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D.M. D.E. W.: The Impact of Health Technology Assessment
D.M. D.E. W.: The Impact of Health Technology Assessment
.Iffuslon
. Evolution Obso lescence
jNNOVATORS
Phase in
OPFRATORS Initial use useof ___
competing
technology
Initial
ASSESSORS efficacy/ trials. More competing
cost data
A key to all h i s activity is evolution of the It is in this complex environment that the
place of the technology in the health care evaluator has to obtain data from innovators and
system over a period of time. This is a dynamic, operators, and seek to influence these groups, and
complex process involving a number of players. government and professional bodies, through
Figure 1 depicts the activities of major sectors analysis and recommendations.
at different points in the cycle. These sectors The process of assessment implies the
might include innovators (typically industry and presence or generation of reasonable data on the
university groups), operators (medical technology in question. Methods available for
profession, hospitals), assessors (agency, gathering data will depend on resources available,
academic and professional groups) and funding the nature of the technology and the setting in
bodies (governments, insurance agencies). Each which it is to be used. Often the most useful
group will undertake different activities as the information will be primary data collection that is
technology matures. There will be the hope of relevant to the local health care system. Typically,
interaction between them in the form of useful it is difficult to secure adequate levels of funding
exchange of information. to support data collection on a range of
Each group will of course have different technologies. Other problems may include
agendas. Innovators will wish to market as reluctance of some participants in the health care
quickly and widely as possible. Operators will system to co-operate in trials. and biases in
seek to provide improved health care, with interpretation.
appropriate reimbursement. Funding agencies Technical problems of health technology
will wish to protect limited budgets and seek assessment may be severe. The most powerful
evidence of overall cost savings and benefits. methods of primary data collection and analysis
Some innovations may evolve very rapidly in a may need major resources and be technically and
technical sense, putting further strains on the logistically difficult. Typically, collection of
funding, assimilation and assessment pro- sufficient data to permit a statistically strong hid
cesses. of a technology will take some time. The ideal of
- Health authorities
ASSIMILATION - insurers
- Medical profession
- Funding decisions
ACTION - Licensing
- Change in clinical practice
4-7 REVIEW
level of usage and potential for inappropriate compatible with the views of those with interests
use; in the health technology under consideration. For
whether the technology has already been example, some proponents of bone mineral
adequately assessed by another organisation; assessment as an aid to the management of
and osteoporosis have advocated more extensive
whether an assessment would be likely to usage than that recommended by the Panel.
influence future deployment and usage of the The topics considered so far in publications by
technology. NHTAP and its committees are summarised in
Table 1. At the time of writing twenty-four
Decisions on whether to und.ertake an technologies had been assessed in thirty-five
assessment of a technology have also been reports, plus a consensus statement. A review
influenced by the state of development of the published separately by AIH in 1989 was intended
technology and the possibility of significant to complement an NHTAP study.' Requests for
further advances, safety considerations, and assessment of technologies were obtained most
implications if its introduction is delayed or a new frequently from the Commonwealth Department.
use not approved. with smaller numbers from the States, professional
Assessments undertaken by the Panel resemble bodies and industry. In seven cases, NHTAP
those of the OTA and the U.S. Office of Health initiated the assessment itself.
Technology Assessment in that they represent a When the twenty technologies assessed up to
synthesis of available information, drawing on the end of 1988 are considered, in eleven instances
published literature, expert opinion and work in the NHTAP reports appear to have had a
progress in industrial, academic and clinical significant influence m the short- to medium-term.
organisations. Each of the Panel's reports has on the basis of acceptance of major
typically included technical, clinical and cost recommendations and subsequent government or
appraisal of a technology. Attention has also been other action. In a further three instances there was
given to woikforce. safety and social issues, probably some influence on short-term decisions
though not in the sense of comprehensive analysis. although some recommendations have yet to be
There has been an emphasis on consultation with implemented. Sixteen of the NHTAP reports,
professional and industrial organisations, and as including three where the recommendations had
far as possible each published assessment no obvious short-term effect. have proved useful
represents a consensus position. as source and educational material. as judged by
Inevitably, the consensus reached by the varied requests received by the NHTAP secretariat and
representation on the Panel is not always wholly citations in the literature.
