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1 Introduction

The main users of HB-HTA are the clinical and administrative managers at the hospitals who need a basis for decisions on whether to invest in new treatments at the hospital. As it is described in this book – Sampietro-Colom et al. [1] – a number of hospitals around the world have started using HB-HTA, and many hospitals have demonstrated positive impact of this approach. However, to what degree does the content of HB-HTA products comply with the need for information by the decision makers? This question has not been studied at an international level before the AdHopHTa project was carried out, and below the results will be described.

The aim of the studies was to assess hospital managers’ need for information when making decisions on investment in new treatments. For this purpose, three studies were carried out: a systematic literature review, see ∅lholm et al. [2]; an interview study with a small sample of European hospital managers, described in Kidholm et al. [3]; and a questionnaire survey with a large sample of European hospital managers.

The results are presented in the table below. The table below describes (with green colour) to what extent the information included in the nine domains in the EUnetHTA core model – see [4] – was assessed as important parts of the basis for decision makers by the hospital managers themselves. In the literature review, 14 studies of hospital managers’ need for information were found. These studies indicate that information about the health problem of the patients, the clinical effectiveness, the economics and the organisational and the strategical and political aspects of new treatment was most frequently considered as important by hospital managers.

The last and tenth domain in the table is not part of the EUNetHTA core model, but was developed and added in the literature review, because a number of articles describe that hospital managers were including strategic and political issues when making decisions on investment in new treatments. Strategic issues are understood information on, e.g. the fit between a given health technology and the research strategy and local values of the hospital or prestige and competition among hospitals. Political issues are understood information on, e.g. the alignment between the decision to invest in a given technology and the local political climate. The relevance of information on especially the strategic aspects associated with the introduction and use of a given new health technology was confirmed in both the interview study and the questionnaire survey.

The interview study with 54 hospital managers and the questionnaire survey with 163 hospital managers gave similar results, as the table below describes. The major difference is that in both these studies, information about the safety aspects was considered as the most important by the decision makers (Table 28.1).

Table 28.1 Results from studies of hospital managers need for information in decision-making
Full size table

2 Implications for HB-HTA

2.1 HB-HTA Should Be More Focused on Fewer Domains

As described above, the results from the three studies indicate that not all domains in the EUnetHTA core model are considered equally important by hospital managers. Information about the health problem of the patients and the clinical effectiveness, the safety, the economics, and the organisational and the strategical and political aspects of new treatment was most frequently considered as important by hospital managers in the studies.

This could indicate that the relative importance given by hospital managers to the different types of information differ from those given by national/regional HTA agencies, as described by Sampietro-Colom et al. [5] and Ehlers et al. [6]. Hospital managers need information with focus on the impact on the hospital, whereas national HTA organisations must produce assessments with a more societal perspective and include information on ethics and social and legal aspects.

2.2 HB-HTA Should Include Information on Effects on Clinical Outcomes and Level of Evidence

The results from the systematic literature review did show that the third domain (D3) dealing with “clinical effectiveness” includes decision criteria concerning on one hand clinical outcomes (e.g. quality of life) and effect sizes (e.g. patient impact) and on the other hand characteristics of the evidence (e.g. quality of the evidence).

This domain was therefore divided into two separate dimensions in the questionnaire survey. The results showed that both dimensions were considered important parts of the basis for decision-making by a majority of the respondents. Thus, both the size of the effect on clinical outcomes and the level of evidence of the studies behind the results should be included in HB-HTA.

2.3 HB-HTA Should Focus on Economic Impact on the Hospital

The results from the literature review and the interview study made it clear that the economic aspects include both decision criteria concerning traditional health economic analyses with a broad societal perspective (e.g. cost-utility analyses) and more narrow budget impact analyses with a hospital perspective (e.g. costs and budgetary constraints).

In the systematic literature review, the majority of identified decision criteria concerning the economic aspects associated with the introduction of a new treatment concerned the narrow hospital perspective. In the interview study, it was not always clear whether the respondents had a broad societal or a more narrow hospital perspective in mind when asked about the economic aspects of new treatments. However, one third of the 39 respondents indicating information on economic aspects of new treatments as highly important referred only to the economic impact on the hospitals by using terms like “budget impact”, “financing”, “reimbursement”, “billing” and “DRG”.

Therefore, in the questionnaire survey, the questions about economics were divided into information from a “societal point of view” and a “hospital point of view”, respectively. The results showed that 52 % of the respondents was considering the hospital point of view as among the most important informations, whereas only 25 % was considered information on economics from a societal point of view as the most important. Thus, the three studies indicate that HB-HTA should have a hospital point of view when describing the economic impact of new treatments.

2.4 HB-HTA Should Include Information on the Strategic Aspects

The domains of EUnetHTA’s Core Model cover the majority of information needed by hospital decision makers when they are to make decisions on whether or not to invest in a new treatment. However, perfect consistency was not observed as decision criteria dealing with strategic and political issues were identified in the systematic literature review as well. These were classified under a tenth and new domain named “political and strategic aspects”.

In the interview study, the respondents were asked to rank the most important domains, and the strategical and the political aspects of a new treatment were separated into two different domains. The results were that 9 % of the respondents was considering the strategical aspects as among the five most important domains in decision-making, whereas only 4 % was considering the political domain as among the most important. This indicates that HB-HTA should include information about potential relations between investing in a new treatment and, e.g. the hospital research strategy or competitive advantages for the hospital.

3 Conclusion

To increase the use of HB-HTA as the basis for decision-making at hospitals all over the world, we must ensure that the assessments on one hand comply with the principles of HTA by being multidisciplinary, systematic and evidence based and on the other hand give the hospital managers the information they need, both with regard to the content of the information and the timing of the information. The studies described above provide a basis for further development of HB-HTA to ensure that goal. However, many questions still remain unanswered and more studies are needed of how HB-HTA should be produced, what HB-HTA should include and differences in the need for information in different countries, different hospitals and among different types of hospital managers.