Health technology assessment (HTA) and performance management (PM): a scoping review on the intersecting realms

Abstract

Background

Both Health Technology Assessment (HTA) and Performance Management (PM) are clinical governance disciplines that aim to improve the quality, equity, and financial sustainability of health organizations and systems. Although HTA and PM share many features, to the authors’ knowledge, few studies have investigated their interplay. This study attempts to fill this gap by analysing how the literature has explored and developed the integration between HTA and PM concepts and tolls within healthcare sector.

Methods

To address this gap, this study examines 33 papers selected through a scoping review that explores the intersection of HTA and PM within the healthcare sector. In particular, the paper adopted the preferred reporting items for systematic reviews and meta-analysis (PRISMA) methodology to select and analyse articles.

Results

The review highlights the dynamic convergence of HTA and PM, emphasizing how combining these frameworks and functions can enhance decision-making in healthcare. This integration ensures that technologies are adopted on the basis of proven effectiveness in pursuing healthcare systems goals and that performance metrics align with evidence-based practices, leading to better resource allocation and improved patient outcomes. The literature review underscores the need for further research to understand the integration between HTA and PM and their combined impact on organizational performance, sustainability, and resilience in the healthcare sector.

Conclusion

This study contributes to the literature by providing a comprehensive overview of the current state of research on HTA and PM, offering insights for future studies, and practical recommendations for integrating these disciplines to improve healthcare management and policymaking.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-12879-3.

Introduction

The healthcare sector continually faces complex, “wicked” problems, necessitating the integration of advanced methodologies and research streams to ensure effective service delivery and timely assessment of healthcare innovations [1]. In the fast-paced landscape of healthcare innovation management, the demand for informed, evidence-based decision-making is essential to improve the efficiency and effectiveness of healthcare organizations and systems [2]. Within this context, adopting clinical governance frameworks is fundamental to implementing evidence-based practices in decision-making [3, 4].

Clinical governance encompasses a comprehensive set of leadership behaviors, policies, procedures, and mechanisms for monitoring and improving clinical outcomes [5, 6]. This structured framework is designed to promote accountability, increase care quality, and ensure high standards in healthcare delivery [7]. It includes various processes—such as risk management, clinical audits, and performance monitoring—focused on enhancing patient safety and clinical outcomes [5]. Central to clinical governance is the commitment to continuous improvement, encouraging healthcare professionals to assess their practices, identify areas for enhancement, and implement evidence-based practice (i.e. the systematic use of the best available evidence to improve decision making processes [8]). This framework fosters a culture of transparency and professional development, distributing responsibility among healthcare teams and aligning organizational structures with individual roles to improve the overall quality and safety of patient care [7, 9].

Clinical governance is often supported by two key healthcare management disciplines: Performance Management (PM) and Health Technology Assessment (HTA). These disciplines do not merely coexist within clinical governance; they actively reinforce its core objectives by addressing distinct yet interrelated aspects of healthcare improvement.

In particular, PM is broadly defined as a set of tools, techniques, and activities aimed at guiding internal stakeholders to pursue organizational objectives by measuring, managing, and evaluating performance [10–13]. Introduced to the public sector in the 1990 s during the “New Public Management” (NPM) reform wave, PM aimed to introduce private sector efficiency and accountability standards into public organizations [14, 15]. The principles of NPM catalyzed the corporatization of public organizations, emphasizing financial performance and productivity metrics that had been previously underexplored. The healthcare sector, particularly in countries with national health services such as the United Kingdom and Italy, was among the first to adopt these NPM principles [16]. Here, PM evolved from a management tool to a regulatory framework, requiring healthcare systems not only to demonstrate financial accountability but also to link financial planning directly to measurable healthcare outcomes. Consequently, PM principles have become integral to public administration controls aimed at generating value in healthcare [16]. This shift paralleled the rise of clinical governance, which introduced a cultural transformation within healthcare, aligning with PM principles to encourage healthcare organizations to “continuously improve service quality and maintain high standards of care”, fostering environments where clinical excellence thrives [17].

Evidence is foundational to PM, equipping decision-makers with key insights and metrics to assess and enhance organizational efficiency, productivity, and overall effectiveness [18]. By systematically collecting, analysing, and interpreting relevant data, organizations can establish key performance indicators (KPIs), track progress toward goals, and make informed decisions to optimize operational processes supporting clinical governance [19]. In this perspective, through the collection and framing of evidence, PM further supports clinical governance by enabling organizations to identify improvement areas, allocate resources more effectively, and align strategic objectives with tangible outcomes [16, 20, 21].

