for over two decades. Its interpretation has been studied in several ways partly guided by the specific settings and the researchers involved. This has again influenced the development of the concept, but not led to universal application. The potential use in health technology assessments (HTAs) has recently been identified by Daniels et al as yet another excellent justification for AFR-based process guidance that refers to both qualitative and a broader participatory input for HTA, but it has raised concerns from those who primarily support the consistency and objectivity of more quantitative and reproducible evidence. With reference to studies of AFR-based interventions and the through these repeatedly documented motivation for their consolidation, we argue that it can even be unethical not to take AFR conditions beyond their still mainly formative stage and test their application within routine health systems management for their expected support to more sustainable health improvements. The ever increasing evidence and technical expertise are necessary but at times contradictory and do not in isolation lead to optimally accountable, fair and sustainable solutions. Technical experts, politicians, managers, service providers, community members, and beneficiaries each have their own values, expertise and preferences, to be considered for necessary buy in and sustainability. Legitimacy, accountability and fairness do not come about without an inclusive and agreed process guidance that can reconcile differences of opinion and indeed differences in evidence to arrive at a by all understood, accepted, but not necessarily agreed compromise in a current context - until major premises for the decision change. AFR should be widely adopted in projects and services under close monitoring and frequent reviews.

Value Assessment Frameworks for HTA Agencies: The Organization of Evidence-Informed Deliberative Processes

Priority setting in health care has been long recognized as an intrinsically complex and value-laden process. Yet, health technology assessment agencies (HTAs) presently employ value assessment frameworks that are ill fitted to capture the range and diversity of stakeholder values and thereby risk compromising the legitimacy of their recommendations. We propose "evidence-informed deliberative processes" as an alternative framework with the aim to enhance this legitimacy. This framework integrates two increasingly popular and complementary frameworks for priority setting: multicriteria decision analysis and accountability for reasonableness. Evidence-informed deliberative processes are, on one hand, based on early, continued stakeholder deliberation to learn about the importance of relevant social values. On the other hand, they are based on rational decision-making through evidence-informed evaluation of the identified values. The framework has important implications for how HTA agencies should ideally organize their processes. First, HTA agencies should take the responsibility of organizing stakeholder involvement. Second, agencies are advised to integrate their assessment and appraisal phases, allowing for the timely collection of evidence on values that are considered relevant. Third, HTA agencies should subject their decision-making criteria to public scrutiny. Fourth, agencies are advised to use a checklist of potentially relevant criteria and to provide argumentation for how each criterion affected the recommendation. Fifth, HTA agencies must publish their argumentation and install options for appeal. The framework should not be considered a blueprint for HTA agencies but rather an aspirational goal-agencies can take incremental steps toward achieving this goal.

Using Cost-Effectiveness Analysis to Address Health Equity Concerns

This articles serves as a guide to using cost-effectiveness analysis (CEA) to address health equity concerns. We first introduce the "equity impact plane," a tool for considering trade-offs between improving total health-the objective underpinning conventional CEA-and equity objectives, such as reducing social inequality in health or prioritizing the severely ill. Improving total health may clash with reducing social inequality in health, for example, when effective delivery of services to disadvantaged communities requires additional costs. Who gains and who loses from a cost-increasing health program depends on differences among people in terms of health risks, uptake, quality, adherence, capacity to benefit, and-crucially-who bears the opportunity costs of diverting scarce resources from other uses. We describe two main ways of using CEA to address health equity concerns: 1) equity impact analysis, which quantifies the distribution of costs and effects by equity-relevant variables, such as socioeconomic status, location, ethnicity, sex, and severity of illness; and 2) equity trade-off analysis, which quantifies trade-offs between improving total health and other equity objectives. One way to analyze equity trade-offs is to count the cost of fairer but less cost-effective options in terms of health forgone. Another method is to explore how much concern for equity is required to choose fairer but less cost-effective options using equity weights or parameters. We hope this article will help the health technology assessment community navigate the practical options now available for conducting equity-informative CEA that gives policymakers a better understanding of equity impacts and trade-offs.

Fair Processes for Priority Setting: Putting Theory into Practice Comment on "Expanded HTA: Enhancing Fairness and Legitimacy"

Embedding health technology assessment (HTA) in a fair process has great potential to capture societal values relevant to public reimbursement decisions on health technologies. However, the development of such processes for priority setting has largely been theoretical. In this paper, we provide further practical lead ways on how these processes can be implemented. We first present the misconception about the relation between facts and values that is since long misleading the conduct of HTA and underlies the current assessment-appraisal split. We then argue that HTA should instead be explicitly organized as an ongoing evidence-informed deliberative process, that facilitates learning among stakeholders. This has important consequences for whose values to consider, how to deal with vested interests, how to consider all values in the decision-making process, and how to communicate decisions. This is in stark contrast to how HTA processes are implemented now. It is time to set the stage for HTA as learning.

