Implementation and Development of Hospital-Based Health Technology Assessment in Poland: A Qualitative Research Perspective
This article, published in Frontiers in Public Health, examines the implementation and development of Hospital-Based Health Technology Assessment (HB-HTA) in Poland. It focuses on the viewpoints of hospital representatives, providing insights into the benefits, obstacles, and potential improvements to the HB-HTA methodology. The research is based on in-depth interviews conducted with representatives from Polish hospitals that participated in a pilot project.
Introduction
In Poland, health technology assessment (HTA) has primarily concentrated on pharmaceuticals, evaluated by the Agency for Health Technology Assessment and Tariffication. However, the increasing investment in various hospital technologies, including hardware, diagnostics, and organizational improvements, along with a growing need to properly assess the costs of implemented healthcare solutions, has led to the development of HB-HTA. A project initiated between 2019 and 2022, involving the National Health Fund (NHF), the National Institute of Cardiology in Warsaw (NIKARD), and Lazarski University (UŁ), aimed to implement HB-HTA within the Polish healthcare system.
Purpose of the Study
The primary goal of this study was to analyze the possibilities for developing HB-HTA in Polish hospitals, based on the experiences of the participants. The study aimed to identify both the advantages and the barriers associated with implementing HB-HTA units within Polish hospitals.
Methods
The research employed a qualitative approach, using in-depth interviews with representatives from hospitals involved in the HB-HTA project. The interviews were analyzed using the Nvivo12 program. A questionnaire, designed to gather information about the pre-project, design, and post-project phases, was administered to respondents from five of the seven participating hospitals. The remaining two hospitals declined to participate. The Ethics Committee of the Jagiellonian University Medical College approved the study.
Results
Hospital representatives indicated that the HB-HTA methodology enables the assessment of investments based on appropriate data. The project provided hospital staff with new skills, such as becoming familiar with medical bibliographic databases. Despite these benefits, comprehensive implementation of HB-HTA in Poland has been limited. According to study participants, facilities do not obtain adequate organizational and financial benefits from the implementation of HB-HTA. Participants suggested modifications to align the methodology with specific facility needs.
Introduction
The assessment of health technologies often focuses on justifying the addition of services or drug technologies to the list of services reimbursed by the public insurer in Poland. The Agency for Health Technology Assessment and Tariffication (AOTMiT) advises the Minister of Health on decisions regarding the financing of solutions from public funds. The Agency’s activities are governed by the Act on Healthcare Services Financed From Public Funds. It also deals with tariffication of health services and evaluation of health policy programs.
This agency works with various entities within the healthcare system, including hospitals, to transmit relevant data. The agency has operated since 2005 and has a strong position in the healthcare system. However, Poland lacks both long-term experience and specific regulations for assessing therapeutic and diagnostic technologies at the hospital level. Data from hospitals has not been adequately considered in the evaluation of medical services, influencing the guaranteed services package funded by the public payer. Hospitals’ role in shaping HTA has been limited, and the data from hospitals did not play that role as they could have. Hospitals suffered from low financing of medical services evaluated by AOTMiT, and many faced cash flow difficulties and financial instability.
Changes involving modern medical technologies at the hospital level need contributions from many actors in the healthcare system. There is a notable need among Polish healthcare facilities to develop various technologies, such as da Vinci or Versius robots, particularly in 2022 with a significant increase in surgical robots. Some large public and private centers have increased the number of procedures using medical robots. The number of procedures performed in public facilities exceeded the number of procedures performed in private facilities. The market for private surgeries (mainly prostatectomies) shrank primarily due to a significant increase in National Health Fund valuations, thanks to which several large private hospitals signed contracts with the fund and began to offer the procedures free of charge to patients.
The use of medical robots could be an area of interest for those introducing modern treatment techniques or equipment to facilitate diagnosis and ensure the development of medical facilities. Such technologies could be assessed in accordance with the HB-HTA methodology. The provision of data by hospitals would help stakeholders make more expedient decisions about financing such innovations. HB-HTA represents a methodology for the dissemination of new technologies. Modern technologies create trends in hospitals. Thanks to them, hospital administrators can set their priorities and long-term plans. Other bodies related to healthcare are also involved in the process of creating those plans, for example the Ministry of Health, which has created its own department for the development of new technologies (Department of Innovations).
