CONFERENCE * CONFERENCE
Is
health
technology assessment
Is health technology, assessnient medicine s rising
star?
Patricia Huston, MD, MPH cost effectiveness. Almost anything can be evaluated: geriatric assessment units can be considered a form of health technology, and the Royal Commission on New Reproductive Technologies has been described as a major HTA process. The growing interest in HTA is due to the conjunction of two forces, and fed by circumstance. First, the 1970s and 1980s saw an exponential rise in medical technologies, especially those involving medical processes such as computerized tomography, nuclear magnetic resonance imaging and cardiac catheterization. The result: a growing portion of the gross national product was being spent on health care. Second, the 1980s and 1990s saw a huge increase in the national debt, and with it came a growing concern about health care spending and the realization that uncontrolled spending could not continue. If not rationing, then some other type of rationale had to be applied to health care expenditures. HTA provides a response to this concern. It has been nurtured by the development of a number of fields, including quality of care, practice guidelines, cost-effectiveness studies and outcomes research. Dr. Renaldo Battista, director is associate editor-in-chief of clinical epidemiology at the Montreal General Hospital, gave
It was a most unlikely crowd: academic physicians, hospital administrators, district health council representatives, provincial health officials, medical devices sales personnel, the vice-president of the Medical Research Council of Canada and a medical sociologist. They had met to have their say about one question: Does health technology assessment (HTA) affect health care? By the end of the recent conference, which was organized by the Canadian Coordinating Office for Health Technology Assessment (CCOHTA), you could still not assuredly say "yes," but you had a fairly good idea about the major issues involved when this question is being addressed. I was left with the distinct impression that the days when the heart of medical care revolved around the doctor-patient relationship were over. What exactly is HTA, and why is it an issue now? Ideally, it involves an interdisciplinary analysis of the procedures, equipment or drugs used in health care to evaluate their safety, cost, efficacy, ethics and impact on quality of life. In fact, most assessments to date have included only safety and efficacy and, more recently, Patricia Huston of CMAJ.
DECEMBER 15, 1992
conference participants an excellent overview of the development of HTA in Canada, the United States, England and France. It is a recent trend. Even though the Office of Technology Assessment was established in the US in 1972, the Offlce of Health Technology Assessment (OHTA) was not established until 1989. In the interim there had been a National Center for Health Care Technology, but it died during the Reagan era. The OHTA informs the executive branch of the US government about technology as it applies to the country's Medicare and Medicaid programs. Although the US was a pioneer in technology assessment in general, its present influence in HTA is limited and indirect. In the United Kingdom, a Committee on Science and Technology was formed in 1988 to report to the House of Lords. In France the first technology assessment body was formed in 1982; the specific HTA component, Agence nationale pour le developpement de l' evaluation medicale, was launched in 1991. In Canada, Quebec was the first province to develop its own HTA body; Conseil d'evaluation des technologies de la sante (CETS) was founded in 1988. The following year the CCOHTA was established by the provincial, territorial and federal ministers of health. In 1990, a HTA office was CAN MED ASSOC J 1992; 147 (12)
1839
created in British Columbia. Because HTA has a rather brief history, operational issues such as clarifying the mandate, setting priorities and choosing implementation strategies are still being clarified. Battista described HTA as a bridge between science and policy. Building that bridge is a major challenge, he said, because of the different realities on each side of the HTA equation. He warned that policy decisions are not always made on the basis of HTA - one recent example is the French scandal involving HIV-contaminated blood. In that case, the blood was not tested for HIV with available technology because there had been a political will for French scientists to develop their own screening test. Dr. Maurice McGregor, president of CETS, said 25% of its evaluations have been carried out in response to requests from the Quebec Ministry of Health. A typical question was: "By what principle should the number and distribution of cardiac catheter laboratories be decided?" The other 75% of the studies were determined by the board after it conducted a market survey and chose topics that were controversial and could have a significant health or economic impact. Assessment of guidelines on the treatment of patients with elevated cholesterol levels is an example of this second type of study. Does HTA make a difference? Dr. John Ferguson, director of the Office of Medical Applications Research at the National Institutes of Health (NIH) in the US, pointed out that HTA is still in its infancy - 80% of studies conducted by OHTA in the US called for more information and often had conclusions based on class 3 evidence. He then reviewed impact studies that had been done to follow up some NIH consensus conferences. In a survey conducted a year after the NIH consensus DECEMBER 15, 1992
conference on breast cancer, 50% of respondents had no knowledge of the recommendations; 40% stated they had some knowledge, but further questioning revealed that almost half were not actually carrying out the recommendations. A 1980 NIH consensus conference had recommended a trial of vaginal delivery after cesarian section, yet the C-section rate continued to rise until 1985. Ferguson concluded by saying there are nonmedical factors that influence physician behaviour, and these must be examined more carefully. Dr. Patrick Parfrey, chief of the Division of Nephrology at Memorial University, St. John's, gave a convincing presentation of how the assessment of low osmolar versus high osmolar contrast media led to policy formation on its use in the St. John's Health Sciences Centre. There the stakes were clear: although low osmolar contrast media appeared to be marginally safer, it was much more expensive and if used for everybody it would cost the province $3 million a year. This would mean bed closures. A randomized controlled trial was conducted, and patients at risk for adverse reactions caused by the high osmolar contrast media were identified. A policy of selective use of low osmolar contrast media was instituted. Thus, HTA can help governments: Where should they put cardiac catheter labs? It can help hospitals: When should they use products that are marginally safer, but much more expensive? It can also help physicians make treatment decisions. However, it appears that these assessments are not the only factor influencing decisions: political pressures, market forces and individual preferences all come into play. Finally, health care technology is not the only route to health. Dr. Andreas Laupacis, head of the Clinical Epidemiology Unit at the
Ottawa Civic Hospital, reminded conference participants that much of the decrease in mortality during the last century occurred before 1950, when health care technology was not a major factor. Between 1950 and 1980 the overall death rate decreased by only 5%, and mortality from cancer, especially lung cancer, actual-
ly rose.