On the other hand, HTA “is a multidisciplinary process that uses explicit methods to determine the value of a health technology at different points in its lifecycle. The purpose is to inform decision-making to promote an equitable, efficient, and high-quality health system” [22]. HTA, in fact, complements clinical governance by providing a multidisciplinary framework to evaluate the value of health technologies throughout their lifecycle [22]. Recent advancements in healthcare have led to marked improvements in patient care, operational efficiency, and organizational performance due to the rapid adoption of new technologies. However, the introduction of innovative healthcare solutions in advanced systems has also contributed to significant increases in healthcare costs and growing demand for services globally [23]. HTA plays a crucial role in informed decision-making and health policy formulation by providing comprehensive insights into the multidimensional impact of innovations—whether organizational, technological, or otherwise—throughout various stages of the technology lifecycle and levels of technological readiness [24–26].

In recent years, the application of HTA has garnered increasing attention, necessitating a more nuanced approach that accounts for the technological maturity and life cycle stage of the interventions being assessed [27]. Scholars and practitioners alike have recognized the significance of distinguishing between various ‘species’ or ‘typologies’ of HTA. This differentiation was articulated by the seminal work of Ijerman et al., which emphasized that the primary distinction lies in the purpose of the assessment [28, 29]. Early-stage HTA primarily aims to guide the development of innovations in their formative phases, encompassing activities from initial ideation and design to clinical validation studies. To achieve this, it employs tailored methodologies, including expert elicitation, computational simulations, and bench studies. The other species of HTA, called mainstream or mature HTA, assesses the clinical and economic impact of technologies that have either entered the market or are in the process of securing market access, depending on country-specific regulatory frameworks. In some contexts, HTA is a prerequisite for market approval, while in others, it is conducted post-launch as part of reimbursement or adoption decisions.

HTA assessments span a range of health technologies, including pharmaceuticals, vaccines, medical devices, surgical procedures, software, and healthcare systems [30]. This evaluative approach aids policymakers and healthcare decision-makers in making informed choices by weighing the benefits, limitations, and costs associated with the development, implementation, and use of each technology throughout its lifecycle [31].

Through PM and HTA, two key features of clinical governance are addressed: one that emphasizes accountability and performance optimization (PM) and another that fosters evidence-based evaluation and integration of innovations (HTA).

With rapid advancements in areas such as precision medicine, gene therapy, and digital health solutions, the need for timely and comprehensive HTA assessments has intensified [32]. In many Countries, the first HTA practices and frameworks have focused on clinical effectiveness and economic efficiency when evaluating health innovations – even though most recent studies emphasize the need to account for other social variables (see for instance [33]). However, with the rise of new digital health technologies—such as digital therapeutics, platforms, and AI-driven innovations—HTA has broadened significantly due to their inner characteristics [34, 35]. For the successful integration of technological innovations within healthcare systems, assessing only their clinical and economic impacts is insufficient. This shift aims to provide a holistic understanding of the impacts of contemporary health innovations [35].

Over the past two decades, HTA has seen significant international growth, with countries collaborating to share data, methodologies, and best practices. Notable initiatives include the European Network for Health Technology Assessment (EUnetHTA) and the International Network of Agencies for Health Technology Assessment (INAHTA). Insights from these international partnerships are vital for shaping healthcare policies and regulations, providing essential information for payers and regulators to make informed decisions regarding the approval, coverage, and reimbursement of innovative technologies. The healthcare sector’s dynamic nature, marked by constant technological evolution and shifting healthcare objectives, has led HTA into a transformative phase. This period of considerable evolution reflects the need for adaptable strategies to address the inherent complexities of modern healthcare.

Following extensive discussions, the European Commission adopted a new regulatory framework for HTA, formalized in the European Regulation for HTA (Regulation (EU) 2021/2282) [36] on December 15, 2021, which entered into force on January 11, 2022 with a concrete application only started on January 12, 2025. This new regulation is a foundational reference for our study, which explores the intersection between HTA and Performance Management (PM). Notably, the regulation emphasizes the importance of collaboration on the clinical domains with the aim to improve equity and access to beneficial technologies to all patients across the EU faster than before. By fostering a shared framework, it aims to streamline assessment processes, reduce duplication of effort, and accelerate the introduction of innovative treatments. Additionally, the regulation mandates that individual member states refrain from requesting duplicate evidence already assessed at the EU level, thereby promoting efficiency and reducing burdens on stakeholders, expanding HTA’s traditional scope beyond purely economic assessments. This adaptation is critical for European nations, which must now integrate additional non-clinical factors related to PM within the HTA framework [37]. These developments underscore the interconnectedness of non-clinical evaluations, the broader HTA landscape, the common framework and the collaboration between countries reflecting a significant paradigm shift in HTA methodologies that allow countries not to require the same evidence.

Aim of the study

The principles of PM and HTA, as outlined above, enable healthcare systems and organizations to enhance performance, deliver quality and sustainable care, and prioritize patient-centred services, —which are defined as services designed to be respectful of and responsive to the individual values, preferences, and needs of patients, ensuring that care decisions are guided by what matters most to them— as required by clinical governance standards [38]. These disciplines share foundational principles and can be integrated to improve the quality, timing, and effectiveness of healthcare decisions. By utilizing evidence from HTA to inform management decisions, healthcare organizations ensure that technologies are adopted based on proven effectiveness. On the other hand, through performance monitoring, PM supports HTA activities by benchmarking the anticipated outcomes of innovations against organizational objectives, addressing questions such as: How does the adoption of this innovation impact organizational and patient outcomes?

