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Abstract
Objectives To systematically review academic literature for studies on any processes, procedures, methods or approaches to purchasing high-cost medical devices and equipment within hospitals in high-income countries.
Methods On 13 August 2020, we searched the following from inception: Cost-Effectiveness Analysis Registry, EconLit and ProQuest Dissertations & Theses A&I via ProQuest, Embase, MEDLINE, and MEDLINE in Process via Ovid SP, Google and Google Scholar, Health Management and Policy Database via Ovid SP, IEEE Xplore Digital Library, International HTA Database, NHS EED via CRD Web, Science Citation Index-Expanded, Conference Proceedings Citation Index-Science, and Emerging Sources Citation Index via Web of Science, Scopus, and Zetoc conference search. Studies were included if they described the approach to purchasing (also known as procurement or acquisition) of high-cost medical devices and/or equipment conducted within hospitals in high-income countries between 2000 and 2020. Studies were screened, data extracted and results summarised in tables under themes identified.
Results Of 9437 records, 24 were included, based in 12 different countries and covering equipment types including surgical robots, medical imaging equipment, defibrillators and orthopaedic implants. We found heterogeneity in methods and approaches; including descriptions of processes taking place within or across hospitals (n=14), out of which three reported cost savings; empirical studies in which hospital records or participant data were analysed (n=8), and evaluations or pilots of proposed purchasing processes (n=2). Studies emphasise the importance of balancing technical, financial, safety and clinical requirements for device selection through multidisciplinary involvement (especially clinical engineers and clinicians) in decision-making, and the potential of increasing evidence-based purchasing decisions using approaches such as hospital-based health technology assessments, ergonomics and device ‘user trials’.
Conclusions We highlight the need for more empirical work that evaluates purchasing approaches or interventions, and greater specificity in study reporting (eg, equipment type, evaluation outcomes) to build the evidence base required to influence policy and practice for medical equipment purchasing.
Protocol registration This review was registered in Open Science Framework: Shokraneh F, Hinrichs-Krapels S, Chalkidou A et al. Purchasing high-cost medical equipment in hospitals in OECD countries: A systematic review. Open Science Framework 2021; doi:10.17605/OSF.IO/GTXN8. Available at: https://osf.io/gtxn8/ (accessed 12 February 2022).
- biotechnology & bioinformatics
- health services administration & management
- health economics
- information management
- organisation of health services
Data availability statement
No data are available. All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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- biotechnology & bioinformatics
- health services administration & management
- health economics
- information management
- organisation of health services
Strengths and limitations of this study
Broad databases searched covering a comprehensive range of disciplines and study types.
Limited to high-cost equipment which is challenging to differentiate across studies and has no standardised ‘value’ globally.
Quality assessments of articles not conducted due to heterogeneity of study types.
Introduction
Context
The World Health Organization (WHO) has emphasised the essential role of medical devices and equipment for maintaining health system performance.1 Inadequate selection and distribution of technologies can create inefficiencies and waste,2 or create risks to the quality of health services, as experienced in the recent COVID-19 pandemic.3 4 To avoid these risks, there are design guidelines to ensure the safety of medical devices,5 as well as regulatory requirements to ensure devices are safe enough for the market. Following these steps, devices may be evaluated to understand their impacts in specific healthcare contexts and compared against available alternatives, which encompass the field of health technology assessment (HTA).6 However, there has been less attention paid to the next steps: acquiring, purchasing or procurement of these devices and equipment by the health system.
