OBJECTIVES: The healthcare industry, specifically the manufacturing, use, and disposal of health technologies has a significant environmental impact that can no longer be denied. This landscape review summarizes evidence currently available on frameworks and methods that aim to include environmental and sustainability metrics into Health Technology Assessments (HTAs).

METHODS: A literature review was conducted to investigate proposed frameworks, action plans, published policies and metrics deployed by HTA bodies and national healthcare systems that were published between 2015 and 2023. The literature review involved reviewing key HTA, government and international websites, and conducted grey literature searches to maximize information collection. Case studies of importance (Europe & US) and their relevance to HTA evaluation models are discussed to evaluate the feasibility of implementation.

RESULTS: The analysis identified four approaches for incorporating environmental metrics into existing HTA models: (1) Enriched Cost-Utility Analysis (CUA) and (2) Cost-Effectiveness Analysis (CEA) both using carbon dioxide emissions (CO₂e) relative to the patient, or QALY, or LY or, ICER threshold, or HRQOL; (3) Cost-Benefit Analysis (CBA) based on the willingness-to-pay per Co₂e, or per QALY/DALY, and (4) Multicriteria Decision Analysis (MCDA) that formulates decision-making on criteria and outcome trade-offs. These approaches have been categorized according to how they included the data in HTA processes, i.e., as additional information to other HTA outcomes (CUA, CEA, MCDA), as cost consequence of environmental impacts in monetary terms (CUA, CEA, CBA), and as health consequence (CUA, CEA, CBA).

CONCLUSIONS: Despite the international consensus on the importance of embedding sustainability into existing clinical guidelines and HTA, there still substantial challenges to overcome. Pillar to the expansion of HTA models is the deployment of a centralized emission assessment methodology, such as life cycle assessment that appears to be the most prominent method of integrating environmental impacts in the assessment of drugs and technologies.