HTA provides evidence-based evaluations of health technologies, prioritizing investments aligned with organizational objectives and cost-effectiveness [39]. While HTA assesses the effectiveness, costs, and broader impacts of health technologies, the resulting information become foundational for PM initiatives, enabling healthcare organizations to evaluate technology value, allocate resources efficiently, and enhance patient outcomes. Integrating HTA data into PM frameworks thus supports evidence-based strategies, ensuring that resources are allocated appropriately, that technologies are adopted effectively, and that care delivery aligns with overarching performance objectives. Notably, the intersection of PM and HTA is particularly evident in budgeting processes, investment planning, and lifecycle management of technology, including obsolescence programming and control.

Despite extensive studies on PM and HTA in the healthcare sector, few studies have focused on the integration between these two areas. Specifically, previous studies have not adequately explored the development of integrated frameworks to align performance management with health technology assessment, nor have they addressed how these systems could be effectively operationalized to support decision-making processes in healthcare organizations. Although both are widely applied, their intersecting significance has received limited exploration. Therefore, this research seeks to analyse the integration between PM and HTA. To that end, we conducted a scoping literature review to integrate and analyse findings from multiple studies. Specifically, our research aims to identify and contextualize trends in the contributions of HTA and PM practices within healthcare at the technology, organization, and system levels.

To achieve this purpose, the article is structured as follows: the next section describes the methodology used to conduct the scoping review; the third section presents and develops the results; the fourth section provides a discussion, including the development of a framework that integrates HTA and PM. Finally, the last section offers conclusions.

Methodology

A scoping review, also known as a “mapping review”, was conducted to explore and understand the integration between the fields of HTA and PM. The primary aim of this review was to provide an overview of the available evidence, analyse the research methods employed by the authors, and assess the healthcare areas in which these methods were applied. A scoping review approach was chosen because it facilitates the synthesis of research findings, allowing for the development of recommendations for future studies. This method supports the systematic identification of both qualitative and quantitative evidence within the existing literature, enabling us to map and organize extracted material effectively, thus deepening our understanding of the findings in these fields [40].

To ensure transparency and thoroughness, the authors conducted scoping reviews and meta-analyses following the PRISMA (Preferred Reporting Items for Scoping Reviews and Meta-Analyses) Statement as a reporting standard [41, 42]. The article selection process involved multiple steps: (i) defining inclusion and exclusion criteria; (ii) establishing a search strategy; (iii) identifying keywords based on the review’s theoretical frameworks; (iv) assigning review tasks to each author; and (v) analysing the identified papers to make final inclusion or exclusion decisions.

Review protocol

Given the exploratory nature of this scoping review, we selected the Scopus database for our literature search, as it is the most comprehensive multidisciplinary database, encompassing a broad range of peer-reviewed literature across multiple fields and journals. Compared with PubMed and Web of Science, Scopus offers wider coverage and more robust citation analysis, as noted by Falagas and colleagues [43]. This choice allowed us access to an extensive and diverse pool of literature, ensuring that our performance analyses are thorough, informative, and insightful.

In the initial phase, eligibility criteria were established based on English language, research type (both primary empirical studies and secondary reviews), and publication type (scientific articles, review and book chapters). No restrictions were applied regarding publication year, research area, or geographic scope, allowing for a comprehensive exploration of the relevant literature.

Following this research, structured search query was developed to optimize the search related to these keywords: “health technology assessment” OR “hta” AND “performance manag*” OR “performance measur*” OR “performance indicator*” OR “kpi” OR “bsc” OR “Balanc* scorecard” OR budgeting OR “management control” without year limitations. This was our research query:

TITLE-ABS-KEY (“health technology assessment” OR “hta” AND “performance manag*” OR “performance measur*” OR “performance indicator*” OR “kpi” OR “bsc” OR “Balanc* Scorecard” OR “budgeting” OR “management control”) AND (LIMIT-TO (LANGUAGE, “English”)).

The search was performed in February 2024. Using the search keywords, the Scopus database provided 93 articles, as shown in Fig. 1, which synthesizes the article screening process based on the PRISMA protocol.

Fig. 1.