Medical device and equipment purchasing, more comprehensively known as procurement, goes beyond basic contracting between the supplier and health provider; it requires consideration of user needs, technical maintenance, training needs, adequate consumables and how they can be disposed. Despite the potential role purchasing processes play in promoting patient safety7 and efficiency,8 studies suggest they are not optimised for efficiency and quality. For example, a study comparing medical device purchasing across five countries found that there is more focus on cost containment, and less on quality and health outcomes.9 Empirical studies of purchasers in UK hospitals have shown that there are a wide range of stakeholders potentially involved in purchasing decisions (from clinicians, nurses, biomedical engineers, finance staff and/or managers), but their responsibilities and protocols are ill-defined, their skills and expertise differ,10 they often work in silos, and make decisions under high-pressure condition.11 Furthermore, the lack of stakeholder analysis as part of purchasing planning processes can result in conflicts and delays in decisions.12 A recent scoping literature review of the logistics function in hospitals demonstrated that these functions can be highly inefficient and fragmented.13
Need for this review
Understanding purchasing processes can help us uncover why these inefficiencies and tensions exist, by exploring the inner workings of the environment, protocols, behaviours and organisation of purchasing staff and their departments, and thereby identifying areas for improved practices. In this review, we sought to identify studies that specifically focus on the purchasing of high-cost medical equipment in hospitals in high-income settings. Specifically, this meant identifying any process, procedure, method or approach used within a hospital to reach decisions about which equipment would be purchased. While there are reviews of good practice in purchasing and supply chain management and their applications in healthcare settings generally,14 15 to our knowledge there are no specific reviews that demonstrate existing approaches, practices and methods used for purchasing of medical devices and equipment in hospitals specifically in high-income settings - to show what works now in practice. The most similar existing reviews that we found so far include a review of methods for procurement of medical devices and equipment focusing exclusively on low- and middle-income countries,16 a realist review of theoretical and empirical literature on procurement and supply chain management practices more generally14 and a rapid evidence assessment of literature with lessons from the non-health sector to inform health purchasing and supply chain management.15 None of these systematically searched for academic studies that focused on the internal workings of a hospital to identify current practices and understand purchasing behaviours, processes and approaches. Two exceptions which do cover activities within hospitals, but with a different scope, are the review by Volland et al17 which examined studies covering materials management and logistics in hospitals, but with a focus on quantitative methods, and Trindade et al which focused on the qualitative assessment of devices, not the process of procurement as a whole.18
Objective and scope of the review
Our research question in this review is framed as: What does the academic literature tell us about the way in which high-cost equipment is purchased in hospitals in high-income settings?
Our review focuses on the steps in hospitals that occur after any HTA exercise, whether it was national-based or hospital-based HTA (sometimes referred to as ‘mini’-HTA). Medical device and equipment purchasing sits within other activities in hospitals, including: health technology management, materials management, supply chain and logistics. Our focus is on what is commonly termed the acquisition process, which begins the moment the need for a new or replacement device or equipment is identified, before the moment it is installed and ready for operation (figure 1). For a comprehensive view of how the medical device and equipment purchasing function of a hospital fits within its wider activities, we refer readers to the WHO procurement process guide.19
Overview of steps involved in purchasing medical devices and equipment (focus of this review in dashed lines). Items in each step taken from WHO procurement process guide.19
Method
We followed Cochrane Collaboration’s methods in conducting this systematic review20 and complied with Preferred Reporting Items for Systematic Reviews and Meta-Analyses.21 The full protocol for this systematic review is published elsewhere22 and summarised below.
Search methods
On 13 August 2020, we searched the following from inception: Cost-Effectiveness Analysis Registry, EconLit and ProQuest Dissertations & Theses A&I via ProQuest, Embase, MEDLINE, and MEDLINE in Process via Ovid SP, Google and Google Scholar, Health Management and Policy Database via Ovid SP, IEEE Xplore Digital Library, International HTA Database, NHS EED via CRD Web, Science Citation Index-Expanded, Conference Proceedings Citation Index-Science, and Emerging Sources Citation Index via Web of Science, Scopus and Zetoc conference search. An information scientist designed, tested, revised and ran the searches in collaboration with the review team. The search consisted of three main blocks of setting, product and process. All search strategies for all sources are reported in online supplemental appendix 1.
Supplemental material
Eligibility criteria
We included the studies if they met the following criteria:
Process: The study describes the process for the purchase (also known as procurement or acquisition) of high-cost medical devices and/or equipment.
Setting: The study setting is one or more hospitals or departments within the hospital(s) in high-income countries (using Organisation for Economic Co-operation and Development (OECD) countries as a proxy indicator for high income).
Practice: Studies conducted between 2000 and 2020 to represent ‘current’ processes reported in hospitals. Studies not explicitly demonstrating influence on purchasing decisions or theoretical models not assessed, piloted nor evaluated within hospital settings were excluded.