1. MRImaging mA
P 83.84.87 YeS YeS
88,89.89 plus
consensus statement
2. Medical cyclotrons Ministn 84.85 YeS YeS
3. NMRspecmscopy mA P 85 - YeS
4. ESWL(renal) DCSH 85.87 YeS YeS
5. EsWL(biliary) m
AP 88 YeS YeS
6. Lasersinmdcine NKMRC 86 - YeS
7. Lasersingynaecology RACOG 87 YeS YeS
8. Vestibular function testing WSH 86 YeS -
9. Digital Subhection Angiography DCSH 86 - -
10. 'Office Pathology' tating AHMAC 84.87.88.88.89 Yes YeS
11. Bone mineral assessment DCSH 86.89 YeS Yes
12. Surgical stapling -try 86 - -
13. Portable fluoroscope DCSH 87 YeS -
14. Oxygen ummtrators m
AP 87 - YeS
15. Endoscopy G/E SocietJ 87 - YeS
16. Mammography AHMAC 88 Yes YeS
17. CTScanning mA P 88 Possible YeS
18. Digital Radiography m A P 88 Possible Yes
19. Computerised primetry DCSH 88 Yes YeS
20. Artificialhearts DCSH 88 Possible YeS
21. Brachytherapy DCSH 89 Possible -
22. High energy radiotherapy NSW 89 - -
23. Dynamometry VACC 89 Possible YeS
24. Coronary Angioplasty mA P 89 YeS -
(AIHlit review 89)
Table 2 presents an indication of the response to artificial hearts was due, in significant part, to the
major recammendations in NHTAP reports dealing Panelk recommendations.
with the first twenty technologies listed in Table 1. In the second group, five of sixteen
Three groups of recommendations are considered- recommendations related to matters such as
those related to introduction or support for a guidelines or safety standards were accepted.In two
technology, those dealing with accreditation, cases (MRI. office pathology) government agencies
guidelines or safety matters and those where further and professional bodies took some action;
research or study were proposed. professional bodies accepted recommendations in a
In the first group, seven of twelve h h e r three.(A recommendation in the most recent
recommendations were accepted by the government NHTAP report, on coronary angioplasty, has also
agencies responsible for provision of funding for been accepted by a professional body).
the technologies. It is less certain whether support In the third group, government agencies
for oxygen concentrators or lack of funding for supported six of thirteen recommendations on
Related to introduction or 7 2
reimbursement (MRI. mal and biliary (vestibular function
ESWL, bonemineral testing. DSA)
assessmms~m
4- fluoroscope.
comp~-paimeay)
Related to accreditation, 5(1) 2
safety, guidelines (MRI. lasers. office (lasers in gyneecol,
PathOlOW. DSA)
m-ography. cr)
(C-w
=%iOPl.Sty)
Further research or 6 4
study (MRI. cyclotrons, (renal ESWL. bone
biliary ESWL. vestibular mind assessment,
function testing. office staple=%cr)
18 8 14
* Still under discussionhooearly to say
further research or study, and subsequent action mineral assessment and osteoporosis has probably
has been undertaken with the active co-operation been influenced only to a minor extent by MAP
of professional groups. recommendations.
Overall. eighteen of forty recommendations
were accepted, including most of those dealing Follow-up to assessment
with introduction/support. The outcome of most A single assessment of a health care
of the recommendations on accreditation. technology will often be insufficient to inform
guidelines and safety remains uncertain. While adequately users and policy makers of relevant
there has been widespread interest and discussion issues. Technologies may evolve rapidly, both in
on preparation of documentation, in a number of technical capability and range of application. Data
cases professional bodies and others have yet to from assessments and routine usage may
put in place these difficult-to-achieve initiatives. accumulate slowly. For significant technologies,
For one area of technology, lasers. them has been there will be a need to continue an assessment and
a mixed reaction, with so111e work on national monitoring process ad their life cycles develop.
