Health technology assessment (HTA) is a scientific field designed to establish tools for the acquisition, use or exchange of medical technologies [1]. The Office of Health Technology Assessment defined the term ‘medical technology’ as “drugs, devices, and diagnostic and therapeutic approaches (general and surgical procedures), as well as administrative frameworks that provide health care” [2, 3]. The methodology of HTA spread around the world in the late 1980s [4,5,6].
The International Network of Agencies for Health Technology Assessment and Health Technology Assessment International deal with strategic issues concerning the present status of HTA, its development and implications for healthcare systems, industry, patients and other stakeholders [3, 7].
The objective in performing HTA is to provide information about treatment alternatives to policy- and decision-makers (Ministry of Health and Government), to medical organisations that provide healthcare services (hospitals or health maintenance organisations), to insurers responsible for the funding, to healthcare practitioners (physicians, nurses, etc.), and to patients and their families [1, 8].
HTA is an inclusive, multidisciplinary scientific process, yielding a profitability estimation of the medical and economic outcomes to the patient and society upon adoption of a specific technology [9]. This estimation takes into consideration various medical and economic variables, such as prevalence of the disease, relevant target population, cost effectiveness and value added, costs, as well as the health system burden of each new technology [10].
Traditionally, an effort has been made to base decisions to adopt hospital technologies on evidence-based medicine, assuming that medical executives translate their knowledge into daily decision-making. In the case of innovations, as uncertainty is dominant, the rule of work suggests that managers lean on the right HTA principles and consult clinicians to support their decisions using the current best evidence. Ensuring decisions are consistent with patient values and preferences is even more challenging, and guidelines to approach this issue have not yet been achieved [11].
In order to assess the comparative benefits of several technologies used for the same purpose, and choose the most advantageous and efficient option, a set of common standard definitions has to be formed [1]. Indeed, in the early 1990s an expanding estimation model was accepted in most countries [12, 13], as well as in Israel. This model included laboratory tests, nanotechnology and disposable equipment. Since 2000, the model also includes information, data and communication systems.
Over the last decade, the need to assess the efficiency of a health technology has been strengthened, especially in hospitalisation institutions, due to their limited resources and the continuous stream of innovative promising technologies arising on a daily basis. The importance of specific HTA in hospitals arises from the unique characteristics of the hospital environment – hospitals are the ‘port of entry’ of new technologies in the healthcare system. Executives face the challenge of effectively adopting innovations with the need to improve rationality of decision-making, the urge to do so in a limited timeframe and with limited resources, while assuring an appropriate risk-benefit balance. The concept of an evaluation mechanism fosters a culture of targeted assessment that integrates scientific and local evidence, combined with practices and management decisions [14].
Therefore, in 2006, hospital-based HTA (HB HTA) emerged to promote HTA at the hospital level, initiating a unique methodology based on integration of the following principles: providing focused information for hospital decision-makers, aiming to define leadership and partnerships, meeting with strategy of HB-HTA units and targeting the economic aspect to allocate adequate resources that ensure the operation of HB-HTA units. Monitoring, through measurement of the short- and long-term impact of the overall performance of HB-HTA units, is important feedback for the mechanisms relating to the expertise of the HB-HTA unit [15].
Nevertheless, HB-HTA varies from one hospital to another and from country to country. The worldwide experience is that the model of HB-HTA is also influenced by the level of integration with other HTA bodies at the national, regional or provincial levels, shaping the HB-HTA approach [16]. Four major approaches appeared, including an integrated specialised HTA unit, a stand-alone HTA unit, an integrated-essential HTA and an independent group unit. Moreover, efforts have been made to spread and share knowledge regarding the use of HTA in the unique circumstances of hospitals, for example, the activity conducted by AdHopHTA (a European project on hospital-based health technology assessment) [17].
Rosenstein et al. [18] found that 90% out of 19 hospitals in the western part of the United States reported the existence of an organised committee responsible for the evaluation process of new technologies, mostly by a proactive HTA process. In many hospitals, the process is neither standardised nor regulated, but rather forms part of a 3- to 5-year general development plan of the institution. Though theoretical guidelines for the process are published, the committee composition is flexible and various representatives may be included – health professionals (physicians, nurses, physiotherapists, dieticians and other caregivers), engineers, bio-technologists, economists, epidemiologists, information specialists, law and ethics professionals, and representatives of patients and the public [18]. Additionally, it is important to note that the majority of HTA is still executed at a national, regional or even local level.
In Israel, a structured national HTA mechanism for established health technologies has existed for almost two decades, mostly in the community setting [7]. The decision-making mechanism is based on defined criteria. An early alert system for emerging technologies operates on a national level by an assessment recommendation body for governmental authorities [19].
In the hospital setting, a group of 11 hospitals, supervised by the governmental division of medical centres with equal influence, simultaneously adopted similar doctrines. Although the basic HTA principles are maintained, HTA in these hospitals is still performed separately without a unified methodological framework, while agility plays a role in the dynamic world of medicine. For example, new approaches enlighten the incorporation of the volume and characteristics of patients, and economic considerations may vary when a new technology is adopted under unique circumstances.
Since the beginning of the 2000s, an HTA committee has been operating at Shamir Medical Center, integrating essential HTA rules alongside principles of clinical benefit, cost and feasibility, presenting its recommendations to the hospital director, who decides about new technology acquisition. The HTA committee includes 16 members – five physicians, two medical directors (one of them a technology assessor), two senior clinical experts (in gastro and ENT), one infectious control expert, three nurses (surgery, risk management, reuse and sterilisation expert), two medical occupation experts, two bio-technicians/engineers, two economists, and two purchasing representatives. The committee meets quarterly on a regular basis to assess new technologies that are candidates for implementation by the hospital management. The members discuss 10–12 new technologies at each meeting; mostly medical devices (72%), procedures (up to 15%), and surgical equipment and laboratory tests. Of note, new drugs are discussed via a different mechanism, as in Israel they are supplied by the Health Maintenance Organizations (the public insurer). The new technology is presented by the physician that requires the utility and/or has experience in using it. A short assessment is conducted prior to the committee meeting by the HB-HTA unit (a technology assessor physician, a quality assurance physician/nurse, and an economist with the support of an informational specialist). Their summary, containing published evidence as well as real world experience, is presented to the committee focusing on the advantages, challenges, barriers and feasibility for local adoption [20]. The technology is compared to alternatives and costs are estimated (including infrastructure requirements, maintenance costs, relevant population needs and insurance coverage, all of which reflect demand and affordability). The recommendations are presented to the hospital executive management for approval and budget allocation. Prioritisation is based on medical effectiveness and skilled experts that inspire clinical excellence and resources. The average annual adoption rate is 55% (~24/44) [21].
The mounting costs of new technologies and their handling demands, the need for skilled and experienced personnel, as well as budget constraints, have led to the necessity for a more complex HTA process.
Thus, the aim of the present study was to examine the positions of various hospital staff members regarding the HTA process performed in a public governmental medical centre, and to analyse the weight of its components in relation to the adoption of new technologies.
