Hospital-Based Health Technology Assessment (HB-HTA) is a heterogeneous phenomenon constantly evolving to respond to the needs of decision-makers at the hospital level. In 2023, The HB-HTA Interest Group of Health Technology Assessment International (HTAi) surveyed HB-HTA activities with the aim to provide an updated description of the actual scenario.

An online survey was conducted to gather data on the main characteristics of hospitals, HB-HTA activities, outputs, role in the decision-making processes, dissemination and training activities, and their interaction and collaboration with other stakeholders and HTA-related regulations. Finally, the survey collected feedback on the perception of and current barriers to HB-HTA. Three categories of responders were identified: Both hospitals performing and not performing HTA and policymakers.

Eighty-seven responses were collected from twenty-eight countries. Nearly half of the responders (n = 41) conducted HB-HTA, whereas eighteen consisted of hospitals not performing HTA, and twenty-eight were policy makers. HB-HTA was performed mainly in hospitals with >500 beds. HB-HTA units were organized in 40 percent of cases as an “independent group.” The survey showed that HTA units could contribute to all the steps of the decision-making processes, whereas the impact of the assessments on the decisions was mainly perceived as a medium. Furthermore, HB-HTA was not seen as a duplication of effort, even without specific regulations.

The survey highlighted the role of HB-HTA in hospital decision-making supporting the vision of HB-HTA as one of the actors in the HTA ecosystem, the success of which depends on collaboration with other stakeholders.

A program for integral, transversal, and multidisciplinary management of aortic stenosis (MITMEVA) is being implemented at the Clinic Barcelona University Hospital (CBUH) to provide adequate treatment for patients with aortic stenosis (AS). Eleven actions at different care points were implemented (e.g., awareness raising for the general population, a single entry path for patient referral, prehabilitation and rehabilitation, and a risk-sharing agreement). Preliminary results are presented.

A before-and-after implementation study was conducted with 131 patients under MITMEVA and 131 matched (for treatment, New York Heart Association classification, sex, age, and referral place) historical controls. Data were collected on resources used and quality of life and to calculate several key performance indicators (KPIs) (e.g., knowledge improvement in citizens, time from diagnosis to treatment, and patient involvement and satisfaction) for each implemented action. A descriptive analysis of KPIs and a Markov model were performed to simulate clinical and economic outcomes for patient health states over time after the first year until the tenth year after intervention.

The MITMEVA program increased quality-adjusted life-years by 1.78 (p=0.011) and reduced time from referral to first hospital visit by 24.7 percent (p=0.05), hospital complications by 19.7 percent (p=0.05), mean conventional ward stay from 12.8 to 8 days (p=0.01), and mean intensive care unit stay from 9.75 to 4.25 days, although the latter difference was not statistically significant (p=0.139). The mean cost per patient was reduced from EUR7,573.27 per patient to EUR6,024.61 per patient (p=0.01). The MITMEVA program was a dominant strategy. There was a 46 percent increase in correct AS symptom identification after delivering training on AS to the general population.

Integrated care approaches can potentially improve patient continuum of care if the strategies are deployed in a multidisciplinary and transversal way across healthcare actors. The MITMEVA program significantly improved clinical and economic outcomes and organization of care, benefiting patients and clinicians. Applying health technology assessment methods to such innovative projects can help prove the value of organizational innovations.

A program for integral, transversal, and multidisciplinary management of aortic stenosis (MITMEVA) was implemented at the Clinic Barcelona University Hospital to provide adequate and personalized treatment for patients with aortic stenosis (AS). MITMEVA includes 11 actions in the AS care pathway. This study aimed to test the scalability of MITMEVA by gathering the perspectives of relevant stakeholders in two other Catalan hospitals.

A mixed method study design was used to collect and analyze the views of relevant stakeholders on the scalability of the MITMEVA project. Qualitative and quantitative methods were used to answer the research question. All participants were interviewed individually using a semi-structured interview guide. The interviews were transcribed and analyzed by performing a content analysis with Atlas.ti software. Quantitative data were gathered and analyzed by adjusting the Intervention Scalability Assessment Tool (ISAT).

Nine participants were interviewed from two tertiary hospitals in Catalonia and eight ISAT questionnaires were completed. From the content analysis, 11 of the 15 themes identified related to actions implemented in the MITMEVA program. The results pointed toward a positive view of implementation of the MITMEVA program in general, showing a good scalability for all the ISAT domains. On a scale of zero to three, most domains were scored two or above.