Product: The purchased product is a single or a group of high-cost (also known as high value or capital) medical devices or equipment, as stated in the study. Studies that did not specify the type of equipment studied (and therefore no assessment could be made on whether it referred to high-cost equipment) were excluded. Studies that used a general term to describe the studied equipment (eg, ‘cardiology equipment’) with no specificity were excluded, unless authors referred to the equipment in their study as ‘capital’ or ‘high-cost’ equipment.
Studies that did specify the type of equipment studied, but did not explicitly state they referred to ‘capital’ or ‘high’-cost equipment, were deemed eligible according to the following criteria:
Studies in which capital equipment was purchased as part of a larger process which included some lower cost equipment (eg, buying an examination table as well as higher cost scanners) were included, if it could be ascertained that the findings related to the purchase of high-cost equipment. If this could not be ascertained, the study was excluded.
Single-use devices were excluded as they were assumed to be lower cost.
Bulk or high-volume purchases were assumed to be low-cost devices/equipment and were excluded. In all cases we could not discern if the results related specifically to high-cost equipment, confirming above exclusion criterion.
Device and equipment that could be considered ‘mid-range cost’ (eg, laryngoscopes, or different types of implants) were discussed among the review team. This was necessary for items that were not of very high cost (which tended to include equipment over £5000 in the UK cases which is considered a ‘capital’ purchase), nor low-cost devices such as thermometers. If no consensus was reached, advice was sought from a group of five practitioners (biomedical and clinical engineers with purchasing and maintenance responsibilities in hospitals in the UK and The Netherlands) to assess their eligibility. These practitioners discerned whether or not the equipment would go through similar purchasing decision-making processes as the very high-cost equipment, and, if so, the equipment was considered high-cost and the study included.
Study selection
We used EndNote to remove the duplicates and Rayyan for screening the titles and abstracts. Two independent reviewers piloted the screening based on eligibility criteria before conducting sensitive screening. Two independent reviewers rescreened these relevant/possibly relevant records from sensitive screening and resolved the disagreements in fortnightly group meetings. We followed dual screening and arbitration by a third reviewer for the full text screening step. We recorded and reported the reasons for exclusion for any excluded paper at full text stage (figure 2).
Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart (adapted from Page et al21 . *We contacted the authors and tried interlibrary loan before giving up on retrieving the full texts. HTA, health technology assessment; OECD, Organisation for Economic Co-operation and Development.
Data extraction
We designed and tested the data extraction form in a spreadsheet shared via Google Sheets to enter: year in which the study was published, country in which the study took place, number of hospitals included in the study, type of high-cost equipment that is the subject of the study (if specified), purchasing process, approach or method outlined in the study (‘intervention’), outcomes, lessons and/or recommendations emerging from the study, research method adopted in the study, limitations of the study as reported by the study authors. One reviewer extracted the information from each study, and the work was double-checked and, if necessary, completed by another reviewer. Any questions were discussed in the fortnightly meetings.
Data synthesis
We summarised the information from the literature in tables and lists. Because of heterogeneity of study designs across the small number of included studies, we did not conduct any quality assessment of the included studies; however, we reported the limitations listed by the researchers for their study.
Protocol registration
This review was registered in Open Science Framework.23
Results
Out of an initial 9437 retrieved records, 24 studies were selected for inclusion (shown in tables 1–3). These included research articles (n=21), PhD/Masters theses (n=2) and one book chapter. Countries in which the hospitals were based for these studies were USA (n=10), UK (n=7), Italy (n=2), Mexico (n=2), Canada (n=2) and one from Australia, Greece, Switzerland, Germany, Netherlands and Scotland, including cross-country comparisons. Most studies were conducted in one hospital, with a few reporting work across 2–44 hospitals. The types of equipment that were the focus of these studies ranged from orthopaedic implants, to diagnostic laboratory equipment, and larger investments such as MRI scanners and surgical robots. We identified a diversity of disciplines represented by the journals where these studies were published, reflecting the diversity in how the subject of purchasing high-cost medical equipment is addressed in academic work. Study types included descriptions of processes taking place within or across hospitals (n=14, table 1), which had no formal evaluations but three of which reported cost savings; empirical studies in which hospital records or participant data were analysed (n=8, table 2), and evaluations or pilots of proposed purchasing processes (n=2, table 3).
