Health Care Technology Assessment Research Articles

EXCHANGING VIEWS ON HTA

This issue of the International Journal of Technology Assessment in Health Care (IJTAHC) brings to the readers a lively discussion on the possibility of benchmarking health technology assessment (HTA) organizations. Michael Drummond and colleagues present a paper discussing “the conceptual and methodological challenges associated with benchmarking” (1). They propose a set of criteria for comparing the quality of organizations that produce assessments on health technologies. Aiming at explicit and transparent comparisons, Drummond et al. also highlight the possible problems in their approach, and present their paper as a starting point for discussion.

Implementing a specification for exceptional data in multilevel modeling of healthcare applications

Missing information are key issues for interoperability and semantic coherence in healthcare information systems. This paper presents the implementation of the Exceptional Package in the Multilevel Healthcare Information Modeling (MLHIM) specifications, and it describes two use cases where missing information is critical for decision-making and healthcare technology assessment.

VOLUME 27: STATISTICS AND THANKS

The 27th year of the International Journal of Technology Assessment in Health Care (IJTAHC) introduced major changes in editorial work. Submission processes were modernized by introducing Web-based submission at http://mc.manuscriptcentral.com/thc in September 2010. The change has been a learning process to staff, authors, and reviewers alike. During the transition period, responses were often slower than usual, with occasional technical problems. Now that the change is completed, we expect to get back to normal reviewing times. From this issue onward, all manuscripts, including letters, are accepted through the Web site only.

Research design hierarchy: Strength of evidence in evidence-based dentistry

As practitioners, thinking critically about how we make clinical decisions is important. As educators, we should evaluate how to teach students to make clinical decisions. To make clinical decisions, and to practice modern dentistry and to educate the dental care professionals, the evidence-based dentistry forms an important asset. The cornerstone of evidence-based healthcare and health technology assessment is critical appraisal of the evidence underpinning a finding. The hierarchy of evidence includes several types of studies used to evaluate treatment effects, starting from case reports, observational studies, and randomized controlled trials (RCTs), the tip of which are systematic reviews, which constitute the highest level of evidence because they attempt to collect, combine, and report the best available evidence using systematic, transparent, and reproducible methodology. Clinicians are interested in the highest quality research report available to determine the best therapy for their patients. This article will assist in framing the questions and categorizing the best available evidence. A search was initiated to locate original research articles, review articles, and case reports pertaining to the key words: Evidence-based dentistry, hierarchy of evidence, ladder of evidence, research design hierarchy, strength of evidence. Electronic database was retrieved from PubMed , Google and Google Scholar to search and select keywords related to evidence-based medicine and dentistry. The keywords used were evidence based dentistry, research design hierarchy, evidence based practice, and strength of evidence. This article is the result of a literature study on evidence-based research design hierarchy. Clinical Relevance to Interdisciplinary Dentistry Evidence-based practice (EBP) is an interdisciplinary approach gaining ground after 1992; hence, its usefulness in any discipline is worth the attention. This article explores links between the state of academic and clinical training regarding interdisciplinary EBP and describes strategies to accelerate the translation of evidence across disciplines. This paper examines the concept of hierarchy of research design, barriers and challenges and applying evidence based dentistry in practice.

Editorial: IMA Health 2010

Ten years into the new millennium, health and social care organisations and policymakers are faced with unprecedented demands to increase both the quantity and quality of service delivery [1]. In the wake of the 2008 financial crisis and resulting tight budgetary conditions across most developed countries, these improvements are expected to take place while simultaneously achieving substantial cost savings [2]. The problems are further exacerbated by the changes in demography and the ageing of the population as observed in particular in the developed countries [3]. At the same time and perhaps more alarmingly, improving health in low-income countries is still as big a challenge as it has ever been [4]. Within this context, health and social care systems are undergoing major changes worldwide. Is there a role for mathematical modelling and computer simulation (statistical analysis, stochastic processes, queuing theory, mathematical programming, heuristics, discrete event simulation, system dynamics, etc.) in helping to solve these multifaceted problems? Over the years, extensive research and development has been carried out to find both shortand long-term solutions to issues routinely faced by health and social care professionals, such as the management of waiting lists and bed capacity, clinical pathway redesign, workforce planning and scheduling, performance management, disease monitoring, and health care technology assessment. More recently, the need for more refined and inclusive approaches to modelling and simulation that embrace technical, organisational, clinical, social and experiential considerations has been recognised (www.cumberland-initiative.org). The Institute of Mathematics and its Applications (IMA, www.ima.org.uk), the UK’s learned and professional society for mathematics and its applications, has been organising the IMA International Conference on Quantitative Modelling in the Management of Health Care since 1995. The aim of the conference is to bring together health care managers, clinicians, management consultants, and mathematicians, operational researchers, statisticians, economists and computer scientists from across the world with a view to bridging the gap between the communities and to exploring recent developments and identifying fruitful avenues for further research. The sixth instalment of the conference (IMA Health 2010) was held at Mary Ward House, London, UK between 29 and 31 March 2010. Chaired by Prof Thierry Chaussalet, professor at the University of Westminster it featured four keynote speakers, about 50 oral presentations organised in 14 parallel sessions and over a dozen poster presentations. The keynote speakers included (in order of presentation):

