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.
 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
Technology knowledge for practical purposes

Any intervention that may be used

Purpose to promote health, to prevent,
diagnose, or treat disease or for
Health technology rehabilitation or long-term care
Drugs, biologics, devices, medical
Scope surgical procedures, support
systems,
A systemic evaluation of
organizational/managerial systems
properties, effects and impacts of
difusion and use of HT. It is a
Health Technology multidisciplinary process to
evaluate safety, efficacy,
Assessment effectiveness, social, economic,
organizational and ethical issues
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
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
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
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
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
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
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
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,
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
 Types of Hospital-based
HTA Model
Ambassador
 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

Low Ambassad Mini HTA

Organizational
or

complexity
(Individual) Model
Model

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

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
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

1diabetic foot
Challenges to establish a HTA unit in CM
Oral prest. in HTAi Congress,
Hospital
Washington, and
Echocardiography 2014the 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
Hospital-based HTA stakeholdres

4 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 …