Included studies under study type ‘descriptions of processes taking place within or across hospitals’ (n=14)
Included studies under study type ‘empirical studies in which hospital records or participant data were analysed’ (n=8)
Included studies under study type ‘evaluations or pilots of proposed purchasing processes’ (n=2)
Although excluded in our own review during full text filtering, we had identified 20 studies that combined hospital-based HTAs or other assessment methods with decision criteria directed towards a purchasing decision, which we had to exclude because of their lack of clarity on whether these methods had direct influence on the purchasing process or final decision itself within a hospital context. These were not deemed eligible according to our inclusion criteria. Examples include Juřičková and Kraina using value engineering and multicriteria methods,24 Girginer et al using analytical hierarchy methods25 and Hospodkov et al using hospital-based HTA.26
Key findings from studies
The two most prominent elements of purchasing processes identified across most of the included studies were (a) the roles of various stakeholders involved, and (b) the approaches to balancing technical, financial and clinical requirements.
Stakeholders and teams involved
Table 4 shows the involvement of roles in the procurement process as mentioned in the included studies, representing a combination of roles either involved in the studies themselves, and in the project teams observed in the studies. The studies reviewed were specific and emphatic about the importance of stakeholders as part of the decision-making process, specifying who exactly should be involved and how. Two stakeholder groups in particular were emphasised: clinicians and the clinical engineers, sometimes explicitly as the sole focus of the study, and at other times mentioned implicitly as part of the process. Greenwood et al reported on how the role of the clinical engineer in a children’s hospital in Canada progressed from a primary responsibility in equipment maintenance to health technology management more generally.27 Madhlambudzi and Papanagnou studied the involvement and salience of several stakeholders in purchasing of diagnostic equipment and found that hospitals fail to identify key stakeholders resulting in possible delays and conflicts.12 Haas et al concluded that a hospital committee resulted in lower purchasing prices than when physicians selected vendors directly in a study of the selection of prosthetic implants.28 However, committees are not flawless; Licona et al described a case study to demonstrate involvement of an interdisciplinary network of professionals in health technology management: despite the involved network several anomalies were identified such as uncertainty of who would install equipment after a bidding process.29
Stakeholders involved in purchasing processes as identified in the studies
Although not always the primary focus of the study, it was made explicit that some form of approach that unifies how various purchasing stakeholders come together is important: Langenburg et al, for instance, describe their new process as developing a ‘vision’ with paediatric surgeons, research director, a biomedical engineer and a physicist and the hospital chief executive officer, to collaboratively (with industry partners) develop a short-term and long-term education, research and education plan for robotic surgery.30 Haselkorn et al also described the importance of an organisational culture as a crucial component for success in the procurement process.31 Regardless of it being a cultural or difference in vision, fundamental differences in purchasing projects can be identified. Finally, one study specifically elicited challenges and barriers to effective purchasing: Kuper et al identified barriers to procurement and implementation of oesophageal Doppler monitoring in three UK hospitals, noting that silo budgeting and scepticism about new products challenged investment decisions, which were overcome by ‘championing’ the technology via clinicians while providing evidence of the potential benefits of the proposed technology.32
Evaluating technical, financial and clinical requirements
The procurement of high-cost, often specialised, medical equipment requires balancing technical, financial and clinical requirements. In some studies, this balancing process was emphasised, but no formalised approaches were followed to achieve it. For example, Langenburg et al described a programme combining technical, financial and clinical criteria condensed in a training, implementation and development programme for surgical robotics, and found that cooperation of surgeons, staff and a corporate partner was key to the development of a successful new programme (eg, within 1 year minimally invasive surgery on a patient is performed).30 Nisbet and Ward describe a process in which financial and technical considerations were taken into account to decide on whether to lease or purchase radiotherapy equipment.33 Li et al ranked the factors that influence purchasing decisions and demonstrated that clinical evidence and cost-effectiveness are more important than personal preference, regardless of the stakeholder role.34 Another example of combining multiple disciplines in order to successfully reduce costs is implementing a value-based process.35–37
More formalised approaches to balance these requirements included user trials and hospital-based HTA. Pandit et al describe a working party set up nationally to advise on how to set up a ‘trial’ specifically for airway devices and guides hospital in implementation of this trial together with the company (who sponsors it); results published for other hospitals and results in final purchase.38 The notion of more information or ‘evidence’ to inform selection is reported in different ways. Satta et al conducted ‘user trials’ for 10 months to test each ophthalmic surgery femtosecond laser in real-life settings before selecting a supplier.39 Other studies reported on the role of hospital-based HTA as a means to bring evidence into decisions. Mitchell et al describe how hospital-based HTA provides more reliable data to the selection process by including local data when there is too little peer-reviewed evidence.40 According to the study by Callea et al, hospital-based HTAs turn out to serve mainly as a cost containment tool in the selection process while at the same time hospitals using this method are found to pay actually 8.3% more for the same equipment.41