Volume 26: Statistics and thanks

During the 26th year of the International Journal of Technology Assessment in Health Care (IJTAHC), 154 original manuscripts were evaluated. Of these, 70 percent were from Europe and 14 percent from North America, as judged by the address of the first author. At the end of September 2010, sixty-four papers (42 percent of submissions) had been accepted for publication, seventy-two (47 percent) had been rejected, fourteen (9 percent) had been invited to submit a new version, and four (3 percent) were still in review.

International survey on attitudes toward ethics in health technology assessment: An exploratory study

The objective of this exploratory study was to survey international health technology assessment (HTA) professionals to determine attitudes toward ethics in HTA. An exploratory, quantitative, cross-sectional study design was developed. The sample population (n = 636) was selected from authors of the 206 articles published in the International Journal of Technology Assessment in Health Care between 2005 and 2007. A survey instrument was piloted and e-mailed. The response rate was low (n = 104; 16.4 percent). Respondents were primarily middle-aged (46 ± 11 years) male (62 percent) health professionals from Western countries (n = 92; 88.5 percent), with a mean of 10 (± 6 years) years of HTA experience. Although at least 90 percent of respondents agreed that healthcare decisions involved value judgments and that ethical analysis was important to HTA, respondents were divided as to whether normative (n = 45; 44.6 percent) or descriptive (n = 38; 37.6 percent) ethical recommendations were necessary. Most respondents (n = 83; 81.4 percent) believed that HTA should include citizen participation, but two thirds (n = 67; 67.0 percent) agreed that the final decision should be restricted to decision makers. A majority of respondents thought that ethical analysis could be discussed anywhere within the HTA process, either by an expert trained in ethics (n = 62; 60.8 percent) or by an external consultant (n = 80; 78.4 percent). This study showed that ethical discourse in HTA is constrained by practical considerations, which serves to limit moral inquiry. To increase ethical analysis, a positive attitude toward ethics needs to be fostered within the HTA community.

Health Technology Assessment at the University of California-San Francisco

Over the past thirty years, various efforts have been made to align the incentives of hospitals and physicians to control healthcare costs while assuring the provision of high-quality patient care. One innovative strategy used by some hospitals involves the creation of technology assessment programs to develop a more thorough and objective review process for new clinical technology. The University of California-San Francisco Medical Center has been a pioneer in this area. Its physician-led healthcare technology assessment program has been successful in changing the culture of how innovative technology is evaluated and adopted by the hospital and fostering an increased awareness among physicians of the clinical, financial, and programmatic implications of their technology decisions. We explore the operational characteristics and various effects of this program and highlight the key components to its success and opportunities for improvement in the context of its reproduction at other medical centers.

Missing data in trial‐based cost‐effectiveness analysis: the current state of play

Randomised controlled trial (RCT)-based cost-effectiveness analyses, which are prone to missing data, are increasingly used in healthcare technology assessment. This has highlighted the need for appropriate methodological approaches to the handling of missing data. This paper reviews missing data methodology used in RCT-based cost-effectiveness analyses since 2003. Complete case analysis, which may lead to inappropriate conclusions, is still the most popular approach and its use has increased with time. The degree of missing data in cost-effectiveness analyses was often poorly reported and the methodology was often unclear. Reporting of missing data sensitivity analyses would improve article transparency.

A Literature Review of Transmission Effectiveness and Electromagnetic Compatibility in Home Telemedicine Environments to Evaluate Safety and Security

The objective of this study was to determine already reported cases of transmission/reception failure and interferences to evaluate the safety and security of the new mobile home telemedicine systems. The literature published in the last 10 years (1998-2009) has been reviewed, by searching in several databases. Searches on transmission effectiveness and electromagnetic compatibility were made manually through journals, conference proceedings, and also the healthcare technology assessment agencies' Web pages. Search strategies developed through electronic databases and manual search identified a total of 886 references, with 44 finally being included in the results. They have been divided by technology in the transmission/reception effectiveness studies, and according to the type of medical device in the case of electromagnetic interferences studies. The study reveals that there are numerous publications on telemedicine and home-monitoring systems using wireless networks. However, literature on effectiveness in terms of connectivity and transmission problems and electromagnetic interferences is limited. From the collected studies, it can be concluded that there are transmission failures, low-coverage areas, errors in the transmission of packets, and so on. Moreover, cases of serious interferences in medical instruments have also been reported. These facts highlight the lack of studies and specific recommendations to be followed in the implementation of biomonitoring systems in domestic environments using wireless networks.