The IOWISZ System
The Evaluation Instrument of Investment Motions in Health Care (IOWISZ) plays a significant role in organizing investments in hospital facilities in Poland. It is a tool for voivodes and the Minister of Health to evaluate the advisability of investments. It was introduced to ensure that new investments are made where they are most needed and where they will bring the greatest benefits to patients. The main goal of the IOWISZ system was to properly supervise and organize the investment process in healthcare, while developing an effective and fully rational system of spending public funds. One may use the IOWISZ IT system to submit a request for an opinion on the role of a given investment and its purpose. An intention of the system was to enable service providers to develop prospectively in line with local health needs, after obtaining a positive opinion from individual stakeholders of the system.
The HB-HTA Project
Support for implementing innovative medical technologies in hospitals and enriching the IOWISZ methodology was to be provided by the Hospital Assessment of Innovative Health Technologies (HB-HTA) project, which was carried out by three consortium members: the National Health Fund (NFZ), the National Institute of Cardiology in Warsaw (NIKARD), and Lazarski University in Warsaw (UŁ). It was financed by the National Center for Research and Development and was implemented during the years 2019–2022. The project was divided into two design phases: research and implementation. As part of the project research design stage, six HB-HTA implementation theoretical models were prepared. Each theoretical model for the implementation of HB-HTA in Poland was developed according to the same scheme. Based on the theoretical models and assumptions, the roles of the various healthcare institutions that are to participate in the creation of the HB-HTA network in Poland was indicated.
In the pilot phase of the project, selected hospitals were required to prepare HB-HTA reports. Seven hospitals, known for their contributions to medical research and expertise in implementing innovative medical technologies, were chosen to participate. The personnel underwent intensive training in HB-HTA, facilitated by the project consortium. Subsequently, pilot HB-HTA units were established within these hospitals and were tasked with conducting pilot assessments of selected innovative medical technologies and producing HB-HTA reports for these technologies.
Methods
Study Introduction
Five hospitals that were involved in preparing HB-HTA reports decided to participate in the study. The remaining two entities refused to participate due to having no further HB-HTA activities. A total of five participants took part in the study, all from facilities involved in the pilot phase of HB-HTA. Before the respondents agreed to participate, they had been sent a letter electronically, which was describing the purpose of the study and the topics that would be discussed during the interview. The participants for the interview were selected based on the decisions of the hospital managers and their engagement with the HB-HTA project. Informed consent forms were sent to all study participants, which they signed and returned. Furthermore, they had participated in training courses prepared by Lazarski University and were identified as leaders within their respective entities within HB-HTA.
Study Design
A qualitative in-depth interview study was conducted with a group of hospital representatives. The interviews were recorded, then transcribed and translated into English. The interviews were conducted between February and March 2024 in the form of an online teleconference. Each interview lasted from 20 to 30 min, during which questions were asked according to a previously developed scenario. Each interviewee responded to the same set of questions, posed by the researcher, in a single session. In conclusion, five individual interviews were conducted as part of the study. Table 1 summarizes the study group characteristics. The following research was prepared through internal discussion between the research team regarding the most suitable questions for exploring the implementation of HB-HTA in Polish hospitals. Of the seven selected hospitals invited to participate in the study, five representatives took part in the research. From the aforementioned seven hospitals, five were selected for inclusion in the study.
Ethical Considerations
The study was anonymized. Consent to conduct the study was obtained by submitting an application to the Research Ethics Committee of the Jagiellonian University Medical College.
Data Analysis
Content analysis (thematic analysis) was performed using the Nvivo12 program. The content of the interviews was analyzed by two members of the research team. The text was then subjected to a process of coding; where the data was divided into subcodes. Ultimately, five overarching concepts, comprising eleven codes and ten subcodes, were identified and subjected to analysis. The results are presented in Table 2.
Results
Project Information and Participation
Respondents learned about the HB-HTA project from various sources, including project organizers and facility directors. Directors and management boards were interested in finding information about the project and were initiators of actions. Among the reasons for participating in the project, the respondents mentioned the innovative nature of their facilities, which regularly implement new medical technologies. They also believed in the value of making decisions based on a well-established scientific methodology and proper data organization.