Three Case Studies in Making Fair Choices on the Path to Universal Health Coverage

The goal of achieving Universal Health Coverage (UHC) can generally be realized only in stages. Moreover, resource, capacity, and political constraints mean governments often face difficult trade-offs on the path to UHC. In a 2014 report, Making fair choices on the path to UHC, the WHO Consultative Group on Equity and Universal Health Coverage articulated principles for making such trade-offs in an equitable manner. We present three case studies which illustrate how these principles can guide practical decision-making. These case studies show how progressive realization of the right to health can be effectively guided by priority-setting principles, including generating the greatest total health gain, priority for those who are worse off in a number of dimensions (including health, access to health services, and social and economic status), and financial risk protection. They also demonstrate the value of a fair and accountable process of priority setting.

CHANGING HEALTH TECHNOLOGY ASSESSMENT PARADIGMS?

Objectives: Health technology assessment (HTA) has to innovate to best support changing health system environments and to help provide access to valuable innovation under fiscal constraint.

Methods: Issues associated with changing HTA paradigms were identified through scoping and explored through deliberation at a meeting of industry and HTA leaders.

Results: Five broad areas of change (engagement, scientific dialogue, research prioritization, adaptive approaches, and real world data) were identified. The meeting focused on two themes derived from these: re-thinking scientific dialogue and multi-stakeholder engagement, and re-thinking value, affordability, and access. Earlier and ongoing engagement to steer the innovation process and help achieve appropriate use across the technology lifecycle was perceived as important but would be resource intensive and would require priority setting. Patients need to be involved throughout, and particularly at the early stages. Further discussion is needed on the type of body best suited to convening the dialogue required. There was agreement that HTA must continue to assess value, but views differed on the role that HTA should play in assessing affordability and on appropriate responses to challenges around affordability. Enhanced horizon scanning could play an important role in preparing for significant future investments.

Conclusions: Early and ongoing multi-stakeholder engagement and revisiting approaches to valuing innovation are required. Questions remain as to the most appropriate role for HTA bodies. Changing HTA paradigms extend HTA's traditional remit of being responsive to decision-makers demands to being more proactive and considering whole system value.

Expanded HTA, Legitimacy and Independence Comment on "Expanded HTA: Enhancing Fairness and Legitimacy"

This brief commentary seeks to develop the analysis of Daniels, Porteny and Urrutia of the implications of expansion of the scope of health technology assessment (HTA) beyond issues of safety, efficacy, and cost-effectiveness. Drawing in particular on experience in the United Kingdom, it suggests that such expansion can be understood not only as a response to the problem of insufficiency of evidence, but also to that of legitimacy. However, as expansion of HTA also renders it more visibly political in character, it is plausible that its legitimacy may be undermined, rather than enhanced by, independence from the policy process.

HTA - Algorithm or Process? Comment on "Expanded HTA: Enhancing Fairness and Legitimacy"

Daniels, Porteny and Urrutia et al make a good case for the idea that that public decisions ought to be made not only "in the light of" evidence but also "on the basis of" budget impact, financial protection and equity. Health technology assessment (HTA) should, they say, be accordingly expanded to consider matters additional to safety and cost-effectiveness. They also complain that most HTA reports fail to develop ethical arguments and generally do not even mention ethical issues. This comment argues that some of these defects are more apparent than real and are not inherent in HTA - as distinct from being common characteristics found in poorly conducted HTAs. More generally, HTA does not need "extension" since (1) ethical issues are already embedded in HTA processes, not least in their scoping phases, and (2) HTA processes are already sufficiently flexible to accommodate evidence about a wide range of factors, and will not need fundamental change in order to accommodate the new forms of decision-relevant evidence about distributional impact and financial protection that are now starting to emerge. HTA and related techniques are there to support decision-makers who have authority to make decisions. Analysts like us are there to support and advise them (and not to assume the responsibilities for which they, and not we, are accountable). The required quality in HTA then becomes its effectiveness as a means of addressing the issues of concern to decision-makers. What is also required is adherence by competent analysts to a standard template of good analytical practice. The competencies include not merely those of the usual disciplines (particularly biostatistics, cognitive psychology, health economics, epidemiology, and ethics) but also the imaginative and interpersonal skills for exploring the "real" question behind the decision-maker's brief (actual or postulated) and eliciting the social values that necessarily pervade the entire analysis. The product of such exploration defines the authoritative scope of an HTA.

Beyond the Black Box Approach to Ethics! Comment on "Expanded HTA: Enhancing Fairness and Legitimacy"

In the editorial published in this journal, Daniels and colleagues argue that his and Sabin's accountability for reasonableness (A4R) framework should be used to handle ethical issues in the health technology assessment (HTA)-process, especially concerning fairness. In contrast to this suggestion, it is argued that such an approach risks suffering from the irrrelevance or insufficiency they warn against. This is for a number of reasons: lack of comprehensiveness, lack of guidance for how to assess ethical issues within the "black box" of A4R as to issues covered, competence and legitimate arguments and finally seemingly accepting consensus as the final verdict on ethical issues. We argue that the HTA community is already in a position to move beyond this black box approach.