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Health technology assessment (HTA) is a multidisciplinary approach to the evaluation of health-care technologies, which aims to

support the decision-making process by driving medical, technical and economic knowledge. It is characterised by the contextual

examination of epidemiological, clinical, economic, social, ethical and organisational implications.

Even if it was born in fields other than medicine, HTA has progressively spread as an innovative tool to assess health-care

technologies such as drugs, medical devices and surgical procedures. Through a scientific literature review the purpose of

applying HTA to public health was explained and discussed. Tackling interventions to control health determinants has great

potential for reducing the burden of disease and for promoting health in the general population. Anyway health expenditure for

public health is low: this could threaten interventions and damage the role of public health itself. HTA could represent a guide to

best invest in this field and to gain in efficacy and effectiveness in line with current strategies to implement health services in all

sectors.

HTA could represent a good tool to address all topics and problems pertaining to choices in public health and could allow

decision-makers to best invest scarce available resources.[PUBLICATION ABSTRACT]

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J Public Health (2013) 21:373378 DOI 10.1007/s10389-013-0557-8

OVERVIEW

The promising application of health technology assessment in public health: a review of background informationand

considerations for future development

Giuseppe La Torre & Chiara de Waure &

Antonio Boccia & Walter Ricciardi

Received: 26 October 2012 /Accepted: 19 February 2013 /Published online: 28 March 2013 # Springer-Verlag Berlin Heidelberg

2013

AbstractIntroduction Health technology assessment (HTA) is a multidisciplinary approach to the evaluation of health-care

technologies, which aims to support the decision-making process by driving medical, technical and economic knowledge. It is

characterised by the contextual examination of epidemiological, clinical, economic, social, ethical and organisational

implications.

Main part Even if it was born in fields other than medicine, HTA has progressively spread as an innovative tool to assess health-

care technologies such as drugs, medical devices and surgical procedures. Through a scientific literature review the purpose of

applying HTA to public health was explained and discussed. Tackling interventions to control health determinants has great

potential for reducing the burden of disease and for promoting health in the general population. Anyway health expenditure for

public health is low: this could threaten interventions and damage the role of public health itself. HTA could represent a guide to

best invest in this field and to gain in efficacy and effectiveness in line with current strategies to implement health services in all

sectors.

Conclusion HTA could represent a good tool to address all topics and problems pertaining to choices in public health and could

allow decision-makers to best invest scarce available resources.

Keywords HTA . Public health . Preventive medicine . Health-care technologies

Introduction: prospective on health technology assessment

What is HTA?

Health technology assessment (HTA) is a multidisciplinary, multiprofessional and multisectoral approach to evaluate health-care

technologies which aims to be a bridge between scientific researchers and policy- and decision-makers. Its final purpose is to

rigorously and systematically transfer medical, technical and economic knowledge to subjects entrusted with leading the political

and socio-economic life of a country (Banta et al. 1978; Velasco Garrido and Busse 2005). Broadly speaking, HTA can be defined

as the systematic evaluation of the properties, effects and/or other impacts of health-care technologies (International Society of

Technology Assessment in Health Care 2002).

If it were possible to identify the main features of HTA, they would be the multidimensionality and the structurality (Granados et

al. 1997). In fact, HTA is multidimensional because technology impact should be assessed by different points of view and experts,

whereas it is structured because it requires the systematic collection and analysis of evidence.

Nevertheless, HTA is not simply research; four features distinguish it: (1) the policy orientation, (2) the interdisciplinary

G. La Torre : A. BocciaDepartment of Public Health and Infectious Diseases, Sapienza University of Rome, Viale Regina Elena 324,

00185 Rome, Italy

C. de Waure : W. RicciardiInstitute of Hygiene, Catholic University of the Sacred Heart,L.go F. Vito 1, 00168 Rome, Italy

G. La Torre (*)

Department of Public Health and Infectious Diseases, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italye-

mail: [email protected]

374 J Public Health (2013) 21:373378

content and process, (3) the integration and synthesis of evidence and primary data and (4) the central role played by the

dissemination and the communication of information (Battista and Hodge 1999).

The main domains addressed by HTA are: technology, patients, economics and organisation (Ham et al. 1995). Technology

efficacy and effectiveness profile, technical performance and safety are evaluated alongside clinical impact and ethical and social

consequences. Moreover, economic features and organisational needs and implications are assessed. In this context, the three

milestones of the HTA process are: the evidence-based approach, systematic reviews and economic analyses.

