National Information Center on Health Services Research and Health Care Technology (NICHSR)
HTA 101: VIII. DISSEMINATE FINDINGS AND RECOMMENDATIONS
- A. Competing for Attention
- B. Basic Dissemination Framework
- C. Dissemination Plan
- D. Managing Access
- References for Chapter VIII
For those who sponsor, conduct, or otherwise participate in an HTA, the importance of its findings and recommendations may be self-evident. However, there is increasing recognition that dissemination of HTA findings and recommendations, whether for internal use by the sponsoring organization or into the national or international health information mainstream, must be carefully planned and implemented in order to enable any HTA to achieve its purpose.
Dissemination of HTA findings and recommendations must inform decisions and policies for improving population risk factors, patient care, health outcomes, and resource allocation, as appropriate. Worthy HTA messages get lost because of misidentified or misunderstood target audiences, poor presentation or format, ineffective or poorly selected communication media, poor timing, and other factors. There is some convergence in the field toward good practices on the format and organization of information to be included in an HTA report, e.g., the INAHTA checklist for HTA reports (INAHTA 2007) and the EUnetHTA core model (EUnetHTA 2008). However, as described in chapter X regarding barriers to HTA, the implementation of HTA findings and recommendations can be hindered by, e.g., lack of access to HTA reports, complex technical formats of HTA reports, lack of confidence in the evidence base, and apparent absence of real-world applications. There is continued need for research regarding how to optimize the dissemination of HTA findings and recommendations.
A. Competing for Attention
The uptake of HTA findings depends in part on the responsibilities, incentives, behavior, other attributes of the target audiences, and various contextual factors. It also depends on the existing knowledge and perceptions of these target audiences. HTA dissemination efforts must compete with the burgeoning flow of health-related information being transmitted via diverse media using increasingly sophisticated means. Advanced communications technologies provide alternative means to transmit more information where and when it can influence clinicians and other decision makers. Health technology companies are highly adept at using advanced and continually evolving marketing techniques that are being adapted throughout the health care sector.
The matter of the accuracy and consistency of information presented in health technology promotional information to clinicians and consumers remains a great challenge in many regions around the world (Mali 2010) and will continue to affect the ability of HTA dissemination efforts to inform evidence-based behavior change in practice. Three particularly relevant areas are direct-to-consumer advertising (DTCA), promotion of off-label use of drugs and other health technologies, and making economic claims about health technologies, as described briefly, below.
In many countries, the interest in DTCA includes whether it should be permitted at all and, if so, what regulatory requirements should pertain to the content and format of its messages and whether such requirements are being sufficiently enforced (Donohue 2007; Mintzes 2009). Steep increases in DTCA spending since the late 1990s, especially in the US, have contributed to increased prescription drug sales and changed consumer behavior. Although DTCA can avert underuse of appropriate indications of prescription drugs, it may contribute to overuse, though the evidence on inappropriate prescribing is limited (Atherly 2009; (Donohue 2007; Lyles 2002). The increase in the volume of drug purchasing may be class-wide rather than product specific (Atherly 2009). DTCA appears to increase public awareness of prescription drugs but may be less effective at educating patients about appropriate use of medications for their condition. With DTCA exposure, patients are reported to be more likely to ask about advertised conditions, request prescriptions, and seek further information about medications, with some evidence that patients have expressed some caution about DTCA due to publicity about drug recalls, e.g., pertaining to certain pain medications (Liu 2008). All of these factors affect the receptiveness of target audiences to HTA findings and recommendations.