Integrating local data into hospital-based healthcare technology assessment: Two case studies

Health technology assessment (HTA) programs influence practice on a broad scale through reimbursement decisions or national guidelines. Hospital-based HTA programs inform clinical decisions at the local level. Typically, they do this by adapting general HTA to their local setting, or by creating new HTA. However, unlike payer-based HTA organizations, hospital-based HTA organizations can also integrate local data into their reports. We describe two examples of local data integrated into hospital-based HTA. In the first, qualitative data were used to select a new cardiac catheterization lab. In the second, quantitative data was used to inform a decision on whether to continue telemedicine services to critical care units. Local evidence sources included equipment service records, and interviews with physicians, technicians, and administrative staff in the first example, and the hospital's administrative and claims databases in the second example. In each case, there was little evidence from the peer-reviewed literature that could be applied to the decision. In the first example, staffing patterns and local preferences had considerable bearing on technology choices. In the second example, local outcomes data from administrative records were decisive. Hospital-based HTA using local data can fill gaps in the published evidence, and also improve the generalizability of evidence to the local setting. To take advantage of local evidence, health systems should encourage the development of hospital-based HTA centers, seek out local preference data, and maintain databases of patient outcomes and utilization of services.

Commentary: Health Care Technology and Medical Education: Putting Physical Diagnosis in Its Proper Place

Bemoaning the lost art of the physical exam is an ancient practice, dating back hundreds, if not thousands, of years. Since the introduction of the stethoscope in the early 19th century, the clinical skills of physicians have waned as their dependence on technology has grown. This "lost skills literature" reflects the ambivalent relationship the medical profession has had with its technology, a relationship also dating back centuries. Despite the dominant role played by technology in the life of the 21st-century physician, medical students and trainees do not receive sufficient formal training in its use and assessment. This lacuna in training likely contributes to the well-documented inappropriate use of health care technology that threatens any attempt at improved patient care and reform of the health care system. The author recommends the introduction of a formal curriculum in the use and assessment of health care technology in medical education and training.

Cost Analysis of Interventions for Antimuscarinic Refractory Patients With Overactive Bladder

To estimate average, initial, and cumulative procedure related costs from a US payer perspective extending up to 3 years for the overactive bladder (OAB) interventions: sacral neuromodulation (SNM), intra-detrusor botulinum toxin A (BoNTA), and augmentation cystoplasty (AC) for antimuscarinic refractory patients. Costs (2007 US dollars) were calculated using Current Procedural Terminology (CPT) codes, Ambulatory Payment Classification (APC) codes; Diagnosis Related Group (DRG) payments, and Healthcare Common Procedure Coding System (HCPCS) Level II Codes extracted from the literature and from the SNM device manufacturer. CPT codes were converted to costs using the Center for Medicare and Medicaid Services (CMS) Relative Value Unit (RVU) fee schedule. Sensitivity analyses were performed to evaluate assumptions and uncertainty of results based on plausible variation in estimates of key cost drivers. The initial treatment cost was $22,226, $1,313, and $10,252 for SNM, intra-detrusor injection of BoNTA, and AC respectively. The first-year cost was $23,614, $2626, and $11,637 respectively. Three years after initiating treatment, the cumulative cost was $26,269, $7651, and $14,337 respectively. Sensitivity analyses revealed that SNM persisted as the most costly intervention in all scenarios. The 3-year cumulative cost range produced by the sensitivity analyses for SNM, BoNTA, and AC was $25,384-$27,357, $4586-$11,476, and $12,315-$16,830, respectively. All estimates of cost endpoints for SNM were greater than those for BoNTA and AC. These cost estimates, when combined with data on outcomes and risks, are important components of a robust health care technology assessment of antimuscarinic treatment failure options.

Flagship Ahoy

Welcome to the 26th volume of the International Journal of Technology Assessment in Health Care (IJTAHC). The editorial office has moved from the Institute of Health Economics in Alberta, Canada, to the National Institute for Health and Welfare (THL) in Finland and its Finnish Office for Health Technology Assessment (FINOHTA). It is exciting and challenging to take the helm of this journal. Knowing its history and cherishing its strengths, I wish to keep the HTA community engaged in making and using the journal as its scientific sounding board and its flagship.

