Integration of ethics into technology assessment in healthcare (HTA) reports is directly linked to the need of decision makers to provide rational grounds justifying their social choices. In a decision-making paradigm, facts and values are intertwined and the social role of HTA reports is to provide relevant information to decision makers. Since 2003, numerous surveys and discussions have addressed different aspects of the integration of ethics into HTA. This study aims to clarify how HTA professionals consider the integration of ethics into HTA, so an international survey was conducted in 2018 and the results are reported here.

A survey comprising twenty-two questions was designed and carried out from April 2018 to July 2018. Three hundred and twenty-eight HTA agencies from seventy-five countries were invited to participate in this survey.

Eighty-nine participants completed the survey, representing a participation rate of twenty-seven percent. As to how HTA reports should fulfill their social role, over 84 percent of respondents agreed upon the necessity to address this role for decision makers, patients, and citizens. At a lower level, the same was found regarding the necessity to make value-judgments explicit in different report sections, including ethical analysis. This contrasts with the response-variability obtained on the status of ethical analysis with the exception of the expertise required. Variability in stakeholder-participation usefulness was also observed.

This study reveals the importance of a three-phase approach, including assessment, contextual data, and recommendations, and highlights the necessity to make explicit value-judgments and have a systematic ethical analysis in order to fulfill HTA's social role in guiding decision makers.

After surveying its members on ethical issues (2003), the International Network of Agencies for Health Technology Assessment (INAHTA) mandated its Ethics Working Group (2005) to reflect on the role of health technology assessment (HTA) organizations in meeting social expectations. Some aspects of these have since been clarified by two studies addressing either the official position of INAHTA's members or the publication authors. An international survey was carried out on the perception of HTA professionals’ expectations when producing HTA reports: how to fulfil HTA's social role, which value judgments should be made explicit and what should be the status of ethical analysis.

A twenty-two question, web-based, anonymous survey was devised from our recent systematic review on the integration of ethics into HTA and carried from April to July 2018. The information on 328 HTA agencies/contact persons from seventy-five countries was collected from the website of INAHTA, Health Technology Assessment International (HTAi), the European Network for Health Technology Assessment (EUnetHTA), EuroScan International Network, the HTA Network of the Americas (RedETSA) and the HTA Network of Asia (HTAsiaLink), a 2015 World Health Organization survey, HTAi members, and our local HTA network (Québec, Canada).

Eighty-nine participants completed and submitted a finalized survey for a 27 percent participation rate representing thirty-three countries. Regarding how the HTA reports should fulfil their social role, our results showed that over 84 percent of the respondents agreed upon the necessity to address it to decision makers, patients and citizens. At a lower and more variable level, the same result was found about the necessity to make value judgements explicit in different sections of the report, including ethical analysis. This contrasts with the variability of responses obtained on the status of ethical analysis although an agreement on the expertise required was observed. Variability in the usefulness of patient, public or stakeholder participation was observed.

At the dawn of this decade, this study reveals high expectations on context-dependent decisions in HTA: the necessity to integrate the ‘explicitation’ of value judgements and systematic ethical analysis to fulfil HTA's social role.

Integration of ethics into health technology assessment (HTA) remains challenging for HTA practitioners. We conducted a systematic review on social and methodological issues related to ethical analysis in HTA. We examined: (1) reasons for integrating ethics (social needs); (2) obstacles to ethical integration; (3) concepts and processes deployed in ethical evaluation (more specifically value judgments) and critical analyses of formal experimentations of ethical evaluation in HTA.

Search criteria included “ethic,” “technology assessment,” and “HTA”. The literature search was done in Medline/Ovid, SCOPUS, CINAHL, PsycINFO, and the international HTA Database. Screening of citations, full-text screening, and data extraction were performed by two subgroups of two independent reviewers. Data extracted from articles were grouped into categories using a general inductive method.

A list of 1,646 citations remained after the removal of duplicates. Of these, 132 were fully reviewed, yielding 67 eligible articles for analysis. The social need most often reported was to inform policy decision making. The absence of shared standard models for ethical analysis was the obstacle to integration most often mentioned. Fairness and Equity and values embedded in Principlism were the values most often mentioned in relation to ethical evaluation.

Compared with the scientific experimental paradigm, there are no settled proceedings for ethics in HTA nor consensus on the role of ethical theory and ethical expertise hindering its integration. Our findings enable us to hypothesize that there exists interdependence between the three issues studied in this work and that value judgments could be their linking concept.

The overarching goal of this research was to (i) evaluate the impact of reports with recommendations provided by a hospital-based health technology assessment (HB-HTA) unit on the local hospital decision-making processes and implementation activities and (ii) identify the underlying factors of the nonimplementation of recommendations.

All reports produced by the HB-HTA unit between December 2003 and March 2013 were retrieved, and hospital decision makers who requested these reports were solicited for enrolment. Participants were interviewed using a mixed design survey.

Twenty reports, associated with fifteen decision makers, fulfilled the study criteria. Nine decision makers accepted to participate, corresponding to thirteen reports and twenty-three recommendations. Of the twenty-three recommendations issued, 65 percent were implemented, 9 percent were accepted for implementation but not implemented, and 26 percent were declined. In terms of the utility of each report to guide decision makers, 92 percent of the reports were considered in the decision-making process; 85 percent had one or more recommendations adopted; and 77 percent had recommendations implemented. The most frequently mentioned reasons for nonimplementation were related to contextual factors (64 percent), production/diffusion process factors (14 percent), content/format factors (14 percent), or other factors (9 percent). Among the contextual factors, the complexity of the changes (i.e., administrative reasons), budget and resources constraints, failure to identify administrative responsibility to carry out the recommendation, and nonpriority status of the HTA recommendation, were provided.

This study highlights that although HB-HTA reports are useful to hospital managers in their decision-making processes, certain barriers such as contextual factors need to be better addressed to improve HB-HTA efficiency and usefulness.

Patients and families play an important role in preventing adverse events. The quality council at our hospital produced a communication tool in considering the main causes of adverse events and requested the health technology assessment (HTA) unit to validate it.

Assess the validity of the content of a tablemat sticker as an information tool for hospitalized patients.

A qualitative validation was first performed with individual interviews and focus groups to evaluate the understanding of the content. The tool was modified and as a second step, a survey was conducted on patients and their families from a surgical care unit to validate their understanding and relevance of the content.

From the survey, patients and families found the tablemat attractive and stimulating (97 percent). It encouraged them to communicate with staff about the safety of their care (84 percent). They understood well the objective (79 percent) and text (90 percent), but less for the pictograms (30 percent to 62 percent). The communication and recommendations to avoid falling were good and 99 percent were wearing the medical identification. However, it was not clear that these indicators represented the real concerns of the patients and healthcare staff because no user evaluation was done when developing the tool.

The tool was well understood, but some improvements are needed considering that pictograms were not always well understood and so need careful consideration from patient perspective. The HTA unit recommended conducting an unbiased survey to assess the concerns of patients and professionals to identify the most relevant indicators.