Acute cerebrovascular disease (CBVD) has an annual incidence of 100–300 per 100,000 inhabitants in the industrialized countries (1,2). CBVD occurs mainly in the elderly. Acute mortality is around 15%. Disablement and decreased quality of life are common consequences. Institutionalized care will be needed after the acute phase for around one-third of the patients (3). Considering the volume of patients and the growing proportion of elderly persons in most countries, stroke poses a major problem for health care. An effective diagnostic work-up as the base for therapy to improve the situation is, therefore, a matter of great public concern, for humanitarian as well as economic reasons.

Dentistry is perhaps the most prevention oriented of the many disciplines in health care. This article examines technologies for the prevention of caries (including the use of fluoride, oral hygiene and prophylaxis, sealants, and dietary modifications), periodontal disease, and soft-tissue lesions that can be used in community-oriented programs.

Canada has a highly decentralized health care system with 13 provinces and territories delivering health care within their own respective jurisdictions. Decisions regarding which innovative health technologies to adopt are often driven by the unique health care priorities of each jurisdiction's population. To understand these needs, the Canadian Agency for Drugs and Technologies in Health's (CADTH's) Early Awareness Service has expanded its activities. In addition to proactively scanning the horizon for new and emerging health technologies, the Early Awareness Service also scans the horizon for national and jurisdictional health policy issues. This paper looks at CADTH's process for identifying and monitoring policy issues at a national and jurisdictional level.

CADTH's Early Awareness Service delivers timely information on emerging health care concerns and technologies that may affect health care finances, facilities, operations, and patient care. The identification of important policy issues can help determine which new and emerging technologies will have the most significant impact on the health care system. The information that CADTH scans can also be used to help decision-makers prepare for potential developments and events that may have an impact on health care systems.

By improving its capability to identify and share policy issues across and within jurisdictions, CADTH is better situated to provide information that can be used by policy-makers to help them plan and anticipate for the introduction of new technologies and future developments affecting the unique health care needs of their jurisdictions.

Over the past few years, there has been an increasing recognition of the value of public involvement in health technology assessment (HTA) to ensure the legitimacy and fairness of public funding decisions [Street J, Stafinski T, Lopes E, Menon D. Defining the role of the public in Health Technology Assessment (HTA) and HTA-informed decision-making processes. Int J Technol Assess Health Care. 2020;36:87–95]. However, important challenges remain, in particular, how to reorient HTA to reflect public priorities. In a recent international survey of thirty HTA agencies conducted by the International Network of Agencies for HTA (INAHTA), public engagement in HTA was listed as one of the “Top 10” challenges for HTA agencies [O'Rourke B, Werko SS, Merlin T, Huang LY, Schuller T. The “Top 10” challenges for health technology assessment: INAHTA viewpoint. Int J Technol Assess. 2020;36:1–4].

Historically, Australia has been at the forefront of the application of HTA for assessing the effectiveness and cost-effectiveness of new health technologies to inform public funding decisions. However, current HTA processes in Australia lack meaningful public inputs. Using Australia as an example, we describe this important limitation and discuss the potential impact of this gap on the health system and future directions.

A short description is given of the interplay between the pharmaceutical industry and its critics regarding the rational use of medicines since the 1960s. This was especially vigorous in the developing countries but also had ramifications in the industrialized world. The initiatives taken by the World Health Organization in starting a dialogue between the industry representatives in the International Federation of Pharmaceutical Manufacturers Associations and the critical voices of Health Action International are specially emphasized. The recent developments in the therapy of primary hypertension and peptic ulcer are discussed briefly as examples of the rapid changes in what should be rational in pharmacologic treatment of disease.

Objectives: Current policy and practice regarding identification of and extent of use of data from conference abstracts in health technology assessment reviews (TARs) are examined.

Methods: The methods used were (i) survey of TAR groups to identify general policy and experience related to use of abstract data, and (ii) audit of TARs commissioned by the National Institute for Health and Clinical Excellence (NICE) and published between January 2000 and October 2004.

