Health Care Technology Assessment Research Articles

Organizing mental health services: an evidence‐based approach

Background and Aims. Health policy makers and program developers seek evidence-based guidance on how to organize and finance mental health services. The Swedish Council on Technology Assessment in Health Care (SBU) commissioned a conceptual framework for thinking about health care services as a medical technology. The following framework was developed, citing empirical research from mental health services research as the case example. Framework. Historically, mental health services have focused on the organization and locus of care. Health care settings have been conceptualized as medical technologies, treatments in themselves. For example, the field speaks of an era of ‘asylum treatment’ and ‘community care’. Hospitals and community mental health centers are viewed as treatments with indications and ‘dosages’, such as length of stay criteria. Assessment of mental health services often has focused on organizations and on administrative science. There are two principal perspectives for assessing the contribution of the organization of services on health. One perspective is derived from clinical services research, in which the focus is on the impact of organized treatments (and their most common settings) on health status of individuals. The other perspective is based in service systems research, in which the focus is on the impact of organizational strategies on intermediate service patterns, such as continuity of care or integration, as well as health status. Methods. Examples of empirical investigations from clinical services research and service systems research are presented to demonstrate potential sources of evidence to support specific decisions for organizing mental health services. Results. Evidence on organizing mental health services may be found in both types of services research. In clinical services research studies, service settings are viewed as treatments (e.g. ‘partial hospitalization’), some treatments are always embedded in a service matrix (e.g. assertive community treatment), and, where some treatments are organizationally combined (e.g. ‘integrated treatment’ for co-occurring mental disorder and substance abuse), sometimes into a continuum of care. In service system research, integration of services and of the service system are the main focus of investigation. Studies focus on horizontal and vertical integration, primary care or specialty care and local mental health authorities—each of which may be conceptualized as a health care technology with a body of evidence assessing its effectiveness. Implications. A conceptual framework for assessing the organization of services as a health care technology focuses attention on evidence to guide program design and policy development. Mental health services research holds promise for such decision-making guidance. Copyright © 2000 John Wiley & Sons, Ltd.

Health technology assessment in Sweden.

Sweden has a welfare system that is based on the fundamental principle that all citizens are entitled to good health and medical care, regardless of where they live or what their economic circumstances are. Health and medical care are considered to be public sector responsibilities. However, there is growing interest in establishing more private alternatives to public care. An important characteristic of the Swedish healthcare system is its decentralization, with a major role for county councils. County councils are now merging into larger administrative units (region). The whole Swedish system is in the process of reform, mainly because of perceptions that it was too rigid and had insufficient patient orientation. An important factor in the reforms is that power in the system will be even more decentralized and will have greater public input. This change is seen as calling for increased central follow-up and evaluation of matters such as social, ethical, and economic aspects. Although the state has decentralized control, it still attempts to control the general direction of the system through regulation, subsidy, recommendations, and guidelines. An important actor in the system is the Swedish Council on Technology Assessment in Health Care (SBU). SBU began in 1987 with assessments of health technologies, but its success has recently led policy makers to extend its coverage to dental care. Health technology assessment is increasingly visible to policy makers, who find it useful in decision making.

Health technology assessment in Germany. Status, challenges, and development.

The objectives of this paper are to describe the status and development of health technology regulation with regard to coverage decisions and utilization, and to analyze the current situation of health technology assessment (HTA) in Germany. The relevant literature for controlling health technologies was identified by searching the literature and databases and through personal contacts. The literature was analyzed with regard to the different sectors in the healthcare system. For the analysis of the current state of HTA in Germany, a national survey was carried out. In addition, the names of topics under assessment were collected. The results show that coverage decisions in the ambulatory sector appear to be much more regulated than those in the inpatient sector. The same is true for diffusion and usage of technologies. The strict separation of the hospital and the ambulatory care sector in Germany constitutes a barrier to regulation and to making HTA an effective instrument in Germany. Until recently, HTA in Germany focused on biotechnology, such as gene technology. Recently the German Scientific Working Group of Technology Assessment in Health Care has adopted a systematic methodology to undertake HTAs. It can be concluded that regulation of health technologies in Germany is characterized by inconsistencies ranging from strict regulation in the ambulatory sector to almost no regulation in the rehabilitation sector. Increasing interest in HTA, in conjunction with a high priority assigned to evaluation of health technologies by the newly elected government, is likely to improve this situation in the future.

