Exploring the Link Between Institutional Country-Level Differences and Consideration of Additional Value Elements in HTAs: Results From a Pragmatic Review

OBJECTIVES: Adapting the health technology assessment (HTA) process to include elements of value beyond clinical/economic benefits is a topic of much discussion. We aimed to expand this discussion by assessing whether the underlying culture and values embedded in the institutional context of a country, its healthcare system, and HTA process may influence the country’s predisposition toward higher acceptance of expanded value elements in HTAs.

METHODS: A pragmatic review was conducted in Embase and MEDLINE (2013–2023) to identify English publications presenting country-level information, and variation in considerations or implementation of value elements (beyond clinical, economic) in HTA decision-making. Eligible publications included guideline reviews, HTA summaries, or previous reviews. Screening and data extraction was performed by two reviewers. Publications on individual countries were excluded. Results were narratively synthesized by presenting trends among countries with comparable socio-economic settings.

RESULTS: Database searches returned 1,602 hits after de-duplication. With 75% of screening completed, seven records (guideline reviews, case studies, and consensus papers) were included. The most common value elements considered were productivity, health equity, and transportation with considerable variation among European countries. A higher number of value elements corresponded with sophistication of country-data infrastructure and HTA processes. All low- and middle-income countries emphasized health equity. Environmental impact was proposed mainly by HTA agencies in Canada and the United Kingdom whose processes are comparable. Social care aspects were more commonly considered in tax-based rather than insurance-based healthcare systems.

CONCLUSIONS: HTA acceptance thresholds of additional value elements by country level varied widely. However, a growing trend was observed toward higher acceptance over time with a link between countries having universal care systems and higher income. Different trends in value considerations between national assessments may threaten the weight of European Union joint clinical assessments in HTAs.