Hospital managers’ need for information in decision-making – An interview study in nine European countries

ContentslistsavailableatScienceDirect

Health

Policy

jo u r n al h om ep age :w w w . e l s e v i e r . c o m / l o c a t e / h e a l t h p o l

Hospital

managers’

need

for

information

in

decision-making

–

An

interview

study

in

nine

European

countries

Kristian

Kidholm

,

Anne

Mette

Ølholm

,

Mette

Birk-Olsen

,

Americo

Cicchetti

,

Brynjar

Fure

,

Esa

Halmesmäki

,

Rabia

Kahveci

,

Raul-Allan

Kiivet

,

Jean-Blaise

Wasserfallen

,

Claudia

Wild

,

Laura

Sampietro-Colom

a_{OdenseUniversityHospital,DepartmentforQuality,ResearchandHealthTechnologyAssessment,Sdr.Boulevard29,5000OdenseC,} Denmark

b_{CatholicUniversityoftheSacredHeart,DepartmentofEconomicsandManagementandALTEMS(GraduateSchoolofHealth} EconomicsandManagement),LargoF.Vito1,00168Rome,Italy

c_{TheNationalKnowledgeCenterfortheHealthServices,P.O.Box7004StOlavsplass,N-0130Oslo,Norway} d_{HelsinkiandUusimaaHospitalDistrict,P.O.Box705,00029Hus,Finland}

e_{AnkaraNumuneTrainingandResearchHospital,HTAUnit(ANHTA),UlkuMahallesiTalatpasaBulvariNo.5,Altindag,06100Ankara,} Turkey

f_{MedicalDirection,TartuUniversityClinics,L.Puuseppst1a,Tartu50406,Estonia}

g_{MedicalDirection,LausanneUniversityHospital(CHUV),Bugnon21,LausanneVDCH-1011,Switzerland} h_{LudwigBoltzmannInstitutefürHealthTechnologyAssessment,Garnisongasse7/20,1090Wien/Vienna,Austria} i_{EvaluationofInnovationandNewTechnologies,HospitalClínicBarcelona,C/Villarroel170,1.7.,08036Barcelona,Spain}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory: Received13March2015

Receivedinrevisedform13August2015 Accepted17August2015

Keywords: HTA

HospitalbasedHTA Decisionmaking Informationalneeds Decisionmakers

a

b

s

t

r

a

c

t

AssessmentsofnewhealthtechnologiesinEuropeareoftenmadeatthehospitallevel. However,theguidelinesforhealthtechnologyassessment(HTA),e.g.theEUnetHTACore Model,areproducedbynationalHTAorganizationsandfocusondecision-makingatthe nationallevel.ThispaperdescribestheresultsofaninterviewstudywithEuropean hos-pitalmanagersabouttheirneedforinformationwhendecidingaboutinvestmentsinnew treatments.ThestudyispartoftheAdHopHTAproject.Face-to-face,structuredinterviews wereconductedwith53hospitalmanagersfromnineEuropeancountries.Thehospital managersidentifiedtheclinical,economic,safetyandorganizationalaspectsofnew treat-mentsasbeingthemostrelevantfordecision-making.Withregardtoeconomicaspects,the hospitalmanagerstypicallyhadanarrowerfocusonbudgetimpactandreimbursement. InadditiontotheinformationincludedintraditionalHTAs,hospitalmanagerssometimes neededinformationonthepoliticalandstrategicaspectsofnewtreatments,inparticular therelationshipbetweenthetreatmentandthestrategicgoalsofthehospital.Iffurther studiesareabletoverifyourresults,guidelinesforhospital-basedHTAshouldbealtered toreflecttheinformationneedsofhospitalmanagerswhendecidingaboutinvestmentsin newtreatments.

©2015TheAuthors.PublishedbyElsevierIrelandLtd.Thisisanopenaccessarticleunder theCCBY-NC-NDlicense(http://creativecommons.org/licenses/by-nc-nd/4.0/).

∗ _{Correspondingauthor.Tel.:+4530586477.}

E-mailaddresses:kristian.kidholm@rsyd.dk(K.Kidholm),anne.mette.oelholm@rsyd.dk(A.M.Ølholm),mette.birk-olsen@rsyd.dk

(M. Birk-Olsen), acicchetti@rm.unicatt.it (A. Cicchetti), Brynjar.Fure@kunnskapssenteret.no (B. Fure), esa.halmesmaki@fimnet.fi (E. Halmesmäki), drrabiakahveci@yahoo.com(R.Kahveci),Raul.Kiivet@ut.ee(R.-A.Kiivet),Jean-Blaise.Wasserfallen@chuv.ch(J.-B.Wasserfallen),claudia.wild@hta.lbg.ac.at (C.Wild),LSAMPIET@clinic.ub.es(L.Sampietro-Colom).

http://dx.doi.org/10.1016/j.healthpol.2015.08.011

0168-8510/©2015TheAuthors.PublishedbyElsevierIrelandLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).

