To the Editor:

We want to comment on the study by Martelli et al. in Volume 23:4, which appears to have several mistakes and seems to be outdated and probably biased.

Several agencies mentioned in the study now have different tasks and mandates and accordingly have different denominations. The CCOHTA for example has been renamed CADTH (Canadian Agency for Drugs and Technologies in Health) in April 2006 to reflect its broader mandate (1). The health technology assessment (HTA) Unit of the Institute of Technology Assessment of the Austrian Academy of Sciences has no role in HTA anymore since the Ludwig Boltzmann Institute of HTA has also been established in April 2006 (2). A third example is the Haute Autorité de Santé (HAS), or French National Authority for Health, formerly (until August 2004!) known as ANAES.

The selection of HTA organizations is not easy to understand, because some of the organizations selected do not seem to be appropriate while others are missing. A knowledgeable person would have suspected to find the AHTAPol (Agency for Health Technology Assessment in Poland, established 2005) in the article (3), but not necessarily the Unit of Health Economics and Health Technology Assessment at the Budapest University in Hungary, because this is an academic institute without regulatory power and, thus, not compatible with the research questions laid out in the methods section. Since 2004, two institutions in Germany, the Federal Joint Committee (G-BA, Gemeinsamer Bundesausschuss) and the Institute for Quality and Efficiency in Health Care (IQWiG, Institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen) have been established. While IQWiG produces evidence reports (4) commissioned by the G-BA, the latter decides upon coverage of health technologies (5). These decisions are legally binding for up to 90 percent of the German population, that is, more than 70 million people. Both organizations are publicly funded and together have a staff of approximately 130 and a total annual budget exceeding 20 million euros. IQWiG is also a member of INAHTA.

The authors do not describe their selection process, apart from the fact that they planned a comparison of the influence of different financing systems on organizational aspects of the respective organization. We suspect that the selection of HTA organizations in the study by Martelli et al. was not systematic; hence, a severe bias that could compromise the findings cannot be ruled out. If, for instance, AHRQ would have been selected as one of the major U.S. HTA agencies, the conclusions concerning the impact of HTA in the United States would probably be different. The two U.S. organizations that were selected, the CMS and the VA HTA program, cannot be compared because they serve very different healthcare sector decisions.

There is also some concern that the analysis of organizational aspects is incomplete. The authors did not ask questions regarding the legal mandate of the HTA agencies within the healthcare system, which is probably the most powerful predictor of impact. On the other hand, contrasting the author's view that year of establishment may have an influence on the agencies' impact, mandate, and spectrum of tasks of an HTA organization may change, as we have mentioned already.