Socioeconomic status appears to have a greater
impact
on mor-
tality than health care technology. Laupacis presented British data showing that, over a 10-year period, those in well-paying occupations had an 1% decrease in mor-
tality that was not shared by man-
ual labourers. This difference in mortality rates actually increased between 1972 and 1983, and remained even though risk factors, such as cigarette smoking, were taken into account. He also provided corroboratevidence from Japan. It is not ing only one of the world's wealthiest countries, but also has one of the lowest income spreads among its workers. The Japanese enjoy the longest life expectancy in the world, yet the country spends only 6.3% of its gross national product (GNP) on health care. (Canada spends about 9.7% of its GNP on health care, the US about 12%). By the end of the conference, it was clear that HTA alone does not determine decisions made by government, hospitals or physicians, and health care technology is not the major determinant of health. Still, there is a need to assess more thoroughly what is being done in health care. Evaluations to date have often been based on incomplete evidence. With better research, better targeting, follow-up studies and the necessary political will, HTA may make a difference. This was the first in a series of conferences sponsored by the CCOHTA. Physicians should stay tuned for the results of future
meetings.CAN MED ASSOC J 1992; 147 (12)
1841
Is
health
technology assessment
Is health technology, assessnient medicine s rising
star?
Patricia Huston, MD, MPH cost effectiveness. Almost anything can be evaluated: geriatric assessment units can be considered a form of health technology, and the Royal Commission on New Reproductive Technologies has been described as a major HTA process. The growing interest in HTA is due to the conjunction of two forces, and fed by circumstance. First, the 1970s and 1980s saw an exponential rise in medical technologies, especially those involving medical processes such as computerized tomography, nuclear magnetic resonance imaging and cardiac catheterization. The result: a growing portion of the gross national product was being spent on health care. Second, the 1980s and 1990s saw a huge increase in the national debt, and with it came a growing concern about health care spending and the realization that uncontrolled spending could not continue. If not rationing, then some other type of rationale had to be applied to health care expenditures. HTA provides a response to this concern. It has been nurtured by the development of a number of fields, including quality of care, practice guidelines, cost-effectiveness studies and outcomes research. Dr. Renaldo Battista, director is associate editor-in-chief of clinical epidemiology at the Montreal General Hospital, gave
It was a most unlikely crowd: academic physicians, hospital administrators, district health council representatives, provincial health officials, medical devices sales personnel, the vice-president of the Medical Research Council of Canada and a medical sociologist. They had met to have their say about one question: Does health technology assessment (HTA) affect health care? By the end of the recent conference, which was organized by the Canadian Coordinating Office for Health Technology Assessment (CCOHTA), you could still not assuredly say "yes," but you had a fairly good idea about the major issues involved when this question is being addressed. I was left with the distinct impression that the days when the heart of medical care revolved around the doctor-patient relationship were over. What exactly is HTA, and why is it an issue now? Ideally, it involves an interdisciplinary analysis of the procedures, equipment or drugs used in health care to evaluate their safety, cost, efficacy, ethics and impact on quality of life. In fact, most assessments to date have included only safety and efficacy and, more recently, Patricia Huston of CMAJ.
