Hospital-based

Health Technology
Assessment

Sudigdo Sastroasmoro
Chairman, HTA Committee, MOH RI
Selected references
Dupouy C, Gagnon M-P. The influence of hospital-based HTA on technology
acquisition decision. Internat J Hosp Based HTA;2016:1:19-28.
Gagnon M-P et al. Engaging patient representative in the identification and
prioritization of health technology assessment topics. Internat J Hosp Based
HTA;2016:1:31-40.
Grenon X, et al. Hospital-based health technology assessment: a 10-year
survey at one unit. Internat J Technol Assess Health Care. 2016:32:116-21.
van Beekhuisen S. Patient participation in hospital-based HTA. Thesis.
University of Oslo, 2016.
Muller DB. HOSPITAL BASED HTA in LMIC. http://www.who.int/ medical_
devices/ Sat_pm_REG_8_MULLER.pdf
Pasternak I, et al., editors. The AdHopHTA handbook. Barcelona, 2016.
 Problem in health care

Research: what we can do

Aman?
HTA: which ones we can do Manjur?
Terbeli?
Clinical guidelines: what we should do

Practice: doing what we should do

Clinical audits: did we do what we should do?

 The application of scientific knowledge for
Technology practical purposes

Any intervention that may be used to promote

Purpose health, to prevent, diagnose, or treat disease
or for rehabilitation or long-term care
Health technology
Drugs, biologics, devices, medical surgical
Scope procedures, support systems,
organizational/managerial systems

A systemic evaluation of properties, effects

Health Technology and impacts of difusion and use of HT. It is a
multidisciplinary process to evaluate safety,
Assessment efficacy, effectiveness, social, economic,
organizational and ethical issues of HT.
Purposes of health technology

Promotion
Prevention
Diagnosis
Treatment
Rehabilitation
Long-term care
 Physical nature
Drugs: beta-blockers, antileukemia
Biologics: vaccines, blood products, stem cells
Devices: cardiac pacemakers, CT scanners, MRI
Medical and surgical procedures: e.g., psychotherapy,
nutrition counseling, coronary angiography
Support systems: e.g., IT, drug formularies, blood
banks, clinical laboratories
Organizational and managerial systems: e.g.,
prospective payment using DRG’s, rules for referral
Attributes / aspects to be assessed

Safety
Efficacy
Effectiveness
Economic
Socio-cultural
Ethical
Legal-Institutional
Religious
Types of economic analysis
Cost-of-illness analysis (CIA): a determination of the economic impact of
an illness, e.g., thalassemia, DM.
Cost-minimization analysis (CMA): a determination of the least costly
among alternative interventions with equivalent outcomes.
Cost-effectiveness analysis (CEA): a comparison of costs in monetary units
with outcomes in quantitative non-monetary units: mortality or morbidity.
Cost-benefit analysis (CBA): compares costs and benefits, both of which
are quantified in common monetary units.
Cost-utility analysis (CUA): a form of CEA that compares costs in
monetary units with outcomes in terms of their utility, e.g., in QALYs
Budget impact analysis (BIA): determine the impact of implementing HT
on designated budget.
What areas can HTA address?

High volume - affects many

High risk - medical, social, ethics
High cost - unnecessary health cost
High variability
Health technology assessment
(HTA)
Health technology
 Pharmaceutical and devices
 Vaccines

 Medical and surgical procedures

 Prevention and rehabilitation

 Health services and organization

Health technology assessment
(HTA)

Multidisciplinary field of policy analysis

Medical, economic, social, and ethical implications of
development, introduction, diffusion, and utilization of
health technology
Provide rigorous and objective data to inform and
improve the health care decision-making process
HTA: Allocate resources more efficiently to
maximise patients’ outcome

Over the last 20 years HTA methods have been

used to assess increasing demands from patients for
new technologies and their impact on healthcare
systems with scarce resources.
HTA helps decision makers to identify which
interventions provide the best value for money and
prioritise their investments accordingly.
HTA Agencies

Support the Minister of Health and decision

makers in their healthcare system by means of
HTAs (evidence-informed decision making)
 Macro (policy) level
 Meso (administrative) level

 Micro (clinical) level

Hospital-based HTA
HTA – International / National level
Local / Hospital-based: Recommended
Specific hospitals
 High / new technology, no National HTA

 Specific mode of care

Other hospitals
 Specific conditions

 May differ from national HTA

Reasons for adopting HB-HTA
Hospitals are the entry point for new technologies to the
healthcare system. HB-HTA facilitates better investment decisions
allowing hospitals to become more efficient
HB-HTA makes it possible to take better-informed decisions
supporting effective, safe and sustainable healthcare. HB-HTA is
based on scientific knowledge and relevant hospital-specific
information. It is objective and targeted to a specific context.
Information derived from HB-HTA differs from information
provided by national or regional HTA agencies: HB-HTA is rapid
and timely. It is tailored to the individual hospital’s setting and to
the specific information requirements of hospital managers there.
Local/hospital-based HTA could influence decision-making
on several aspects. It is difficult to evaluate the real
impacts of local HTA at the different levels of health care
given the relatively small number of evaluations with
quantitative data and the lack of clear comparators.
Today, there are more than 500,000 medical devices on the
market and we are witnessing an annual growth rate of in-
patient pharmaceutical spending
Hospitals are the main entry door for health technologies
Hospital managers need to make decisions that maximize the
value generated from each dollar the hospital spends.
HB-HTA is not only about producing context-specific and
methodologically sound reports for hospitals; it is also a way
of organizing HTA activity in hospitals.
HB-HTA is growing around the world.
Why local/hospital HTA is important?