1. Introduction

Inmany countriesnewhealthtechnologies(e.g.new pharmaceuticalsornewdevices)arebeingsystematically assessedbynationalorregionalhealthauthoritiesbefore decisions on investmentand implementationare made at thelocalhospitals [1].However,the numberof new healthtechnologiesconsideredandimplementedat hospi-talseachyearisoftenmuchhigherthanthecapacityofthe nationalHealthTechnologyAssessment(HTA)units[2–4]. Hospitalshavethereforestartedproducingtheirown hos-pitalbasedHTAs.Examplescanbefoundfrome.g.Canada, Spain,Italy,Denmark,Norway,France,Israel,Australiaand

USA[5–13].

Severalguidelinesexist onhow toproduceHTA and whattypeofinformationtheyshouldinclude.An exam-pleistheEUnetHTAHTACoreModel[14,15]thatdescribes outcomemeasuresdividedintoninedomains.Thismodel wasdevelopedbyalargenumberofprimarilynationalHTA institutions.Littleisknown,however,aboutthe compli-ancebetweenthisandotherHTAmodelsandtheneedfor informationonnewhealthtechnologiesbyadministrative andclinicalhospitalmanagers.

This subject is being studied in the European FP7 researchprojectAdHopHTA[16].Theoverallobjectiveof this projectis tostrengthentheuseandimpactof HTA inhospitals.AdHopHTAbringstogether10partnersfrom ninedifferentcountries:sixhospitalswithHTAprograms (Spain,Denmark,Finland,Switzerland,Italy,Turkey);one hospitalwithoutaHTA program(Estonia);twonational HTA agencies (Norway and Austria); and one business school(Spain).

Theoverall aimofthis studyistounderstandwhich informationEuropeanhospitalmanagersneedwhen mak-ing decision oninvestmentin newhealth technologies. Theresultsofthestudyshouldalsoformthebasisforthe developmentofguidelinesforhospitalbasedHTAinthe AdHopHTAproject.

Asystematicliteraturereviewwascarriedoutbefore startingthisstudy[17].Theaimofthereviewwasto iden-tifyempiricalstudiesontheinformationhospitalmanagers need when deciding onhealth technology investments. The review included 14 empirical studies. The studies were mainly semi-structured interviews and question-naire surveys with health care managers from Europe, USA and Australia. The main results found were, that hospitalmanagersmostfrequentlymentionedthe clini-cal effectiveness andthe economic aspectsas themost importantaspectsofnewtechnologiesin decision mak-ing. In parallel to this, an interview study [18] shows thathospitalmanagersrankedinformationaboutclinical effectivenessandeconomicimpactasmostimportantin decisionmaking.Secondly,thathospitalmanagersrarely mentioned information on the ethical, legal and social aspectsofnewtechnologiesasbeingimportant.Thirdly, that even though the political and strategic aspects of technology investments are traditionally not part of a HTA,thehospitalmanagersoftenconsideredtheseaspects as importantwhen makinginvestmentdecisions. Asan exampleaCanadianstudy[19]reportedthathospital man-agersalsoincludedconsiderationsregardingprestigeand

competition among hospitals in their decision making. Finally,thereviewshowsthathospitalmanagersneeded informationontheeconomicaspectsincludingontheone handsocietalcost-effectivenessanalysisandontheother handmorenarrowhospitalbudgetimpactanalysis.

Inthelightoftheresultsofthesystematic literature review it wasdecided that the interview study should specifically examine (i) whether information on some aspectsofnewhealthtechnologiesareconsideredmore importantthanotheraspects,(ii)whetherthepoliticalor strategicaspectsofinvestmentinnewtechnologiesshould beincludedinhospitalbasedHTAand(iii)whether infor-mation onthe economic aspects of investment in new technologies should include description of the societal cost-effectivenessorthebudgetimpactforthehospitalor both.

2. Materialsandmethods

Thestudyinvolvedface-to-face,structuredinterviews withconveniencesamplesofhospital managersinnine Europeancountries.

2.1. Theinterviewguide

An interview guide was developed including seven backgroundquestionsdealingwiththehospitaland the respondent(e.g.sizeandtypeofhospitalandthegender, age and education of the respondent), three introduc-toryquestionsregardingdecisionmakingatthehospital ingeneral,fivequestions abouttheinformation needed fordecision-makingandsixquestionsaboutthe decision-making process. See the interview guide in the online Appendix.Thecurrentarticlepresentstheanswerstothe questionsabouthospitalmanagers’informationalneeds.