Discourse and Morality

Previous articleNext article No AccessDiscourse and Morality*Christopher McMahon Christopher McMahon Search for more articles by this author PDFPDF PLUS Add to favoritesDownload CitationTrack CitationsPermissionsReprints Share onFacebookTwitterLinkedInRedditEmail SectionsMoreDetailsFiguresReferencesCited by Ethics Volume 110, Number 3April 2000 Article DOIhttps://doi.org/10.1086/233322 Views: 51Total views on this site Citations: 13Citations are reported from Crossref © 2000 by The University of Chicago. All rights reserved.PDF download Crossref reports the following articles citing this article:Longtao He The Path to a Culturally Integrated Foucauldian Discourse Analysis, (Aug 2021): 111–152.https://doi.org/10.1007/978-981-16-1880-2_5Suzie Kim On the need for real dialogue: What's wrong with monological contractualism?, European Journal of Philosophy 27, no.44 (Nov 2018): 939–956.https://doi.org/10.1111/ejop.12421Cristian Tileagă Transgression and the Social Construction of Moral Meanings, (Oct 2018): 179–208.https://doi.org/10.1007/978-3-319-97394-4_8Norman Daniels, Gert Jan van der Wilt HEALTH TECHNOLOGY ASSESSMENT, DELIBERATIVE PROCESS, AND ETHICALLY CONTESTED ISSUES, International Journal of Technology Assessment in Health Care 32, no.1-21-2 (Jul 2016): 10–15.https://doi.org/10.1017/S0266462316000155William Rehg Discourse ethics for computer ethics: a heuristic for engaged dialogical reflection, Ethics and Information Technology 17, no.11 (Dec 2014): 27–39.https://doi.org/10.1007/s10676-014-9359-0Nick O'Donovan Does deliberative democracy need deliberative democrats? Revisiting Habermas’ defence of discourse ethics, Contemporary Political Theory 12, no.22 (Aug 2012): 123–144.https://doi.org/10.1057/cpt.2012.13Kenneth Baynes Critical Theory, (Feb 2013).https://doi.org/10.1002/9781444367072.wbiee579Cristian Tileagă The right measure of guilt: Moral reasoning, transgression and the social construction of moral meanings, Discourse & Communication 6, no.22 (May 2012): 203–222.https://doi.org/10.1177/1750481312437443Andrew Mason Rawlsian Theory and the Circumstances of Politics, Political Theory 38, no.55 (Jun 2010): 658–683.https://doi.org/10.1177/0090591710372862STEFAN RUMMENS Democratic Deliberation as the Open-Ended Construction of Justice, Ratio Juris 20, no.33 (Sep 2007): 335–354.https://doi.org/10.1111/j.1467-9337.2007.00364.xJeffery D. Smith A precis of a communicative theory of the firm, Business Ethics: A European Review 13, no.44 (Oct 2004): 317–331.https://doi.org/10.1111/j.1467-8608.2004.00373.xWilliam Rehg Grasping the Force of the Better Argument: McMahon versus Discourse Ethics, Inquiry 46, no.11 (Mar 2003): 113–133.https://doi.org/10.1080/00201740304524James Gordon Finlayson, Jude Browne Women and the standpoint of concrete others, (): 13–51.https://doi.org/10.1017/CBO9781139855938.002

Health technology assessment in Finland.

Finland has a long tradition of supporting social programs that promote equality and the welfare state. The healthcare system is financed mainly by taxation. Everyone is insured against illness. Each of Finland's five provinces is run by a provincial government that monitors the provision of social welfare and health care. However, the municipalities actually provide the services and regulate medical equipment and regionalization of services. During the early 1990s, gross domestic product (GDP) fell dramatically, and healthcare expenditure rose to 9.4% of GDP. Due to the economy's rapid recovery, the share of healthcare expenditure has again decreased and now matches the average level of OECD countries of approximately 7.7%. The former Finnish method of central planning and norm setting has guaranteed a fairly uniform development of necessary services throughout the country and free or low-cost access. Tight central planning did not, however, create incentives to contain costs. Therefore, in the beginning of the 1990s, decision-making power was largely decentralized to the municipalities, and the principles of state subsidies were reformed. In 1995, the Finnish Office for Health Care Technology Assessment (FinOHTA) was set up as a new unit of the National Research and Development Centre for Welfare and Health (STAKES). FinOHTA is intended to function as a national central body for advancing HTA-related work in Finland, with the ultimate goal of promoting the effectiveness and efficiency of Finnish health care. At present, the importance of HTA is widely recognized in Finland, especially in the face of rising healthcare costs.

