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Health care technology and its assessment
Health Policy 27 (1994) 193-200
Book Reviews
Health Care Technology and its Assessment By H. Banta (Ed.) Oxford University Press, Oxford, 304 pp., 1993, ISBN 019-262297-8,
45.00.
In this book two leading practitioners of health technology assessment present an extended overview of the lield, with the aid of ten other contributors from six nations. As noted in the preface, the book is an attempt to describe health technology assessment as it existed in the world in 1992 and is organised to give a context for examining various issues involved. The live sections cover an historical introduction, development and diffusion of health technology, health technology assessment, case histories relating to specific types of technology and an international perspective of experience in several countries. The examples given and literature cited draw on experience from a number of nations, though there is some emphasis on the USA and the Netherlands, reflecting the backgrounds of the two main authors. Most of the literature cited is up to the end of 1991, with some 1992 material, mostly relating to conference proceedings. The Introductory section on the historical perspective usefully gathers together definitions of health care technology and concerns related to it. The second section gives a further setting of the scene with discussion on diffusion of health care technologies and factors in their development, adoption and use. This draws on well established material prepared by a number of agencies including the Office of Technology Assessment. Those familiar with health technology issues will recognise some old favourites such as diffusion of cardiac pacemakers and CT scanners and the rise and fail of gastric freezing. This is a concise overview of some fundamental issues associated with health care technologies which would be valuable to those new to the area, including those in the policy setting role. As with other sections of the book, the discussion and the references provided would give a basis for further exploration of the issues. Some of the examples could leave the general reader up in the air for example, a reference to rapid development in hip joint replacement is not really explained. Overall the section gives a good indication of the complexity and variation associated with health technologies and their use. The section on assessment provides a good general description of the various components of evaluation and the approaches that have been taken in a number of countries. Efficacy, safety, financial cost, quality of life and social applications are all covered though the section of techniques for assessing social implications makes reference only to earlier OTA publications and does not mention some of the qualitative research approaches. This section also includes a chapter on assuring the quality of health care which usefully introduces some concepts in quality assurance, making the point of the need to link this area closely with other aspects of health care technology appraisal. The need to evaluate technology early in its life cycle is a point made early in this section although the reasons for this, and the need to maintain evaluation activities as the technology matures are not developed in detail. Some indication is given in an interesting commentary on the impact of assessments which includes some examples of studies which have influenced policy and of the more debatable question of the effect of assessments on actual use of technologies by health care professionals. The newcomer to health technology issues would find much of value in this section which would provide a good start for further investigation. There are some limitations. Some of the material provides little more than an indication for future study by the reader. The discussion on discounting, for example, runs to only seven lines, Also, the authors do not seem to fully succeed in integrating the information provided. Elsevier Science Ireland Ltd. SSDI 0168-8510(94)0617-N
194
Book Reviews / Healh Policy 27 (1994)
193-200
The dilemma remains of how to balance the need for timely assessment of a number of technologies with resource constraints, data requirements and the many possible approaches to evaluation. Nevertheless the section does give a good impression of the enormous breadth of issues associated with health care technologies and their assessment. The section on the individual case studies covers assessment of prevention, medical imaging, surgical practice, drugs, and picture archiving and communication systems (PACS). The chapter on assessment of prevention gives a reasonable indication of the potential complexity of this area and the difficulty in assessing outcomes of some programs. This is a useful introduction to the area although some further discussion of the significance of outcome measures such as potential years of life lost would have been helpful. The chapter on diagnostic imaging discusses assessment in part with reference to the well known classification by Fineberg of evaluation for efftcacy. It is noted that most early assessments were at the first level (technical evaluation), but there is no real indication of the extent to which this has changed - many would feel that only a small proportion of current studies progress much beyond level two (diagnostic accuracy). This chapter revisits CT scanning and refers to earlier assessments of this technology. However, there is little discussion on its diagnostic yield, safety and cost effectiveness now that diffusion is widespread. The section on magnetic resonance imaging makes some useful general points, but given the still quite limited information on costs of this technology and its effects on patient management would have benefited by including data available from UK and