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Health technology assessment (HTA) adopts a multidisciplinary approach to comprehensively assess safety, efficacy, effectiveness, economic and organizational impact, and any potential social and ethical implications associated with adoption and diffusion of a technology in a healthcare system. Canada was one of the first pioneers in using HTA as a research tool to support evidence-based decision-making. This article describes the current application of HTA in Canada, with a focus on some federal and Ontario initiatives in which the authors have extensive knowledge and experience to illustrate how academic researchers conduct HTA in collaboration with decision makers. Some issues and challenges are also highlighted that will hopefully stimulate a broader discussion among HTA stakeholders to move HTA forward.

Objective: To assess the impact of the 1997 Canadian guidelines on the methods and presentation of economic evaluations conducted from a Canadian perspective in the published literature., Methods: A systematic literature review was conducted to identify health technology economic evaluations conducted from a Canadian perspective published in peer-reviewed journals between 2001 and 2006. To investigate the impact of the 1997 Canadian Coordinating Office of Health Technology Assessment guidelines, each included study was assessed against 17 of the 25 recommendations., Results: Of the 153 included studies, a base set of 9 methodological standards, as outlined by the 1997 guidelines, were followed by over 50% of the studies including: indications, outcomes for cost utility analysis, outcomes for cost benefit analysis, discounting future cost and outcomes, cost identification and valuation, evaluating uncertainty and disclosing funding relationships. Main divergences from the guidelines were found for analytic technique (38%), study perspective (23%), source of preferences (8%), equity (7%), and cost measurement (24%)., Conclusion: The current assessment has shown that the 1997 Canadian guidelines have set a minimum methodological standard within the community of "doers" conducting economic analyses from a Canadian perspective. Although there was divergence from some of the recommendations, the majority were reflected as changes in the 2006 Canadian guidelines.

Economic evaluations involve the comparison of alternative courses of action in terms of both their costs and their consequences. In response to increasing health care costs, economic evaluations of competing technologies, including radiologic interventions, are increasingly used to inform resource allocation decisions. It is therefore crucial that radiologists have a thorough understanding of the methods. The objective of this paper is to present a detailed overview of the principles and methods of economic evaluations of health technologies, including recent methodologic developments. For the purpose of this paper, the key elements of an economic evaluation are divided into 5 broad sections: 1) types of economic evaluations (eg, cost-effectiveness analysis, cost-utility analysis), 2) study perspectives (ie, temporal and cost perspectives), 3) analysis of costs and effects (eg, incremental cost-effectiveness ratios, cost-effectiveness planes), 4) conducting economic evaluations alongside trials or using decision-analytic models, and 5) dealing with the different forms of uncertainty in economic evaluations (eg, sampling uncertainty in trials, parameter uncertainty in models). Examples from the recent radiology literature are used to explain the key concepts. This review improves upon the previous educational papers published in radiologic journals, as it covers recent methodologic advances regarding the treatment of uncertainty.

Objective: The aim of this paper is to present an economic evaluation of diagnostic technologies using Helicobacter pylori screening strategies for the prevention of gastric cancer as an illustration., Methods: A Markov model was constructed to compare the lifetime cost and effectiveness of 4 potential strategies: no screening, the serology test by enzyme-linked immunosorbent assay (ELISA), the stool antigen test (SAT), and the (13)C-urea breath test (UBT) for the detection of H. pylori among a hypothetical cohort of 10,000 Canadian men aged 35 years. Special parameter consideration included the sensitivity and specificity of each screening strategy, which determined the model structure and treatment regimen. The primary outcome measured was the incremental cost-effectiveness ratio between the screening strategies and the no-screening strategy. Base-case analysis and probabilistic sensitivity analysis were performed using the point estimates of the parameters and Monte Carlo simulations, respectively., Results: Compared with the no-screening strategy in the base-case analysis, the incremental cost-effectiveness ratio was $33,000 per quality-adjusted life-year (QALY) for the ELISA, $29,800 per QALY for the SAT, and $50,400 per QALY for the UBT. The probabilistic sensitivity analysis revealed that the no-screening strategy was more cost effective if the willingness to pay (WTP) was <$20,000 per QALY, while the SAT had the highest probability of being cost effective if the WTP was >$30,000 per QALY. Both the ELISA and the UBT were not cost-effective strategies over a wide range of WTP values., Conclusion: Although the UBT had the highest sensitivity and specificity, either no screening or the SAT could be the most cost-effective strategy depending on the WTP threshold values from an economic perspective. This highlights the importance of economic evaluations of diagnostic technologies.

Randomized controlled trials may lack generalizability and cannot always provide sufficient information for policymakers to make decisions regarding the use of new technologies entering into a health care system. Information related to other aspects of health technologies, in addition to clinical endpoints, such as economic, patient-related, and organizational issues, may be needed before making policy decisions. To address generalizability issues related to a health care technology, primary data collection conducted within a health care system may be required. A process for primary data collection to inform health policy in Ontario regarding health care technologies was initiated in 2003. Following recommendations from the Ontario Health Technology Advisory Committee, conditionally funded field evaluations for promising technologies with insufficient information are initiated. The conduct of these field evaluations occurs in 3 stages. The translation of the policy problem to research questions that can be answered through the design of a practical clinical trial is the first stage, followed by implementation, data collection, quality control, and quality assurance activities. After the completion of the field evaluation data collection and analysis, the results of the study are presented to the committee to respond to its request. Technologies evaluated by this process include drug-eluting stents, the endovascular repair of abdominal aortic aneurysms, and multifaceted interventions in diabetes care. This process, developed in Ontario for the evaluation of health technologies, has been a successful collaborative effort between practitioners, academia, government, health policymakers, and industry that has permitted an evidence-based framework for the approval and funding of technologies within the health care system.

Background: Health care expenditures continue to escalate, and pressures for increased spending will continue. Health care decision makers from publicly financed systems, private insurance companies, or even from individual health care institutions, will continue to be faced with making difficult purchasing, access, and reimbursement decisions. As a result, decision makers are increasingly turning to evidence-based platforms to help control costs and make the most efficient use of existing resources. Most tools used to assist with evidence-based decision making focus on clinical outcomes., Health Technology Assessment: Health technology assessment (HTA) is increasing in popularity because it also considers other factors important for decision making, such as cost, social and ethical values, legal issues, and factors such as the feasibility of implementation. In some jurisdictions, HTAs have also been supplemented with primary data collection to help address uncertainty that may still exist after conducting a traditional HTA., Role of Primary Data Collection: The HTA process adopted in Ontario, Canada, is unique in that assessments are also made to determine what primary data research should be conducted and what should be collected in these studies. In this article, concerns with the traditional HTA process are discussed, followed by a description of the HTA process that has been established in Ontario, with a particular focus on the data collection program followed by the Programs for Assessment of Technology in Health Research Institute. An illustrative example is used to show how the Ontario HTA process works and the role value of information analyses plays in addressing decision uncertainty, determining research feasibility, and determining study data collection needs.