Linking HTA to priority setting – framework, concepts, and values

1. Linking HTA to priority setting – framework, concepts, and values Professor Ole F. Norheim Department of Public Health and Primary Care University of Bergen, Norway U n i v e r s i t y o f B e r g e n

2. Drummond et al IJTAHC 2008 U n i v e r s i t y o f B e r g e n

3. Framework: HTA in Norway Health policy/ priority setting HTA Appraisal Guidelines Clinical research Assessment of evidence Clinical practice U n i v e r s i t y o f B e r g e n

4. Concepts • EBM: Evidence based medicine • CER: Comparative effectiveness research • HTA: Health technology assessment • AFR: Accountability for reasonableness • Partly overlapping aims and potential use:  coverage decisions U n i v e r s i t y o f B e r g e n

5. Accountability for reasonableness(Daniels & Sabin, 2002/2008) • Publicity • Relevant reasons • Revision and complaints • Institutionalization U n i v e r s i t y o f B e r g e n

6. Common values in EBM, CER, HTA, AFR • Transparency • Explicit about reasons • Unbiased, impartial • Open too critical review • Institutionalized processes • Except AfR U n i v e r s i t y o f B e r g e n

7. Norwegian Council for Priority Setting in Health Care • As recommended in Lønning II • Standing committee • Served by Norwegian Knowledge Centre for the Health Services • Chaired by the head of Norwegian Directorate of Health • Committed to stakeholder involvement, publicity and accountability for reasonableness U n i v e r s i t y o f B e r g e n

8. New guidelines and new principles for primary prevention of cardiovascular disease in Norway: differentiated risk thresholds according to age(HDir, 2009) U n i v e r s i t y o f B e r g e n

9. Linking priority setting to HTA Health policy/ priority setting HTA Identify consequences Guidelines Clinical research Assess evidence Clinical practice U n i v e r s i t y o f B e r g e n

10. Background • Low risk thresholds • Risk of ”medicalization” of healthy people • Resource use, priority setting U n i v e r s i t y o f B e r g e n

11. Risk table

12. Priority-relevant recommendations: • Medication for the following groups: • 40-49 years: if 10-year risk of cardiovascular death is ≥ 1% • 50-59 years: if 10-year risk of cardiovascular death is ≥ 5% • 60-69 years: if 10-year risk of cardiovascular death is ≥ 10% U n i v e r s i t y o f B e r g e n

13. Priority table

14. Impact on distribution U n i v e r s i t y o f B e r g e n

15. Process • Independent review of evidence on • Effectiveness • Cost-effectiveness • Independent guidelines development process • GRADE-system • Explicit on reasons • Medical • Ethical • Political U n i v e r s i t y o f B e r g e n

16. Securing legitimacy for hard choices • Advice from Norwegian Council for Priority Setting in Health Care on • Risk differentiation • Risk thresholds • Wide hearing process with key stakeholders U n i v e r s i t y o f B e r g e n

17. Implementation • Guidance linked to coverage decisions • (But less systematic and transparent process) • Too early to evaluate U n i v e r s i t y o f B e r g e n

18. Linking priority setting to HTA Health policy/ priority setting HTA Identify consequences Guidelines Clinical research Assess evidence Clinical practice U n i v e r s i t y o f B e r g e n