The qualitative and quantitative results indicated that the MITMEVA program has potential for scaling up to other Catalan hospitals to improve the management of AS. Generally, stakeholders from the two participating hospitals were positive about the project. However, small adjustments will be needed to account for the culture and organizational characteristics of the hospitals when scaling up the MITMEVA program.

Integrated care (IC) is a patient-centered approach to the provision of health care that overcomes the fragmentation in the delivery of services that often occurs in older people with multiple comorbidities. Medical device innovations could help tackle this and other challenges of health systems when facing the adoption of high quality IC. Nevertheless, this should be accompanied by the right innovation funding scheme to encourage adoption.

A systematic search strategy to identify payment models for IC was performed in PubMed for the period from 2014 to 2023 using the International Foundation for Integrated Care Knowledge Tree tool. This was complemented with both a gray literature search in Google and a benchmark of payment models for innovative medicines. A scoping review was then performed identifying the following information: payment scheme; advantages and disadvantages for IC; inclusion of innovation; type of IC program or initiative described (sectors and providers); population (therapeutic area); country; and whether the information was conceptual or empirical.

According to the literature reviewed, five payment schemes used in IC were identified. However, they were rarely used in isolation; more often a mix of payment schemes was used. Based on conceptual and empirical articles, the combination of bundled payment, shared savings, and pay for performance (based on the quality of care delivered) seemed to be the most comprehensive payment scheme. However, references to inclusion of innovation were not mentioned even in this mixed system. Payment systems for innovative medicines were benchmarked for medical devices.

A mixed system of bundled payment, shared savings, and pay for performance appears to be the most complete payment model for IC, since it counteracts the limitations of individual funding schemes. No evidence was found on how to incentivize medical device innovation in the context of IC delivery. However, inspiration from current payment schemes for innovative medicines can provide a starting point for innovative medical device schemes.

Interest in early detection of complications in hospitals has increased recently. Complications after elective or urgent surgery are frequent and are associated with higher mortality rates, longer hospital stays, and more resource utilization. The ZERO project implemented an educational nursing program and developed an innovative algorithm that assesses a patient’s complication risk based on clinical parameters to prevent complications and reduce hospital burden. Our aim was to present the results from one year of implementing ZERO at the Clinic Barcelona University Hospital.

A comparative effectiveness and cost study was conducted. Data from patients admitted after elective or urgent surgery were collected for one year retrospectively (n=8,844 from January 2019 to December 2019) and prospectively (ZERO) (n=8,163 from October 2021 to October 2022). Effectiveness was measured in terms of mortality, complications, and life-years gained (LYG). Length of stay (LoS) at conventional, intermediate, and intensive care units and rates of readmissions were collected for resource use. The chi-square test was used to compare categorical variables. The t-test and Wilcoxon test were used for normally and non-normally distributed continuous variables, respectively.

There was a significant decrease in the rate of complications (7.8%, 95% confidence interval [CI]: -8.46, -7.19; p<0.001) with ZERO. Moreover, there were statistically significant reductions in mean LoS for readmissions to conventional wards (-5.04 days, 95%CI: -9.9, -0.18; p=0.04) and to the intensive care ward within the same episode (-4.68 days, 95%CI: -9.26, -0.14; p=0.02). The mean cost per patient was EUR2,772.92 and EUR2,591.57 before and after ZERO implementation, respectively. After accounting for the cost of implementing ZERO, there was a cost saving of EUR147.76 per patient (p=0.048), which yielded a yearly impact of EUR1,206,165 for the hospital budget.

This one-year analysis of the effect of ZERO on surgical patients shows that it decreases complication rates and all types of LoS, leading to overall cost savings for the hospital.

Limited knowledge of the symptomatology of aortic stenosis (AS) among the general population may delay diagnosis and have a major impact on morbidity and resource use. Training programs have often been advocated by the scientific community. The present study reported the results of an assessment of a training program for the general population.

Patients who attended healthcare centers were asked to answer a questionnaire on their level of knowledge around AS. A cohort of patients without training (n=681) answered the questionnaire and a second cohort answered the questionnaire via phone 24 hours after training (n=197). Propensity score matching by sex and age was used to obtain a balanced sample between the two cohorts, giving a total study sample of 394 individuals (197 without training and 197 with training). A descriptive analysis was performed to compare differences in the level of knowledge between the two cohorts. Predictors of AS symptomatology were identified using multivariate logistic regression.