Results: Five of seven TAR groups reported a general policy that included searching for and including studies available as conference abstracts and presentations. A total of sixty-three published HTA reports for NICE were identified. Of these reports, thirty-eight identified at least one randomized controlled trial available as an abstract/presentation. Twenty-six (68 percent) of these thirty-eight TARs included studies available as abstracts.

Conclusions: There are variations in policy and practice across TAR groups regarding the searching for and inclusion of studies available as conference abstracts. There is a need for clarity and transparency for review teams regarding how abstract data are managed. If conference abstracts are to be included, reviewers need to allocate additional time for searching and managing data from these sources. Review teams should also be encouraged to state explicitly their search strategies for identifying conference abstracts, their methods for assessing these abstracts for inclusion and, where appropriate, how the data were used and their effect on the results.

The aim of Working Group 3 has been to identify possible joint assessments and to coordinate findings and existing resources within the community to support joint assessments.

Are we in a period of significant change? Is health technology assessment (HTA) undergoing a fundamental transformation? Or should it be? Are we in the middle of a paradigm shift? These are some of the questions the paper by Facey et al in this journal (1) raises about the future of HTA, based on discussions at the HTAi Policy Forum in February 2015. To further share the deliberations of the Forum and with a view to opening this debate among the wider HTA community, a panel within the HTAi 2015 Annual Meeting in Oslo was organized. Presentations at the panel included a summary of the HTAi Policy Forum deliberations and perspectives from a patient, a clinician, and representatives of an HTA organization, industry, and a health system. This letter presents issues and thoughts raised in the panel session.

Objectives: There has been a rapid growth in the use of patient-assessed outcomes (PAOs) that are measured in the assessment of health technologies. The process of collection of such measures can be costly, and there may be problems associated with the ability of the patient to complete them. The use of electronically stored routine data may reduce costs and overcome the problems associated with patient completion. The feasibility of using routine data surrogates for the UK Inflammatory Bowel Disease Questionnaire (UKIBDQ) and the Short Form 36 (SF-36) was examined.

Methods: Clinical terms and codes for the UKIBDQ and SF-36 questions were identified, and data from electronic routine sources were sought on patients participating in a randomized controlled trial. The presence or absence of relevant symptoms was used to generate surrogate scores, which were compared with the original scores.

Results: Most questions in the UKIBDQ and SF-36 were codable but only one third of the terms were recorded routinely in electronic form. The surrogate total IBDQ score had reasonable reliability (Kuder–Richardson coefficient = 0.51), but this reliability could not be determined for the SF-36. Intraclass correlations between routine and designed data were poor to weak.

Conclusions: Although electronic routine data sources had the capacity to develop surrogate measures for patient assessed outcomes, there was evidence of wide underutilization of coding systems leading to an underreporting of symptoms. This finding is consistent with previous literature where only poor correlations were illustrated between patient assessed outcomes and surrogate scoring of symptoms.

Objectives: The aim of this study was to explore whether Bayesian reasoning can be applied to therapeutic questions in a way that is similar to its application in diagnostics.

Methods: A clinically relevant, therapeutic question was formulated in accordance with Bayesian reasoning for the clinical management of patients with newly diagnosed rheumatoid arthritis (RA). Prior probability estimates of response to drug treatment (methotrexate, MTX) were obtained from the literature. As a marker of treatment response, changes in the Health Assessment Questionnaire (HAQ) scores were assessed after three months of treatment. Likelihood ratios for this marker were calculated on the basis of data from a clinical registry, using changes in the Disease Activity Score (DAS) as gold standard. Using Bayes’ theorem, prior probability and likelihood ratios were combined to estimate posterior probabilities of treatment response in individual patients.

Results: On the basis of the literature, the prior probability of response of RA patients to MTX was estimated 45 percent. At 3 months follow-up, this probability increased to 80 percent or decreased to 23 percent, depending on the changes that were observed in Health Assessment Questionnaire scores.

Conclusions: Bayesian reasoning can be applied to therapeutic issues in a way that is conceptually fully compatible with its use in diagnostics. As such, it can be used to bridge the gap between aggregate data and individual patient management.

Objectives: The aim of this study was to establish a national Early Awareness and Alert (EAA) system for the identification and assessment of new and emerging health technologies in Italy.