Organizing mental health services: an evidence-based approach.

BACKGROUND AND AIMS: Health policy makers and program developers seek evidence-based guidance on how to organize and finance mental health services. The Swedish Council on Technology Assessment in Health Care (SBU) commissioned a conceptual framework for thinking about health care services as a medical technology. The following framework was developed, citing empirical research from mental health services research as the case example. FRAMEWORK: Historically, mental health services have focused on the organization and locus of care. Health care settings have been conceptualized as medical technologies, treatments in themselves. For example, the field speaks of an era of "asylum treatment" and "community care". Hospitals and community mental health centers are viewed as treatments with indications and "dosages", such as length of stay criteria. Assessment of mental health services often has focused on organizations and on administrative science. There are two principal perspectives for assessing the contribution of the organization of services on health. One perspective is derived from clinical services research, in which the focus is on the impact of organized treatments (and their most common settings) on health status of individuals. The other perspective is based in service systems research, in which the focus is on the impact of organizational strategies on intermediate service patterns, such as continuity of care or integration, as well as health status. METHODS: Examples of empirical investigations from clinical services research and service systems research are presented to demonstrate potential sources of evidence to support specific decisions for organizing mental health services. RESULTS: Evidence on organizing mental health services may be found in both types of services research. In clinical services research studies, service settings are viewed as treatments (e.g. "partial hospitalization"), some treatments are always embedded in a service matrix (e.g. assertive community treatment), and, where some treatments are organizationally combined (e.g. "integrated treatment" for co-occurring mental disorder and substance abuse), sometimes into a continuum of care. In service system research, integration of services and of the service system are the main focus of investigation. Studies focus on horizontal and vertical integration, primary care or specialty care and local mental health authorities - each of which may be conceptualized as a health care technology with a body of evidence assessing its effectiveness. IMPLICATIONS: A conceptual framework for assessing the organization of services as a health care technology focuses attention on evidence to guide program design and policy development. Mental health services research holds promise for such decision-making guidance.

Healthcare systems and end-stage renal disease (ESRD) therapies--an international review: access to ESRD treatments.

Assessment of healthcare technology and economics can be used to assess the access to healthcare, its quality and efficacy as well as its cost and cost efficiency. This report addresses these issues for the provision of care for end-stage renal disease (ESRD) patients. An international comparison of access to ESRD treatment modalities was made with reference to the healthcare provider structure in a range of industrial countries. The countries were grouped into 'public' (Beveridge model), 'mixed' (Bismarck model) and 'private' (Private Insurance model). In 'public' provider countries, 20-52% of dialysis patients are treated with home therapies (haemodialysis and peritoneal dialysis), and the number of patients with renal transplants is 45-81% of all ESRD patients. In 'mixed' provider countries, only 9 17% of all dialysis patients are treated with home therapies, and 20-48% of ESRD patients have renal transplants. In 'private' provider countries, 17% of US and 6% Japanese dialysis patients are treated with home therapies. Japan has 0.3% and the US has 26% of ESRD patients who receive renal transplants. It thus seems that provider structure influences access to and choice of ESRD treatment. With a growing elderly population and longer life expectancy, there will be an increased requirement for ESRD treatments in all industrial countries. Equal access to, and quality of ESRD care in the future will require adequate funding and reimbursement strategies in a cost-constrained healthcare environment. growing elderly population, new and innovative healthcare technologies, increasing expectations of the population and the dilemma of economic constraints. Therefore, new disciplines such as health technology assessment and healthcare economics are developing to support the needs of health policy decision makers. Their main objective is to create a balance between the three key factors of a healthcare system: access to healthcare (equity for all), quality of healthcare (efficacy) and finally the cost or cost efficiency of healthcare provision [1; see also Lameire et al., this issue]. This report will assess access to healthcare in a very specific and very costly area that of end-stage renal disease (ESRD). An international comparison of access to ESRD treatment for patients from a series of industrial countries will be used as a means for evaluation of this access.

Ethical issues in the economic assessment of health care technologies.