The trained cohort was more aware of AS disease than the untrained cohort (79% versus 31%, 95% confidence interval [CI]: 0.39, 0.56; p<0.001). They were also better at distinguishing the symptoms associated with AS (80% versus 43%, 95% CI: 0.28, 0.48, p<0.001) and were more aware of its severity (36% versus 12%; 95% CI: 0.16, 0.32, p<0.001). Moreover, the trained cohort were better at identifying symptoms that should make them consider visiting a doctor (76% versus 65%; 95% CI 0.02, 0.20, p<0.02). No differences were observed in level of concern regarding AS (8% versus 4%; 95% CI: -0.0046, 0.09, p=0.08).

The trained people who were aware of AS (p=0.04) correctly classified AS as a valvular disease (p=0.025), would seek medical consultation when AS symptoms occurred (p=0.04), and were more likely to correctly detect AS symptoms.

The training program significantly improved the knowledge and awareness of AS in the general population. This can improve the timeliness of AS diagnosis, reducing the health and economic burden of AS for the healthcare system.

The assessment of current technologies needs a more holistic approach to obtain accurate recommendations for decision-making. The VALues In Doing Assessments of health TEchnologies (VALIDATE) methodology considers that facts and values from all stakeholders need to be included in the scoping of an assessment to gather the comprehensive information needed for unbiased decision-making. This report aimed to explore how to properly assess the integrated care of patients with aortic valve stenosis (AVS) using the VALIDATE approach.

A literature review was conducted, and 11 semi-structured interviews were performed with various hospital-based healthcare professionals (cardiac surgeon, clinical cardiologist, interventional cardiologist, anesthetist, process coordinator nurse, and others) and patients. Content analysis was used for data analysis and integration.

The literature review showed that the cardiology and cardiac surgery perspectives were dominant in 90 percent of the articles and present in the remaining ten percent. The perspectives of other specialties (anesthesiology, primary care, and psychology) were included in three percent of the articles and patient perspectives were included in nine percent. Interviewing and considering the perspectives of the different stakeholders involved in the care pathway identified the following indicators that should be included in the assessment care for patients with AVS: difficulties associated with late diagnosis of AVS; the need to incorporate a multidisciplinary approach in patient risk assessment; the importance of geriatric evaluations; considering patient (and family and caregiver) preferences for type of treatment; the importance of following up pharmaceutical treatment and palliative care; use of telemonitoring; and digital exclusion of patients with respect to the use of apps for prehabilitation and rehabilitation.

The stakeholders interviewed were involved in different steps of the care pathway and had differing needs, some of which were not found in the literature. The indicators suggested for inclusion in the assessment differed according to type of stakeholder and their involvement in the care pathway. Therefore, this case study exemplifies the VALIDATE method and endorses the need for multistakeholder involvement in eliciting values when scoping the assessment of a complex technology.

The public health areas without commercial value continue to be underserved, while those of high profit for industry will not be sustainable for much longer. We hypothesize that the lack of equity and efficiency in the biomedical research and development system is mainly due to a pharma-led short-term profit orientation that ignores the values of other relevant stakeholders.

This pilot study reached some consensus on the principles of a co-created biomedical research and development process based on the preferred supplier (PS) model, which proposes a public health procurement system prioritizing business with companies fulfilling the “4 Share” criteria of priorities, risks and rewards, results, and outcomes to ensure that health needs are met.

A constructive health technology assessment, which included VALues In Doing Assessments of health TEchnologies (VALIDATE) methodology, was used to analyze the values and dissent of a pilot sample of ten global key informants. The methodology comprised qualitative techniques such as an online preliminary survey, in-depth semi-structured interviews, and a Delphi survey to reach a joint construction by reconstructing the stakeholders’ interpretive frames and applying an adaptation of the Richardson model to contested values.

