A scoping review was conducted to understand which environmental factors are currently being discussed as candidates for inclusion in health technology assessments (HTAs). By mapping the current literature, the results of the scoping review will inform future work to assess the importance policymakers place on aspects of environmental concern.

The scoping review involved literature searches across three electronic databases (MEDLINE, CINAHL, and PsycINFO), encompassing articles published up to the end of 2023, to identify a starting set of articles. Backward and forward citation searching of relevant studies was then employed to expand the scoping review, with inclusion criteria established to select studies based on the specific focus on HTA. Screening was conducted independently by two reviewers in two stages: title and abstract and then full-text screening. Data extraction involved a structured approach, collating relevant information for thematic analysis.

While the scoping review is ongoing, emerging issues included: methods for incorporating environmental pollution externalities into HTAs; the impact of climate change on health outcomes; intergenerational equity of health outcomes and definitions of sustainability; environmental epidemiology; and the potential for technologies to mitigate the impact of climate change. The ongoing thematic analysis will synthesize the results of the scoping review using mapping and categorization to identify knowledge gaps.

The threat of climate change is the greatest issue faced by HTA in a generation, but this challenge is intersectoral and demands an intersectoral response. This paper identifies environmental concerns that might, in principle, be included within the HTA process. Ultimately, the HTA community must do its part to address the environmental crisis we face and move toward a more sustainable future.

In the era of cardiovascular-kidney-metabolic syndrome, thorough evaluation of medicines with multiple treatment effects/indications demands a multifaceted modeling philosophy, despite the requirement of health technology assessment (HTA) models to focus on one disease. Using Cardiff, a model previously built for type 2 diabetes (T2D), we illustrate the changes needed to capture contemporary, holistic, patient-centered decision-making, and argue that HTA bodies should revise their approach.

The upgraded model enables therapy selection and escalation determined by HbA1c thresholds, cardiovascular risk (QRISK3), comorbidities (established cardiovascular or chronic kidney disease), and weight (body mass index ≥35 kg/m2). Risk factor trajectories were updated by incorporating UKPDS-90 equations and other relevant data sources. Clinical outcomes were predicted using new risk equations incorporating cardiovascular outcomes trial data whenever possible. The updated model was applied to assess quality-adjusted life years (QALYs) and lifetime costs in newly diagnosed T2D patients in the UK, modeled via a conventional glycemic-centric approach versus a multifactorial treatment algorithm. Extrapolation to the national level utilized estimates of annual incidence.

The updated treatment algorithm captured and quantified the impact of nuanced comorbidity management called for in guidelines. In a cohort of newly diagnosed T2D patients, 81 percent initiated an SGLT2 inhibitor within five years, predominantly due to increasing cardiovascular risk, versus zero percent when escalation was dictated by HbA1c alone. Broad, early use of SGLT2 inhibitors resulted in an additional 0.73 predicted QALYs and GBP10,757 (USD13,600) in predicted lifetime cost savings per patient versus a “traditional” approach. Cost savings were primarily due to avoided renal events; extrapolation to the national level predicted cost savings to the payer of GBP2.8 billion (USD3.5 billion), which traditional models cannot capture.

The modernized Cardiff model incorporates multifactorial prescribing guidelines and contemporary evidence around cardio-renal protection and is more adept at modeling costs and outcomes of multidimensional antidiabetic treatments; traditional glucose-centric modeling methods may introduce bias. Economic modeling and HTA processes must adapt to follow the complexities of modern disease management and remain relevant as healthcare systems address the cardiovascular-kidney-metabolic syndrome epidemic.