“Insufficient Evidence of Effectiveness” Is Not “Evidence of No Effectiveness:” Evaluating Computer‐Based Education for Patients with Severe Mental Illness

This article reports on commissioned research funded by the Swedish Council of Technology Assessment in Health Care (SBU) and the Swedish Nursing Society (SSF). The objective was to review computer-based education programs. However, as the review produced insufficient evidence of effectiveness, the publication was withheld due to a previous incident where such evidence was misunderstood by Swedish policy and health care decision makers. This article highlights the concept of evidence with regard to the consequences of insufficient evidence of effectiveness being mistaken for evidence of no effectiveness. The aim is also to present a systematic review evaluating a computer-based education program for patients suffering from severe mental illness. Systematic database searches in Medline, CINAHL, PsycINFO and the Cochrane Library identified a total of 131 potentially relevant references. Thereafter, 27 references were retrieved as full-text documents, of which 5 were finally included and co-reviewed by two independent researchers. The review found no decisive evidence of effectiveness regarding computer-based education programs designed to assist persons suffering from severe mental illness. Failing to see the difference between insufficient evidence and evidence of no effectiveness may have unexpected consequences. As a result, practice may be misguided and treatments withheld, which at worse may have harmful consequences for patients. In the end, it is of utmost importance that researchers do good quality research by ensuring statistical power and quality of outcome measurement. For example, this review of computer-based education programs could have revealed effective ways of dealing with severe mental illness if the studies included had been conducted using more sophisticated designs.

The history of the International Journal of Technology Assessment in Health Care – Corrigendum

The history of the <i>International Journal of Technology Assessment in Health Care</i> – Corrigendum

History of healthcare technology assessment in Japan

There has been a rapid growth of healthcare technology assessment (HTA) activities among health service researchers and physicians in Japan in the younger generation since the mid-1980s. HTA has become visible since the Ministry of Health, Labor, and Welfare (MHLW) set up the several committees related to HTA in the late 1990s. The MHLW had to participate in regulatory and administrative reform, coping with the serious economic stagnation since 1991, following the economic recession in the 1980s. However, HTA has not been developed as expected. The most important failure is that the application of HTA to health policy has been neglected by the MHLW. Only application to clinical practice has been implemented by developing evidence-based clinical practice guidelines. The MHLW had the main aim of containing costs by reducing excess or useless healthcare services through guidelines, rather than to implement a radical reform. Without a central organization for HTA, several researchers have still continued to do HTA studies, but most researchers and physicians promoting HTA have been moved into diverse related areas. Ultimately, increasing efficiency may be the only way of reconciling rising demands for health care with public financing constraints. Therefore, the reconsideration and reorganization of HTA, which covers not only healthcare services but also the healthcare system as a whole, is becoming an urgent matter for healthcare reform.

History of the international societies in health technology assessment: International Society for Technology Assessment in Health Care and Health Technology Assessment International

The International Society for Technology Assessment in Health Care (ISTAHC) was formed in 1985. It grew out of the increasing awareness of the international dimensions of health technology assessment (HTA) and the need for new communication methods at the international level. The main function of ISTAHC was to present an annual conference, which gradually grew in size, and also to generally improve in quality from to year. ISTAHC overextended itself financially early in the first decade of the 2000s and had to cease its existence. A new society, Health Technology Assessment international (HTAi), based on many of the same ideas and people, grew up beginning in the year 2003. The two societies have played a large role in making the field of HTA visible to people around the world and providing a forum for discussion on the methods and role of HTA.

Health technology management in Israel: HTA in action

The aim of this study was to describe the history and present situation with health technology assessment (HTA) in Israel. The method used in this study was a historical analysis based mainly on the knowledge of the authors, but supplemented by the published literature. HTA originated in Israel as a centralized function conducted under the auspice of research, developing into an active multidisciplinary center. Throughout the expansion of the field, HTA was performed in affiliation with several local and international bodies, while providing direct and indirect support at the national level. Today, mainly as a result of vigorous dissemination of the principles, methodology and tools for HTA by the Israeli Center for Technology Assessment in Health Care (ICTAHC), this discipline is increasingly a decentralized activity conducted by a great variety of institutions. Israeli health policy decisions are increasingly based on the results of HTA. ICTAHC's role and functioning has expanded since its beginnings. HTA has become an important part of health care in Israel.

The history of the International Journal of Technology Assessment in Health Care

The 1970s and early 1980s was the period in which high technology medicine became dominant. It had begun in the late 1950s with the introduction of effective artificial respiratory technology. This gave physicians, patients, and families the hope that the threats to fundamental life processes such as breathing could be countered by technology, and the dilemma of both meeting its costs and the ethical challenges of how to remove it when its use no longer produced benefits.