Additional findings: managing the procurement process and supplier relationships
In this section, we report on approaches and processes identified less frequently across the included studies. Less prominent approaches and processes identified in the studies included the need for strategic and long-term planning, streamlining management processes, varied approaches to the tendering process and relationships with suppliers. Greenwood et al described a system in which clinical engineers adopt the role of a long-term manager for health technology using three long-term planning variants (eg, theoretical replacement, emerging technology and fleet equipment), resulting in an improvement in safety and continuation of clinician acceptance.27 A suggestion to streamline the management process is the implementation of a management information system described by Larios et al,42 where necessary information for specification and selection of medical equipment can be documented and it is found to improve timeliness, procedural efficiency, consistency and information integration. For the development of new programmes a business plan is essential, according to two studies,30 31 and proper planning and management can result in prevention of unnecessary buying according to Verma and Peacock.43 With regard to tendering, Satta et al described a process in which stringent specifications were laid out in a tender specification for an ophthalmic surgery femtosecond laser, but note the disadvantage that their whole process of laying such specific specifications and conducting trials took about 4 years.39 Licona et al describe several iterations in the specification process to avoid last minute changes, and discuss that stringent specifications may lead to the selection of products with the lowest technical and qualitative requirements.29 In another study, less stringent tender specifications actually showed to lead to substantial cost savings: instead, an iterative negotiation process with multiple vendors after a broad request for proposals led to an aggressive form of competition with varying strategies to form a solution.44 Finally, there appears to be a reciprocity between industry and hospitals: as clinical trials with equipment have the potential to deliver evidence of functionality for devices, healthcare and industry are incentivised to cooperate in creating and obtaining this evidence.38
Discussion
In this systematic review we sought to identify studies that focus on approaches to purchasing of high-cost medical equipment in hospitals in high-income countries (using OECD countries as a proxy indicator for higher income). Given the heterogeneity of study designs considered in this review, we did not apply formal quality rating system to the studies, and did not seek to find examples of ‘best’ practices, but rather attempt to identify and describe any empirical work conducted in hospital environments focusing on purchasing processes, to characterise the nature of the academic literature on this topic and types of approaches or interventions reported.
Limitations of this review
We note in our introduction that this review fulfils a gap in current academic literature, which is the evidence on empirical work conducted in hospitals for purchasing medical devices and equipment. We only partly fill this gap because our review is limited to ‘high-cost’ equipment and to high-income countries, resulting in a limited picture of the purchase of other materials, supplies and devices in hospitals in a variety of contexts. Our main reasoning for this is the very different nature of processes and financial accounting for higher cost equipment in hospitals compared with lower cost devices, consumables and other supplies, which helped give a specific focus to our study. However, we note that studies that did not specify whether they were dealing with high-cost or low-cost equipment were excluded (n=47 during full text review), although some important insights could have been drawn from these.
Overall, we found the distinction between high cost and low cost extremely challenging and consulted expert practitioners involved in hospital purchasing to advise on an appropriate demarcation, and checked for conflicts in inclusion decisions across the review team. These consultations with practitioners highlighted two further issues: first, investment decisions do not only account for the single price of a product, but might be creating a contract of high value through bulk purchases of lower priced devices, which means that the process of purchasing a lower cost item, if bought as a larger contract, might be similar. Second, the single cost purchase of equipment is not always the main factor in deciding which purchasing process takes place, but rather, whether or not the item has implications for full life-cycle costing in terms of maintenance, repair and decommissioning in the hospital’s accounts. Items, for example, that are of very high value, but are given to the patient to use in a home or community setting, would not fall in the hospital’s budget line. Despite these limitations, through consultation with our expert practitioners we concluded that these specific demarcations can vary between hospitals within and across countries, and the themes derived from our review are still helpful indications of how these internal hospital processes work for the items we did include.