Australian studies. The discussion on assessment of surgical practice provides a summary of many of the issues involved and a good account of the evolution of laparoscopic cholecystectomy which points to further developments with this technology since the book went to press. The section on drugs makes a number of very valid points relating to assessment of their impact, including economic effect, and the continuing lack of certainty as to their impact on health outcomes. The chapter on PACS is valuable in that it points explicitly to the need to evaluate information technology in health care. Some major issues in this area are usefully addressed. It could perhaps have been made clearer that relatively few hard data are yet available on the true costs and benefits of this high cost imaging support system. The final section starts with short chapters dealing with approaches to health care technology in Sweden, the UK, the Netherlands and the USA. These chapters all give some detail of the administrative structures associated with health care and will be helpful for those who are confused by the relationship between the various agencies. These accounts are useful in giving an indication of the sometimes complex processes through which health technology assessment contributes to the formulation of policy decisions, and in pointing to the realities of other, major inputs to the policy formulation process. There are several examples of health technology assessment influencing funding decisions, such as those on insurance coverage for some high cost technologies, though line is said about the evidence for a more general impact of assessment on these health care systems. The section then goes on to include descriptions of medical technology in Mexico and China where approaches to systematic evaluation and procurement are at a much earlier stage. Brief details are then given of selected experience of other countries - these are notes which give an indication of assessment activities in various nations without necessarily capturing the full perspective of any of these. Some of the programs referred to in this chapter have subsequently developed in other directions or have been wound up. In their conclusions, the authors make comment of the need to appropriately tailor health care technology to the characteristics of individual health care systems and to share information. They finish with an essay covering policies towards health care technology, technology transfer and attitudes towards funding and maintaining technologies in industrialized and developing countries. Overall, this is a useful general introduction to health care technology and its assessment and how things have progressed to the early 1990s. It would be a good starting point for further study by those seeking an introduction to this important and rapidly evolving field of study and as a guide for further reading. Dr. D. Hailey Head Technology Division Australian Institute of Health and Welfare Canberra, Australia
Book Reviews
Health Care Technology and its Assessment By H. Banta (Ed.) Oxford University Press, Oxford, 304 pp., 1993, ISBN 019-262297-8,
45.00.
In this book two leading practitioners of health technology assessment present an extended overview of the lield, with the aid of ten other contributors from six nations. As noted in the preface, the book is an attempt to describe health technology assessment as it existed in the world in 1992 and is organised to give a context for examining various issues involved. The live sections cover an historical introduction, development and diffusion of health technology, health technology assessment, case histories relating to specific types of technology and an international perspective of experience in several countries. The examples given and literature cited draw on experience from a number of nations, though there is some emphasis on the USA and the Netherlands, reflecting the backgrounds of the two main authors. Most of the literature cited is up to the end of 1991, with some 1992 material, mostly relating to conference proceedings. The Introductory section on the historical perspective usefully gathers together definitions of health care technology and concerns related to it. The second section gives a further setting of the scene with discussion on diffusion of health care technologies and factors in their development, adoption and use. This draws on well established material prepared by a number of agencies including the Office of Technology Assessment. Those familiar with health technology issues will recognise some old favourites such as diffusion of cardiac pacemakers and CT scanners and the rise and fail of gastric freezing. This is a concise overview of some fundamental issues associated with health care technologies which would be valuable to those new to the area, including those in the policy setting role. As with other sections of the book, the discussion and the references provided would give a basis for further exploration of the issues. Some of the examples could leave the general reader up in the air for example, a reference to rapid development in hip joint replacement is not really explained. Overall the section gives a good indication of the complexity and variation associated with health technologies and their use. The section on assessment provides a good general description of the various components of evaluation and the approaches that have been taken in a number of countries. Efficacy, safety, financial cost, quality of life and social applications are all covered though the section of techniques for assessing social implications makes reference only to earlier OTA publications and does not mention some of the qualitative research approaches. This section also includes a chapter on assuring the quality of health care which usefully introduces some concepts in quality assurance, making