There was consensus on combining efficiency and social justice norms by incentivizing diseases affected by market failure due to small subpopulations (e.g., rare diseases), low availability to pay, restricted use (e.g., antibiotics), and difficulty demonstrating results (e.g., Alzheimer’s disease). Stakeholders mainly agreed on the PS 4 Share principles, highlighting the need for price to be linked to impact modulated by tracked research and development costs and investments, as proposed by the PS model. More market incentives such as push, and especially pull incentives (market access), should be included. The PS model should be cause-solution oriented, promote open-disruptive innovation, and guarantee fast patient access.

The PS model achieved multistakeholder consensus for desirability (values) and plausibility (shifting incentives). Stakeholders pointed out the need to apply health technology assessment to further develop the model and pilot it in the European Union with the NextGenerationEU.

In the past decade, health technology assessment (HTA) has narrowed its scope to analyses of mainly clinical and economic benefits. Technology challenges in the 21st century emphasize the need for holistic assessments to obtain accurate recommendations for decision-making, as in HTA’s foundations. Using the VALues In Doing Assessments of health TEchnologies (VALIDATE) methodology for complex technologies provides a deeper understanding of problems through analysis of stakeholders’ views, allowing for more comprehensive HTAs. This study aimed to assess a pharmaceutical clinical decision support system (CDSS) using VALIDATE.

Semi-structured interviews with different stakeholders were conducted in the following domains: problem definition (medication error [ME] occurrence and prevention); judgement of solution (existing preventive methods and previous experiences of the CDSS); background theories (future impact and personal beliefs); and barriers to and facilitators of implementation. The following individuals were interviewed: medical informatic specialists (n=3), pharmacists (n=2), nurses (n=2), physicians (n=2), CDSS company representatives (n=1), electronic health record developer (n=1), and health consultancy firm representatives (n=1). Content analysis was used to integrate and analyze the data.

The multistakeholder interviews identified various barriers to the acceptance and implementation of a pharmaceutical CDSS that were different from those reported in the literature. These included: (i) occurrence of ME (no traceability of medication taken or poor patient medication empowerment); (ii) perception of current level of MEs (huge improvement from ten years ago); (iii) perception of technology as a tool to prevent ME (not enough if only implemented at one point of care); (iv) previous experiences with a CDSS (low rates of development of CDSSs are due to medication prescriptions being digitalized last in hospitals); (v) CDSS metrics (input data should be measured to control CDSS performance); and (vi) other barriers.

Including facts and stakeholders’ values in problem definition and the scoping of health technologies is essential for the proper conduct of HTAs. Incorporating views from multiple stakeholders when scoping the assessment of health technologies brings additional values to literature findings, resulting in a more holistic evaluation. The lack of multistakeholder scoping can lead to inaccurate information and result in wrong decisions about if, when, and how to adopt a CDSS.

The performance of diagnostic health technologies is usually assessed by comparing them with standard care using the kappa statistic. These comparisons are made based on comprehensive clinical information (e.g., anamnesis and complementary tests). However, not all digital applications (DAs) execute over complete information, which leads to work under non-uniform distribution of values. Using kappa statistic in this situation has serious methodological limitations. Kappa assumes that the marginal values are uniformly distributed and highly weights the discordant values when calculating concordance, which underestimates the real effectiveness of DAs (i.e., observed concordance). We aimed to present the application of the B statistic to WtsWrng, a symptom triage DA for individuals.

WtsWrng was used by 382 patients at the emergency department of a hospital. Diagnoses provided by WtsWrng, given 19 symptoms, were compared with those logged in the hospital’s electronic clinical records at discharge. Observed concordance was calculated using contingency tables. The concordance using the kappa and B statistics were compared for the 12 most frequent diagnoses at hospital discharge. Sensitivity and specificity were also calculated.

Real observed concordance fluctuated from 0.4 to 0.98 for the 12 most frequent diagnoses, eight of which had a concordance greater than 0.8. The results ranged from -0.005 to 0.37 when using the kappa statistic and from 0.36 to 0.99 when using the B statistic. The sensitivity and specificity of WtsWrng were greater than 0.8 for three and eight of the 12 diagnoses, respectively.

The results show that the B statistic is closer to the real observed concordance when kappa statistic assumptions are not fulfilled by a DA. Therefore, the B statistic is better suited for assessing the effectiveness of this type of technology. Analysis of WtsWrng using the B statistic showed that its diagnoses were close to those provided by clinicians, which were arrived at using complete clinical information. Moreover, the high specificity of the WtsWrng DA suggests that it is a good tool for determining the appropriate use of healthcare resources.

