Ultimately, HTA decisions should inform funding of the most valuable interventions within health systems and investment decisions on R&D efforts made by industry. Hence, the methods used by HTAs, which are statements of preferred evidence and approaches for conducting such assessments, are crucial.
When considering why a review should be triggered, there are supply side factors that matter, such as technological advances (and we have seen many in the last few years, from digital health technologies to gene therapies). Novel regulatory frameworks have been created to accelerate approval of promising interventions, but they haven’t been translated into HTA methods updates, increasing the pressure for methods revisions. Key in triggering changes are also methodological developments, particularly when applying a certain technique or framework for value assessment has proven challenging or inadequate in supporting the system in meeting its goals.
OHE has explored and provided solutions on many of these challenges, for example those related to the appropriate evidence and type of economic evaluation to assess digital health technologies, and on the methods to split the value of combination therapies.
When considering how a review can take place, first there is a need for willingness to change practice by the key decision makers including HTA agencies but it is also important to get support from the broader community. An example of when this didn’t take place was in 2014 when, as part of the Value Based Assessment (VBA) proposals, the introduction of proportional shortfall as a measure of severity of illness was suggested but found little endorsement among stakeholders responding to the consultation.
Another key enabler is the availability of accepted approaches to incorporate new methods into practice. Related to severity, proportional shortfall was proposed in the early 2000s by a group of Dutch health economists and since then has been tested and implemented in different contexts. NICE has just introduced an explicit severity modifier based on proportional shortfall and another metric in its new manual. Another example of slow methodological uptake is provided by OHE’s Chris Sampson in his latest editorial.
Finally, we need evidence, in particular empirical evidence in support of methods change. In the case of severity that means studies demonstrating that society is willing to prioritise sicker patients which is available but it is not necessarily captured in HTA decision making.
We might be observing some signs of change endorsement in HTA systems (I am thinking, for example, about the new “modular” approach that NICE is committed to using in upcoming updates) but it still takes far too long (over 10 years in some cases) to alter, evolve or adapt unsatisfactory methods used to assess the value of innovative treatments. The wind of change should be stronger!