Theinterview guidealsoincludedinformation about thenine domainsoftheHTACoreModelaswellasthe domaincoveringstrategicandpoliticalaspectsidentified in theliterature[18,19].In anattempt toavoid biasing therespondentsinfavorofHTA,thequestionnairedidnot includequestionsabouttherespondents’perceptionofthe valueofthecontentofHTA.Instead,anopenquestionwas askedatthebeginningoftheinterview(seeQuestion4in

Box1).

Theinterviewernotedalltheinformationmentioned bytherespondents inanswerto thefirstquestion(see Question4inBox1)usingtherespondentsownwording.

Ifarespondentdidnotspontaneouslymention infor-mationalneedswithinoneormoreofthe10domains,the interviewerthenaskedexplicitlyaboutthatdomain(see Question5inBox1).

Therespondents’fullanswertothequestionincluding explanationsandexampleswererecordedornotedbythe interviewer.

Finally,respondentswereasked(inQuestion6,seeBox 1)toassesswhetherinformationonsomedomainswere moreorlessrelevantfromtheirpointofview.Theobjective ofthisquestionwastotest,whethersometypesof infor-mationwasinfactmoreimportanttohospitalmanagers thanothersastheliteraturereviewindicated[17].

Box 1: Questionsabout decision makers need forinformation.

Question4:

Whichinformationwouldyou–intheidealsituation– wishtohaveatyourdisposalasabasisforyour deci-siononwhetherornottoinvestinanewtreatment? Question5:(Askonlyifthefollowingdomainshave notbeentouchedupon)

Doyouthinkthatthefollowingshouldbepartofthe basisfordecisionmaking:

a.Informationonthehealthproblemofthepatients, the patients’ needs and the current technology shouldbepartofthebasisfordecisionmaking? b.Informationonthecharacteristicsandcontentofthe

newtreatmentshouldbepartofthebasisfor deci-sionmaking?

c.Information on the clinical effectiveness of and patientsatisfactionwiththenewtreatmentshould bepartofthebasisfordecisionmaking?

d.Informationonsafetyaspectsofthenewtreatment shouldbepartofthebasisfordecisionmaking? e.Information onthe economic aspectsof the new

treatmentshouldbepartofthebasisfordecision making?

f.Informationontheethicalaspectsofthenew treat-ment should be part of the basis for decision making?

g.Informationontheinternalandexternal organiza-tionalaspectsofthenewtreatmentshouldbepart ofthebasisfordecisionmaking?

h.Informationonthesocialaspects,e.g.influenceon thelifeofthepatients,ofthenewtreatmentshould bepartofthebasisfordecisionmaking?

i.Informationonthelegalaspectsofthenew treat-ment should be part of the basis for decision making?

j.Informationonpoliticalandstrategicaspectsofthe newtreatment?

Question6:

Wehavenowbeenthroughanumberofdifferent infor-mation or criteria that according to you should be partofabasisfordecisionmaking.Couldyouassess whethersomeofthisinformationis“highlyrelevant” andother“lessrelevant”?

If“yes”→Pleaseindicatethemostrelevant informa-tion?

Aninterview instruction was produced toassist the interviewersin thistask(seeonline Appendix).To sim-plifytheanalysisoftheanswers,eachpartnerwasasked toreporttheresultsinaReportingtemplateinEnglish(see onlineAppendix).

Thus,theinterviewersshouldsummarizeeach respon-dents’answertoeachofthequestionsinthequestionnaire withoutlimitationonlengthsof thetextetc. The inter-viewerswerealsoaskedtorecordexpressivequotations fromtherespondentsinordertodocumentandsupport thefindings.

Toavoid misunderstandingsand -interpretations the interviewers were alsoasked to resubmitthe template withtheanswersfromtheinterviewtotherespondentfor approval.

The interview guide was piloted with three man-agersatOdense UniversityHospital(Denmark)tocheck itsconstructvalidity.Thequestionsweregenerallywell understoodbytherespondents.However,therespondents statedthattheterm“newhealthtechnologies”were con-sidered to be a very broad term that made it difficult toanswerthequestions.Onerespondentmentionedthat hisneedforinformationvarieddependingonthetypeof healthtechnologyinquestion.Thereforeitwasdecidedto usetheterm“treatment”inordertofocusonthesmaller groupofnewmedicalorsurgicaltreatmentswithaclear clinicalobjective.

2.2. Therespondents

Respondentswereclinicalmanagers(i.e.headofclinical departments)andhospitalmanagers(i.e.chiefexecutive officeror chief medical officer)of hospitalsin the nine countriesparticipatingintheAdHopHTAproject.

The respondents were a convenience sample since partners from each country were asked to select the respondents.Partnerswereaskedtointerviewone clini-calmanagerandonehospitalmanagerfromthreedifferent typesofhospitals:

•Auniversityhospital/researchandtraininghospitalwith aHTAunit.

•Auniversityhospital/researchandtraininghospital with-outaHTAunit.