A related area of interest is the ability of health product companies to distribute published and unpublished reports of clinical trials of their products for indications that have not been cleared for marketing by the appropriate regulatory authority, known as “off-label” use. In the US, the FDA does not regulate the practice of medicine, and physicians may prescribe drugs and other regulated technologies for indications other than those for which they were approved by the FDA, unless doing so violates certain safety regulations or ethical standards. Off-label use of drugs is widespread. According to a comprehensive study of outpatient drug prescribing patterns in the US during 2001, 21% of prescriptions were off-label, led by cardiac medications and anticonvulsants; with 31% off-label prescriptions of psychiatric drugs. A majority (73%) of the off-label prescriptions were reported to have had little or no scientific support (Radley 2006). A study of primary physician prescribing patterns in Quebec, Canada, during 2005-2009 found that the prevalence of off-label use was 11%, 79% of which lacked strong scientific support. Off-label use was highest for central nervous system drugs (26%), particularly anticonvulsants, antipsychotics, and antidepressants (Eguale 2012). Among the legal concerns is whether providing “truthful information” about “widely accepted” off-label use of a drug, whether or not there is supportive scientific evidence, should be permissible (Gilhooley 2011). In the US, current FDA guidance addresses the types of literature that may be distributed to health care providers (e.g., it should be peer-reviewed, not in special journal supplements, and not significantly influenced by the manufacturer) and how that literature can be disseminated (unabridged, accompanied by approved product labeling, etc.), including that it must state that the uses described in the information have not been approved or cleared by the FDA, and other requirements (US FDA 2009).
Another aspect of information dissemination concerns the conditions under which heath technology companies can make economic claims (regarding prices, market share, cost-effectiveness, etc.) in their marketing information, what the rigor of supporting evidence should be, and which agencies should have regulatory oversight for such economic claims (Neumann 2000). Although patterns of economic claims by pharmaceutical and medical device companies about their products have changed in recent years, the use of supporting evidence in pharmaceutical formulary claims and medical device advertisements in particular remains low (Ackerly 2010; Palmer 2008).
“Academic detailing” has arisen in part to balance or offset the industry-based information dissemination efforts noted above. Academic detailing is a form of evidence-based educational outreach to physicians and other drug and device prescribers by health care professionals with no ties to industry. It is patterned after the highly effective practice in the US and some other countries of physician “detailing” (in-person visits) by pharmaceutical and device company representatives to promote prescribing of their products by practicing physicians (Solomon 2001; Soumerai 1990). To the extent that is provides clinicians with unbiased evidence-based syntheses of the best available evidence, academic detailing is intended to overcome challenges of interpreting evidence, provide trusted sources of information, and translate research findings into clinical practice (Fischer 2012).
Findings of a systematic review suggest that printed educational materials may improve process outcomes (e.g., certain physician and patient behaviors) but do not lead to significant improvement in patient outcomes. Further, there is insufficient knowledge about how to improve the effectiveness of educational materials and the effectiveness of educational materials compared to other interventions (Farmer 2008).
B. Basic Dissemination Framework
While HTA report findings can be delivered in various forms and communications media, the mere provision of information often results in little behavior change. More is being learned about techniques to increase the likelihood of changing behavior, such as face-to-face interaction, active involvement of the learner, message repetition, making recommendations explicit and relevant to clinical practice, use of opinion leaders (or “champions”), and influence of peers. As the health care information and communications environment evolves, further insights are needed about clinicians’ motivations and decision making, as well as those of patients and consumers. In the last decade, research findings on the effectiveness of various approaches for disseminating or sharing evidence-based information among clinicians has been assembled in systematic reviews, with identification of areas for further research, e.g., on continuing education (Forsetlund 2009), educational outreach visits (O’Brien 2007), opinion leaders (Flodgren 2011), audit and feedback (Jamtvedt 2006), and ways to promote interprofessional education and collaboration (Reeves 2013; Zwarenstein 2009).
HTA report dissemination can be described using three basic dimensions: target groups, media, and implementation techniques or strategies, as shown in Box VIII-1. HTA reports and documentation derived from those reports can be packaged for dissemination in different formats, e.g., for patients, clinicians, health care facility managers, payers, policymakers, researchers, the public, and news organizations. Reaching and influencing any target audience may require multiple messages and media (Kahan 1988).
Box VIII-1. Options for Dissemination of HTA Findings and Recommendations
- Target groups
- Clinicians (individuals, professional/specialty associations)
- Patients/consumers/general public (individuals, organizations)
- Disease/disorder associations (voluntary/non-profit)
- Provider institutions (hospitals, clinics, laboratories, etc.)