Conference papers in the field of operations management and supply chains can provide useful insights into current innovations in the field. We did include them if the full text was available for review, but had to exclude those with only abstracts available. We note that we excluded studies not written in English (about 40 studies post-2000) which might have included important lessons of practice and research conducted in various global settings. During our first exclusion step (abstract/title) we came across many articles written by professional and academic experts, with no reported empirical work, but potentially extremely useful experiences to inform future practice. As our study was limited to academic research, these were excluded but could provide the basis for a future targeted review of professional practice. We note that time will have elapsed between the date of our search and time of publication: while we note that the paucity of studies in this area may not have resulted in hugely different conclusions, we still recommend any further studies and similar searches to keep our search dates in mind. Finally, we defined the scope of this review to start when the need for equipment is identified. We note that this leaves out a major factor of influence to the technology management process: how the need is identified, which can influence cost containment and risk assessment further down in the procurement process.
Limitations of the reviewed studies: the nature of ‘evidence’ in this field
The motivation for conducting this review stemmed from an initial scoping search for literature on how different disciplines and researchers approach the subject of purchasing in hospitals. We sought empirical work (broadened to include single-case studies) in order to provide an overview of the current evidence base for approaches to purchasing of high-cost medical equipment in hospitals. However, only two studies included any form of evaluation of their ‘purchasing process’ intervention, including one which was a pilot study based on the model developed in the study. The majority of the studies described the purchasing process in the hospital and reported outcomes such as cost savings, but did not fully report how these outcomes were assessed. We concluded that there is not yet a solid ‘evidence base’ for how to improve the process of purchasing. Conscious that we make this conclusion for studies only of high-cost medical equipment, we propose that more research that encompasses a variety of health technologies in intramural care settings can begin to provide a more comprehensive evidence base. Despite our limited focus, however, our conclusions echo those made by previous studies. A review of non-health approaches to purchasing and supply chain management literature noted that empirical work was limited, and studies ‘frequently fail to assess (or describe) the robustness of their methodological approaches when linking interventions with outcomes, such as cost savings or improved performance’.15
Conducting strong empirical work in this domain can be challenging: the theories, frameworks and methodologies necessary to address the organisational domain of healthcare (of which purchasing is one component) need to be drawn from fields such as operations research, economics and supply chain management, and include approaches such as decision theory, and systems and design approaches. This presents challenges: first, the fields of purchasing and supply chain management, for example, have in itself been criticised for the lack of strong empirical work45 and poor quality of theoretical development and discussion, and coherence,46 and second, the application of design and systems approaches in real healthcare settings has also been limited, exemplified by a recent systematic review of application of systems approaches in healthcare.47 A recent review on logistical parameters within international research on hospitals noted that ‘the international literature does not, by definition, reflect what really happens in hospitals’.13 Generally, it has been noted that evidence-based management (if we consider procurement processes to fall under a hospital’s management) in healthcare is not yet commonplace and takes various forms.48
Implications for practice: lessons learnt for hospital purchasing
Despite the limitations discussed above, there are some repeating actions identified in our studies that have implications for practice. Specifically, the necessity of bringing together a skilled multidisciplinary team for large investment items is highlighted across most of the studies as the key ‘intervention’ for their purchasing process. We recognise these are not conclusions made based on evaluations, but their prominence in reporting this as a key feature merits its mention. Specifically, the role of the clinician in some form of committee or decision team is emphasised, as well as the clinical engineering team as a genuine stakeholder in the final decision. Studies conducted elsewhere on lower value equipment have also highlighted the role of the clinical engineer, and the WHO’s technical series on medical device procurement specifically mentions clinical engineers as the primary role for health technology management in hospitals.49 But how seriously this role is taken when it comes to the final investment decision remains unknown in practice and in the academic literature.