•Asmall/middlesizehospital.

Thetotal samplewasthusexpected toconsist ofsix managersfromeachcountry,with54respondentsintotal. Eachrespondentwascontactedbyemailbythelocal partners.Hereafter,theplaceandtimeforthemeetingwas arrangedwitheachrespondent.Usuallytheinterviewtook placeatthehospitalwherethehospitalmanageror clin-icalmanagerwasworking.Interviewswereconductedby thestudypartners inthelocallanguage.Generally, two interviewersparticipatedineachinterview.

2.3. Dataanalysis

Analysisofdatafromtheinterviewswasdonebyuseof contentanalysis[20]bytheDanishpartnersintheproject. FirstlytheteamofDanishpartners(KK,AMØ,MBO)read thereportingtemplatestogetafirstoverallpictureofthe data.Hereafter,answerstothequestionsabout informa-tion needs(seeQuestions 4–6inBox 1)were codedto identifythetermsandconceptsusedinthedescriptionof theneedforinformationonnewtreatmentswithineachof theninedomainsintheHTACoreModelandtheadditional domainonpoliticalandstrategicaspects.

Codingwasdonefortheexistenceofaconceptwithin theanswerstoeachofthethreequestions(seeBox1)and not forthefrequencyoftheuseof theconcept byeach respondent.Thetermsandconceptswerehereafter exam-inedusingconceptualanalysistoestablishtheexistence andfrequencyofconceptswithinthe10domains.Thiswas donemanuallywithouttheuseofasoftwareprogram.

Table1

Descriptionofrespondentsbycountry,managerialposition,age,genderandeducation. Country Numberof respondents Proportionof hospital managers Proportionof managersfrom universityhospitals Meanage (years) Proportionof women Proportion withamedical education Austria 7 3/7 4/7 52.7 1/7 6/7 Denmark 6 3/6 4/6 53.6 1/6 6/6 Spain 6 3/6 4/6 55.8 3/6 6/6 Estonia 6 3/6 4/6 55.3 1/6 5/6 Finland 6 3/6 4/6 54.4 1/6 6/6 Italy 6 3/6 4/6 62.8 0/6 6/6 Norway 4 2/4 3/4 52.8 1/4 3/4 Switzerland 6 4/6 4/6 60.0 0/6 5/6 Turkey 6 4/6 4/6 46.5 0/6 6/6 Total 53 52.8% 66.0% 54.9 15.1% 92.4% Table2

Typesofinformationthathospitalandclinicalmanagerswishtohaveattheirdisposalasabasisfordecisionmaking(basedonQuestions4and5). AnswerstoQuestion4 AnswerstoQuestion5 Answersintotal Numberof respondents (%total) Numberof respondents (%total) Numberof respondents (%total) D1:Healthproblem 27 (50.9%) 15 (28.3%) 42 (79.2%) D2:Contentoftreatment 16 (30.2%) 15 (28.3%) 31 (58.5%) D3:Clinicaleffectiveness 41 (77.4%) 7 (13.2%) 48 (90.6%) D4:Safety 23 (43.4%) 22 (41.5%) 45 (84.9%) D5:Economics 50 (94.3%) 3 (5.7%) 53 (100.0%) D6:Ethics 6 (11.3%) 34 (64.2%) 40 (75.5%) D7:Organizationalaspects 23 (43.4%) 28 (52.8%) 51 (96.2%) D8:Socialaspects 4 (7.5%) 33 (62.3%) 37 (69.8%) D9:Legalaspects 3 (5.7%) 38 (71.7%) 41 (77.4%)

D10:Politicalandstrategicaspects 11 (20.8%) 32 (60.4%) 43 (81.1%)

3. Results

3.1. Therespondents

TheinterviewswereconductedinApril–June2013.Fifty oftheinterviewswerecarriedoutaspersonalinterview, andthree weredonebytelephoneforpracticalreasons. Themeandurationoftheinterviewswas40min.

Table1displaysthecharacteristicsoftherespondents.

About 50% are hospital managers (the restbeing clini-cal managers) and 66%are fromuniversity hospitalsas planned.Mostoftherespondentsweremalemedical doc-torsaged50–60.

3.2. Managersneedforinformationonnewtreatments Alloftherespondentswereabletoanswerthe ques-tiononthetypeofinformationtheyintheidealsituation wish tohave asthe basis formaking decisionsonnew treatments (see Question 4 in Box 1). The information mostfrequentlymentioned wasabouteconomics, clini-caleffectiveness,organizationalandsafetyaspectsofnew treatmentsasshowninTable2.Thenumberofdomains mentionedvariedbetweenoneandnine,butmost respon-dentsmentionedinformationwithinthreeorfourdomains. Themostfrequentcombinationofinformationneededwas withinthedomainsonclinicaleffectivenessandeconomic aspectsalone (fiverespondents) orincombinationwith organizationalaspects(threerespondents)orsafety(three respondents).

