Improving the quality of healthcare through the best scientific evidence available in a context of scarce resources is a challenge for health systems . Health technology assessment (HTA) is a multidisciplinary field of applied research aimed at providing high-quality information about the clinical effectiveness, cost-effectiveness, and broader impact of drugs, medical technologies, and health interventions in order to support and inform those who make decisions about health policy and purchasing, health services organisation and management, and clinical practices [2, 3]. In Canada, the Canadian Agency for Drugs and Technologies in Health (CADTH), and provincial agencies, such as the Agence d'évaluation des technologies et des modes d'intervention en santé (AETMIS) in Quebec, are responsible for conducting health technology assessments at a macroscopic level. However, HTA recommendations are seldom transferred into decisions and practices . In order to favour knowledge transfer and to support evidence-based decision making at both mesoscopic and microscopic levels, local HTA units have been implemented in all five university hospitals in Quebec. The implementation of these local HTA units is viewed as a strategy to improve the relevance and timeliness of HTA recommendations and, ultimately, to facilitate their uptake . This implementation could thus favour a culture of evaluation in university hospitals, which is coherent with the promotion and uptake of effective healthcare decisions.
Effective healthcare decisions are more and more conceptualised as the best course of action given the current scientific evidence, healthcare resources, clinical circumstances, and patient preferences . With the increased emphasis on the engagement of patients as full partners in their care, there is a need to determine effective ways to involve them in the decision process [7, 8]. It is expected that the need for "patient guidance will only increase as clinical options multiply and the world of information continues its rapid growth" . This is congruent with the fact that several HTA agencies and academics associated with HTA are now considering ways to incorporate the perspectives of patients in their methods, thus calling for patient-centred HTA [10, 11].
The literature proposes different terms to refer to the various groups of end-users of HTA, such as patients, consumers, citizens and public. There is a lack of terminological consensus with the term public involvement. The analysis by Gauvin  identified six publics that he grouped into two categories. Publics "whose role is to provide a societal or lay perspective about health technologies" constitute the first category that includes citizens, groups representing citizens, and other representatives such as elected officials. The second category consists of "those publics directly affected by a given health condition or health technology" and includes individual patients, services users, and the entities representing them . According to Cayton , these two categories could be considered as the two sides of the same coin because they represent different roles individuals could take when they engage with health services. However, according to Gauvin , most experts in HTA believe that the broader perspective of citizen is more likely to be involved in the organizational and policy-making domains and the perspective of patients and service users in the research domain. In this last domain, patients and service users are better positioned to highlight matters relevant to service users such as social and ethical consideration, patient acceptance of the technology, and psychological implications. In this study, we are interested mainly by patients because they are the group most directly affected by HTA decisions, and their unique insight can most usefully contribute to the HTA process. They could provide 'experiential' evidence to the HTA process . We include members of the public (i.e citizens) in our literature review because of their role in some HTA activities and given the lack of terminology consensus about these terms. However, the other stages of the project are focusing more precisely on the patients.
The value of an increased participation of patients in healthcare decisions is now recognised and leads decision makers to consider effective ways or strategies to incorporate patients' perspectives in decision making processes.
Gaps in knowledge this study is addressing
Although opportunities to favour patient participation in HTA activities are increasingly considered [11, 15], few experiences of patient involvement in HTA appear to be reported in the literature . Furthermore, these experiences mostly concern national HTA agencies, such as NICE and NCCHTA in England [17, 18] and DACEHTA in Denmark . Also, few studies have examined the participation of patients, consumers, or the general public in priority setting regarding health technologies [20–22]. To the best of our knowledge, patient involvement in university hospital-based HTA units has not been studied yet. According to a survey among Canadian health consumer groups representing various diseases or conditions, respondents reported a desire for greater involvement in HTA, and provided feedback on mechanisms for facilitating their participation . The HTA program of the Alberta Heritage Foundation for Medical Research in Canada has identified a need for greater public involvement in its strategic planning, particularly for the identification of potential topics of investigation . Other countries, such as England  and Denmark , have also suggested increased citizen and patient participation in HTA.
However, several gaps in knowledge remain in order to support the implication of patients in HTA. These gaps concern, for instance, the willingness of patients and members of the public to be involved in healthcare decisions, including the nature of their involvement , the attitude of healthcare professionals regarding patient involvement [26–28] and the absence of proven effective strategies to guide their implication [29, 30].
Goal, objectives and conceptual framework
The aim of this project is to explore how the patient perspective could be introduced into the structures and activities of a local HTA unit. To do so, three objectives are proposed: 1 – To synthesise international knowledge and experiences on patient and public involvement in HTA activities; 2 – To explore the perceptions of stakeholders (administrators, clinical managers, health professionals, HTA producers, and patients) regarding patient participation in the various HTA activities, effective strategies to support their participation, as well as barriers and facilitators to this participation; and 3 – To produce a consensual framework to guide interventions supporting patient participation in HTA activities at the local level. The research will use analytical frameworks developed in the field of patient involvement in clinical decision making [31, 32] and public participation in research and HTA activities [11, 12, 23, 33] for each objective of the research.