AAOS Bulletin - October, 2005

Health technology assessment and medical societies

International meeting explores how to bring them together

By Jill Elaine Hughes, MA, and Wendy L. Sherman, MSc

What is health technology assessment (HTA) and why should it be important to both American and international physicians? How will physicians in the United States and around the world learn about the latest developments in health technology assessment?

These were among the questions addressed during the Health Technology Assessment International annual meeting held in Rome this past June. James S. Breivis, MD, and David A. Wong, MD, of the AAOS Evidence-Based Practice Committee, attended the meeting. Dr. Breivis moderated a panel discussion on the current state of health technology assessment within medical societies around the world, and gave a brief presentation on the state of health technology assessment in the United States.

Defining HTA

HTA is “a profession that reviews the scientific basis of methods used in health care and evaluates their cost, risks, and benefits.”1 HTA evaluates both emerging and established technologies. Because it is a relatively new discipline, many U.S. physicians and medical societies are still unaware of what HTA entails. Indeed, most physicians worldwide do not know what HTA is nor do they understand how it affects their practices. The panel explored solutions to this worldwide problem.

According to Dr. Breivis, “all the [session] participants felt strongly that physicians and their professional organizations, as applicable, need to be involved in HTA.”

In addition to Drs. Wong and Breivis, panelists included Sir Miles Irving, MD, national director of health technology assessment for the British National Health Service (NHS) and former president of the British Academy of Surgeons, and Pietro Biondetti, MD, chair of diagnostic radiology at Oespedale Maggiore Policlinico Regina Elena Milano of Milan, Italy, and a member of the Italian Society of Radiology’s Board of Directors.

Dr. Breivis opened the session by discussing the level of involvement of U.S. medical specialty organizations in HTA activities. His presentation illustrated just how far the United States lags behind Europe and other areas of the world in HTA activity. Although a few American medical specialties, such as cardiology and general surgery, are taking an active role in researching, developing, and disseminating health technology assessment information, most of the American medical community has conducted little to no activity in the HTA arena.

HTA in the United States

Dr. Breivis presented the results of a survey of five U.S. medical specialty societies: American College of Surgeons, American Academy of Pediatrics, American College of Radiology, American College of Obstetrics and Gynecology and American College of Cardiology (ACC). The survey was conducted by AAOS staff via telephone and e-mail. When asked about their involvement in HTA activities, three of the five societies gave “no response” and two of the five confused HTA with information technology.

Although three of the five societies stated that they were involved in developing evidence-based clinical practice guidelines, they did not supply sufficient information for determining whether the guidelines were truly evidence-based. The remaining two societies were not involved in guideline development at all. Of note, the society with the highest level of member involvement (ACC) also had the highest level of HTA-related activities.

Dr. Breivis concluded that medical specialty societies are an “untapped resource” with the potential to become conduits for the dissemination of HTA information and study results. He encouraged physicians worldwide to pressure their respective professional organizations to develop HTA support infrastructure.

Both AAOS and the North American Spine Society (NASS) have been involved in various HTA activities for several years. Dr. Wong, a NASS member and past president, discussed the results of an HTA survey conducted at the National Orthopaedic Leadership Conference (NOLC) in May 2005. Survey participants were asked about the resources they used to aid in their clinical decisionmaking:

• 60 percent used “personal experience/knowledge”

• 70 percent used a “colleague’s experience/knowledge”

• 56 percent used “information provided by industry”

• 50 percent used “published summaries/ HTA reports”,

• Less than 35 percent conducted their “own review of the Fevidence”

Participants were then asked about the role of the AAOS in providing evidence and HTA reports:

• 61 percent stated that AAOS should provide summary reviews of current evidence to members

• 63 percent were “definitely” willing to pay increased membership dues in order to have HTA reports available to them

Dr. Wong also described the proposed improvements in HTA methodology referenced in the AAOS and NASS strategic plans. Both include a high-priority ranking for society-sponsored activity in the HTA arena. However, professional medical societies face two major challenges to their participation in HTA—the difficulty in keeping track of new and emerging technologies and evaluating the corresponding evidence, and the potential for liability when manufacturer’s and independent studies on the technology reach different conclusions.

HTA in England

Another presenter at the HTA annual meeting, Sir Miles Irving, illustrated how the United Kingdom’s NHS has emerged as a world leader in HTA. According to Dr. Irving, HTA is the main focus of the NHS Research and Development department.

HTA reports are commissioned by the National Coordinating Centre for Health Technology Assessment (NCCHTA), overseen by a medical director and advised by panels of the Royal College and Specialty Associations. Once completed, the HTA reports are posted on the NCCHTA Web site and sent to the U. K.’s National Institute for Clinical Excellence (NICE) for dissemination.

NICE is an independent arm of the NHS that serves as a national clearinghouse for health technology assessment. NICE and the NCCHTA disseminate HTA information to British physicians in the form of “technology appraisals”—recommendations on the use of both new and existing medicines and treatments within the NHS, such as medicines, medical devices, diagnostic techniques, surgical procedures, and health promotion activities.

In accordance with HTA principles, both organizations evaluate health technology using both clinical and economic evidence—how well the medicine or treatment works in relation to how much it costs the NHS. Other European countries, Australia and Canada also have a higher participation level in HTA activities than the United States.

HTA in Italy

In Italy, as in the United Kingdom, government-sponsored health care management and administration professionals are more likely to be involved in HTA activities than medical societies. Dr. Biondetti presented the results of a survey of 110 Italian medical societies he’d identified on the Internet. Although only five responded, four of them had begun some kind of HTA process, including surgical endoscopy, hospital cardiology, radiation therapy, and radiology. Since conducting the survey, Dr. Biondetti has determined that an increasing number of Italian medical societies are starting to use various approaches to HTA.

Rome’s Universita Cattolica del Sacre Cuore Medical Center, where Pope John Paul II was treated during his final illness, was the site of the HTA International meeting in June 2005.

NHS organizations such as NCCHTA and NICE are held publicly accountable for continuously improving the quality of their services and safeguarding high standards of care under a process called “clinical governance.” This helps create an environment where excellence in clinical care flourishes. “The National HTA program encourages medical professional societies to bid for and undertake HTAs and that involvement ensures collaboration and ultimately ownership of the results,” said Dr. Irving.

Next steps

Following Dr. Biondetti’s presentation, the panelists and more than 50 audience members made several suggestions about how best to increase HTA awareness and utilization. These included: holding HTA sessions and courses at non-HTA physician meetings; submitting HTA study findings to non-HTA journals; developing “user-friendly” HTA approaches for physicians; and providing funding to physicians who wish to conduct HTA studies of new and emerging technologies. The panelists also offered a number of suggestions on how to improve the worldwide dissemination of HTA-related information to physicians. These included: dissemination of “user-friendly” HTA approaches for physicians; funding to support medical societies that want to establish a medical technology evaluation committee; and providing training in the application of HTA to those physicians and societies committed to using an evidence-based healthcare decision making process. Medical societies are an “untapped resource” for providing these services.

Jill Elaine Hughes is the AAOS staff liasion to the Evidence-Based Practice Committee. She can be reached at hughes@aaos.org Wendy L. Sherman is senior research associate and director of education programs at Hayes, Inc., an independent health technology assessment organization working with the AAOS.


1. Breivis, J: HTA studies treatment costs, risks, benefits. AAOS Bulletin 48-5, 2000.

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