Untangling the complexity of funding recommendations: a comparative analysis of health technology assessment outcomes in four European countries

Objectives
Health Technology Assessment (HTA) agencies produce recommendations that guide public funding of pharmaceuticals, based on various criteria. We explored factors that may contribute to explaining differences in coverage decisions by the National Institute for Health and Care Excellence (NICE) in England and Wales, the Scottish Medicines Consortium (SMC), the Dutch College voor Zorgverzekeringen (CVZ), and the French Haute Autorité de Santé (HAS).

Methods
A dataset of 977 HTA decisions made in 2004–2009 was created. A three-category outcome variable was used (decision to ‘recommend’, ‘restrict’ or ‘not recommend’ a technology). Multivariate analyses explored impacts of clinical, economic, process and socio-economic variables in their decision making.

Results
Relative to the CVZ and adjusting for a range of confounders, technologies were more likely to be recommended by NICE and HAS, and restricted or not-recommended by the SMC. Recommendation was significantly associated (p ? 0.10) with several variables: strength of clinical evidence (number of trials, use of active comparator-arm, demonstration of clinical superiority) orphan status and indication for cancer. Simultaneous assessment of multiple rather than single pharmaceuticals was associated with increased probability of restriction.

Conclusions
In this European multi-HTA study, appraisal outcomes differed significantly across HTA bodies. A range of evidence and non-evidence factors were associated with HTA decisions, confirming the value of comprehensive, multivariate analyses. Nevertheless, a large proportion of variance in HTA decisions remained unexplained, suggesting that greater transparency of decision making is needed, along with associated further research.