Downloaded from www.ajronline.org by 186.216.247.190 on 10/09/15 from IP address 186.216.247.190. Copyright ARRS. For personal use only; all rights reserved
652
Commentary
-
.
..
,.
, 2
I
Implications C. John
#{14
‘:
...
of Technology
Assessment
for the Radiologist
Rosenquist1
In this issue of the AJR, Hendee has written a timely and perceptive article about the increasing importance of technology assessment in radiology [1 1. He explains why technology assessment has become important, describes the various methods for evaluating new technology, and discusses the government and private organizations that are involved in this process. Hendee makes the important point that radiologists, either directly or through professional organizations such as the American College of Radiology, should take an active role in technology assessment. Why has technology assessment become such an active area of investigation? Probably the most compelling reason is the effort being made to curb the continuing increase in costs of medical care in this country. Because of these increasing costs, many knowledgeable experts in health policy and health economics believe that rationing and resource allocation are inevitable [2]. As new technology is one of the major factors increasing medical costs, it is obviously important to know whether a new test or procedure has a beneficial effect on a patient’s outcome. Radiologists may be involved with the issues of technology assessment in several different ways. They should be well informed about the type of evaluations described by Hendee and may be involved in research activities that address these issues. It also is important to understand the steps in evaluation of technology described by Hillman [3]. The five-stage progression of technology assessment includes evaluation of image efficacy, diagnostic and therapeutic efficacy, patient’s outcome, and cost-effectiveness. Every radiologist should be aware of the various levels of acceptance of new technology
This article is a commentary ‘ Department of Aadiology.
on the preceding article by Hendee. University of California, Davis, School of Medicine,
as applied to radiology. The first level compromises those procedures of proved usefulness and cost-effectiveness. An example is the use of chest radiographic examination for patients suspected of having pneumonia. The second consists of technology of proved usefulness but of questionable cost-effectiveness. An example in this category is the use of nonionic contrast agents for all contrast injections. The third level comprises procedures of unproved usefulness and costeffectiveness. An example in this category is the use of sonography for prostate cancer screening. The radiologist should be aware of several ethical and legal issues that may arise as a result of technology assessment and subsequent health policy decisions. The physician may find himself in an ethical dilemma because of his responsibility for an individual patient vs the health needs of society [4]. On the one hand, the physician should serve an individual patient as the patient’s advocate. On the other, the well-informed physician may be aware of the limits of medical resources and realize the need to establish policies concerning the best use of these resources. If, as expected, the future will bring a greater limitation of medical resources, this ethical dilemma will become more pervasive. There are two legal concerns that have arisen because of technology assessment. The first is the potential for antitrust litigation based on alleged attempts to restrain medical practice [5]. For example, if a large medical insurance company decided against reimbursement for a new procedure, could this be regarded as restraint of trade? Challenges to reimbursement decisions based on antitrust probably would be based on Section 1 of the Sherman Act, which “prohibits
Am. 1009A, Professional
reprint requests to C. J. Aosenquist. AJR 154:652-653,
March
1990 0361 -803X/90/1
543-0652
© American Roentgen Ray Society
Bldg., 4301 X St., Sacramento,
CA 9581 7. Address
Downloaded from www.ajronline.org by 186.216.247.190 on 10/09/15 from IP address 186.216.247.190. Copyright ARRS. For personal use only; all rights reserved
AJR:154,
March
1990
IMPLICATIONS
OF TECHNOLOGY
