A MULTI-COUNTRY SURVEY EXAMINING PAYER AND HTA EXPERT PERCEPTIONS OF DECISION UNCERTAINTY
Author(s)
Anne M. Loos, MA1, Rachel C. Wright, PhD2, Laetitia Dewavrin, MBiochem2, Ryan Chapa, Level 6 Diploma3, James E. Harris, PhD4, Eddie J. Gibson, DPhil2.
1Wickenstones Ltd, New York, NY, USA, 2Wickenstones Ltd, Leek, United Kingdom, 3Techspert, Cambridge, United Kingdom, 4Wickenstones Ltd, Carlow, Ireland.
1Wickenstones Ltd, New York, NY, USA, 2Wickenstones Ltd, Leek, United Kingdom, 3Techspert, Cambridge, United Kingdom, 4Wickenstones Ltd, Carlow, Ireland.
OBJECTIVES: ‘Decision uncertainty’ refers to the extent to which uncertainty in the available evidence affects confidence in decision making. We examined how decision uncertainty is understood and communicated across geographies.
METHODS: A survey of 25 HTA experts and payers was fielded in June 2026, covering five respondents from each of Germany, Japan and the UK, and 10 US payers, generating 700 individual data points. Participants described the frequency and drivers of decision uncertainty, and were asked to assign probability to common terms (including from GRADE’s four levels of evidence). In parallel, the same survey questions were run through a searchable dataset of 826 past NICE appraisals (https://nice.shoulde.rs).
RESULTS: Across the countries, respondents reported experiencing decision uncertainty in both HTA evaluations and downstream access assessments, with uncertainty being driven by estimation error, real-world variability and model representation. The survey responses were reflected by the NICE dataset, which suggested that NICE committees frequently face decision uncertainty. Survival extrapolation was the most frequently documented, and the biggest impact on decision uncertainty was from unvalidated surrogates as primary outcomes and lack of UK generalisability data. There was variability in how respondents interpreted common terms used to express certainty/uncertainty. This variability was observed even for terms with standardised definitions in GRADE (‘high certainty’, ‘moderate certainty’, ‘low certainty’, and ‘very low certainty’). Our analysis also suggested that individuals' perceptions may not be fixed, with different interpretations in different contexts. The NICE dataset indicated that uncertainty terminology appeared commonly in disagreements between manufacturers and evidence review groups/committees.
CONCLUSIONS: Uncertainty affects reimbursement and access decisions across countries. The language to describe decision uncertainty may have limited usefulness as its implied meaning varies by country and stakeholder type — but also by the fact that an individual may not have a fixed interpretation over time.
METHODS: A survey of 25 HTA experts and payers was fielded in June 2026, covering five respondents from each of Germany, Japan and the UK, and 10 US payers, generating 700 individual data points. Participants described the frequency and drivers of decision uncertainty, and were asked to assign probability to common terms (including from GRADE’s four levels of evidence). In parallel, the same survey questions were run through a searchable dataset of 826 past NICE appraisals (https://nice.shoulde.rs).
RESULTS: Across the countries, respondents reported experiencing decision uncertainty in both HTA evaluations and downstream access assessments, with uncertainty being driven by estimation error, real-world variability and model representation. The survey responses were reflected by the NICE dataset, which suggested that NICE committees frequently face decision uncertainty. Survival extrapolation was the most frequently documented, and the biggest impact on decision uncertainty was from unvalidated surrogates as primary outcomes and lack of UK generalisability data. There was variability in how respondents interpreted common terms used to express certainty/uncertainty. This variability was observed even for terms with standardised definitions in GRADE (‘high certainty’, ‘moderate certainty’, ‘low certainty’, and ‘very low certainty’). Our analysis also suggested that individuals' perceptions may not be fixed, with different interpretations in different contexts. The NICE dataset indicated that uncertainty terminology appeared commonly in disagreements between manufacturers and evidence review groups/committees.
CONCLUSIONS: Uncertainty affects reimbursement and access decisions across countries. The language to describe decision uncertainty may have limited usefulness as its implied meaning varies by country and stakeholder type — but also by the fact that an individual may not have a fixed interpretation over time.
Conference/Value in Health Info
2026-11, ISPOR Europe 2026, Vienna, Austria
Value in Health, Volume 29, Issue 12S
Code
HTA297
Topic
Health Technology Assessment, Methodological & Statistical Research
Topic Subcategory
Decision & Deliberative Processes
Disease
No Additional Disease & Conditions/Specialized Treatment Areas