International Journal of Technology Assessment in Health Care


Framework for describing and classifying decision-making systems using technology assessment to determine the reimbursement of health technologies (fourth hurdle systems)

John Hutton a1, Clare McGrath a2, Jean-Marc Frybourg a2, Mike Tremblay a3, Edward Bramley-Harker a4 and Christopher Henshall a5
a1 University of York and The MEDTAP Institute at UBC
a2 Pfizer Ltd.
a3 Tremblay Consulting International
a4 NERA Economic Consulting
a5 The London School of Hygeine and Tropical Medicine and University of York


Objectives: Australia, Canada, and many European countries now use various forms of health technology assessment (HTA) in decision making regarding the reimbursement of drugs and other health technologies. To achieve a better understanding of the potential for use of HTA in this context, an analytical framework was developed to describe and classify existing fourth hurdle systems.

Methods: Based on a review of published literature, and official documentation, the key aspects of a fourth hurdle system were identified at two levels: policy implementation and individual technology decision. Characteristics of the systems were grouped under four main headings: constitution and governance, objectives, use of evidence and decision processes, and accountability. The comprehensiveness and relevance of this framework was assessed by an independent group of experts in HTA. A pilot study was undertaken, using only published sources, to test the feasibility of obtaining the information needed to complete the framework.

Results: The framework was found to be sufficiently broad to encompass all the issues of interest regarding the systems, but the proportion of information available from published sources was variable between sections of the framework and between countries, with average availability of 45 percent.

Conclusions: The analytical framework will help researchers and policy-makers in individual countries to understand their own systems and will allow some preliminary sharing of experience between countries. More experience of its application is needed to judge whether it will provide the basis for more formal comparison of systems and whether it will determine the appropriateness for particular decision contexts.

Key Words: Health technology assessment; Fourth hurdle; Reimbursement decision making; Policy analysis; Analytical framework.