OBJECTIVES: Health technology assessment is used to inform reimbursement decisions for pharmaceuticals in many countries. The political and administrative contexts in which HTA is used vary considerably between countries, as do the decisions on individual products. The aim of this study was to investigate the influence of HTA and other factors on reimbursement decisions. METHODS: A systematic search was conducted to obtain the documentation for reimbursement decisions on cancer and cardiovascular medicines. Where insufficient information was published, or reports were not available in English, decisions were excluded. The analysis was conducted using discrete response models and included methods of assessment, evidence included and stakeholder involvement. RESULTS: Detailed information was obtained on 194 decisions from Australia, Belgium, Canada, England, France, Scotland and Sweden. The pooled analysis showed that 27% of medicines were recommended, 41% were recommended for restricted use and 32% were not recommended. The multinomial logistic regression showed that the number of RCTs, disease area, use of sensitivity analysis and public interest had a statistically significant impact upon decisions. The use of cost-utility analysis in the supporting HTA was found to reduce the probability of a positive recommendation. The analysis for those countries that included cost-utility analysis showed that the value of the ICER had a statistically insignificant impact upon the decision. However, a sub-analysis for decisions in England showed that this was found to be statistically significant. CONCLUSIONS: These findings may reflect varying approaches to conducting economic analysis, differences in cost-effectiveness thresholds and variation in the weight given to economic evidence in informing decisions within countries. The individual product level factors explain some of the variation in reimbursement decisions across countries. Further variation may be explained by the health system and policy context in which decisions are made. The next stage of the work will investigate these factors directly.