To conduct a formative evaluation of applying the VALIDATE approach in practice by (i) assessing how students appreciated the e-learning course, (ii) exploring how, for what purposes and with what outcomes the acquired VALIDATE competences subsequently were used in internships in different institutional contexts, and how this was shaped by these contexts, and (iii) what this shows on real-world use of VALIDATE.

Comparative discussion of experiences of applying the VALIDATE approach via a semistructured survey and oral feedback from e-course students; final reports on internships in health technology assessment (HTA) practice, followed by semistructured interviews with interns and supervisors to complement and interpret results.

All students considered the VALIDATE approach an enlightening and important addition to current HTA knowledge, especially regarding understanding the relation between empirical analysis and normative inquiry, identifying policy relevant questions and using the method of reconstructing interpretive frames for scoping. The latter appeared intellectually challenging and requiring some prior HTA knowledge. The use the VALIDATE approach in practice shows that interns productively redefined the HTA problem, based on appreciation of different stakeholders’ definition of the issue; they experienced constraints from retrieving all relevant perspectives from existing literature as well as from institutional rules and routines.

Some challenges in applying the VALIDATE approach deserve attention for its future use: currently used research approaches often assume a problem as “given”; and the data needed on different perspectives is often not reported in scientific literature. Finally, data gathering on and evaluation of value dimensions was experienced as challenging.

In the past decade, health technology assessment (HTA) has narrowed its scope to the analysis of mainly clinical and economic benefits. However, twenty-first century technology challenges require the need for more holistic assessments to obtain accurate recommendations for decision-making, as it was in HTA's foundations. VALues In Doing Assessments of health TEchnologies (VALIDATE) methodology approaches complex technologies holistically to provide a deeper understanding of the problem through analysis of the heterogeneity of stakeholders’ views, allowing for more comprehensive HTAs. This study aimed to assess a pharmaceutical clinical decision support system (CDSS) using VALIDATE.

A systematic review of the empirical evidence on CDSS was conducted according to PRISMA guidelines. PubMed, the Cochrane Library, and Web of Science databases were searched for literature published between 2000 and 2020. Additionally, a review of grey literature and semi-structured interviews with different hospital stakeholders (pharmacists, physicians, computer engineers, etc.) were conducted. Content analysis was used for data integration.

Preliminary literature results indicated consensus regarding the effectiveness of CDSS. Nevertheless, when including multistakeholder views, CDSS appeared to not be fully accepted in clinical practice. The main reasons for this appeared to be alert fatigue and disruption of workflow. Preliminary results based on information from the literature were contrasted with stakeholder interview responses.

Incorporation of facts and stakeholder values into the problem definition and scoping for a health technology is essential to properly conduct HTAs. The lack of an inclusive multistakeholder scoping can lead to inaccurate information, and in this particular case to suboptimal CDSS implementation concerning decision-making for the technology being evaluated.

Ningún sistema de salud cuenta con los recursos necesarios para evaluar todas las tecnologías. Contar con un proceso claro para priorizar qué tecnologías serán evaluadas por las agencias de evaluación de tecnologías sanitarias (ETESA) constituye un principio de buena práctica reconocido a nivel internacional. El objetivo del Foro de Políticas en Latino América (LatamPF) 2020 de Health Technology Assessment International fue explorar cómo puede mejorarse la forma en que las agencias de ETESA de Latino América identifican y priorizan las tecnologías a ser evaluadas.

Este manuscrito está basado en un documento base, una encuesta, y en el trabajo deliberativo realizado por los miembros (cuarenta y seis participantes, once países) que participaron del LatamPF, a través de la metodología design-thinking.

Los participantes coincidieron en que la falta de mecanismos claros de priorización trae como consecuencia una falta de legitimidad de las decisiones y procesos de ETESA, que son percibidos como poco transparentes y demasiado expuestos a presiones políticas o de grupos de interés. También se identificaron barreras y acciones para mejorar los mecanismos de priorización de ETESA en América Latina. Los criterios identificados como más importantes para ser tenidos en cuenta por las agencias de ETESA de la región al momento de priorizar una tecnología para ser evaluada fueron la carga de enfermedad, el potencial beneficio clínico, la alineación con prioridades de salud nacionales, el potencial impacto en la equidad, ausencia de otras alternativas para los pacientes, y el potencial impacto económico.