DECEMBER 15, 1992
conference participants an excellent overview of the development of HTA in Canada, the United States, England and France. It is a recent trend. Even though the Office of Technology Assessment was established in the US in 1972, the Offlce of Health Technology Assessment (OHTA) was not established until 1989. In the interim there had been a National Center for Health Care Technology, but it died during the Reagan era. The OHTA informs the executive branch of the US government about technology as it applies to the country's Medicare and Medicaid programs. Although the US was a pioneer in technology assessment in general, its present influence in HTA is limited and indirect. In the United Kingdom, a Committee on Science and Technology was formed in 1988 to report to the House of Lords. In France the first technology assessment body was formed in 1982; the specific HTA component, Agence nationale pour le developpement de l' evaluation medicale, was launched in 1991. In Canada, Quebec was the first province to develop its own HTA body; Conseil d'evaluation des technologies de la sante (CETS) was founded in 1988. The following year the CCOHTA was established by the provincial, territorial and federal ministers of health. In 1990, a HTA office was CAN MED ASSOC J 1992; 147 (12)
1839
created in British Columbia. Because HTA has a rather brief history, operational issues such as clarifying the mandate, setting priorities and choosing implementation strategies are still being clarified. Battista described HTA as a bridge between science and policy. Building that bridge is a major challenge, he said, because of the different realities on each side of the HTA equation. He warned that policy decisions are not always made on the basis of HTA - one recent example is the French scandal involving HIV-contaminated blood. In that case, the blood was not tested for HIV with available technology because there had been a political will for French scientists to develop their own screening test. Dr. Maurice McGregor, president of CETS, said 25% of its evaluations have been carried out in response to requests from the Quebec Ministry of Health. A typical question was: "By what principle should the number and distribution of cardiac catheter laboratories be decided?" The other 75% of the studies were determined by the board after it conducted a market survey and chose topics that were controversial and could have a significant health or economic impact. Assessment of guidelines on the treatment of patients with elevated cholesterol levels is an example of this second type of study. Does HTA make a difference? Dr. John Ferguson, director of the Office of Medical Applications Research at the National Institutes of Health (NIH) in the US, pointed out that HTA is still in its infancy - 80% of studies conducted by OHTA in the US called for more information and often had conclusions based on class 3 evidence. He then reviewed impact studies that had been done to follow up some NIH consensus conferences. In a survey conducted a year after the NIH consensus DECEMBER 15, 1992
conference on breast cancer, 50% of respondents had no knowledge of the recommendations; 40% stated they had some knowledge, but further questioning revealed that almost half were not actually carrying out the recommendations. A 1980 NIH consensus conference had recommended a trial of vaginal delivery after cesarian section, yet the C-section rate continued to rise until 1985. Ferguson concluded by saying there are nonmedical factors that influence physician behaviour, and these must be examined more carefully. Dr. Patrick Parfrey, chief of the Division of Nephrology at Memorial University, St. John's, gave a convincing presentation of how the assessment of low osmolar versus high osmolar contrast media led to policy formation on its use in the St. John's Health Sciences Centre. There the stakes were clear: although low osmolar contrast media appeared to be marginally safer, it was much more expensive and if used for everybody it would cost the province $3 million a year. This would mean bed closures. A randomized controlled trial was conducted, and patients at risk for adverse reactions caused by the high osmolar contrast media were identified. A policy of selective use of low osmolar contrast media was instituted. Thus, HTA can help governments: Where should they put cardiac catheter labs? It can help hospitals: When should they use products that are marginally safer, but much more expensive? It can also help physicians make treatment decisions. However, it appears that these assessments are not the only factor influencing decisions: political pressures, market forces and individual preferences all come into play. Finally, health care technology is not the only route to health. Dr. Andreas Laupacis, head of the Clinical Epidemiology Unit at the
Ottawa Civic Hospital, reminded conference participants that much of the decrease in mortality during the last century occurred before 1950, when health care technology was not a major factor. Between 1950 and 1980 the overall death rate decreased by only 5%, and mortality from cancer, especially lung cancer, actual-
ly rose.
Socioeconomic status appears to have a greater
impact
on mor-
tality than health care technology. Laupacis presented British data showing that, over a 10-year period, those in well-paying occupations had an 1% decrease in mor-
tality that was not shared by man-
ual labourers. This difference in mortality rates actually increased between 1972 and 1983, and remained even though risk factors, such as cigarette smoking, were taken into account. He also provided corroboratevidence from Japan. It is not ing only one of the world's wealthiest countries, but also has one of the lowest income spreads among its workers. The Japanese enjoy the longest life expectancy in the world, yet the country spends only 6.3% of its gross national product (GNP) on health care. (Canada spends about 9.7% of its GNP on health care, the US about 12%). By the end of the conference, it was clear that HTA alone does not determine decisions made by government, hospitals or physicians, and health care technology is not the major determinant of health. Still, there is a need to assess more thoroughly what is being done in health care. Evaluations to date have often been based on incomplete evidence. With better research, better targeting, follow-up studies and the necessary political will, HTA may make a difference. This was the first in a series of conferences sponsored by the CCOHTA. Physicians should stay tuned for the results of future
meetings.CAN MED ASSOC J 1992; 147 (12)
1841