Beginnings of HTA

The term technology sssessment (TA) was first used during the deliberations of the Committee on Science and Astronautics of

the US House of Representatives in 1967. Congressman Emilio Daddario emphasised that the purpose of TA was to serve

policymakers and stated that Technical information needed by policymakers is frequently not available, or not in the right form. A

policymaker cannot judge the merits or consequences of a technological program within a strictly technical context. He has to

consider social, economic, and legal implications of any course of action (US Congress 1967).

In 1972, the Congressional Office of Technology Assessment (OTA) was established and TA was defined as a comprehensive

form of policy research that examines the short and longterm social consequences of the application or use of technology (Office

of Technology Assessment 1976).

Since its beginnings HTA was shaped as a policy-driven multidisciplinary tool to support decision processes even if, in its first

applications, it was used in choices other than those regarding health. In the field of health care, the OTA recognised that

assessment would have emphasised efficacy, with health improvement the goal of health care (Banta 2003). The first institution

that aimed to apply TA in the field of health care was CEDIT, founded in 1982 in France to support choices made by general

directors of public hospitals. In general, anyway, the first application of HTA to health-care technologies took place within the

framework of pharmaceutical and drug licensing regulation. Different reasons forced the spread of HTA. The first was the

diffusion of new technologies whose employment is often under-researched and guided by common practice instead of evidence

(Stevens et al. 2003). The second driver was costs and, particularly, health services costs which increase because of the general

inflation, the growing health demand and the spread of new technologies (Wanless 2001). The third main reason for the spread of

HTA was the change in consumers expectations and demands (Stevens et al. 2003).

Development of HTA in Europe and in the world

HTA has been carried out and supported by many organisations and individuals worldwide and, nowadays, public and/or private

organisations address it.

At the international level, two important organisations are involved in the promotion and regulation of HTA. The first one, the

International Network of Agencies for Health Technology Assessment (INAHTA) is composed of 52 organisations, mainly funded

by the public sector, from 29 nations and focuses on provision of advice to governments. The second one, the HTA international

(HTAi), born in 2003, is the international society of HTA that embraces well-known public or private organisations involved in HTA

and non-institutional organisations from different countries. Apart from these two international organisations some other

important players in the production of HTA exist, also within pharmaceutical companies themselves.

In Europe, the first institutions involved in HTA were established in France and Spain in the early 1980s and in Sweden in 1987

(Velasco Garrido and Busse 2005; Garca-Alts et al. 2004). Thereafter, academic governmental and nongovernmental units began

to show interest in HTA in almost all European countries even if only part of them are government mandated and play a regulatory

function (Garca-Alts et al. 2004). The European Commission promoted the foundation, in 2005, of a European network, the

European Network for Health Technology Assessment (EUnetHTA) which nowadays coordinates the activities of organisations

involved in HTA from 32 European countries including 26 Member States. In Italy the HTA activities were supported by some

academic institutions, regions, local health authorities and hospitals (Ricciardi et al. 2005); in 2003, the Italian Ministry of Health

funded a research project which led to the institution of an Italian network of HTAwhose work resulted in the Trento chart (Carta

di Trento 2006) in 2006. In 2007 the Italian Society of Health Technology Assessment (SIHTA) was instituted.

Application of HTA

Over the last 20 years, health systems across the world have witnessed an explosion of interest in HTA, evidence-based health

care and cost-effectiveness analysis. Since the 1970s, HTA has broadened to encompass a wide range of health technologies

including drugs, medical devices, medical and surgical procedures, organisational frameworks and support systems for provision

of care (Sorenson et al. 2006). However, the majority of HTA reports have been conducted on pharmaceuticals rather than other

technologies such as medical devices and surgical procedures (Jonsson 2002). Furthermore, HTA was first and primarily applied

at a macro level, in the regulatory field, and later on became a useful tool at the meso and micro level. This evolution was driven

J Public Health (2013) 21:373378 375

by the growing social and economic pressure on each health care system, by the progressive decentralisation of power from the

state to the regions and by the spread of interest in quality, efficiency and efficacy/effectiveness.

Nowadays, HTA is recognised as an instrument to be implemented in order to support informed decision-making processes and

set up the conditions for the stewardship and the resource generation, as recently underlined by 53 nations of the World Health

Organisation (WHO) with the adoption of the Tallinn Charter (WHO 2008).

Main part: future development of HTA in public health

Public health

According to the Oxford Textbook, public health is the process aimed at assuring healthy life conditions through the mobilisation

and the engagement of local, national and international resources; moreover, it is said that What can be done will be determined

by scientific knowledge and the resources available. What is done will be determined by the social and political situation existing

at the particular time and place (Detels and Breslow 2002).