safety standards proceeding, but perhaps less Such a process should obtain relevant information
action on guidelines at institutional level. on costs and effectiveness, and provide
Recommendations on research/study have led perspective on the place of the technologies in the
to significant evaluations m several areas. notably health care system, particularly when competing
MRI. medical cyclotrons and office pathology methods are available.
testing. The effect on mammography is less As suggested in Figure 1. action in relevant
certain. The NHTAP recommendation on the need policy and other sectors will develop as the
for appraisal of cost effectiveness probably had a technology evolves, and to some extent be
minor influence on decisions taken o n the interactive. With wider diffusion of a technology,
AHMAC cancer screening project. The continuing the impact of assessment will be increasingly
strong Australian research effort into bone dependent on the degree of influence of
DATA ON
ASSESSMENT ASSESSMENT; ' COSTS, USAGE
TECHNOLOGY
MANAGEMENT UPDATE
' CONSENSUS
POLICY
I
PROPOSALS
ACCEPTED
HEALTH
RACR) H DELAY DUE TO BUDGET
PRESSURES(FEDERAL
COORD. DEPARTMENTS]
FEDERAUSTATE
POLICIES ON FEES,
NUMBERS OF UNITS,
APPLICATIONS
INTRODUCTION
- PLACE IN MAJOR HOSPITALS - KEEP UNDER REVIEW
ASSESSMENT - CAUTION ON NEED FOR
- ACCESS TO ALL SUITABLE FUTURE ESWL
PATIENTS
- MONITOR DATA GALLSTONE
ESWL TRIAL
4 BASIS ONLY
DISCUSSION ON
POLICY SECTOR UNITS
FUTURE SERVICES
Hospitals 7 15 59 68
Companies 5 14 52 40
Medical Practices 3 5 39 29
state Government 5 4 m 31
Individuals 1 1 19 8
Professional Organisations 1 0 18 25
Overseas 0 2 14 20
Universities and Research Institutes 1 3 16 25
Commonwealth Departments 5 4 8 12
Health Insurance Groups 0 2 6 3
Total number of requests 28 50 251 261
~~ ~
consultation and consensus strategy, obvious Some limitations on the impact of health
limitations are the restricted amount of time technology assessment arise from characteristics
possible for committee meetings and the relatively in the health care system. Health care is frquendy
small number of technologies that can be a conservative area and practices may be very
considered in MYdetail. The policy of seiving to slow to change. Decisions on reimbursement, once
achieve balanced views and being open to follow- taken, are difficult to reverse.
up assessments, taking account of new data and Expanded activities in the areas of health
valid criticism, is resource-intensive. economics, work force analysis and social
To some extent, these limitations could be considerations have been suggested for the
eased by provision of additional resources for the NHTAP.'O Without additional resources there are
Panel and its secretariat. Gross has suggested a limited prospects for expanding in these
different avenue of approach for the Panel with directions to meet the challenge of integrating
NHTAP acting more as a peak council receiving these further perspectives into timely and
reports and recommendations from other groups appropriate assessments of a realistic range of
including a heavy emphasis on representation technologies.
from professional bodies." While there might well
be merit in the use of alternative approaches, for Conclusions
example consensus development conferences on From the NHTAP experience, it has become
appropriate topics, such a suggestion runs into the apparent that the Panel's assessments and their
difficulty of achieving worthwhile results in a recommendations CM have an important influence
suitably short period of time, with the level of on policy and the subsequent use of a technology
resourcing likely to become available. This but that much depends on the presence of stable
proposal might also face problems if applied in and receptive policy areas. any significant
any widespread sense, because of the logistical changes to the technology and inputs from wider
difficulty of co-ordinating the operation and government. industry and professional-body
output of a large number of assessment activities interests. It also seems true that the level of the
undertaken by other groups. While the consensus impact is not necassarily related to the depth of
and consultation process is a useful discipline, its analysis - timing is crucial.
worth will be minimised if it takes too long and The impact of health technology assessment
the opportunity to realistically inform policy will often depend on support and funding for
decisions is missed. significant follow-up evaluation to the original
References