This paper challenges traditional views which oppose health economics and medical ethics by arguing that economic assessment is a necessary complement to medical ethics and can help to improve public participation and democratic processes in choices about resource allocation for health care technologies. In support of this argument, four points are emphasized: (1) Most current biomedical ethical debates implicitly deal with economic issues of resource allocation. (2) Clinical decisions, which usually respect the Hippocratic code of ethics, are nevertheless influenced by economic incentives and constraints. (3) Economic assessment is concerned with both efficiency and equity and potential trade-offs between the two, which means that ethical judgements are always embedded in welfare economics. (4) The real debate is not between economics on the one side and medical ethics on the other. Rather it is between different ethical conceptions of social justice and the contrasting approaches they entail to reconciling individual interests and preferences with collective goods and welfare.

Assessing the costs of healthcare technologies in clinical trials.

Assessing the costs of healthcare technologies in clinical trials.

Report from the Department of Epidemiology, Social Medicine, and Health System Research, Medizinische Hochschule Hannover, Germany.

The Department of Epidemiology and Social Medicine at the Medizinische Hochschule Hannover is one of the leading university-based public health departments in Germany. It is divided into units for health system analysis, epidemiology, prevention, and health economics. The department offers a postgraduate master's degree program in public health. The staff number is approximately 25, two-thirds of whom are researchers. The German Federal Ministries of Health and of Education, Science, Research, and Technology are the major providers of research grants. The department is the managerial focus of the North German Center for Public Health Research. Internationally, the department is an active member of the International Society of Technology Assessment in Health Care (ISTAHC), the European Healthcare Management Association (EHMA), and the International Society for Quality Assurance (ISQua). The department has been involved in several European-wide studies and collaborates with the World Health Organization (WHO).

Lipid-lowering drug use must be based on evidence of cost effectiveness

The majority of lipid-lowering drug prescriptions dispensed in the Canadian province of British Columbia are for population groups for which there is no research evidence to support the use of such drugs. So says Dr Isabelle Savoie from the British Columbia Office of Health Technology Assessment, Vancouver, Canada. She made this comment at the 14th Annual Meeting of the International Society of Technology Assessment in Health Care (ISTAHC) [Ottawa, Canada; June 1998] during a presentation of pharmacoeconomic studies of lipid-lowering drug therapy. The preliminary results of Dr Savoie’s study1and those of other of presenters at the session are discussed below.

Complementary medicine conquers new ground. 14th Annual Meeting of The International Society of Technology Assessment in Health Care (ISTAHC).

Complementary medicine conquers new ground. 14^th Annual Meeting of The International Society of Technology Assessment in Health Care (ISTAHC).

Dominance for donepezil in the treatment of mild-to-moderate AD

T he results of a Canadian pharmacoeconomic modelling study show that the acetylcholinesterase inhibitor donepezil is dominant over the alternative of no donepezil in the treatment of patients with mild-to-moderate Alzheimer’s disease. That is, donepezil not only saves costs but reduces the time spent with severe disease. The results of this modelling study were presented by Dr Bernie O’Brien from McMaster University in Hamilton, Canada, at the 14th Annual Meeting of the International Society of Technology Assessment in Health Care [ Ottawa, Canada; June 1998 ]. *

The scientist-practitioner in the twenty-first century

The development of the role of the scientist­ practitioner may be a powerful way of meeting the demands of providing effective, high-quality care at a reasonable cost in the next century. The four commentaries provide impressive and thought­ ful depth to the issues raised in the Focus article as well as pointing out potential weaknesses. I am sincerely grateful for the insights provided. I especially relished the suggestions provided for improving evidence-based prac­ tice (ESP) and the transfer of knowledge from research to clinical practice. Clearly, there is considerable labor and cooperation needed from us all, if our common goal of providing the best possible pain management is to be met; however, if we do not realize that the behavior of health care practitioners is governed by much more than evidence summarized in a meta-analysis, the results may be disappointing and far from maximal. The great need for pain relief demands continual advancements in clinical practice and ESP is designed to enhance this process. Consequently, ESP is a wel­ come tool. A basic part of ESP is to obtain the latest information, and here meta-analysis is put forth as a means of objectively summarizing the results of several trials. These basic aims are worthy objectives indeed, and I not only endorse them, I also attempt to employ ESP. In addition, I am also involved in documenting the best evidence regarding neck and back pain treatment, along with a panel of others, for the Swedish Council on Technology Assessment in Health Care. Thus, I recog­ nize the need for summaries as well as ESP. Neverthe­ less, the Focus article, as the title implied, was designed

The early experiences of a national system for the identification and assessment of emerging health care technologies in Sweden.