Methods: In 2008, Agenas, a public body supporting Regions and the Ministry of Health (MoH) in health services research, started a project named COTE (Observatory of New and Emerging Health Technologies) with the ultimate aim of implementing a national EAA system. The COTE project involved all stakeholders (MoH, Regions, Industry, Universities, technical government bodies, and Scientific Societies), in defining the key characteristics and methods of the EAA system. Agreement with stakeholders was reached using three separate workshops.

Results: During the workshops, participants shared and agreed methods for identification of new and emerging health technologies, prioritization, and assessment. The structure of the Horizon Scanning (HS) reports was discussed and defined. The main channels for dissemination of outputs were identified as the EuroScan database, and the stakeholders’ Web portals. During the final workshop, Agenas presented the first three HS reports produced at national level and proposed the establishment of a permanent national EAA system.

Conclusions: The COTE Project created the basis for a permanent national EAA system in Italy. An infrastructure to enable the stakeholders network to grow was created, methods to submit new and emerging health technologies for possible evaluation were established, methods for assessment of the technologies selected were defined, and the stakeholders involvement was delineated (in the identification, assessment, and dissemination stages).

Objectives: This study proposes the method requirements for a valid costing study in anesthesia to allow differences to be identified between treatments and uses these method requirements to design and conduct a robust costing study.

Methods: A prospective, patient-based costing study was carried out in adult and pediatric day surgery in the United Kingdom. The perspective was that of the National Health Service and the patient. Data were collected for each patient until 7 days after hospital discharge.

Results: Data were collected for 1,063 adults and 322 children undergoing day surgery between October 1999 and January 2001. Statistically significant differences were found only between variable costs, which accounted for 11.4 percent and 9.0 percent of adult and pediatric costs, respectively. There were no differences in length of stay, fixed costs, or semi-fixed costs. Differences were not found in total costs in adults but were found in children. By day 7, postdischarge primary and secondary care costs were not different between groups in either study. No differences were found in costs to patients or parents.

Conclusions: The use of prospective, patient-based cost data enabled the detection of differences in variable costs between difference anesthetic regimens in day surgery. The stochastic nature of the data provided a measure of variability around mean cost estimates. Practice patterns in the study reflected normal practice in the United Kingdom so the costing data have direct clinical relevance. The use of different anesthetic agents only affected variable costs and had no effect on larger cost drivers such as length of stay or staff input.

The article by O'Malley and Jordan (2009) contains fundamental errors and misunderstands the process it claims to describe (4).

The premise of the paper is that the Australian and New Zealand Horizon Scanning Network (ANZHSN) “was set up to scan the introduction of new and emerging medical technologies into the public sector, with consideration to the private sector.” However, the terms of reference of the policy body (HealthPACT) directing the ANZHSN's activities state that its role is to “provide a forum for monitoring, reviewing, and sharing information regarding health technology to inform service planning and policy development in the public sector” (1). HealthPACT is largely a jurisdictional committee, with representation from the Australian Government, each of its seven states and territories, the New Zealand Health Ministry and district health boards.

Objectives: The aim of this study was to explore definitions of value and the use of budget impact and affordability considerations in health technology assessment (HTA) in the Asia region, particularly in relation to high cost technologies.

Methods: Issues were debated by senior representatives from HTA and payer systems in Asian countries, delegates from industry, and invited experts at the 2016 meeting of the HTAi Asia Policy Forum (HAPF). A premeeting survey was used to gather data on how value is assessed and budget impact calculations are used within current processes, as well as current approaches to managing affordability.

Results: All systems consider health benefit to be the key component of value. There is little consensus around “wider” elements of value that should be included. All systems use budget impact in decision making, although meeting attendees noted the challenges in making accurate estimates. The most common strategies used to address affordability concerns to date have been: restricting coverage, for example, to patients who are likely to get the highest value; discounts; and revenue caps. It was noted that these “solutions” may have unintended consequences of creating inequitable access to therapies and failing to provide adequate rewards for innovation.

Conclusions: Decision makers, HTA agencies, and industry need to continue to work together to find mutually agreeable solutions to ensure that patients continue to get equitable access to effective therapies at costs that can be afforded throughout the Asia region.