Public health accounts for the health of the community as a whole and aims to fulfil societys interest in assuring conditions in

which people can be healthy. The three core public health functions are thus:

1. The assessment and monitoring of population health in the light of identifying health problems and priorities

2. The formulation of public policies designed to solve local and national health problems and priorities

3. To assure that the entire population has access to appropriate, effective and cost-effective care, including health promotion

and disease prevention services.

Some public health topics are: vaccination, motor vehicle safety, workplace safety, control of infectious diseases, control of

coronary heart disease and stroke, safer and healthier foods, mother and child care, family planning, fluoridation of drinking water

and control of tobacco use (La Torre et al. 2007a). Tackling major health determinants has great potential for reducing the burden

of disease and promoting the health of the general population. Health determinants encompass: personal behaviour and

lifestyles; influences within communities which may sustain or damage health; living and working conditions; access to health

services; and socio-economic, cultural and environmental conditions.

Evidence-based medicine and public health: a bridge to HTA

One of the first definitions of evidence-based public health (EBPH) was given by Jenicek who described it as the

conscientious, explicit and judicious use of current best evidence in decision-making about all health domains (Jenicek 1997).

Brownson et al. defined EBPH as the development, implementation, and evaluation of effective programs and policies in public

health through application of principles of scientific reasoning includingsystematic uses of data and information systems

andappropriate use of program planning models (Brownson et al. 1999; Brownson et al. 2003).

Alternatively EBPH may be defined as a public health endeavour in which there is an informed, explicit and judicious use of

evidence that has been derived from a variety of science and social science research and evaluation methods (Sackett et al.

1996).

Two aspects arise from the definitions given: the use of a particular type of evidence to inform public health decisions and the

emphasis on clear reasoning in the process of appraising and interpreting that evidence.

Public health is a relative newcomer to the area of research synthesis and evidence-based practice. In the USA, the Task Force on

Community Preventive Services was formed in 1996 to synthesise scientific information about the effectiveness of health

promotion and disease prevention interventions and has, to date, reviewed hundreds of topics for recommendations on effective

practices. The Cochrane field of health promotion, officially registered in 1996 and expanded to include public health in 1999, also

addresses these topics and has completed a bulk of reviews about them.

Nevertheless, until the mid-1990s few public health practitioners and policymakers were familiar with methods of synthesis for

evidence-based practice. Only in the 2000s has EBPH become internationally, nationally and regionally widespread also in the

decisional context. Nowadays, worldwide, public health policies identify the evidence supporting the effectiveness as a requisite

for considering an intervention. In Italy, for example, one of the requisites to list a health service among essential levels of care

(LEA) is its effectiveness and cost-effectiveness.

On the other hand, even if the demand for evidence-based practice has grown and evidence has become a guide for undertaking

decisions, methods to produce evidence and to contribute to knowledge for decision-making may be further implemented

(Anderson et al. 2005). HTA in this context represents an attempt to meet this need. Systematic reviews, meta-analyses and

economic evaluations cannot alone support decision-makers so far. They must be integrated in a more complete and exhaustive

process of evaluation that takes into account all the aspects related to the introduction of a new technology. As an example, HTA

was recognised as an instrument to be developed and employed to support decision-making in the Italian Health National Plan

2006 2008 (Ministero della Salute 2006). At the European level, several countries relied on HTA in order to reach decisions

376 J Public Health (2013) 21:373378

on health. As an example, HTA represents one of the main research areas of the Department of Health of the National Health

Service in the UK providing the basis for health and social care policy planning.

HTA in public health: strengths and future developments

Public health is a fundamental field of medicine aimed at promoting the health of all individuals. The amount of health

expenditure for public health and prevention is anyway paltry; only 1.7 % of the global pharmaceutical market was dedicated to

vaccines in 2002 for example (Peny et al. 2005). Vaccines are one of the most successful public health interventions: they have

allowed diseases to be eradicated and controlled and need to be continuously implemented despite the possibility of controlling

infectious diseases by other strategies and instruments. Overall, European Member States invest less than 3 % of health

expenditure in prevention (OECD 2012). But it is not only money that justifes the application of HTA to public health and, in

particular, to preventive medicine. Bonsel, during the HTAi annual meeting in 2005, stated that Its [public health] increasingly

marginal existence can also be judged from the mere absence of assessments of public health systems. Most of the avoidable

burden of diseases in Western countries is to be found in the realm of risk factors which are amenable to collective efforts, that is

interventions at the system level rather than the individual level. According to the author, instruments to evaluate public health

interventions should be developed to let public health reach a central role at the national level (Bonsel 2005).