The second most prominent theme across the studies is the importance of balancing technical, financial and clinical requirements, specifically by using some formalised method for this assessment. This could be implemented through user trials to gather the necessary evidence on device performance, literature reviews or indeed through a formal hospital-based HTA process. However, we note from some of the other studies we came across on the emergence and progress of hospital-based HTA that there is limited evidence on whether or not these processes end up influencing investment or purchasing decisions (see, for example, Gagnon50 and Almeida et al51), and research suggests that there has been a low to moderate use of economic frameworks or value-oriented decisions in local hospital technology decision-making.52 So while it is not yet clear if such formalised methods are influencing better purchasing decisions, the studies we reviewed imply that some approach to do this is necessary, and this is also a way of incorporating the different expertise from multiple stakeholders in a hospital.
Implications for future research
Based on the limitations and implications discussed above, we recommend where research is needed to improve the evidence base for improving medical equipment purchasing decisions in hospitals. First, the demarcation challenges identified earlier (in our case, between high-cost and low-cost equipment) highlight the importance of encouraging specificity in studies pertaining to any management of technology in hospitals in future research. Some studies simply mention ‘supplies’ or ‘materials’ or ‘technology’ or ‘equipment’, and are insufficient to glean best practices and to ascertain how the lessons learnt from the studies can be applied in both future research and practice. Specificity can also help create other ways of investigating the processes for different types of hospital purchases: in practice, many materials and supplies tend to involve different processes simply depending on their cost (and not unit cost, but cost of the whole purchase contract). Future studies could also investigate how creating processes differentiated by risk (or patient safety or criticality) rather than cost would affect the effectiveness of the purchasing processes in supporting clinical needs. Second, it would be worth investigating the increase in assessment and evaluation methods (such as hospital-based HTA and human factors engineering), and how this connects and affects the ultimate purchasing decision. Connecting hospital-based HTA to final hospital investments in particular has been shown to be limited, the research challenge would be to investigate why this is so, and whether and how barriers need to be overcome to enable more evidence-informed hospital purchases. Further, we feel there could be other future reviews that would provide additional insights in the literature: for example, a targeted search on experiences derived from expert practitioners in the field, which can be found from grey literature, as well as a scoping review of all studies relating to health technology purchasing in general (including high- and low- cost devices, equipment and supplies). Finally, we challenge the research community to increase the evaluation of interventions within hospital’s organisational domain, explore the application of theories from different disciplines (including, but not limited to, operations research, engineering design, systems theory and decision theory) in this domain and use future empirical work in hospital settings to further inform the theoretical advances back into those disciplines.
Conclusions
In this review, we sought to identify studies that focus on the purchasing of high-cost medical equipment in hospitals in high-income countries. Our 24 included studies point to the importance of multidisciplinary involvement (especially clinical engineers and clinicians) in purchasing decision-making to balance technical, financial, safety and clinical aspects of device selection, and highlight the potential of increasing evidence-informed purchasing decisions using approaches such as hospital-based HTAs or conducting user ‘trials’ of the device in use before purchase. Our recommendation for future research is to have increased specificity in the types of materials, devices or equipment being studied and reported, given that the diversity of such purchases with and across hospitals globally means lessons learnt in one setting will be challenging to transfer to other settings. Alongside this, we advocate for more intervention-based and empirical work in hospital settings and evaluations to advance the evidence base in this domain.
Data availability statement
No data are available. All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Acknowledgments
We are grateful to the expert practitioners working in hospital purchasing who provided guidance and advice during this project.
References
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Twitter @sabziehin, @FarhadShokrane
Contributors FS and SHK drafted the protocol. HB, BD, AC and JE commented on the draft protocol. FS and JE piloted the title and abstract screening stage for the first 500 records. FS completed the first round of screening. SHK, HB and AC screened the Included and Maybe folders. SHK made the final decisions when disagreements continued. FS, HB and BD extracted the data and SHK double-checked and completed the extracted data when needed. SHK and BD summarised the results and drafted the final report. All authors read, commented, revised and approved the final manuscript before submission. SHK is responsible for the overall content as the guarantor.
Funding This project was initially funded through an internal grant from King’s College London awarded to SHK, and later subsidised through the internal grant for the Delft Technology Fellowship awarded to SHK.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.