Health Technology Assessment (HTA) agencies often lay out the methods and processes for recommendations through guidelines. However, evidence suggests that the presence of guidelines does not necessarily lead to more systematic, evidence-based decisions. This article explores the differentiating features of HTA guidelines that have successfully promoted change in decision-making practice.

We compared the development and impact of HTA guidelines over time in eight countries through a multi-case study design. Data from interviews and literature review were analyzed qualitatively by pattern matching.

In settings without a guideline owner, guidelines were most successful if the development process targeted key stakeholders who are able to influence change in an open process of joint learning, and an agency with relevant expertise was assigned to oversee future guideline implementation and revisions. In settings with a clear guideline owner, guidelines were most successful if stakeholders continued to be engaged after guideline publication, to incorporate interim updates and when there was continuous learning between stakeholders and the HTA agency. Enforcing guideline compliance through laws was not found to be a predictor of guideline success nor was the level of HTA institutionalization in a country.

At any stage of HTA institutionalization, HTA guideline success depends on whether the development and revision process successfully builds shared understanding and trust among stakeholders. Ensuring HTA guideline impact requires an open and inclusive approach to stakeholder engagement during and after guideline development, as well as effective accountability mechanisms for guideline ownership.