Article selection process - PRISMA flow diagram

Two members of the research team analysed the titles and abstracts of the results obtained to determine, based on the inclusion and exclusion criteria, whether to incorporate the article into the final sample. To ensure a rigorous selection of relevant studies, we included articles that explicitly addressed both PM and HTA within the healthcare sector, particularly those discussing their integration at the technology, organization, or system levels. Articles were excluded if they focused solely on either PM or HTA without exploring their integration, as well as those that were not peer-reviewed or written in languages other than English. When doubts arose about whether an article should be included, the whole research team discussed and built consensus on inclusion or exclusion. We carefully examined all the identified papers for eligibility, and after a thorough review, we selected the 30 articles that were most relevant to our scoping review. Upon the identification of the final sample of papers designated for analysis, the authors conducted an in-depth examination of the citations contained within each selected article. This hand-search methodology resulted in the identification and subsequent inclusion of three additional articles that were deemed pertinent to the research purpose.

Upon finalizing the selection of the sample, a Data Extraction Form (DEF) was constructed in an Excel spreadsheet to facilitate systematic data collection. The variables delineated within the DEF for each included article encompassed the following dimensions: theoretical framework, research methodology, levels of analysis—specifically macro (system level), meso (hospital level), and micro (technology level)—as well as the critical link or nexus between HTA and PM disciplines. These variables were determined according to a deductive-inductive approach. In particular, the authors followed a structured process consisting of different steps: (i) initially, two members of the research team identified the main emerging theoretical backgrounds, research methodology and levels of analysis explicitly mentioned within the abstract. Where such reference was not clearly present in the abstract, the analysis was extended to the content of the article, establishing it in an inductive way; (ii) subsequently, articles were categorised according to the variables by the four authors in groups of two, doubts that arose were clarified through two brainstorming sessions, facilitating the categorisation of contributions; (iii) lastly, a final brainstorming session was organised with all authors to review the 33 articles and check the consistency of the categorisation, ensuring that the assignment to clusters was appropriate and agreed upon.

The DEF, along with the pertinent values for each variable, can be found in the Appendix for the included articles of this review.

Results

The initial analysis conducted pertains to the temporal distribution of the acquired publications. An analysis of the temporal distribution of the examined sample, as depicted in Fig. 2, reveals a discernible growing trend. These preliminary findings suggest a continuing interest among the scientific community in this topic, particularly from the year 2012 onwards. Notably, a period of stagnation was observed between 2014 and 2020; however, a resurgence of interest emerged from 2021 to the nowadays. This trend indicates a continuing interest in this thematic area, which is likely attracting an increasing number of researchers. Our investigation revealed that the earliest and most pertinent publication considered during our PRISMA selection process dates back to 2001. Notably, the study by Herbert (2001), titled “Telehealth Success: Evaluation Framework Development” [44], serves as a foundational reference. Herbert established that HTA encompasses more than mere technological evaluation; it also integrates performance metrics, outcomes, and operational considerations. Although published in 2001, this study underscored the critical role of HTA in health system evaluations, which can significantly influence technology adoption decisions. It has been instrumental in advocating for a comprehensive perspective on the HTA discipline, positioning it as a methodological framework that incorporates various domains, including health economics—specifically, economic evaluations in healthcare, such as cost-effectiveness analysis, cost‒benefit analysis, and cost-utility analysis. Furthermore, the article broadens the definition of technology to encompass the application of knowledge, incorporating both hard and soft technology dimensions [45].

Fig. 2.

Temporal distribution of scientific products

The analysis of the publication year trend in our review emphasized that the research area of HTA-PM attracted great interest in 2021, when it peaked with five publications. It is equally evident that many (42%) of the articles selected in the study came in recent years (2020–2023) possibly related to the advent of the global pandemic that shook the entire global healthcare system, in which the adoption of technologies played a key role.

Table 1 shows the scientific journals dealing with the subject. The journal that published the greatest number of articles (4 articles) in our review is the International Journal of Technology Assessment in Health Care, followed by BMC Health Service Research (2), Health Policy (2), Sustainability (2), Technology and Health Care (2), and Value in Health (2). The other 19 articles were published in 19 different journals.

Table 1.

Most important journals

Journal	Number of articles published
International Journal of Technology Assessment in Health Care	4
BMC Health Services Research	2
Health Policy	2
Sustainability (Switzerland)	2
Technology and Health Care	2
Value in Health	2
Other	19

We also conducted a geographical analysis of the articles to determine the origins of the authors, thus defining their geographical area of provenance. This analysis is illustrated in Fig. 3. Notably, the data reveal a pronounced concentration of research output, with Italy contributing 14 out of 33 articles, whereas Canada and the United States accounted for 6 and 3 publications, respectively. This distribution underscores the substantial variation in research interest across different nations.

Fig. 3.

