gms | German Medical Science

4. Symposium Health Technology Assessment
Bewertung medizinischer Verfahren

Deutsche Agentur für HTA des DIMDI – DAHTA@DIMDI

13. bis 14.11.2003, Krefeld

Cross-border issues in health technology assessment

Die Bedeutung der „Cross-Border-Problematik“ für die Bewertung medizinischer Verfahren


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  • corresponding author Menno van Leeuwen - Health Council of the Netherlands (Gezondheidsraad), The Hague, The Netherlands

Deutsche Agentur für Health Technology Assessment des Deutschen Instituts für Medizinische Dokumentation und Information. 4. Symposium Health Technology Assessment - Bewertung medizinischer Verfahren. Krefeld, 13.-14.11.2003. Düsseldorf, Köln: German Medical Science; 2004. Doc03hta08

The electronic version of this article is the complete one and can be found online at:

Published: April 29, 2004

© 2004 van Leeuwen.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( You are free: to Share – to copy, distribute and transmit the work, provided the original author and source are credited.



Health care systems all over the world have to deal with the same questions that HTA is expected to answer. A quick search of the HTA literature produces HTA reports from various agencies on, for example, prostate cancer and breast cancer screening, on positron emission spectroscopy, urinary incontinence, obesity, stents, helicobacter, etcetera. Why couldn't we use an assessment done in an other country? This is the basis of INAHTA, the International Network of Agencies for HTA. INAHTA now has 41 member agencies in 20 countries. The idea behind INAHTA was that the evidence-part of an HTA-report could be 'reusable' if we could agree on a common methodology and if reporting was transparent. Science, after all, is international and so is industry. This idea was nicely expressed by John Eisenberg as "Globalize the evidence - localize the decisions". Over the years consensus has been reached about what is a good HTA-report. An excellent tool to judge the quality of such reports is the INAHTA checklist for HTA-reports, which can be downloaded from

A comprehensive technology assessment considers not only the "technical", but also the ethical, social and legal aspects of a technology. It is often thought at best the synthesis of data is reusable. However, there is no reason why a thorough analysis of the ethical dilemmas couldn't be just as useful. Of course, the interpretation of the evidence and the analysis must take place within the national or local context. However, health services research and results from high-quality studies about effectiveness of various social interventions could do much to ease this process.

Information science distinguishes a knowledge hierarchy, also known as Knowledge Pyramid. At the bottom of this pyramid we find the data (facts, symbols). Discovering relationships between data leads to information (giving answers to "who, what, where and when" types of questions. The next level is reached with understanding patterns, yielding knowledge. This answers the "how" question (know-how). The highest level in the hierarchy is wisdom, the result of understanding underlying principles. This enables us to answer "why?" questions. As we move to the top of the pyramid, our level of understanding increases, but so does the influence of value judgements. Implicit value judgements are already involved in the data: why was the research done, which in- and exclusion criteria were used, and why? However, the obvious value judgements enter as we turn knowledge into wisdom. This is where most cross-border problems will arise. They are caused, e.g., by differences in demography, epidemiology, health care systems, the legal system, culture, religion and the political system. And even if these barriers are overcome there is still the language problem and, perhaps the biggest cross-border problem, the "not invented here" syndrome.

Within the EU cross-border questions arise because of EU rules and regulations. These very often are about the free movement of patients. These issues are gradually being resolved by jurisprudence by the European Court of Justice (EJC). In a recent judgment the ECJ ruled that insurers could not refuse treatment in another member state if that treatment could not be had in the patient's own country within a reasonable time and if it was "sufficiently tried and tested by international medical science". This means that legal decisions in these cases, just like clinical ones, need to be evidence-based. Surprisingly, therefore, the resolution of cross-border issues will require HTA.

Europeans travel a great deal, and get accustomed to the culture and habits of other countries. Gradually some of the cultural differences will diffuse. Of course cultural, language and religions differences will always exist, but probably less as cross-border problems than as a national problem in some countries, unrelated to HTA. The Internet, finally, will also contribute to diminishing cultural division.


• Cross-border issues exist, but let us not exaggerate them

• There is a need for good quality, wide-scope technology assessments, to avoid creating cross-border issues unnecessarily

• Legal and health system issues will become less prominent, because of European legislation and jurisprudence

• Even in the EU cross-border questions will not entirely disappear, but

• Travel and Internet will lessen cultural differences

• Social interventions may become increasingly evidence-based, eliminating some cross-border problems in policy decisions