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Health technology assessment (HTA) can impact health inequities by informing healthcare priority-setting decisions. This paper presents a novel checklist to guide HTA practitioners looking to include equity considerations in their work: the equity checklist for HTA (ECHTA). The list is pragmatically organized according to the generic HTA phases and can be consulted at each step.
A first set of items was based on the framework for equity in HTA developed by Culyer and Bombard. After rewording and reorganizing according to five HTA phases, they were complemented by elements emerging from a literature search. Consultations with method experts, decision makers, and stakeholders further refined the items. Further feedback was sought during a presentation of the tool at an international HTA conference. Lastly, the checklist was piloted through all five stages of an HTA.
ECHTA proposes elements to be considered at each one of the five HTA phases: Scoping, Evaluation, Recommendations and Conclusions, Knowledge Translation and Implementation, and Reassessment. More than a simple checklist, the tool provides details and examples that guide the evaluators through an analysis in each phase. A pilot test is also presented, which demonstrates the ECHTA's usability and added value.
ECHTA provides guidance for HTA evaluators wishing to ensure that their conclusions do not contribute to inequalities in health. Several points to build upon the current checklist will be addressed by a working group of experts, and further feedback is welcome from evaluators who have used the tool.
An environmental scan conducted by the Canadian Agency for Drugs and Technologies (CADTH-March-2019) revealed that several health technology assessment (HTA) organisations are currently developing standard health technology reassessment (HTR) processes. Here we present methods used to conduct an HTR of a prioritization programme for non-immediate life-threatening urgent surgeries implemented in 2017 at a tertiary referral hospital in (Quebec-Canada). This HTR initiative was conducted by a regional HTA unit to optimize the programme efficiency and resources utilization as well as to motivate change in the clinical community of other hospitals within its healthcare network. Patient and healthcare personnel satisfaction levels towards the programme were also considered.
In this case study, HTR methods and outputs were elaborated using elements presented in the CADTH environmental scan and relevant publications identified through PubMed and in the grey literature. Documents in English and French, published between January 2002 and March 2019 were considered. Key stakeholders were consulted to identify barriers of the programme implementation to other hospitals in regards to aspects related either to the local medical practice or organizational factors.
The prioritization process was conducted using the same tool applied for HTA appraisal with the additional criterion that the HTR could facilitate the programme implementation. The research processes used in this HTR included: i) systematic review of the literature, ii) hospital database search (efficacy and resource utilization), iii) perceptions of healthcare teams and patients. HTR outputs consist of specific recommendations on implementation barriers and methods to monitor the impacts of the programme.
In this evolving field, sharing lessons from HTR methods provides information to develop standard adaptable processes to different contexts. Hence, this work applies HTR to a healthcare programme while most of the literature focuses on the HTR processes on drug and interventional medicine disinvestment. These elements represented HTR methods used from prioritization appraisal, research processes for evaluation and outputs used to plan the implementation and finally monitoring from a regional HTA unit. It also showcases that HTR being conducted as a structured evidence-based assessment adds value to a healthcare programme and could also facilitate its implementation.
Hospital-based health technology assessment (HB-HTA) needs to consider all relevant data to help decision-making, including patients’ preferences. In this study, we comprehensively describe the process of identification, refinement and selection of attributes and levels for a discrete choice experiment (DCE).
A mixed-methods design was used to identify attributes and levels explaining low back pain (LBP) patients’ choice for a non-surgical treatment. This design combined a systematic literature review with a patients’ focus group, one-on-one interactions with experts and patients, and discussions with stakeholder committee members. Following the patient's focus group, ranking exercises were conducted. A consensus about the attributes and levels was researched during discussions with committee members.
The literature review yielded 40 attributes to consider in patients’ treatment choice. During the focus group, one additional attribute emerged. The ranking exercises allowed selecting eight attributes for the DCE. These eight attributes and their levels were discussed and validated by the committee members who helped reframe two levels in one of the attributes and delete one attribute. The final seven attributes were: treatment modality, pain reduction, onset of treatment efficacy, duration of efficacy, difficulty in daily living activities, sleep problem, and knowledge about their body and pain.
This study is one of the few to comprehensively describe the selection process of attributes and levels for a DCE. This may help ensure transparency and judge the quality of the decision-making process. In the context of a HB-HTA unit, this strengthens the legitimacy to perform a DCE to better inform decision-makers in a patient-centered care approach.
Clinical care pathways (CPWs) provide a step-wise multidisciplinary care plan for patients with a particular health condition. Their aim is to optimize patient outcomes and organization of care by supporting evidence-based practice. It therefore seems inevitable that health technology assessment (HTA) should be incorporated within the development process of a CPW. As CPWs become increasingly utilized, there is a need to understand the added value and strategies to integrating HTA in the development of a CPW.
Through a case study of an HTA on treatments for chronic low back pain requested as part of the development of a CPW for chronic musculoskeletal pain, we demonstrated the three key strategies to include HTA in CPWs described by Rehaluk 2016 and added a fourth one. We then showed how these strategies contribute to the development of a CPW which answers the quality criteria outlined by the Cochrane Effective Practice of Care group through a strength, weaknesses, opportunities, and threats analysis.
We confirmed four key strategies to including HTA in CPWs (organizational positioning of the HTA unit, partnership and communication with stakeholders, tailoring the integration of contextual data with evidence from the literature, explore tools to facilitate the use of HTA findings). The inclusion of HTA through these strategies contributes to the development of a CPW which meets the ten criteria to evaluate the quality of a CPW outlined by the Cochrane Effective Practice of Care group. Through a strength, weaknesses, opportunities, and threats analysis, we describe how each of the criteria were met and how this led to recommendations influencing our regional organization of care.
The inclusion of HTA in CPW development increases its capacity to directly influence organization of care. HTA can represent a pivotal vehicle to ensure good quality CPWs.
There is increased recognition of the need to include equity considerations in HTA. Despite this, a recent World Health Organization report has found that this is seldom the case. We developed a preliminary version of an equity checklist in the hopes that tangible guidance will increase such analyses in the future and contribute to smart capability building.
The checklist is based on the Equity Framework for HTA developed by Culyer & Bombard (2012). The elements presented in the framework were revised to follow the stepwise HTA process. A comprehensive literature search was used to update and complete the elements. The checklist was then piloted in an HTA in 2018 and subsequently further refined through a workshop during a national HTA conference in Canada.
These steps resulted in a 27-item checklist leading to consider different aspects of the three major phases in the HTA process. The scoping phase brings questions relative to defining and contextualizing equity, such as highlighting potential minority groups and including vulnerability factors in the logic model. The development phase leads methodological approaches facilitating the analysis of inequities as well as considering contextual realities leading to inequities. The last phase, drafting of recommendations, aims to be aware of the evidence synthesis approaches as well as the various aspects to ensure recommendations consider existing inequities and avoid contributing to their development.
Given the essence of HTA to protect health by ensuring optimal technologies and interventions are adopted to the benefit of all system users, the consideration of inequities should constitute an integral part of its process. The use of a pragmatic and simple checklist to aid the planning of an HTA could contribute to greater consideration of inequities in the future. A movement in this direction could also lead to greater methodological developments for health equity analysis in HTA.
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