Recommendations for incorporating equity into HTA evaluation

Many health policy experts–including myself–have noted that treatments that help reduce health disparities may be especially valuable whereas those that exacerbate inequalities may be somewhat less valuable than predicted by standard cost-effectiveness analysis. A key question is, health disparities over what dimension(s)? Is it race? Income? Education?

O’Nell et al. (2013) developed the PROGRESS framework. More recently, the PROGRESS-Plus proposes an even more extended list of dimensions:

• Place of residence
• Race/ethnicity/culture/language
• Occupation
• Gender/sex
• Religion
• Education
• Socioeconomic status
• Social capital
• Plus
  • Personal characteristics associated with discrimination (e.g. age, disability)
  • Features of relationships (e.g. smoking parents, excluded from school
  • Time-dependent relationships (e.g. leaving the hospital, respite care, other instances where a person may be temporarily at a disadvantage) 

Also, a paper by Benkhalti et al. (2021) developed the Equity Checklist for HTA (ECHTA). The checklist is very detailed and I have summarized the key questions around equity they seek to have answered by HTA bodies.

Scoping Phase

• Problem Definition
  • Equity of what?
  • Define population subgroups to consider through the use of a logic model and/or theoretical basis.
  • Could the scope of the HTA lead to potential biases for or against specific population groups?
• Contextual considerations
  • What are the opportunity costs of conducting an HTA of one intervention/technology over another
  • How will the intervention/technology be funded and what would be the distribution of the opportunity cost?
  • Are there legal contexts to consider regarding institutionalised discrimination?
  • Are there historical disadvantages to consider that might impact the choice of variables to assess, the choice of methods, etc.?
• Stakeholder involvement
  • Were all relevant stakeholders included in the scoping process
  • Does the inclusion of different stakeholders impact/change the process?
  • Which are the most appropriate ways of including patient perspectives?

Evaluation Phase

• Outcome measures
  • Are the outcome measures chosen relevant to patients’ perspectives?
  • Do outcome measures include the different aspects through which inequities can emerge? (e.g., coverage, prevalence, uptake, access to care)
  • Are the thresholds used to define improvements or deteriorations in outcome measures appropriate for all population groups?
  • Is there an economic analysis and does it include an equity analysis? (e.g., DCEA, extended CEA, subgroup analysis)
• Data collection and analysis.
  • Are the methods used to collect and/or identify data conducive to finding data on disadvantaged population groups?
  • Are analytical methods appropriate for all groups?
  • Do the tools used to assess the evidence incorporate the consideration of equity elements?
  • Does the analysis of potential inequities consider cumulative life experiences of those impacted?
• Contextual considerations
  • Are there any institutional biases that might contribute to inequalities?
  • Are there care processes that might contribute to discrimination?
  • Do certain special claims have to be considered in the contextual analysis?
  • Are there psychosocial issues relevant to your context that impact specific population groups?
  • Does the distribution and supply of services in your context impact inequities in health outcomes?
• Stakeholder involvement
  • Are the methods used to include patient perspectives appropriate and do not lead to a systematic exclusion or under-representation of certain population groups?
  • Do the methods used to involve stakeholders allow for all relevant parties to be represented?

Recommendations and Conclusion Phase

• Scope
  • Were the results synthesized using a summary table which included findings relating to inequity?
  • Do the recommendations account for the different aspects through which inequities can emerge?
  • Are recommendations generalizable to all population groups?
  • Could certain recommendations increase inequities?
• Contextual considerations
  • Are there legal contexts to consider in the recommendations?
  • Are there historical disadvantages to be considered in the recommendations?
  • Are there recommendations relating to a change in culture and/or the institutional system which could contribute to inequities?
• Stakeholder involvement
  • Were all relevant stakeholders included in the scoping process?
  • Do the methods used to involve stakeholders allow for all relevant parties to be represented?

Knowledge Translation and Implementation Phase

• Do the approaches selected to implement recommendations favour certain population groups above others?
• Does the prioritisation of recommendations to be implemented favour certain population groups above others?
• Do certain population groups within each stakeholder category require targeted knowledge translation approaches

Reassessment Phase

• Does the methodological approach chosen allow for the analysis of disaggregated data by relevant population groups?
• Were certain population groups not considered in previous HTA phases impacted differently?
• Were there contextual changes that might impact HTA outcomes with regards to different population groups?