- Third party payers/health plans/drug formularies (government, private sector)
- Government policymakers (international, national, state, local)
- Judicial systems (e.g., for legal challenges to payer coverage policies)
- Journal editors (general/popular, scientific/health/specialty clinical)
- News services/professionals (general/popular, scientific/health/specialty clinical)
- Researchers (biomedical, health services, public health, etc.)
- Life sciences companies (pharmaceuticals, biologics, medical devices, etc.)
- Academic institutions (schools, continuing professional education programs)
- Quality assurance and utilization review organizations
- Printed: scientific/professional journals and newsletters, direct mail, newspapers and popular journals, posters, pocket cards
- Electronic: Internet (including cloud), television, radio, digital video disks, flash drives, webinars, podcasts, other computer databases (online, disk, etc.)
- Social i.e., Internet-based and mobile interactive media, including: collaborative sites (e.g., wikis); blogs, vlogs, and microblogs (e.g., Twitter); social networking (e.g., Facebook, LinkedIn); content communities (e.g., YouTube), crowdsourcing
- Word of mouth: in-person/face-to-face interaction, e.g., informal consultation, formal lectures and presentations, focus groups
Implementation techniques or strategies
- Patient/consumer-oriented: mass media campaigns, community based campaigns, interaction with clinicians (including shared decision procedures, interactive electronic resources), modify insurance coverage (more or less generous benefits, change copayments)
- Clinician-oriented: conferences and workshops; continuing education; professional curriculum development; opinion leaders; one-on-one educational visits (“academic detailing”); coverage/reimbursement policy; practice guidelines; precertification; mandatory second opinion; drug formulary restrictions; audit, peer review, and feedback (e.g., on laboratory test ordering relative to criteria/guidelines); clinical decision-support systems; reminder systems (e.g., as part of computer-based patient record systems); criteria for board certification/recertification, state licensure, specialty designation, professional/specialty society membership; public availability of performance data (e.g., adjusted mortality rates for certain procedures)
- Institution-oriented: accreditation, standards (e.g., hospital infection control, clinical laboratories), benchmarking, public availability of performance data
C. Dissemination Plan
Dissemination should be designed to inform and influence behavior of the relevant decision makers, as appropriate. Although each HTA program should have certain standard dissemination protocols and success measures, this does not mean that dissemination plans should be the same for all HTAs. HTA programs should develop, continue to improve, and adapt their dissemination activities for particular HTAs. Dissemination planning should start at or before the initiation of each HTA. The costs, time, and other resources allocated for dissemination should be budgeted accordingly, yet should allow flexibility. As they emerge during the course of the HTA, the findings and recommendations themselves may affect target group selection, the types of messages to be delivered, and the media for delivering these messages.
There is growing recognition of the benefits of early involvement of HTA target groups in improving the design, conduct, and use of HTA reports. This includes gaining insights about overcoming scientific, professional, social, cultural, organizational, economic, and other barriers to acting on HTA findings and recommendations (Hivon 2005). For patients and consumers, this includes efforts to:
- Identify patient and consumer organizations that are stakeholders on particular HTA topics
- Acknowledge patients and consumers as target groups for HTA findings, where appropriate
- Determine ways in which such organizations could help to disseminate HTA findings
- Involve representatives of these groups during the HTA process where appropriate (e.g., to gain input on key questions, interventions, comparators, outcomes/endpoints of importance, concerns about access, review of draft reports)
- Engage these groups in HTA report dissemination strategies and implementation (Fattal 2008)
Chapter X has further discussion of the patient and consumer role in HTA, including matters related to dissemination. Although there is wider recognition of the need to improve HTA dissemination, much work is needed to augment the body of knowledge and methods for doing so. Perhaps because HTA originally focused on generating reports for policymakers, current efforts are addressing more active and adaptive dissemination to other stakeholders who use or are affected by HTA findings, such as hospital and other health care facility managers; clinicians; patient, consumer, and care-giver organizations; the general public; the health technology industry; researchers; and news organizations and other “vectors” of health information (Battista 2009; Lehoux 2005). This includes packaging HTA reports into more diverse products, conveying HTA findings in the contexts or decision-making environments of target groups; translations into target users’ languages, and adjusting clinical and technical terminology as needed (Lehoux 2004; Sobrido Prieto 2007).