Geographical distribution of the reviewed articles

Theoretical perspectives

To enrich our review, we extended the analysis beyond the mere collection of empirical data to include an analysis of the theoretical perspectives expressed in the different articles. This approach allowed us to examine not only the results and conclusions reached by the authors but also the conceptual frameworks and theories that guided their investigations, providing a deeper understanding of the different perspectives and theoretical underpinnings that inform the academic and practical debate on HTA and PM in healthcare. As previously detailed in the Methodology section (review protocol), the authors identified eight theoretical backgrounds through a deductive-inductive approach, following a structured process to ensure consistency and agreement in article classification. Our analysis, illustrated in Fig. 4, identified eight distinct clusters: “value-based care”, “quality”, “human resources”, “hospital-based health technology assessment”, “digital technology”, “decision-making”, “collaborative governance” and “budgeting”. An analysis of the figure reveals that a significant number of the research articles included in the review are grounded in the theoretical framework of “budgeting”. This theoretical orientation has garnered significant attention from scholars since the emergence of heightened interest in HTA research and related investigations.

Fig. 4.

Theoretical background of scientific products

Budgeting theoretical background (cluster 1) was adopted in eight studies. Budgeting is a tool of PM that allows decision-makers to understand the future effects of their choices. In this sense, budgeting represents a feed-forward tool that enhances the comprehension of how a specific technology or device may impact the different performance dimensions of a healthcare organization/system.

Three of these studies [46–48] focused on how to develop a budgeting process at the hospital level. The remaining five studies were based on Program Budgeting and Marginal Analysis (PBMA), a technique used in resource allocation, particularly within the healthcare sector [49]. PBMA focuses on strategically allocating resources across various programs and activities in alignment with organizational priorities and objectives. This method employs a comprehensive framework to delineate different programs’ costs and anticipated outcomes, promoting transparency and coherence with the organization’s goals. Additionally, PBMA facilitates the identification of optimal strategies for enhancing outcomes by evaluating the effects of incremental adjustments, thereby maximizing the efficient utilization of available resources [49]. These studies were conducted in Australia, Canada, and the USA [49–53].

Seven studies had theoretical footings on “Decision-making” (cluster 2). This cluster includes articles aimed at discussing methodologies and techniques that can support decision-making during HTA processes. Three of the studies [54–56] give specific relevance to the development of a set of Key Performance Indicators (KPIs) to support decision-makers. The other four focus on combining multicriteria decision analysis (MCDA) and decision support systems (DSS) with HTA [57–60]. Overall, the authors based their theoretical framework on the belief that KPIs allow for an accurate and measurable evaluation of various aspects of the healthcare system and that these indicators may improve the quality of decision analytic models in HTA.

The “Quality” theoretical background (cluster 3) was also appreciably used by some authors. This includes articles focusing on Donabedian’s [61] framework [44, 62–64] and how to develop and use performance measures within the HTA process [44, 65, 66], such as the quality-adjusted life-years (QALYs) as an outcome for the economic evaluation of health interventions. The most cited article from this theoretical perspective is that of Garrido et al. [64], which discusses the development of HTA, emphasizing the information needs of all levels and areas of health policymaking through quality monitoring. Another relevant article in this category is the study by Carini et al. [62], which thrived to identify and classify the dimensions of hospital performance indicators to develop a common language and identify a shared evidence-based way to frame and address performance assessment.

Another important theoretical model underscores the importance of “Hospital-based Health Technology Assessment” (HB-HTA) through five articles (cluster 4) [23, 58, 67–69]. HB-HTA involves the evaluation of health technologies within the hospital setting to facilitate informed decision-making regarding their adoption and utilization. It is important to mention that also other articles that have been clustered in other background focuses on the HTA at the organizational level – e.g. Cionini et al. [50], Lettieri [47], Carini et al. [62]. Palozzi et al. [67] is the most cited article focusing on the integration of HB-HTA with specific attention to hospital-specific clinical, economic, organizational, and ethical considerations. The research emphasized the importance of tailored evaluations that account for the unique requirements and settings of individual facilities. The primary objective was to facilitate well-informed decision-making concerning health technologies, with the overarching goal of enhancing the effectiveness, quality, and sustainability of healthcare services. Additionally, Lafortune et al. [68] discussed the HB-HTA model as a decentralized approach aligned with clinical priorities and hospital management. This model advocates for comprehensive reviews that promote a participatory approach involving various stakeholders, such as patients, managers, and clinicians. Similar to the goal of Palozzi et al. [67], the focus on the selected referenced articles is to achieve a balance between innovation and resource allocation, optimizing patient care, and organizational performance.

Other emerging theoretical backgrounds that the literature reviewed in this study hinged on include the theory of Collaborative Governance [20], value-based care [70], Human Resource (HR) [71], and Digital Transformation [72–75].

Methodological perspectives

We finally examined the methodology adopted in the reviewed articles. The results show that many of the articles (17 articles) adopted the literature review approach in their studies. This means that many of the studies in the collection of reviews did a critical summary and evaluation of existing research literature on the topic of HTA or PM that was deemed relevant in understanding their touchpoints. They equally provided an overview of relevant studies, identified gaps in knowledge, and contributed to the theoretical framework of a research project that has been performed by some researchers. Most of the studies in the literature review address the development of performance measures to support HTA, e.g., Lafortune et al. [68], Carini et al. [62], Fasterholdt et al. [72], and Palozzi et al. [23, 67]. The wide use of this methodology can be explained by the novelty of the topic related to the integration between HTA and PM.