Walter Holland also affirmed that possible areas for future assessment should include such issues as smoking, drug and other

substance misuse, nutrition, and health inequalities. Concentrating on drugs and clinical procedures does not really have a great

influence on population health. Of course, this is much more difficult, but essential if the objective is a national, effective, efficient

health policy (Holland 2004).

The assessment of interventions, whose impact is on the whole population and not only on the individual patient, should be

promoted in order to guarantee a proper allocation of resources. In this field the National Institute for Health and Clinical

Excellence (NICE) is undertaking numerous efforts by being involved in the revision of different public health practices, with

respect to prevention of cardiovascular diseases in particular.

The application of HTA to vaccines was the first attempt done in order to apply HTA to public health and prevention and the

Health Technology Assessment Center of the Catholic University of the Sacred Heart was one of the first organizations to work on

it.

The reports on human papillomavirus (HPV) vaccines, carried out by the Danish Centre for Evaluation and Health

Technology Assessment (Danish Centre for Health Technology Assessment 2007) and by the Health Technology Assessment

Center of the Catholic University of the Sacred Heart (La Torre et al. 2007b; La Torre et al. 2009), demonstrated the bulk of aspects

which have to be considered in introducing a new technology, such as a new vaccine, and how useful it is to have a document

summarising all evidence and forecasting possible scenarios of vaccination introduction. The evaluation of both HPV vaccines

available on the market has allowed assessment of the burden of HPV-related diseases, showing the cost-effectiveness of both

vaccines and pointing out the needs for a careful organisation of vaccines offered. The method which has been developed and

applied is characterised by different steps and guarantees a complete analysis of the problem from different viewpoints. In fact,

the following aspects have been addressed by the Health Technology Assessment Center of the Catholic University of the Sacred

Heart in HTA as applied to public health and preventive medicine topics:

& Epidemiology and burden of disease& Description of current strategies to prevent/treat disease & Identification and valuation of

resources used to treat disease (costs of illness)& Evaluation of the technology being introduced from both a biotechnological

and a clinical point of view& Mathematical modelling to evaluate clinical benefit derived from the introduction of the technology&

Budget impact analysis& Cost-utility analysis of the introduction of the technology & Definition of ethical, social and legal

implications& Description of organisational impacts and definition of the best strategies to supply the new technology

The instruments used to address all these issues encompass epidemiology (surveys, systematic reviews, meta-analysis, cross-

sectional studies and register analysis), mathematical models, economics (cost-effectiveness or cost-utility analysis),

organisational analyses and sociological tools (focus groups).

In public health a huge number of fields may benefit from HTA; indeed horizon scanning should be conducted. Horizon scanning

could be carried out keeping in mind the epidemiological setting of each country and population health needs alongside

directions coming from health decision-makers.

The potential future application of HTA in public health could be represented by:

Primary prevention interventions such as vaccinations or educational campaigns to avoid starting cigarette consumption or drug

abuse or quitting the consumption, or interventions to promote road safety (La Torre et al. 2008)

Secondary prevention interventions such as some new screening for cancer

J Public Health (2013) 21:373378 377

Tertiary prevention interventions to allow patients to maintain health status or gain in health once affected by particular

conditions

The implementation of support systems such as informatics devices

Organisational models such as hospital departmental structure or ambulatory services organisation

It is clear that new methods and the standardisation of the ones already existing should be assured in order to broadly apply the

HTA approach to public health. It is on the other hand obvious that not all of the new proposals or strategies could be assessed

with such a comprehensive method because of the limitedness of human resources and the timeliness. Some criteria should be

followed to choose technologies being evaluated with the HTA approach; one suggestion could be to assess innovations able to

improve health outcomes or whose evidence of use are counteracted or interventions which could save money or require huge

investment. Anyway the scant amount of evidence which is available on particular technologies, in particular organisational

frameworks, should not limit the choice of the objective of HTA.

Conclusion

Following the increasing need for evidence-based practice in medicine, HTA could be adapted to the study of all health

technologies, from vaccines to medical devices, from organisational procedures to educational campaigns. This is expected also

because profound changes in health-care systems are ongoing and decision-makers as well as physicians themselves should aim

to guarantee quality, safety, equality and value. In this context, HTA could represent a good tool to address all of the problems

arising from specific choices in health-care services and delivery. Ultimately, it could support decision-making in particular where

resources are very scant such as in public health in order to sustain an informed, effective and efficacious allocation of

resources.

Conflict of interest The authors declare that they have no conflict of interest.

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