D. Managing Access
There are many approaches to managing or enhancing access to HTA reports. As noted above, some HTA reports are public documents available at no cost via the Internet or other public sources, while others are available only to paid subscribers or membership organizations. Others are for internal use only and not made public. Access to HTA reports and related literature is also subject to the capacity, policies, and priorities of bibliographic organizations (e.g., the US National Library of Medicine and commercial database vendors) regarding the scope of their online databases and other information sources (e.g., inclusion of peer-reviewed journals, grey literature, or other sources) and capacity to index the literature. Also, the word choice of HTA authors for report titles and abstracts can influence the indexing (e.g., designation of MeSH terms and other controlled vocabularies) and retrieval of HTA reports. Over time, these controlled vocabularies evolve with the terminology used in the field of HTA, toward improvement of indexing and retrieval.
Eguale T, Buckeridge DL, Winslade NE, Benedetti A, et al. Drug, patient, and physician characteristics associated with off-label prescribing in primary care. Arch Intern Med. 2012;172(10):781-8. PubMed
EUnetHTA (European Network for Health Technology Assessment). HTA Core Model for Medical and Surgical Interventions Version 1.0 Work Package 4. The HTA Core Model. December 2008. Publisher free report.
Flodgren G, Parmelli E, Doumit G, Gattellari M, et al. Local opinion leaders: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2011;(8):CD000125. PubMed | PMC free article
Forsetlund L, Bjørndal A, Rashidian A, Jamtvedt G, et al. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2009;(2):CD003030. PubMed
INAHTA. International Network of Agencies in Health Technology Assessment Secretariat. A Checklist for Health Technology Assessment Reports. Version 3.2. August 2007. Accessed March 22, 2016 at: http://www.inahta.org/wp-content/uploads/2014/04/INAHTA_HTA_Checklist_English.pdf.
Lehoux P, Denis JL, Tailliez S, Hivon M. Dissemination of health technology assessments: identifying the visions guiding an evolving policy innovation in Canada. J Health Polit Policy Law. 2005;30(4):603-41. PubMed
Lehoux P, Tailliez S, Denis JL, Hivon M. Redefining health technology assessment in Canada: diversification of products and contextualization of findings. Int J Technol Assess Health Care. 2004;20(3):325-36. PubMed
Mali SN, Dudhgaonkar S, Bachewar NP. Evaluation of rationality of promotional drug literature using World Health Organization guidelines. Indian J Pharmacol. 2010;42(5):267-72. PubMed | PMC free article.
Palmer JA, Timm AR, Neumann PJ. Drug company advertising in medical journals about the health-economic advantages of their products for 2000-2006 versus 1990-1999. J Manag Care Pharm. 2008;14(8):749-55. PubMed
Reeves S, Perrier L, Goldman J, Freeth D, Zwarenstein M. Interprofessional education: effects on professional practice and healthcare outcomes (update). Cochrane Database Syst Rev. 2013 Mar 28;3:CD002213. PubMed
Sobrido Prieto M, Gonzalez Guitian C, Cerda Mota T. Strategies for the diffusion and dissemination of health technology assessment (HTA) products. Santiago de Compostela: Galician Agency for Health Technology Assessment (AVALIA-T). avalia-t No 2007-072009; 2007. Publisher free report.
US Food and Drug Administration. Guidance for Industry - Good Reprint Practices for the Distribution of Medical Journal Articles and Medical or Scientific Reference Publications on Unapproved New Uses of Approved Drugs and Approved or Cleared Medical Devices. January 2009. Accessed November 27, 2013, at: http://www.fda.gov/RegulatoryInformation/Guidances/ucm125126.htm.
Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD000072. PubMed