What is driving HTA decision-making? Evidence from cancer drug reimbursement decisions from 6 European countries

Health Policy. 2019 Feb;123(2):130-139. doi: 10.1016/j.healthpol.2018.11.003. Epub 2018 Nov 20.


Background: Decisions on the reimbursement of the same cancer drugs are different across European countries, but empirical work on the reasons behind these differences has been scarce. The main objective of this paper is to make a methodological contribution to existing research, specifically by outlining the systematic process of analysis to address such questions and determining the factors that might lead to different drug reimbursement decisions, and to explore its application in the field of oncology.

Methods: Reimbursement decisions on cancer drugs in six European countries (Belgium, England, Poland, Portugal, Scotland, and Sweden) between 2006 and 2014 were included in the study. A taxonomy was developed, comprising two groups of variables (system-level and product-specific) and an econometric model was specified (multilevel mixed-effects ordered probit).

Results: Only one in six evaluations in the sample reach the same reimbursement recommendation. Most health system variables were not determinants of a higher or lower probability of a positive reimbursement recommendation. However, the probability of reimbursement was higher when a drug was considered cost-effective by NICE/SMC and when there was a financial Managed Entry Agreement. This work also demonstrated a possible econometric approach for analysing differences in reimbursement decisions and contributes a structured approach for collecting and preparing data for such analyses.

Conclusions: Drug reimbursement decisions can be analysed in detail along a set of factors that are related to each decision. This information is essential, not only for understanding why a particular drug is accepted in one country and not in another but also when trying to implement a new HTA system or reform an existing one. This analysis provides policy makers and stakeholders with a model that enables a better understanding of the factors that drive HTA decisions and is adaptable to answer similar questions. Moreover, the data collection limitations encountered and described in this work shed light on the need for greater accessibility and transparency in HTA systems and regarding HTA outcomes.

Keywords: Cancer drugs; Drug reimbursement; Health Technology Assessment (HTA); Multilevel mixed-effects Ordered Probit.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Antineoplastic Agents / economics*
  • Decision Making, Organizational
  • Drug Approval / organization & administration
  • European Union
  • Humans
  • Models, Econometric
  • Reimbursement Mechanisms / organization & administration*
  • Technology Assessment, Biomedical / organization & administration*


  • Antineoplastic Agents