Table3

Thetypesofinformationconsideredbyhospitalandclinicalmanagers tobethemostrelevantwhenmakingdecisionsaboutinvestinginnew treatments(basedonQuestion6).

Domain Numberof respondents (N=53) Proportion D1:Healthproblem 12 22.6% D2:Contentoftreatment 1 1.9% D3:Clinicaleffectiveness 38 71.7% D4:Safety 20 37.7% D5:Economics 39 73.6% D6:Ethics 2 3.8% D7:Organizationalaspects 11 20.8% D8:Socialaspects 1 1.9% D9:Legalaspects 1 1.9%

D10:Politicalandstrategicaspects 10 18.9%

Table2alsoshows theanswers toQuestion5 about

additionalinformationthatshouldbepartofthebasisfor decisionmaking.Thenumberofdomainsmentioned var-iedbetweenzeroandnine.Asthetableshows,information withinalldomainsareconsideredrelevantbyatleast50% oftherespondents.

Table3showsthetypesofinformationconsideredas

mostrelevantbytherespondents(Question6inBox1). Ofthe53respondents,50identifiedsomeinformationas beingmorerelevant thanotherinformation. Onlythree respondentssaidthatalltypesofinformationwereequally important.

Themost frequent combinationsof information that the respondents considered as most relevant were

Box 2: Examples of political and strategic aspects of new treatments mentioned by the respondents.

Politicalaspects Strategicaspects (No2):“Political

decisionsoften overruleeverything else.Thatweknow of.”

(No23)“Political aspectsaregrowing inFinland.”

(No.3)“Researchstrategies.” (No.16)“Evenifwedonotlikeit, political/strategicconsiderationsare veryimportantbecauseifonewantsto beapioneerinthefield,wehavetobe thefirsttoadoptanewtechnology.” (No.16)“Strategicaspectsinorderto becomeanauthorityinSpainand Europe.”

(No.8)“Politicalaspectsno.But hospitalstrategicaspectsarerelevant.” (No.23)“Politicalno.Buthospitalhas strategy.”

(No24)“InFinlandpoliticsaffectonly onbudget,butinourhospitalswehave ourownstrategy.”

(No.34)“Thehospitalhasitsstrategic investmentplan.”

(No.38)“Relevantinformationisalsoif atechnologyis“profile-building.”

(i)clinicalandeconomicaspects(10respondents)or(ii) clinical,safetyandeconomicaspects(9respondents).As thetableshows,clinicaleffectivenessandeconomicswere consideredasthe mostimportant information bymore than70% ofthe respondents.Hereafter comes informa-tiononsafety,thepatients’healthproblem,organizational aspectsandpoliticalandstrategicaspects.

Tables 2 and 3 show consistency in the answers to

Questions4and6.Theeconomicandclinicalaspectsof newtreatmentsarementionedmostandsecondmost fre-quentlyinbothquestionsandthefivemostfrequenttypes ofinformationarealsothesameinthetwoquestions. 3.3. Theimportanceofpoliticalandstrategicaspects

Politicaland strategic aspectswere identifiedas rel-evant for hospital based HTA in the literature review

[17].Politicalaspectsreferforexampletothealignment betweenthedecisiontoinvestinatechnologyandthelocal politicalclimateorvalues.Strategicaspectsreferfor exam-pletothefitbetweenagiventechnologyandthehospital’s researchstrategy.Aftertheidentificationandcodingofthe termsusedbytherespondentsintheinterviews,theterms weredividedinthesetwo groups.The termsthat were codedintothistenthdomainweresubsequentlydivided intopoliticalandstrategicaspects(seeBox2forverbatim quotationsfromrespondents).Mostofthetermsrelated tothehospital’sownstrategicresearchgoals,competition withotherhospitals,profile-buildingandinvestment.The numberofeachrespondentispresentedinbrackets. 3.4. Thecontentoftheeconomicaspects

Therespondents’perceptionofthetypeofinformation theyneedregardingeconomicswasalsocaptured.Box3

showssomeexamplesofquotesfromrespondentswho

Box 3: Examples of societal and hospital perspectiveintheneedforinformationon eco-nomicaspects in Questions4,5or 6(see Box 1).