Los participantes del Foro coincidieron en que el establecimiento de procesos transparentes de priorización es un elemento clave para todos los sistemas de salud. Las mejoras en este proceso fortalecerán la ETESA en Latino América y darán mayor legitimidad a sus decisiones.

There is no health system that has the resources to evaluate all technologies. The presence of a clear process to prioritize health technologies for assessment by health technology assessment (HTA) agencies is a good practice principle recognized at the international level. The objective of Health Technology Assessment International's 2020 Latin American Policy Forum (LatamPF) was to explore how to improve the way HTA agencies in Latin America identify and prioritize technologies for assessment.

This paper is based on a background document, a survey, and the deliberations of the members of the LatamPF (forty-six participants from eleven countries) using a design thinking methodology.

Participants agreed that a lack of clear prioritization mechanisms results in HTA processes and decisions that are perceived to be of low transparency and overly exposed to political or interest group pressures. The LatamPF identified barriers and recommended actions to improve HTA prioritization mechanisms in Latin America. The criteria identified as the most important to be taken into consideration by HTA agencies in the region when prioritizing a technology for assessment were: the burden of illness, the potential clinical benefit, the alignment with national health priorities, the potential impact on equity, a lack of treatment alternatives for patients, and the potential economic impact.

Forum participants agreed that the establishment of transparent prioritization processes is a key element for all health systems. Improvements in these processes will strengthen HTA and provide greater legitimacy to decision making.

Un vínculo claro entre la evaluación y la toma de decisión constituye un principio de buena práctica en evaluación de tecnologías sanitarias (ETESA) reconocido a nivel internacional. El objetivo del Foro de Políticas en Latino-América (LatamPF) 2019 de Health Technology Assessment International fue explorar los diferentes modelos que vinculan la ETESA y la toma de decisión y discutir su potencial aplicabilidad en Latino-América.

Este manuscrito está basado en un documento base y en el trabajo deliberativo realizado por los miembros (54 participantes, 12 países) que asistieron al LatamPF, a través de la metodología design thinking.

Los participantes coincidieron en que la relación inapropiada entre la ETESA y la toma de decisión atenta hoy contra la legitimidad de las decisiones, expone al proceso de ETESA a una excesiva influencia política y judicial, y condiciona que algunos actores se sientan relegados del proceso de evaluación y toma de decisión. Se identificaron los atributos del proceso de ETESA más prioritarios y factibles de ser mejorados en la región, y con el mayor potencial para generar un cambio positivo en los sistemas de salud. La mayor parte de estos están vinculados con la apropiada institucionalización de la ETESA, ampliar la participación de los diferentes actores y mejorar la transparencia de los procesos de ETESA.

El LatamPF ha identificado barreras y recomendado acciones para reforzar el vínculo entre ETESA y la decisión. A su vez, existe en estos momentos una ventana de oportunidad en la región, ya que el tema es visualizado como una prioridad por gran parte de los actores de la sociedad. Por ello, los diferentes actores de los sistemas sanitarios deberían ahora tomar esta oportunidad para avanzar en el fortalecimiento del vínculo entre ETESA y toma de decisión.

One of the good practice principles for health technology assessment (HTA) is having a clear link between the assessment and decision making. The objective of the 2019 Latin American Policy Forum (LatamPF) of Health Technology Assessment International was to explore different models of connection between HTA and decision making and to discuss the potential applicability of such models in Latin America.

This paper is based on a background document and the deliberations of the members of the LatamPF (fifty-four participants from twelve countries) where a design-thinking methodology was used.

The participants agreed that insufficient links between HTA and decision making undermine the legitimacy of decisions, expose the HTA process to excessive political and judicial influence, and promote the exclusion of some stakeholders from participating in the assessment process and decision making. High priority aspects of the HTA process that could feasibly be improved and which hold the greatest potential to generate positive changes in the health systems in the region were identified. The majority of these aspects were associated with the appropriate institutionalization of HTA, a greater degree of participation by different stakeholders, and improved transparency in the HTA process.

The LatamPF identified barriers and recommended actions to strengthen the link between HTA and decision making. Participants emphasized that there is now a window of opportunity in the region as many societal actors see this as a priority. For this reason, health system stakeholders must take this opportunity to increase efforts toward strengthening the link between HTA and decision making.