contracts, combination, and conspiracy in restraint of trade or commerce.” Those who have studied this problem recommend that care be taken to base technology assessment decisions on careful review of all evidence and that legal counsel be obtained if decisions extend beyond opinions to recommendations regarding reimbursement or use of new procedures. The second legal issue relates to the potential for liability should a patient’s outcome be affected adversely by a decision based on technology assessment. For example, if the government, a health maintenance organization, or an insurance company decides that a procedure is not indicated or not cost-effective, there is the potential for liability if a patient suffers as a result of this decision. Thus far, the courts have been reluctant to take this position and have generally followed the “standard of care” policy. Again, the best defense against this possibility is a thorough, meticulous, and welldocumented study of the technology in question. In his paper, Hendee makes the point that radiologists should be involved in technology assessment in order to balance needs of patients, which are the concern of the practicing physician, against the direction of health policy decisions, which are more concerned with aggregate health care. He makes this recommendation because of the possibility that health policy may place inappropriate emphasis on the goal of limiting new technology in order to curb health care costs. While I agree completely with Hendee’s recommendation, there are several additional reasons why radiologists and other physicians should be involved in this process. First, the physician is best able to identify what new technol-
ASSESSMENT
653
ogies
should be assessed. Second, the physician who is trained in methods of technology assessment may be helpful in deciding what type of assessment, as described by Hendee, is likely to be successful. Is a controlled clinical trial possible or ethical, or would a less-expensive case trial be adequate? In some cases, a new technology is of such obvious benefit that perhaps no trial is needed. These types of questions are best answered by the physician who is knowledgeable in this field. Finally, radiologists and other physicians should be instrumental in encouraging federal and private support for clinical studies of technology assessment. Despite their different perspectives, health policy analysts and physicians share a common goal. Both are interested in determining if a new technology will improve the patient’s outcome. By working together, it should be possible to establish a system in which the government, industry, and medical organizations cooperate in the evaluation of new technology before its introduction into general medical practice.
REFERENCES 1 . Hendee WA. Technology assessment: the contribution of professional organizations. AiR 1990; 1 54 :647-651 2. Evans AW. Health care technology and the inevitability of resource allocation and rationing decisions. JAMA 1983;249:2047-2053 3. Hillman BJ. The value of imaging technology to patients’ health. AJR 1988;150:1191-1 192 4. Weale A. Cost and choice in heafth care: the ethical dimension. London:
King Edward’s 5. Rose
Hospital Fund, 1988
M, Leibenluft
sessment. N EnglJ
RF. Antitrust Med
implications
1986:314:1490-1493
of medical
technology
as-
652
Commentary
-
.
..
,.
, 2
I
Implications C. John
#{14
‘:
...
of Technology
Assessment
for the Radiologist
Rosenquist1
In this issue of the AJR, Hendee has written a timely and perceptive article about the increasing importance of technology assessment in radiology [1 1. He explains why technology assessment has become important, describes the various methods for evaluating new technology, and discusses the government and private organizations that are involved in this process. Hendee makes the important point that radiologists, either directly or through professional organizations such as the American College of Radiology, should take an active role in technology assessment. Why has technology assessment become such an active area of investigation? Probably the most compelling reason is the effort being made to curb the continuing increase in costs of medical care in this country. Because of these increasing costs, many knowledgeable experts in health policy and health economics believe that rationing and resource allocation are inevitable [2]. As new technology is one of the major factors increasing medical costs, it is obviously important to know whether a new test or procedure has a beneficial effect on a patient’s outcome. Radiologists may be involved with the issues of technology assessment in several different ways. They should be well informed about the type of evaluations described by Hendee and may be involved in research activities that address these issues. It also is important to understand the steps in evaluation of technology described by Hillman [3]. The five-stage progression of technology assessment includes evaluation of image efficacy, diagnostic and therapeutic efficacy, patient’s outcome, and cost-effectiveness. Every radiologist should be aware of the various levels of acceptance of new technology
This article is a commentary ‘ Department of Aadiology.