Societal perspective

Hospital perspective

Bothsocietaland hospital perspective (No1):“Focus shouldtoa greaterextentbe onawider perspective acrosshealth care(e.g.general practice, hospital).” (No.18) “Cost-effectiveness, cost-QALY. Whetherthe technologywill helptoreduce lengthofstay, useofhuman resources,less complications, longterm effects...” (No.24)“There’s nousetogetsame resultsspending moremoneythan withprevious techniques.Budget givestheframes forwhatweare abletoinvestin.” (No33):“The servicesare providedandnew technologies purchasedonlyin casetheseare financedbythe EHIF(Estonian HealthInsurance Fund)andlistedin theannual contract.” (No.34)“Thereis nowayto implement technologies,which arenotcoveredby theannual contract.” (No35)“Costof treatmentis importantas cost-effectiveness hastobefavorable inordertheHealth Insurancewill approvethe treatmentandadd ittothelistof reimbursed services.” (No.36)“Direct costsoftechnology incomparisonwith reimbursement possibilities.” (No.37)“Onetime investment, multiple consumablesand staffcosts,staff implications.” (No.38) “Replacementor newinvestment/ additionalor substitute, supplier(s), maintenance, effectsonstaff (needforlessorfor more),

(No.5)“Economy ofthedepartment aswellas socio-economy, e.g.veryexpensive medicine. (No9)“Very important,forthe hospitalaswellas forsociety includingprivate businessesi.e. returntowork.” (No.16) “Cost-effectiveness iskey.Maintenance costandfungibles (e.g.batteries)are importantandmay bemuchlarger thantheinitial investment.” (No.27)

“Cost-effectiveness andcomparisonare important.Budget isthebiggest determiner.”

investment-costs (once),running costs/overheads, additionalcosts(IT, energy,heating, roomadaptation etc.)....” (No52) “Acceptablecosts tothehealthcare system,withif possiblecoverage bytheinsurance companies.” (No54)“Impacton costofcareand outpatient treatment.” (No55)“Economic aspectsinvolved settingupthe project,runningthe project (infrastructureand equipment, maintenanceand runningcosts, personaland training).Awhole chapterabout medicaleconomic analysisincluding billingpossibilities andrateof coverageis included. (No56) “Economical aspectsare importantbut sometimes,anew technologyshould befoundedevenif leadingtoan economicalloss (forexample,until itisreimbursedor untilpricesfallon themarket).” (No.57)“Economic impactonhospital giventheDRG system.”

mentionedtheeconomicaspectsasmostrelevant.These quotesaredividedinthreegroups:

•Economicinformationrelatedtoasocietalperspective.

•Economicinformationrelatedtoahospitalperspective.

•Economicinformationrelated tobothasocietalanda hospitalperspective.

As shown in Box 3, it is not always clear whether therespondentsarehavinga societalora morenarrow perspective of theeconomic aspects inmind. However,

somerespondentsclearlyfocusedonthereimbursement tothehospitalandnotthesocietaleconomicimpact.The examplesalsorevealthatofthe39respondents mention-ingeconomicsasoneofthemostrelevantinformation(in Question6),aboutonethirdwasreferringonlytothe eco-nomicimpactonthehospitalbyusingtermslikebudget impact,financing,reimbursementandDiagnosis-Related Groups(DRG).Onlyfourrespondentsexplicitlystatedthat bothasocietalandahospitalperceptiveontheeconomic aspectswereneeded.

3.5. Variationbetweensettingsandtypesofmanagers Respondentsfromuniversityhospitalsandthosefrom smaller hospitals varied somewhat in their answers to Question6aboutthemostimportantinformationbetween respondentsfromuniversityhospitalsandsmaller hospi-tals.Themajordifferencewasthathospitalmanagersfrom universityhospitalsmorefrequentlymentioned informa-tionrelatedtotheclinicalandeconomicaspectsasthemost relevantinformation,whereasmanagersfromsmaller hos-pitalsmorefrequentlymentionedinformationrelatedto theorganizationalandthepoliticalandstrategicdomain. Thedifferencesbetweentheanswersfromclinicaland hos-pitalmanagersweresmaller.Table4showstheseresults. 3.6. Differencesbetweencountries

Becauseof the smallnumber of respondents, it was difficulttoidentifydifferencesbetweencountries.Inthe contentanalysis,however,sometypesofinformationwere moreoftenconsideredtobeimportantindecision-making (Question6inBox1)insomecountries,seeBox4.

4. Discussion

Thisinterviewstudywith53hospitalmanagersfrom nineEuropeancountriesfoundthatinformationabout clin-icaleffectivenessandeconomicaspectswereconsidered themostrelevantwhendecidingaboutinvestmentsinnew treatments.Hereaftercomesinformationonsafety, orga-nizationalaspectsandthehealthproblemofthepatients.

Aboutoneinfive respondentsalsoconsidered infor-mationonthepoliticalandstrategicaspectsasimportant indecision making.Whenlookingatthetermsused by therespondents,theresultsindicatethatinparticularthe relationbetweeninvestmentinnewtreatmentsandthe hospitals’strategicgoals(e.g.regardingresearchor com-petition)areofimportance.Thishasalsobeensuggested recentlyinotherstudies[21]and[22].Thepoliticaland strategicinformationdomainisnotincludedintheHTA CoreModel,suggestingthattheneedforthiskindof infor-mationisspecificforhospitalbasedHTAandperhapsnot relevantfornationalHTAinstitutionsandthusnottypically includedinguidelinesfornationalHTA.

