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Health Technology Assessment EXAM QUESTIONS (+ ANSWERS)
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25 questions with answers of past exams and of the March 2022 exam
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HTA Questions:1. New surgery for stomach cancer is more cost-effective than conventional surgery”.
Please comment on the statement of the New York Times:
Without a third comparator the statement “more cost effective” is not possible to make. To assess
whether an intervention is more cost-effective we need to compare treatment A with treatment C
and treatment B with treatment C. Only when A has a lower cost per QALY gained (in comparison
with C) than the cost per QALY gained of B (compared with C) we can say that A is more cost-
effective than B.
2. The conventional surgery is currently reimbursed, the new surgery not yet. Do you as
reimbursement authority have enough information (see above) to give and advice to the
Minister of Health regarding reimbursement of the new surgery in the basic benefit
package? If yes, please explain why. If no, please indicate what additional information
(and why) you would like to have in order to give a good advice
To be able to give advice regarding the possibility to reimburse the drug we need more
information. For instance, the incidence and the prevalence of the disease in the population. The
budget impact per year of implementing the new intervention. The number of QALYs gained in
comparison to the old intervention. How much the minister is willing to pay per QALY gained
(threshold value). The perspective of the analysis. And possibly the uncertainty around the cost-
effectiveness estimates. The availability of alternatives
3. The implantable device is very expensive: 80% of the additional costs of the new surgery
relate to the costs of the device. It has a patent for the coming 10 years. Could you think
of sensible ways to advise the minister to deal with this affordability problem?
The minister could negotiate a better price for the device (for a fixed volume) with the company
that patented and produces it. A pay for performance agreement is also feasible, where if the
device turns out to not be effective the minister will not pay. In case it is too expensive the
Minister can still resort to the old surgery, although there would be no health gain. In alternative
the devices could be rationed based on highest needs first, limiting the number of new surgeries in
a year.
4. The source of health state values remains to be an area of contention. Dutch guidelines
prescribe that health state values are derived from the general public. What are the main
arguments for use of social values?
The main argument in favour of a valuation of health states carried out by the general public is
that the allocation of the resources will probably affect society as a whole, hence the general
public should decide the value of specific health states. This is particularly relevant in countries
with national health services and social health insurance. There might also be ethical issues in
asking patients specific questions about their condition, however it can also be that the general
public is not motivated enough to participate seriously in this type of studies. Furthermore, it
prevents adjustment bias.
, 5. Give two reasons why public and patients’ valuations may diverge
The score given to a condition from someone who has experienced it might be different from the
score of someone who could never really grasp what it means to live with that condition.
However, sometimes using the general public might favour the patient’s interests; a patient might
value a condition as less debilitating because of adjustment throughout the years. The general
public might value conditions (especially chronic ones) with lower utility scores than patient
reported values, leading to better incremental effects and to higher chances that the technology is
introduced/reimbursed
6. The EuroQol EQ5D and similar instruments like SF6D are usually self-administered by
patients. Do these instruments produce patient values or social values? Motivate your
answer
These instruments produce different combinations of health states based on the answers of the
patients. However, the utility scores are calculated through algorithms that take into account
preferences and scores assigned by the general public. Although the values produced are
expression of the general public preferences, each country should have its own table of
corresponding value. Cultural preferences and society’s values do influence the outcomes and
what might be considered an improvement or a deterioration of a health status.
7. Producers of pharmaceuticals and medical devices favour the use of condition specific
preference-based measures over generic preference-based measures, arguing that this
increases the responsiveness for specific health problems. HTA researchers tend to view
condition specific instruments however as a second-best alternative in the case that also
a generic instrument could be applied. Explain why
Although specific instruments are better able to capture the patient’s health state, generic
instruments make the study comparable with other interventions. There exists the possibility to
turn disease-specific results into generic measures of health (mapping/cross-walking). Mapping
involves estimating the relationship between a disease-specific instrument and a generic
preference-based measure through statistical association. However, it is argued that there is still
not enough discussion on the right theoretical framework for mapping models and that current
quality standards are inadequate for producing robust estimates of health state preference. For
these reasons it is still advantageous to collect data directly using preference-based instruments
and mapping should be used as a second-best solution.
8. Please explain why informal care should be incorporated in economic evaluation studies
of those health care programs.
Assuming a societal perspective, all relevant costs should be included in economic evaluations.
Informal care plays a key role in those programs aimed at the elderly and the chronically ill.
Relatives taking care of someone do sacrifice working/leisure time leading also to productivity
losses. Informal caregivers are affected by the treatment (in terms of quality of life) and by
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