on the preceding article by Hendee. University of California, Davis, School of Medicine,
as applied to radiology. The first level compromises those procedures of proved usefulness and cost-effectiveness. An example is the use of chest radiographic examination for patients suspected of having pneumonia. The second consists of technology of proved usefulness but of questionable cost-effectiveness. An example in this category is the use of nonionic contrast agents for all contrast injections. The third level comprises procedures of unproved usefulness and costeffectiveness. An example in this category is the use of sonography for prostate cancer screening. The radiologist should be aware of several ethical and legal issues that may arise as a result of technology assessment and subsequent health policy decisions. The physician may find himself in an ethical dilemma because of his responsibility for an individual patient vs the health needs of society [4]. On the one hand, the physician should serve an individual patient as the patient’s advocate. On the other, the well-informed physician may be aware of the limits of medical resources and realize the need to establish policies concerning the best use of these resources. If, as expected, the future will bring a greater limitation of medical resources, this ethical dilemma will become more pervasive. There are two legal concerns that have arisen because of technology assessment. The first is the potential for antitrust litigation based on alleged attempts to restrain medical practice [5]. For example, if a large medical insurance company decided against reimbursement for a new procedure, could this be regarded as restraint of trade? Challenges to reimbursement decisions based on antitrust probably would be based on Section 1 of the Sherman Act, which “prohibits
Am. 1009A, Professional
reprint requests to C. J. Aosenquist. AJR 154:652-653,
March
1990 0361 -803X/90/1
543-0652
© American Roentgen Ray Society
Bldg., 4301 X St., Sacramento,
CA 9581 7. Address
Downloaded from www.ajronline.org by 186.216.247.190 on 10/09/15 from IP address 186.216.247.190. Copyright ARRS. For personal use only; all rights reserved
AJR:154,
March
1990
IMPLICATIONS
OF TECHNOLOGY
contracts, combination, and conspiracy in restraint of trade or commerce.” Those who have studied this problem recommend that care be taken to base technology assessment decisions on careful review of all evidence and that legal counsel be obtained if decisions extend beyond opinions to recommendations regarding reimbursement or use of new procedures. The second legal issue relates to the potential for liability should a patient’s outcome be affected adversely by a decision based on technology assessment. For example, if the government, a health maintenance organization, or an insurance company decides that a procedure is not indicated or not cost-effective, there is the potential for liability if a patient suffers as a result of this decision. Thus far, the courts have been reluctant to take this position and have generally followed the “standard of care” policy. Again, the best defense against this possibility is a thorough, meticulous, and welldocumented study of the technology in question. In his paper, Hendee makes the point that radiologists should be involved in technology assessment in order to balance needs of patients, which are the concern of the practicing physician, against the direction of health policy decisions, which are more concerned with aggregate health care. He makes this recommendation because of the possibility that health policy may place inappropriate emphasis on the goal of limiting new technology in order to curb health care costs. While I agree completely with Hendee’s recommendation, there are several additional reasons why radiologists and other physicians should be involved in this process. First, the physician is best able to identify what new technol-
ASSESSMENT
653
ogies
should be assessed. Second, the physician who is trained in methods of technology assessment may be helpful in deciding what type of assessment, as described by Hendee, is likely to be successful. Is a controlled clinical trial possible or ethical, or would a less-expensive case trial be adequate? In some cases, a new technology is of such obvious benefit that perhaps no trial is needed. These types of questions are best answered by the physician who is knowledgeable in this field. Finally, radiologists and other physicians should be instrumental in encouraging federal and private support for clinical studies of technology assessment. Despite their different perspectives, health policy analysts and physicians share a common goal. Both are interested in determining if a new technology will improve the patient’s outcome. By working together, it should be possible to establish a system in which the government, industry, and medical organizations cooperate in the evaluation of new technology before its introduction into general medical practice.
REFERENCES 1 . Hendee WA. Technology assessment: the contribution of professional organizations. AiR 1990; 1 54 :647-651 2. Evans AW. Health care technology and the inevitability of resource allocation and rationing decisions. JAMA 1983;249:2047-2053 3. Hillman BJ. The value of imaging technology to patients’ health. AJR 1988;150:1191-1 192 4. Weale A. Cost and choice in heafth care: the ethical dimension. London:
King Edward’s 5. Rose
Hospital Fund, 1988
M, Leibenluft
sessment. N EnglJ
RF. Antitrust Med
implications
1986:314:1490-1493
of medical
technology
as-