Analysisof the terms used by the respondents also showsthattheeconomicfocusofthehospitalmanagersis quitenarrow.Therespondentsareoftenfocusedonbudget impactandreimbursementandlessfrequentlyonsocietal cost–utilityanalysis.Thishasalsobeendemonstratedin otherstudiesin[19,23].

Table4

Thetypesofinformationconsideredbymanagersfromuniversityhospitalsandsmallerhospitalstobethemostrelevantwhenmakingdecisionsabout investinginnewtreatments(basedonQuestion6).

Domain Managersfromuniversityhospitals(N=35) Managersfromsmallerhospitals(N=18) Numberofrespondents Proportion Numberofrespondents Proportion

D1:Healthproblem 8 23.5% 4 21.1% D2:Contentoftreatment 1 2.9% 0 0.0% D3:Clinicaleffectiveness 27 79.4% 11 57.9% D4:Safety 14 41.2% 7 36.8% D5:Economics 27 79.4% 12 63.2% D6:Ethics 3 8.8% 0 0.0% D7:Organizationalaspects 6 17.6% 7 36.8% D8:Socialaspects 1 2.9% 0 0.0% D9:Legalaspects 1 2.9% 0 0.0%

D10:Politicalandstrategicaspects 5 14.7% 5 26.3%

Box 4: Examples of answers from different

countriesreflectingtheimportanceof

informa-tionabouttheeconomicimpactonthehospital.

Estonia:

-(No.34)“Ithastobesurethatthetechnologieswill notcreateeconomiclossestothehospitalandfor most investment decisions cost–recovery analysis aresufficient.”

-(No33)“Theservicesareprovidedand new tech-nologiespurchasedonlyincasethesearefinanced bytheEHIF (EstonianHealthInsuranceFund) and listedintheannualcontract.”

-(No36)“InEstonia99%ofdecisionstoimplementor rejectnewtechnologiesarenotmadeatthehospital level,butbytheEstoniaHealthInsuranceFund.” Switzerland:

-(No.52)“Availability ofthetechnologyinthe can-toninSwitzerlandorinEuropeandtheexistenceof concurrenceinthisfieldisimportant.The competi-tionbetweenpublicandprivatesectorisobviously interesting.”

-(No55)“However,inSwitzerland,outpatient treat-ment is totally free and anybody can enter the market,whereasthereissomeregulationinthe pub-licsectorofhospitals.Thisaspectshouldbetaken intoaccountifpresent.”

Turkey:

•(No.61)“Patientdemandwastheprimaryfactorfor thedecisionmakingprocess.”

•(No. 63)“Patients’ demands mainlyforcedus for theDaVincirobot.Patientspreferredhospitalswith robotsforprostatectomy.Sowedecidedtobuyone toincreasenumberofurologiccases.”

Ourinterviewfindingsaregenerallyconsistentwiththe resultsofasystematicliteraturereviewcarriedoutprior totheinterviewstudy[17].Thereviewalsofoundahigh frequencyofstudiesindicatingthatclinicalandeconomic aspectsofnewhealthtechnologiesareofmostimportance tohospitalmanagers.Thecurrentinterviewstudycanbe seenasavalidationoftheresultsfromthereview.

Arelativelysmallnumberofrespondentsareincluded inthisinterviewstudy,andthatrespondentswereselected bylocal(i.e.hospital),regionalornationalHTAinstitutions involvedintheAdHopHTAproject.Therespondentsshould thusnotbeconsideredrepresentativeforallhospital man-agersinEurope.Insteadthereisariskthatmanagersand hospitalswithaninterestinHTAandevidencebased deci-sionmakinghaveahigherprobabilityofbeingincluded inthestudy.However,itshouldbenoticedthattheaim of the study was to do a qualitative study and to get anunderstandingofhospitalmanagersneedfor informa-tion.

Thestrengthofthemethodusedisthatpersonal inter-viewismorerelevantwhenthesubjectandthequestions arecomplicatedandwhenthespecificwordingsandterms usedbytherespondentsareof interest.Alsotheuseof localinterviewerswithagoodunderstandingofthehealth caresysteminthecountrymayhaveresultedinmorevalid answersandfewermisunderstandings.

Theweaknessofthisstudyisthatdifferent interview-ershavecarriedouttheinterviewsindifferentcountries. Eventhougha detailedinterviewinstructionswere pro-duced(see onlineAppendix)and theinterviewerswere trainedintheuseofthequestionnaireandthereporting template,thereisstillariskthatdifferentunderstandings ofthequestionsandtasksbytheinterviewershavehad influenceontheresultsfromtheinterviews.The transla-tionoftherespondentsanswerintoEnglishmayalsohave influencedthereportingoftheresults.