Other methodologies that have gained the popularity of authors include statistical analysis and case study methodology, which were used in 7 reviewed publications and reported successful experience or evidence of HTA and PM integration, respectively. Statistical analyses have been applied to primary data collected [49, 69]. Seven case studies analysed HTA and PM at the hospital level [47, 48, 58, 69]. In addition to offering real-world applications, best practices, and lessons learned that can direct future implementations, the case studies in this analysis of the review also offer a comprehensive perspective on the influence of health technology on performance while accounting for a variety of contextual circumstances.

As shown in Fig. 5, action research and sentimental analysis were other approaches used in 1 reviewed publication. Action research is iterative and fosters interactively reflective practice among participants, which makes it a valuable tool for implementing technology in healthcare settings and measuring performance. Sentiment analysis, on the other hand, was used in one of the reviewed publications to analyse and quantify opinions and attitudes expressed in text data, which complemented quantitative performance metrics and monitored sentiment trends.

Fig. 5.

Methodology utilized in the publications reviewed

Discussion

The primary objective of this study is to thoroughly examine the literature that focuses on the intersection between HTA and PM. In this work, we explored and considered HTA within the broader healthcare system to understand the links between the multidisciplinary assessment of new technologies and performance management in the system. Given the increasing importance of HTA studies, as reflected in the studies by Hollingworth et al. [76], Uzochukwu et al. [77] and Joore et al. [78], we conducted a scoping literature review and analysis of the relevant literature of published in peer-reviewed papers integrating HTA activities and PM activities. The scoping review approach offers the flexibility necessary for studying a multidisciplinary or cross-disciplinary field. Here, it was used to examine the intersection between HTA, PM, and clinical governance, thereby highlighting their combined impact on healthcare quality and innovation. This review thus may serve as a base for refining a theoretical framework aimed at healthcare improvement. In light of our scoping review, four issues emerged for scholarly discourse.

First, our review reveals that the researchers have begun to explore the intersection of these two disciplines for over two decades, demonstrating interest in the scientific and academic world. However, only in recent works [20, 23, 67] scholars have focused on developing frameworks that integrate and intersect HTA and PM.

Second, the identified outstanding and evidential potential of HTA and PM research shown through the publication domains in internationally renowned journals spanning diverse scopes (as shown in Table 1) is worthy of discussion. Overall, the most significant scientific disciplines that have devoted attention to the investigated topic are health policy, health service research and healthcare management. We believe that there is room to participate in this debate in accounting and general management journals, which currently devote significant attention to the topic of PM in healthcare but neglect the debate on HTA.

Another interesting emerging result from our study is the widespread geographical locations of the study areas of the articles reviewed (as shown in Fig. 2). This implies that the subject or focus of the study has garnered global interest across countries over the years. However, our review revealed that most of the articles in our sample were produced in Italy, followed by Canada. The reason for this phenomenon may be attributed on the one hand to the reliance of their health systems on general taxation [79, 80]; on the other hand, to the institutionalization of PM practices in public service in countries such as Italy following the NPM reforms [14–16]. In addition, the constraints on their available resources necessitate a rigorous ex-ante assessment of the financial implications and multidimensional health impacts expected with the adoption of new technologies. The representation of the Italian academic community highlights the active engagement and scholarly contributions of Italian researchers in the domains of HTA and PM within the healthcare sector. This could be facilitated by the specific Beveridge-type healthcare system (NHS) and the presence of specific mandatory laws and policies that impact both the introduction of performance management and HTA strategies such as National HTA Program for MDs (PNHTADM) [79–81]. In contrast, the comparatively lower output from other countries, including the United States, may imply a greater emphasis on these topics within government-funded health systems. Understanding these disparities could inform future strategies for collaboration and the allocation of resources to bolster international research initiatives.

Finally, the descriptive analysis of the theoretical backgrounds and the methodologies utilized in the different studies reviewed were also identified and formed a significant pillar of our discussion. The four prominent theoretical frameworks upon which many of the articles were based were “Budgeting”, “Decision-making”, “Quality”, and “Hospital-Based HTA”.

Overall, these insights highlight how HTA links well with budgeting activities to activate feed-forward mechanisms that explain ex-ante how the introduction of a new technology may impact healthcare organization and system results. This supports priority setting and resource allocation processes by fostering decision-making at different governance levels [46, 49, 82]. In summary, the studies highlight the importance of multidisciplinary approach in the budgetary process by involving healthcare practitioners, administrators, and policymakers in deliberations regarding budget priorities with the aim of optimizing resource utilization and enhancing patient outcomes.

