Health Technology Assessment International 7th Annual Meeting

Abstract

A record number of delegates from industry, academia and health policy convened at the 7th Annual Meeting of Health Technology Assessment International (HTAi) which was held in Dublin, Ireland in June 2010. The theme of this year’s meeting was ‘Maximizing the Value of HTA’. The scientific program covered a broad range of topics from coverage with evidence development to timeliness of conducting HTAs, early engagement with stakeholders, value of information analysis, patient involvement and international collaboration. There was also a lively social program with the conference dinner held at the Guinness Storehouse.

The 2010 Health Technology Assessment International (HTAi) conference in Dublin attracted a record number of 1215 delegates, from 53 countries. This is a reflection of the universal relevance of the theme of the conference, maximizing the value of HTA. The conference plenary sessions took a focused look at maximizing the value in meeting the needs of decision-makers, conducting HTAs and international collaboration. This theme was echoed throughout the extensive scientific program with particular emphasis on coverage with evidence development (CED), timeliness, early engagement with stakeholders, value of information (VOI), patient involvement in HTA and international collaboration. There was also a high attendance at the informal session ‘Building a Career in HTA’, which was intended for students or those just embarking on a career in HTA. The preconference workshops covered a wide range of topics, including methods of meta-analysis and systematic review, introduction to Bayesian methods for HTA, introduction to economic evaluation and critical appraisal of cost–effectiveness models submitted to reimbursement agencies.

The conference was opened by the Irish Minister for Health and Children, Mary Harney. In her opening speech, she identified the conference as an invaluable opportunity to learn from the world’s leading experts in HTA and highlighted the need to re-examine available resources, to ensure that best value and performance is achieved within the healthcare system. The second plenary was opened by the President of HTAi, Laura Sampietro Colom and Vice-Chair of International Network of Agencies for Health Technology Assessment (INAHTA) Marjukka Makela, and a minute silence was held for Jill Sanders (HTAi Vice President, Chair of INAHTA and CEO of the Canadian Agency for Drugs and Technologies in Health [CADTH]) who passed away in February 2010. The Jill Sanders Memorial Scholarship was announced to honor Jill’s commitment to HTA. The scholarship will benefit individuals working in and with HTA in Africa.

Coverage with evidence development

International experiences of the introduction of new technologies within a CED or risk-sharing framework were presented, illustrating varying degrees of success. Les Levin (University of Toronto, Canada) illustrated the successful engagement of government and hospital stakeholders in the HTA program in Ontario, Canada [101]. Mega-analyses and field evaluation studies including CED were used to assess effectiveness of health technologies and, in certain circumstances, led to revised recommendations based on real-world clinical utility. The relative benefit of drug-eluting stents in patients with varying risk of restenosis, and subsequent reimbursement decisions, was provided as an example of how these studies feed into the decision-making process. However, the Ontario experience, where datasets are already in existence, is not something that can easily be generated around the world. The UK’s multiple sclerosis risk-sharing experience was presented as an example of a ‘failed scheme’ [1]. The scheme was set up in 2002 to allow patients access to certain disease-modifying drugs after The National Institute for Health and Clinical Excellence (NICE) recommended that these drugs should not be used. It is clear from discussions that many risk-sharing schemes have not achieved stated objectives and more transparency is required regarding research design characteristics, scheme governance and financing. Key lessons are that future efforts must gather evidence in a less costly and time-consuming manner. It was also suggested that these schemes should be the exception not the norm and should not obviate the need for quality research from the outset.

Timeliness

The value of HTA to decision makers and other end users is significantly enhanced if HTA is conducted in a timely manner, ensuring that the output is still relevant to the original research question. The decision maker’s perspective was provided in the opening plenary session by Michael Scanlon, Secretary General of the Irish Department of Health and Children, who noted the key roles of affordability and timeliness in conducting HTAs. Guy Maddern, Director of the Australian Safety and Efficacy Register of New Interventional Procedures – Surgical (ASERNIP-S) addressed the issues of timeliness and relevance, in their rapid review process [2,102]. The involvement of clinicians in the review process may be time-consuming but adds value to a report, ensuring that the questions being answered in a rapid review are relevant to them.

The importance of timeliness to policymakers was addressed by NICE in the development of their single technology appraisal process [103]. The main change from the traditional multiple technology appraisal (MTA) process is reliance on a standard template of industry submissions, shifting the burden of proof on industry and increasing the requirement for frequent communication. The roles and responsibilities of those involved are clearly defined and the publication of industry submissions has helped to maintain the transparency that is inherent in the MTA process.