the point of the need to link this area closely with other aspects of health care technology appraisal. The need to evaluate technology early in its life cycle is a point made early in this section although the reasons for this, and the need to maintain evaluation activities as the technology matures are not developed in detail. Some indication is given in an interesting commentary on the impact of assessments which includes some examples of studies which have influenced policy and of the more debatable question of the effect of assessments on actual use of technologies by health care professionals. The newcomer to health technology issues would find much of value in this section which would provide a good start for further investigation. There are some limitations. Some of the material provides little more than an indication for future study by the reader. The discussion on discounting, for example, runs to only seven lines, Also, the authors do not seem to fully succeed in integrating the information provided. Elsevier Science Ireland Ltd. SSDI 0168-8510(94)0617-N
194
Book Reviews / Healh Policy 27 (1994)
193-200
The dilemma remains of how to balance the need for timely assessment of a number of technologies with resource constraints, data requirements and the many possible approaches to evaluation. Nevertheless the section does give a good impression of the enormous breadth of issues associated with health care technologies and their assessment. The section on the individual case studies covers assessment of prevention, medical imaging, surgical practice, drugs, and picture archiving and communication systems (PACS). The chapter on assessment of prevention gives a reasonable indication of the potential complexity of this area and the difficulty in assessing outcomes of some programs. This is a useful introduction to the area although some further discussion of the significance of outcome measures such as potential years of life lost would have been helpful. The chapter on diagnostic imaging discusses assessment in part with reference to the well known classification by Fineberg of evaluation for efftcacy. It is noted that most early assessments were at the first level (technical evaluation), but there is no real indication of the extent to which this has changed - many would feel that only a small proportion of current studies progress much beyond level two (diagnostic accuracy). This chapter revisits CT scanning and refers to earlier assessments of this technology. However, there is little discussion on its diagnostic yield, safety and cost effectiveness now that diffusion is widespread. The section on magnetic resonance imaging makes some useful general points, but given the still quite limited information on costs of this technology and its effects on patient management would have benefited by including data available from UK and Australian studies. The discussion on assessment of surgical practice provides a summary of many of the issues involved and a good account of the evolution of laparoscopic cholecystectomy which points to further developments with this technology since the book went to press. The section on drugs makes a number of very valid points relating to assessment of their impact, including economic effect, and the continuing lack of certainty as to their impact on health outcomes. The chapter on PACS is valuable in that it points explicitly to the need to evaluate information technology in health care. Some major issues in this area are usefully addressed. It could perhaps have been made clearer that relatively few hard data are yet available on the true costs and benefits of this high cost imaging support system. The final section starts with short chapters dealing with approaches to health care technology in Sweden, the UK, the Netherlands and the USA. These chapters all give some detail of the administrative structures associated with health care and will be helpful for those who are confused by the relationship between the various agencies. These accounts are useful in giving an indication of the sometimes complex processes through which health technology assessment contributes to the formulation of policy decisions, and in pointing to the realities of other, major inputs to the policy formulation process. There are several examples of health technology assessment influencing funding decisions, such as those on insurance coverage for some high cost technologies, though line is said about the evidence for a more general impact of assessment on these health care systems. The section then goes on to include descriptions of medical technology in Mexico and China where approaches to systematic evaluation and procurement are at a much earlier stage. Brief details are then given of selected experience of other countries - these are notes which give an indication of assessment activities in various nations without necessarily capturing the full perspective of any of these. Some of the programs referred to in this chapter have subsequently developed in other directions or have been wound up. In their conclusions, the authors make comment of the need to appropriately tailor health care technology to the characteristics of individual health care systems and to share information. They finish with an essay covering policies towards health care technology, technology transfer and attitudes towards funding and maintaining technologies in industrialized and developing countries. Overall, this is a useful general introduction to health care technology and its assessment and how things have progressed to the early 1990s. It would be a good starting point for further study by those seeking an introduction to this important and rapidly evolving field of study and as a guide for further reading. Dr. D. Hailey Head Technology Division Australian Institute of Health and Welfare Canberra, Australia