Decentralised health care system: many decisions

regarding health technologies are taken at the local level.
Recognition of the importance of considering the local
context when assessing health technologies.
Local/hospital HTA could improve the relevance and
timeliness of recommendations, and ultimately their uptake
A need for a more relevant approach for
hospital decision makers
HTA was mainly to establish: evidence-informed health
policy making
Local / HB-HTA is needed:
 Decision-making tends to be more decentralised in healthcare
systems nowadays. Hospitals are under increasing pressures to
control budgets and increase their efficiency
 The benefit and risk of the use of any of HT depends on the
specific context of the healthcare organisation.
 In the hospital context it is extremely challenging to perform a
comprehensive HTA evaluation every time a decision has to be
made on the acquisition of a new technology.
A hospital’s economic decision-makers and clinicians need
tools to better manage the allocation of resources to improve
the clinical governance.
Hospital-based HTA has been developed to address the
specific challenges of technology evaluation in hospital
settings. It may have unique characteristics, such as the
choice of an available comparator and the specific
organisational patterns.
At the hospital level, HTA may be applied in different
formats.
The AdHopHTA initiative: Creating
hospital-based HTA
In order to foster the development of HB-HTA, the European
Commission has provided a three-year research grant to a
collaboration of 10 institutions in Europe for their project
AdHopHTA, or Adopting H-B HTA.
The AdHopHTA project will facilitate the start of new HB-HTA
programmes and improve the quality of existing ones.
The key objective of the project is ‘to perform a critical analysis
of existing HB-HTA Initiatives and to evolve methods, instruments
and processes to evaluate technology in hospital settings’.
Practical approach to start evaluating
new technologies in hospital settings
May be challenging
Needs practical tool
 Introduction: Who is the proposer (hospital, department,
person)? What is the name and designation of the new
technology?
 The technology: Based on which indications is the technology
going to be used? What is the comparator?
 The patient: Does the proposal entail any specific ethical or
psychological considerations? Is it expected to influence the
patients’ quality of life, social or employment situation?
Practical approach to start evaluating
new technologies in hospital settings

The organisation: What are the effects of the

proposal on the staff in terms of information, training
or working environment?
The economic aspects: Are there any start-up costs of
equipment, rebuilding, training? What are the
consequences in terms of activities in the next coming
years? What is the additional or saved cost for the
hospital in the next couple of years? What
uncertainties apply to these calculations?
 Types of Hospital-based HTA
Ambassador Model
 Organization - Individual
 Focus of action - Clinical practice
Mini-HTA Model
 Organization - Individual
 Focus of action - Managerial decision making
Internal Committee Model
 Organization - Group, Team, Unit
 Focus of action - Clinical practice
HTA Unit Model
 Organization - Unit
 Focus of action - Managerial decision making
 Focus of action
Clinical Managerial
practice decision making

Organizational complexity
Low Ambassador Mini HTA
(Individual) Model Model

Internal HTA
High Committee Unit
(Team, Unit) Model Model

Models in local / hospital-based HTA

HTA Unit
Physicians: clinicians, pharmacologists,
clinical epidemiologists
Hospital pharmacists
Health economists
Biomedical engineers
Statisticians
Methods

Literature review: Systematic reviews and meta –

analyses for clinical aspects
Hospital survey: Real world data for clinical
effectiveness, primary economic data
Complimentary data collection
Database construction
Statistical analysis
Problems: No clear policy / pathway
Approach to local level HTA and decision making
processes are not consistently applied throughout the
organization.
Pathways for technology assessment and decision
making are not clearly defined.
There is no policy to guide HB-HTA nor technology
acquisition decision making leaving processes open to
interpretation.
Problems: stakeholders involvement and
decision criteria
Stakeholders: middle managers, frontline staff,
patients are not involved to the level they could or
should be.
Data collection in relation to specific decision criteria
is not standardized & the tools to collect this
information is not priority focused or user friendly.
Assessment is not comprehensive due to inconsistently
applied decision criteria.
Problems: transparency in decision making
process

Criteria for decision making are not identified or

communicated to requestors, leaving some important
criteria unassessed unknowingly.
The decision making process at all levels is vague
and non-transparent.
Timelines regarding approval and stage in the
approval process is not clearly communicated to the
requestors.
Hospital-based HTA in Indonesia

Still in early development

Last decade has been introduced to hospital
directors
Subdirectorate of Referral, is currently planning to
conduct National Workshops on HB-HTA
Should be conducted as such so that the program is
effective and sustainable
CM Hospital: Hospital-based HTA
Modern dressing and skin grafting in diabetic foot

1 Challenges to establish a HTA unit in CM Hospital

Oral prest. in HTAi Congress, Washington, 2014
Echocardiography and the length of stay of congestive

2 heart failure (Taiwan, 2014)

Cochlear implant in children

Megaprosthesis implant

3 Gamma knife stereotactic radiosurgery

Long-acting antipsychotic injections
Oral prest. HTA – Int Congress, Oslo, June, 2015

4
Hospital-based HTA stakeholdres perspective in CM
Hospital
Oral prest. HTA – Int Congress, Rome, 2017

5 Plasma derived factor VIII prophylaxis vs. on demand in

patients with severe thalassemia A
Take home message

Hospital-based HTA is a sine qua non

While the principles of HTA should be

followed, there is no universal HB-HTA model
Develop yourself …
Adopt multidisciplinary approach as much as
possible
Thank you …