Decision-making in the HTA context needs to collect and process information related to different performance dimensions, including financial, effectiveness, and sustainability principles [58, 67]. The decision-making theoretical background holds the belief that HTA supports evidence-based decisions and policy-making that encourage the uptake of efficient and effective healthcare technologies [83], which ultimately helps the performance of healthcare systems.

Moreover, combining HTA with PM is particularly relevant in organizational contexts such as hospitals. This may be explained by the fact that technology adoption and utilization are often decisions taken at the organizational unit level, and budgeting and other PM tools support investments and disinvestment decisions [48, 52]. Given that the HB-HTA is primarily done for individual hospitals, this review places a significant emphasis on this aspect. The integration of HB-HTA with PM is a strategic approach to enhancing hospital performance through evidence-based technology adoption and rigorous performance monitoring, which ultimately results in improved patient outcomes and more efficient healthcare delivery. Hospital research institutes, teaching hospitals, large public hospitals, and private healthcare facilities are increasingly motivated to lead in technological innovation. This competitive landscape compels these institutions to adopt and deploy impactful and innovative technologies that optimize the health outcomes of patients and society both effectively and expeditiously. In this context, it becomes imperative for hospital organizations to be at the forefront of implementing mechanisms and strategies that integrate the iterative activities of HB-HTA with PM activities. Such integration is required to facilitate comprehensive and strategic continuous monitoring of technological innovation, enabling a systematic comparison between ex-ante expectations and ex-post performance, while also addressing the growing demand for in-market surveillance. Especially, this approach is an opportunity for monitoring adverse effects associated with innovative medical devices and biomedical technologies in hospital organizations, an area that has traditionally been the domain of pharmaceuticals and medicinal products alone.

Attempting to improve clinical governance and healthcare outcomes, three touch points have been identified on the basis of the scoping review results.

The first touchpoint refers to the adoption and use of KPIs in HTA processes [54–56]. The integration and alignment of performance indicators and HTA criteria enable the effective coordination and targeting of healthcare organizations’ efforts toward similar goals, such as improving healthcare outcomes and optimizing the use of health technologies [20].

A second touchpoint refers to the need to track and organize the large volumes of data required for PM and HTA to ensure traceability, transparency, accuracy, reliability, and valuable insights [47]. While PM experts can consult the HTA to identify what data are suitable for assessing technologies, the tools developed to measure and manage healthcare performance with the data collected in the information systems may deliver useful performance related information to the HTA.

Third, both HTA and PM are required to engage with stakeholders, both internally and externally, to understand and account for their interests and expectations. The involvement of various stakeholders (physicians, patients, and managers) ensures that their needs and concerns are considered in both performance results and technology assessments, improving the acceptance and effectiveness of implemented solutions [51, 62].

A conceptual framework integrating health technology assessment and performance management

Based on the systematization of this evidence, a process can be identified and outlined to enhance the integration of HTA evaluation methods with the continuous monitoring and improvement processes of PM. This integration and the consequent framework, although potentially applicable at the health system level, is relevant mostly at the hospital level, i.e., in the HB-HTA setting.

It begins with thorough stakeholder involvement, forming multidisciplinary committees including clinicians, administrators, patients, and policymakers to comprehensively consider all performance dimensions. This collaborative approach enhances the legitimacy of the objectives and the relevance and applicability of both assessments and performance measurements.

As the PM cycle identifies, through stakeholder engagement, the key objectives that should be addressed by the healthcare organization and hence, considered to be measured; HTA may provide information on how new technologies may contribute to achieve specific goals and how they may impact the overall organizational level – both ex-ante, through feedforward mechanisms such as budgeting (see cluster 1), and ex-post, through feedback coming from performance monitoring. A comprehensive framework may integrate performance metrics by utilizing balanced scorecards and KPIs to actively monitor clinical outcomes, financial performance, patient satisfaction, operational efficiency, and the different pillars of sustainability (see cluster 2). It can facilitate informed decision-making by providing real-time, evidence-based guidance to healthcare providers through decision support systems and interactive dashboards (see cluster 2 and 3).

Based on what is described above, a possible framework can be identified and outlined to enhance the integration of HTA evaluation methods with the continual monitoring and improvement processes of PM at the organizational level (Fig. 6). The conceptual framework was initially developed through insights garnered from the scoping review, accompanied by reflective discussions among the research team. Subsequently, it was further refined based on feedback obtained from scholars participating in internal seminars at the authors’ universities, as well as during a scientific conference on health economics and management in 2023.

Fig. 6.

HTA and PM integration framework

In contemporary healthcare systems and organizations, the pursuit of defined objectives aimed at enhancing overall performance in alignment with established goals, often is challenged by the necessity to integrate novel technologies. The foundational aspect of the conceptual framework presented in Fig. 6 underscores the multifaceted objectives – such as improvements in care quality, operational efficiency, patient satisfaction, cost reduction, and social and environmental sustainability – that healthcare organizations or systems aspire to achieve. To realize these objectives and thus satisfy stakeholders’ needs, the implementation of new technologies – including clinical innovations and sophisticated instruments – may serve as a catalyst for the organization, enabling the achievement of superior performance outcomes.