The necessary balance that must be achieved between the added value from complexity in health economic modeling, and the time taken to incorporate such complexity was discussed by Uwe Siebert (University of Health Sciences, Austria) [102], particularly where the HTA process can be delayed as a result. The trade-off between validity, which increases the chance of an optimal decision, and complexity, which can lead to reduced transparency, reduced acceptance and increased person time and time to decision, was highlighted.

Early engagement with stakeholders

Universal positive feedback was reported by international stakeholders sharing separate experiences of three-way dialogue at early stages of technology development [3]. Representatives from industry, regulation and HTA shared their experiences and reflected on the opportunities and pitfalls of this approach. Novartis have piloted direct engagement with seven prominent pricing and reimbursement agencies in five countries in tandem with licensing authorities in the development of a new compound for plaque psoriasis. The pilot found more similarities than differences across the agencies and highlighted the importance of treating pricing and reimbursement agencies as coprimary users of evidence from Phase III clinical trials.

The National Institute for Health and Clinical Excellence’s experience of collaboration with industry at this early stage, resulted in a greater understanding of the challenges faced by industry in the resource-constrained environment of drug development. Likewise, NICE’s Scientific Advice Program provides an understanding of NICE methods for specific therapeutic indications and information needs for robust HTA. Scientific discussions have focused on various topics including measure of health-related quality of life, use of surrogate end points, choice of comparator, place in clinical practice, modeling beyond trial data, specification of subgroups and usefulness of the primary clinical end point.

Value of information

The potential for VOI and expected value of sample information methods to inform research decisions was debated among methodologists and research funders [4,104]. It was proposed that the cost of uncertainty is associated with a potential for health gains lost. VOI can show where uncertainty lies, focusing research priorities and reducing the probability and consequences of wrong decisions. Examples were provided with a retrospective case study on the use of steroids in head injury; a pilot software tool for VOI modeling and presentation for real-time comparison of economic value of alternative cancer clinical trials; and expected value of sample information for alternative designs of osteoporosis trials. The use of VOI in practice has been variable, however, with limited uptake of the methodology by research funders. Traditionally, the allocation of research funds by the UK National Institute for Health Research is decided by an expert panel of National Health Service (NHS) decision makers taking into account of numerous issues, including timeliness, burden of disease, potential for health gain, economic benefit (though not always formally quantified), and general ‘gut feeling’. A pilot engaged by the Institute on the use of VOI to aid decision making had little impact on decisions. Although VOI was recognized as adding some value, issues, such as equity of access and the capacity to perform the trial, needed to be considered. Methodologists accepted that the more complex the model, the lower the acceptance by decision makers. This may be due to lack of familiarity with formal methods or technical language. The importance of tying pragmatism and theory was a final reminder for all panelists.

Patient engagement

The need to move faster to engage patients’ views, to wake up to the ‘Facebook influence’ was proposed by Albert Jovell (Spain) [102]. Currently, patients view HTA as too complex and focused on cost-containment rather than maximizing health value. Patient engagement through information, education, research and support is needed to incorporate valuable views into HTA. The role of patient adherence to medication was discussed at a special meeting, which explored the potential for HTA to bridge a gap between patients, carers and healthcare professionals by recognizing technologies that facilitate better adherence to treatment and incentivizing such technologies by adding value to a product in terms of innovation [5].

International collaboration

Emerging HTA initiatives throughout the world and experiences of international collaboration were showcased with experiences from Argentina, Taiwan and Poland during the final plenary [105]. A survey of HTA researchers and decision makers throughout Latin America and the Caribbean found that HTA reports from Europe or the USA were regarded as more useful than reports from Latin American/Caribbean countries, including the individual respondents’ own country. Barriers to local applicability of HTA reports include a lack of transparency, low methodological quality and low level of production. However, the region is confident that quality and quantity of local HTA will improve and minimize reliance on adaptation of international research.

The creation of a HTA division in the Taiwan Centre for Drug Evaluation has improved the structure, transparency and consistency of the decision-making process in healthcare in Taiwan. While there is almost complete reliance on reports produced by international HTA organizations, the growing HTA team in Taiwan will soon be in a position to conduct their own evaluations of health technologies.

The potential for capacity building in a new HTA organization through international collaboration was illustrated by the Agency for Health Technology Assessment in Poland (AHTAPol). Using EU funds, staff were given the opportunity to participate in international internships through the European Network for Health Technology Assessment (EUnetHTA) in France, Spain, UK and Denmark. This has allowed AHTAPoL to grow, develop and retain well-trained staff.

These experiences illustrated HTAi’s central role in encouraging and supporting such international collaboration, as in its President’s words, “an important hub of a scale-free network of the decision-making process”.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.