DISCUSSION

HTA has five main aims: (i) Identification (monitoring technologies, setting priorities), (ii) Testing (data collection and analysis), (iii) Synthesis (collecting and interpreting existing information), (iv) Dissemination (providing HTA information to users), and (v) Implementation (helping to ensure the application of HTA results). Coordination of these aims is considered crucial to the successful development and implementation of HTA in any region (Reference Banta and Oortwijn2;Reference Banta and Oortwijn3).

This exploratory study shows that programs in LA were not adhering entirely to the concept of HTA in six important ways. First, although document production increased incrementally during the period of this study, the types of HTA documents produced were mostly short documents (82 percent) rather than comprehensive HTA reports (1 percent). Full HTA reports may be seen as too lengthy, technical, or detailed to be digestible for decision makers; furthermore, longer documents may be difficult to produce in situations where decisions need to be made within a very short timeframe. On the other hand, busy decision makers may prefer shorter documents that are either stand-alone summaries of full HTA reports, or rapid technology assessments that are designed to provide brief (and, perhaps, provisional) answers to specific questions. Nonetheless, producing short documents requires a systematic and rigorous approach to summarizing and interpreting evidence in a concise way (Reference Lehoux, Tailliez, Denis and Hivon12). If full HTA reports are viewed as impractical, then standards and guidelines for developing short documents should be developed—not only to facilitate supply side work, but also to help the demand side distinguish among the different types of HTA products (Reference Hailey, Corabian and Harstall7;Reference Mowatt, Grant, Bower, Stevens, Abrams and Brazier14).

Second, although HTA programs in LA seem to make a conscious effort to identify, test, and synthesize information about different technologies, the majority of programs focus on practical concerns that address current problems, rather than procedural areas or less-pressing needs. During the study period, most HTA programs focused on high-technology areas such as drugs (31 percent), diagnostic and/or screening technologies (18 percent), medical procedures (18 percent), or surgical procedures (14 percent). Little attention was paid to health services (5 percent), general essays and/or research tools (2 percent), or vaccines (1 percent). Perhaps this shift in focus is an acknowledgment of limited resources within LA, as well a conscious decision on behalf of programs to try to influence decision makers in areas where funding is concentrated.

Third, one of the tenets of HTA is that issues need to be integrated into a conceptual framework that embraces all aspects of HTA (e.g., medical, economical, organizational). From January 2000 to March 2007, however, 40 percent of published HTA documents in LA addressed clinical effectiveness, while 26 percent attempted to correlate the efficacy and safety of a new technology in economic terms. This trend does not suggest a balanced approach, but emphasizes how the current rate of healthcare spending weighs on the assessment process, almost to the exclusion of other considerations. In effect, the technology itself is being quantified, without considering that the data needed for quantification is often limited and subject to error (Reference Wilensky19). After all, health is not solely a scientific or technical activity, nor can values be analyzed by strict clinical or economical evaluations—especially when a concept such as “quality of life” does not explicitly include variables such as human rights or human dignity. In this sense, the central paradox of HTA emerges. HTA attempts to balance appraisal (values plus scientific data) against assessment (technical data analysis). To make an integrated conceptual framework practical in LA, a genuine positive attitude toward other issues needs to be encouraged as it has in evidence-based medicine or health economic analysis.

Furthermore, although other issues in LA were explored, the issues addressed are not key components of HTA guidelines, even though they may be relevant to practice and policy—for example, the state of current practices (29 percent) and other outcomes (6 percent) (i.e., impact on service utilization). Perhaps this can be interpreted as a subtle attempt to redefine HTA by providing a more contextualized informational base for decision makers, even though several related issues are ignored. Overall, although, it is fair to state that an integrated conceptual framework in LA is wanting.

Fourth, HTA is often promoted as an interdisciplinary process that addresses a wide spectrum of issues, from effectiveness to ethics (Reference Lehoux and Blume11). While the approach may be true in principle, this study suggests that it is not the case in practice. With the exception of one program (A4), ethical, social, and/or legal issues were not addressed in HTA documents. From a producers’ perspective, the oversight may be due to practical considerations, as the staffs of HTA programs are usually trained in epidemiology and may feel less equipped to analyze ethical, social, and/or legal issues (Reference Lehoux, Tailliez, Denis and Hivon12). From the users’ perspective, however, the need to obtain concise and simple answers to well-defined policy questions may prevent a sophisticated analysis of inherently complex issues (Reference Bero and Jadad5). Although these reasons may serve as explanations for current practices, it is an inescapable truth that both health policy and clinical practice are shaped by legal incentives (Reference Battista, Lance and Lehoux4). HTA has an obligation to examine equity and to encourage the socially responsible allocation of resources (Reference Cookson and Maynard6). Thus, collaboration between HTA practitioners and ethicists, sociologists, and jurists should be increased to respond to specific requests of decision makers as well as to maintain a broad interdisciplinary perspective (Reference Johri and Lehoux10).

Fifth, although HTA information is meant to be disseminated to all users, this study shows that HTA documents mainly targeted two groups: third-party payers (55 percent) and government policy makers (41 percent). As many HTA programs are legally part of the Ministry of Health within their respective countries, it is likely that the focus of their activities catered to those groups controlling economic resources. Private sector entities did not receive much attention, possibly because those organizations already possess their own internal Research and Development Units; thus, in many HTA programs, the perception may exist that those groups do not require further support. Although this perception may be accurate, it must also be accepted that information cannot be properly implemented if it is not disseminated thoroughly beforehand.

Sixth, the proper implementation of HTA results relies on recommendations put forward by HTA programs. During the study period, nearly half (48 percent) of all recommendations were positive, with formal recommendations for a given health technology advocated in nearly half or more (45 percent to 92 percent) of HTA documents produced by four programs (A2, A4, A5, A6). The balance of recommendations either questioned the weakness of the evidence while urging that additional research be conducted (38 percent) before reaching a final determination, or rejecting a new technology entirely (11 percent) because it was ineffective, risky, or not cost-effective. Therefore, a balanced approach to the responsibilities of HTA seems to be accepted, even if caution prevails.

As with any analysis, the shortcomings of the study must be acknowledged. First, the study was exploratory and thus limited to conditions in LA during the study period. Between 2000 and 2007, LA had only one proper HTA agency (A6), three HTA units (A1, A3, A4), and two programs (A2, A5) that produced HTA documents as a supplementary role within a Ministry of Health agenda. Second, most of the data came from one HTA agency (A6), which produced 55 percent of all HTA documents analyzed in this study. Although this concentration of information suggests a bias, the prejudice is not methodological because it reflects actual HTA conditions in LA throughout the study period. Despite these limitations, the underlying value of this study is that it explored HTA in a region not previously emphasized in the literature.