This article presents the experiences from a pilot study and the establishment of a permanent system called SBU Alert. The question of establishing a system for the identification and assessment of emerging technologies in health care in Sweden has been on the agenda since the late 1980s. The demand came primarily from policy makers. The pilot study showed that the awareness of the project in the target group (politicians, leading managers, hospital directors, and senior medical advisors) was high. Almost all of those who replied to an assessment questionnaire were in favor of a continuation of the work. In 1997, the Swedish Council on Technology Assessment in Health Care (SBU) was selected to establish a permanent organization. This work has resulted in the identification of a number of methodological problems and tentative solutions concerning all components in the SBU Alert system. We have found that a system for systematic identification and early assessment of emerging technologies is a new and promising tool in the health technology assessment arsenal. Still, experiences are limited. Methodology and the impact of early judgments on decision making need further evaluation.

Report from the Swedish Council on Technology Assessment in Health Care (SBU). Treatment with neuroleptics.

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The new realities in health care technology assessment in US institutions

Changes in US health care financing have prompted changes in technology assessment in US health care institutions. Emphasis is shifting from capital budgeting proposals in support of revenue enhancement to marginal cost analysis in support of cost-reducing measures. This requires skills related to marginal cost finding and analysis, detailed process and activity mapping, outcome mapping, and integrative modelling. The implementation of these skills also calls for structural adjustments related to top management involvement and governance processes, multidisciplinary analysis teams, financial management outside of capital budgeting, and institutional values with respect to resource allocation, skills which many institutions currently lack. If they are not to be at the mercy of vendors and payers who are trying to specify the technologies to be used, they must be equipped to make independent judgments about efficiency, effectiveness, quality and value.

An early system for the identification and assessment of future health care technology. The Dutch STG Project.

This article is based on the report, Anticipating and Assessing Health Care Technology, written in the Netherlands between 1985-88. The project was carried out because of increasing concern in the Dutch Ministry of Health (STG, then WVC) about the costs and benefits of new technologies for health care. At that time, there were no established models for early identification, so the project was not only the most extensive such effort to that date, but had to develop its own methods. Overseen by a special commission, the project staff identified many future and emerging technologies in health care and assessed selected technologies. Although the actual information produced was quickly dated and the project was discontinued in 1988, it did stimulate the Ministry of Health to ask the Dutch Health Council (Gezondheidsraad) to continuously identify important new technologies. The reports also demonstrated the potential usefulness of such an effort to Dutch policy makers, and probably to those in other countries as well.

A model of cost-outcome analysis for assistive technology

During the CERTAIN study (research carried out in 1994–96 within the Technology Initiative for Disabled and Elderly (TIDE) programme of the European Union), a number of real life case studies of provision of assistive technology to disabled persons were investigated in order to assess the applicability of socio-economic principles, methods and techniques already available from Health Care Technology Assessment studies. A retrospective study on cost, effectiveness and utility resulting from the implementation of assistive technology was carried out over a sample of disabled persons who had adopted technical aids before the start of the project. The sample was selected in such a way to include different pathologies (steady or progressive), impairments, ages, technology and social environment. Each case was described by considering all clinical, technical and social aspects; a common structure for case reporting was developed and tested; attempts were carried out to apply and refine concept and tools derived from health technology assessment studies; on the grounds of such experience a decision support model was elaborated for the choice between different alternatives in order to maximize the client's quality of life while making efficient use of scarce resources. A computer implementation of such a model was also developed, along with a mathematical structure of cost analysis. Within a national research programme such findings were further exploited, leading to the development of a prototype cost-outcome instrument designed for use in clinical practice in the provision of assistive technology to individual cases.

Ethical issues in technology assessment. Conceptual categories and procedural considerations.

The practice of health care technology assessment involves ethical considerations in all of its varied functions and techniques. Ethical issues in technology assessment can be grouped into the broad categories of normative concepts, diagnosis, prevention and therapy, research and the advancement of knowledge, and allocation of resources. Moreover, the ethics of the assessment process itself must be evaluated in terms of the integrity of the project's goals, procedures, and effects, and evaluators' open and self-critical acknowledgment of their purposes. As a relatively new field, technology assessment can benefit from using a variety of analytic approaches as it works to develop its own methods for evaluating ethical issues related to technology.