Methods for Health Technology Assessment Before the Project
All respondents indicated that their institutions had previously conducted short internal analyses and completed external applications under IOWISZ. However, the current solutions, such as IOWISZ, are not ideal. The assessment of introduced technologies is conducted in an ad hoc manner. Respondents indicated that the role of IOWISZ in the process of assessing solutions implemented in hospitals was not appropriate.
Benefits of Participation
Experiences gained through participation in the HB-HTA project included familiarization with articles from medical scientific databases. They can also develop their skills by the project. Hospital representatives pointed out that proper data analysis was a very important issue and they can develop their skills by the project. There is also a need to systematize activities in the assessment of modern medical technologies. Interviewees can also use structured methodology in HB-HTA reports. HB-HTA made it possible to look at the purchase of technological solutions not only from the perspective of the equipment costs, but also from the perspective of the processes of implementing a solution. HB-HTA allows to look at technologies from different perspectives.
Organizational and Financial Changes
Respondents stated that HB-HTA required financial resources and the interest of various healthcare institutions. Currently, no hospital benefits fully from using HB-HTA, and hospitals need to ensure the project team is not disbanded. Hospitals will need more visible effects of HB-HTA and stability of employment of people responsible for HB-HTA in hospitals. Facilities are struggling with the problem of retaining employees, which may affect further activities towards HB-HTA. Respondents of the study highlighted the problem of data exchange between institutions, which often relies on archaic ways.
Need for Methodology Modification
Respondents stated that the HB-HTA methodology is extensive. Shortening and simplifying the HB-HTA documents might be an incentive for more medical entities to employ this methodology, leading to more effective medical technologies implementation. Respondents noticed a number of advantages of implementing HB-HTA in hospitals.
Discussion
The study’s findings suggest that the HB-HTA methodology enables the systematization of knowledge and data-driven decision-making by hospital managers. The HB-HTA teams formed during the pilot study continue to evaluate the technologies introduced to the hospitals. The guidelines for creating HB-HTA reports may need to be adjusted to focus more on business analysis. Hospitals also require significant tangible benefits to continue employing HB-HTA. Health technology assessment at the hospital level should also be supported by central institutions (Ministry of Health, the National Health Fund). The respondents emphasized that organizational activities should resolve clinical issues through the implementation of HB-HTA.
The Hospital Health Technology Assessment should determine the appropriateness of the investment in line with the literature and based on up-to-date data.
HB-HTA has been developed in several European countries through the AdHopHTA project. The Hospital Technology Assessment is intended to fulfill the following tasks:
- Properly assessing implementation time and adjusting the pace of introducing modern technologies to hospital budgets;
- Providing appropriate information about a given technology to representatives of the hospital management;
- Increasing the efficiency of using technology in hospitals;
- Improving patient safety.
The respondents expressed a need to base HB-HTA reports more on business aspects and simplify the methodology created by the project team. The study indicates the direction in which HB-HTA should be developed, based on interviews with selected representatives from hospitals participating in the HB-HTA pilot. The assembled team of experts demonstrated significant knowledge of HB-HTA, not only from the perspective of the hospital, but also from the perspective of the entire healthcare system.
Conclusion
Implementing HB-HTA in Poland requires further development and increased interest from various healthcare institutions. Employees of the hospitals participating in the HB-HTA project have implemented investment assessment methodology, although it is more applicable to internal activities and has been adapted to the context of the given facility. There are no appropriate incentives for using HB-HTA methodology, either financially or organizationally. Based on the experiences of the interview participants, it can be concluded that HB-HTA needs strong institutional support in terms of implementing activities, both organizationally and economically.
Author Contributions
- MF: Conceptualization, Data curation, Formal analysis, Methodology, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing, Project administration, Software.
- MG-S: Conceptualization, Funding acquisition, Investigation, Methodology, Project administration, Resources, Supervision, Writing – review & editing.
- IK-B: Conceptualization, Data curation, Formal analysis, Investigation, Software, Supervision, Validation, Writing – original draft, Writing – review & editing.
