Health Technology Assessments as an Alternative to Clinical Practice Guidelines

Introduction Clinical practice guidelines (CPGs) rely on moderate- and high-quality randomized controlled trials (RCTs) and make binary recommendations (effective or not effective). Health technology assessment (HTA) reports include non-randomized studies of interventions (NRSIs). In addition to assessing effectiveness, HTA reports assess harms and safety, differential effectiveness, and cost-effectiveness. The Washington State Health Care Authority (HCA) uses the Health Technology Clinical Committee (HTCC) to decide which technologies will be covered and under which clinical conditions. Methods Ninety-two HTA reports and the HTCC coverage and conditions decisions from the Washington State HCA were reviewed from inception through January 31, 2025. Thirty-five HTA reports related to musculoskeletal technologies were reviewed and data abstracted including report date, topic, subtopic, comparisons, number of RCTs for each decision/comparison, number of NRSIs for each decision/comparison, highest effectiveness quality of evidence (QoE) for each decision/comparison, and coverage decision. HTCC coverage decisions were compared to American Academy of Orthopaedic Surgeons (AAOS) CPG recommendations to assess the congruence between HTCC coverage decisions and AAOS CPG recommendations. Results Thirty-eight percent (35/92) of the HTA evidence reports addressed musculoskeletal technologies. The 35 HTA reports resulted in 61 coverage decisions. Thirty-six of the 61 (59%) reviewed technologies were not covered, 25 (41%) were covered with conditions, and no technology was covered unconditionally. If a technology was likely to be covered unconditionally, there would be no need for review. Of the technologies covered with conditions, the highest quality of evidence supporting the coverage decision was high-quality evidence – 8% (2/25), moderate-quality evidence – 32% (8/25), low-quality evidence – 40% (10/25), and very low-quality evidence – 12% (3/25). The most common subspecialties or joints that were included in the coverage decisions were spine (31%), knee (20%), and hip (11%). Eleven technologies had applicable AAOS CPG recommendations. Six of the AAOS CPG recommendations were congruent with HTCC coverage decisions. Of the five non-congruent decisions, four had limited evidence to support the recommendation and one recommendation was inconclusive. Conclusions Clinical practice guidelines developed with GRADE methodology provide binary recommendations: effective or not effective. GRADE methodology automatically downgrades observational studies to low-quality evidence. Observational studies (prognostic evidence) are needed to determine coverage conditions and for shared decision-making. The process used by the Washington State HCA HTCC could complement CPGs by providing more nuanced, condition-specific guidance. The inclusion of safety and harms, differential effectiveness, and cost-effectiveness provides a robust assessment of technologies. Standardized coverage conditions would simplify pre-authorization.