ICER white paper recommends health technology assessment strategies to improve health equity
ICER publishes their white paper proposing a series of recommendations and guidelines for health technology assessment to advance society’s ethical goal of improving health inequity related to racial, ethnic, and socioeconomic status.
In March 2023, the independent non-profit Institute for Clinical and Economic Review (ICER) published their white paper entitled Advancing Health Technology Assessment Methods that Support Health Equity. The white paper was developed by a senior Advisory Committee in consultation with expert contributors, who together explored functions and methods of current health technology assessment (HTA) practice in the United States (US) and established a series of action points for HTA that aim to improve health equity for racial, ethnic, and socioeconomically disadvantaged groups.
Health equity
The World Health Organization defines heath equity as: the absence of unfair, avoidable or remediable differences in health among population groups, defined by social, economic, demographic or geographic characteristics.
“We need to be looking at everything that we do in and around healthcare with an equity lens,” asserted Rebekah Angove, Executive Director of the US Patient Insight Institute and Executive VP of Research and Evaluation with the Patient Advocate Foundation, speaking with Joanne Walker of The Evidence Base about her contribution as a member of the ICER Advisory Committee for this initiative. Rebekah’s career has been focused on bridging the space between technical and scientific teams and the patient community, since gaining a PhD in public health, from the Medical College of Wisconsin.
“I think it’s particularly important here because it’s an area that has been overlooked or neglected,” continued Rebekah. “We often see technology as being neutral or objective, when that’s not always the case because we know that people build technology and people deploy technology and so there is opportunity for it to not advance health equity.”
Advisory Committee
“ICER brought together a group of people, a multi-stakeholder group, to serve as a health equity advisory group,” explained Rebekah Angove, adding “they did a really great job of gathering a diverse group.” The Advisory Committee of seven senior healthcare participants was convened following the award of a Commonwealth Foundation grant for this ICER initiative in July 2022, and featured varied and complementary representatives including patient advocates, payers, pharma groups, HTA and policy experts to provide guidance and feedback on all aspects of the project.
Rebekah elaborated that the Advisory Committee remit was: “Looking at different aspects of health equity as it relates to HTA and providing input and insights on how to really frame health equity assessment, and the things that we need to be thinking about, the things that we need to be looking at, the things that are important.”
The ICER project team also interviewed six key opinion leaders and methods experts identified by recommendation from the Advisory Group and through a literature search. Their interviews enhanced ICER’s knowledge and understanding of the field and were used to generate fresh ideas for new methods to address health equity concerns, in addition to gathering opinions on the potential advantages and limitations of methods already proposed.
Action statements
The white paper presents its findings and conclusions as a series of action statements, spread across 7 focus areas. Several key recommendations include:
- HTA bodies should engage directly with patients and patient groups during the scoping of reviews to learn about the experiences of diverse groups of patients and understand their views of the potential impact of the intervention under review on health equity.
- Establish a minimum threshold for adequate representation of racial and ethnic populations in clinical trials to provide incentives for improvement.
- Even if clinical evidence suggests differences in the magnitude of net benefit by race, ethnicity, or socioeconomic status, do not calculate cost-effectiveness estimates for subpopulations defined solely by these characteristics.
- Avoid using quantitative equity-informative economic evaluation as a substitute for a deliberative process that should integrate multiple important social values in policy decisions.
- Use deliberative processes to highlight structural aspects of the health care system that should be changed in order to ensure that disparities are not worsened with the introduction of new interventions.
Commenting on the first recommendation, Rebekah Angove said:
“The inclusion of patients — patient perspective, patient voices — on the front end, as these things are being developed, deployed, monitored, and evaluated is something that’s really, really important and I think the field is still trying to figure out how exactly to do that.”
Limitations of the study
Due to time frame constraints, ICER did not publish a draft of the paper for public comment. ICER acknowledges they did not coordinate efforts with other US groups embarked on similar ventures. Also, they did not conduct a formal systematic review of methods in the literature or practices of all international HTA bodies, but instead benchmarked against NICE in the United Kingdom and the CADTH in Canada.
Going forward
ICER declares it will immediately take each of the action statements as guides to their methods and procedures going forward, incorporating them into their Value Assessment Framework document later in 2023. They will disseminate the white paper among other HTA groups internationally, with US government leaders responsible for management of groups involved in HTA (such as the Agency for Healthcare Research and Quality, the United States Preventive Services Task Force, and the Medicare Evidence Development and Coverage Advisory Committee), and with life science organizations and payers.
Rebekah Angove concluded:
“This starts the conversation, making sure that these issues of equity and all their complexities are part of the planning, the development, the measurement – they’re part of the conversation upfront. I hope we’re moving the needle a little bit there, that it’ll be more of a standard procedure to include some of these content concepts and methods to ensure equity in this space.”
Disclaimers:
The opinions expressed in this feature are those of the interviewee/author and do not necessarily reflect the views of The Evidence Base® or Becaris Publishing Ltd.