When considering the variation in the respondents’ answersit shouldalsobeconsideredthathospital man-agers needforinformation mayalsovarywiththetype ofhealthtechnologyinquestion.Toreducethisproblem therespondentswereaskedabouttheirinformationneeds whendecidingoninvestmentinnewtreatmentsinorder tofocus onthesmallergroupofnewmedical or surgi-caltreatments.However,thereisstillariskthatvariation in theanswers reflectsthatrespondentswere consider-ingdifferenttypesofhealthtechnologieswhenanswering thequestions.Similar,someofthevariationintheneed forinformationabouteconomicaspectsofnewtreatments mayreflectdifferencesinthelocalreimbursementsystems inthecountriesinvolvedinthestudy.

Inadditionitisunknowntowhatextenttheanswers fromthehospitalmanagersarereflectingthemanagers’

trueneedforinformation–orratherthemanagers’ per-ceptionofthesocially,politicallyorscientificallycorrect answer.Thiskindofsocialdesirabilitybiasmayhavebeen present[20].Forexamplehospitalandclinicalmanagers maynot revealtheinfluenceoff thirdparties (e.g.local politicians,pharmaceuticalindustry,patientlobbiesetc.) ontheuseofinformationintheirdecisions.

Theresultsmayalsosimplyreflectthemedical educa-tionalbackgroundoftherespondents.However,thefirst questionaboutneedforinformation(seeQuestion4inBox 1)wasanopenquestionwithnolimitationontheanswer. Thefactthatthemostfrequentanswerwasrelatedtothe economicdomainprobablyreflectsthattherespondents arehospitalmanagersdealingwithhospitalcostsand rev-enuesintheirdailylife.

Iftheresultsareconsideredvalidandconsistentwith otherstudiesoftheneedforinformationbyhospital man-agersinEurope,thentheimplicationforhospitalbasedHTA needtobeconsidered.Oneimplicationcouldbethat hospi-talbasedHTAapproaches–e.g.mini-HTA[8]–shouldfocus ontheclinical,economic,safetyandorganizationalaspects ofnewtreatments.However,astheanswerstoQuestion5

show(seeTable2)informationabouttheotherdomains

canalsoberelevanttohospitalmanagersandshouldnot beconsideredinsignificant.

Anotherimplicationisthatassessmentoftheeconomic impactshouldfocusontheconsequences forthe hospi-talandincludebudgetimpactandreimbursementissues. Societalcost–utilityanalysisisnotirrelevantbutshouldbe combinedwitheconomicanalyseswithanarrower per-spective.

Inaddition,thestudyfindingsalsosuggestthat descrip-tionofthestrategicaspectsforthehospitalconsidering investinginanewtreatmentshouldbeincludedin hospi-talbasedHTA.Thisisquitedifferentfromthetraditional contentofHTA,asdescribedine.g.theHTACoreModel

[14,15]andopensthedoortonewandstrategicaspectsof

decisionmakingtobeincludedinthehospitalbasedHTA report.Moreresearchisneededonthissubjectbeforethe practicalimplicationsforhospitalbasedHTAisclearand thissubjectwillbeincludedinalargescalesurveyof Euro-peanhospitalandclinicalmanagersthatisplannedasthe nextstepintheAdHopHTAproject.

5. Conclusions

Theresultsfromthisinterviewstudywith53European hospitalmanagersshowthattheirneedforinformation in decision making aboutnew treatmentsdeviate from known accepted guidelines for production of HTA, as described in e.g.theHTA CoreModel. Theclinical, eco-nomic,safetyandorganizationalaspectsofnewtreatments wereconsideredthemostrelevantinformationfor deci-sionmaking.However,atthesametimetheresultsreveal thatinformationaboutotherdomainscanalsobeof rele-vancetohospitalmanagersandshouldnotbeconsidered insignificant.Withregardtotheeconomicaspects, hospi-talmanagersoftenhaveaquitenarrowfocusonbudget impactandreimbursement.Inadditiontothetraditional HTA domains hospital managers sometimes also need

informationaboutthepoliticalandstrategicalaspectsof newtreatments,inparticulartherelationshipbetweenthe newtechnologyandthestrategicgoalsofthehospital.This showstheneedtocontextualizeHTAinformationtothe hospitalsetting.Iffurtherstudiesareabletoverifythese results,guidelinesforhospitalbasedHTAshouldbealtered toreflecttheinformationalneedsofhospitalmanagersfor decidingaboutwhethertoinvestinnewtreatments.

Conflictofinterests

The author(s) declare that they have no competing interests.

Acknowledgements

This work has been supported by the AdHopHTA project,grantagreementnumber305018,co-fundedbythe ECSeventhFrameworkProgrammetheme FP7-HEALTH-2012-INNOVATION-1.

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