PERSPECTIVE: SOME CONCLUSIONS FROM MY LIFE IN HEALTH TECHNOLOGY ASSESSMENT.

I have worked in health technology assessment (HTA) since 1975, beginning in the United States Congress Office of Technology Assessment (OTA), where we were charged with defining "medical technology assessment". My main concern in HTA has always been efficacy of healthcare interventions. After years in OTA, I was invited to the Netherlands in 1985, where the Dutch government invited me to head a special commission concerning future healthcare technology and HTA. From there, I became involved in over forty countries, beginning in Europe and then throughout the world. My most intense involvements, outside the United States and Europe, have been in Brazil, China, and Malaysia. During these 40-plus years, I have seen HTA grow from its earliest beginnings to a worldwide force for better health care for everyone. I have also had some growing concerns, outlined in this Perspective article. Within HTA, I am most disappointed by a narrow perspective of cost-effective analysis, which tends to ignore considerations of culture, society, ethics, and organizational and legal issues. In the general environment affecting HTA and health care, I am most concerned about the need to protect the independence of HTA activities from influences of the healthcare industries.

Public health services and cost-effectiveness analysis.

Cost-effectiveness analysis as an aid to decision making has been increasingly publicized and discussed during the past two to three decades. However, the total body of cost-effectiveness analyses in health care is actually rather small, and high-quality studies are rather rare. Furthermore, the applications of economic analysis to health policy have been hampered by a number of problems, including those that are methodological and contextual. We consider a number of areas of public health policy but pay special attention to a growing area of inquiry and application: the overall coverage of health services. Cost-effectiveness analysis has played a relatively small role in general coverage decisions, but in recent years, it has been applied increasingly to decisions concerning pharmaceutical coverage. We speculate on concerning reasons for this particular focus in cost-effectiveness analysis. Future progress will depend heavily on discussion and consensus building.

Situation analysis of prenatal diagnosis technology utilization in China: current situation, main issues, and policy implications.

OBJECTIVES: The purpose of this study is to describe the situation with the distribution and utilization of prenatal diagnosis technology in China, to identify some important barriers to prenatal diagnosis use, and to suggest changes to improve the present situation. METHODS: The study uses cross-sectional surveys to capture quantitative data from both providers and consumers. Qualitative information based on focus group discussions is also presented. RESULTS: A mail survey of the provincial Bureaus of Health (BOHs) reveals that sixteen provincial prenatal diagnosis centers and twelve city level centers were accredited by the BOHs by July of 2001. These centers were located in thirteen provinces, of thirty in all of China. Of 147 selected institutions surveyed separately, 90.5 percent offer ultrasound examination, 72.1 percent provide pathogen tests (mainly Toxoplasma, rubella virus, cytomegalovirus, and herpes simplex or TORCH), 57.1 percent do biochemical tests, 21.8 percent have genetic counseling, 13.6 percent do karyotype testing, 7.5 percent do enzymology testing, and 5.4 percent carry out molecular genetic testing. Chromosome diseases, congenital diseases, and several gene diseases are the target diseases. According to qualitative data, macromanagement for prenatal diagnosis, supplier provision of tests, and population demand are the main influences on prenatal diagnosis use. CONCLUSIONS: From the quantitative and qualitative analysis, it is clear that the technology of prenatal diagnosis is not diffusing well throughout China and is apparently not appropriately used. The situation of prenatal diagnosis has implications for policy-makers, including identification of priorities, regulation of prenatal diagnosis, strategic planning, development of guidelines based on health technology assessment, and consumer orientation.

Electronic fetal monitoring. Lessons from a formative case of health technology assessment.

OBJECTIVES: The assessment of electronic fetal monitoring (EFM) carried out by the authors in the late 1970s provides an early case of a systematic review of evidence in health technology assessment. This paper identifies lessons pertinent for the present day in this field. METHODS: We reviewed our own files for the description of our assessment and reactions to it. We also reviewed recent literature to evaluate our observations in relation to recent evidence. RESULTS: Our findings of insufficient evidence of efficacy and concerns about safety have been confirmed by subsequent research. Still, despite findings and recommendations of prominent professional and governmental bodies, EFM continues in widespread use in the United States and Europe and is spreading into developing countries around the world. Aggressive attacks on our assessment as well as our skills and integrity have been mirrored in recent years by criticism of other researchers in health technology assessment. CONCLUSIONS: The case of EFM points to the limitations of assessment without other actions to assure the implementation of results. Health technologies that are accepted by the majority of clinicians in a particular field may require extraordinary efforts to assure appropriate use of technology assessments.

Tecnologia para a saúde / Technology for the health

Aborda a tecnologia como instrumento principal do sistema de saúde, associada a implicaçöes sociais, éticas, legais e econômicas. Näo basta que as tecnologias discutíveis sejam simplesmente descartadas, para se resolver o problema da seleçäo do que pode e do que deve ser usado. Muitos países em desenvolvimento têm sido incapazes de racionalizar a adoçäo e o uso de tais tecnologias. Além de decidir o que importar e o que desenvolver internamente, os políticos precisam aprender a combinar recursos econômicos e necessidade estratégica