Evaluating the appropriateness of these technologies is supported by the HTA process, which provides a comprehensive framework to systematically examine clinical, financial, economic, social, ethical, legal, and sustainability impacts. This dual approach fosters that the technology aligns with the objectives outlined in the PM cycle. The ex-ante assessment, conducted through HTA, involves budgeting and comparative analysis within established goals and projected performance metrics, ensuring that selected technologies have the potential to improve performance in alignment with these goals. Once the technology is integrated within the organization, KPIs serve as evaluative tools for an ex-post analysis to verify whether the technology has achieved the anticipated performance and met the objectives.

Following the adoption of a technology, KPIs are used to continuously assess whether it enables the desired level of performance and supports achieving the planned objectives. This ongoing monitoring compares actual performance with initial objectives, thereby determining the effectiveness of the technology across multiple dimensions. The insights gained from this feedback loop inform strategy-makers in setting future objectives and enhance the HTA process by highlighting whether budgeting activities are conducted effectively or if additional factors need consideration.

Such an iterative evaluation process can support ongoing performance monitoring against benchmarks, allowing a comprehensive assessment of the deployed technology’s multidimensional impact. A key aspect of our conceptual framework is the technology lifecycle (illustrated in Fig. 6 as early-stage and mainstream HTA), which reflects the maturity of the technology. Our framework acknowledges that the evidence supporting HTA assessments evolves alongside the technology, shaped by dynamic interactions between HTA and PM. As the technology matures and more multidisciplinary data become available, HTA assessments are increasingly grounded in real-world evidence. Consequently, feedback from PM informs HTA assessments as the technology reaches its mature stages of adoption and diffusion.

In summary, integrating HTA with PM enables an understanding of whether performance aligns with organizational objectives and whether the new technology can support the achievement of these goals. By combining ex-ante assessment of technology’s multidimensional impact prior to implementation with ex-post evaluations of performance post-implementation, we facilitate that technology introduction is both evidence-based and results-oriented, fostering improved performance and goal attainment.

Our conceptual framework also emphasizes the role of real-world data collected during the post-launch phase, especially as technology matures within post-market surveillance of medical devices and advanced biomedical solutions. This focus on real-world data highlights the convergence of HTA and PM, presenting a valuable opportunity for effective implementation of new EU regulations—particularly in non-clinical evaluations. Future developments in our research aim to operationalize this conceptual framework into a practical tool for application at the hospital level. This tool, focusing on the predominant cluster identified in our scoping review—HB-HTA—intends to enhance the integration of HTA within PM activities, promoting transparency and effectiveness in healthcare technology management.

Conclusion

This study sought to examine the link between Health Technology Assessment (HTA) and Performance Measurement (PM). This was accomplished through a literature review of the 33 most relevant scientific publications selected via the PRISMA selection technique and the development of a conceptual framework that has been internally validated.

In a nutshell, the integration between PM and HTA represents a dynamic and synergistic alliance essential for enhancing healthcare sustainability, quality, and value. By integrating HTA methodologies within robust PM frameworks, legislators and healthcare organizations can make evidence-based decisions that help to optimize resource allocation, improve clinical outcomes, and promote patient-centred care.

This study’s limitations primarily stem from the choice of a scoping review methodology, which introduces potential biases related to the research team’s judgments during data extraction, synthesis, and framework conceptualization. These biases may have influenced the development of the framework and its features. Additionally, the developed framework has only undergone internal validation, meaning that its practical utility and adaptability in real-world contexts remain untested. These limitations suggest that while the framework provides a foundation for integrating HTA processes with PM, its implementation may face challenges, such as contextual variations and differing governance structures. Future research could address these limitations by employing methods such as survey or Delphi panels to gather insights directly from healthcare organizations in various settings, potentially revealing context-specific practices and challenges. In addition, incorporating grey literature, such as national and hospital guidelines, could further enhance the framework’s relevance and applicability. Moreover, validating the conceptual framework across various governance levels, including health systems and hospitals could strengthen its generalizability. Finaly, further studies might explore the integration between HTA and PM within real-world empirical cases, which could provide valuable insights into the practical challenges and opportunities of implementing integration strategies for PM and HTA, ensuring the framework is both robust and operationally feasible.

Authors’ contributions

A.E.O. Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Software; Validation; Visualization; Writing-original draft. F.D.D. Conceptualization; Methodology; Project administration; Resources; Supervision; Visualization; Writing - original draft; Writing - review & editing. G.N. Conceptualization; Methodology; Project administration; Resources; Supervision; Visualization; Writing - original draft; Writing - review & editing. S.M. Supervision; Writing - original draft; Writing - review & editing. All authors read, reviewed and approved the final manuscript.

Funding

Not applicable.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.