Technology
Assessment
10-17-01
Definition – the process
that examines the available evidence to form a conclusion as to the merits
or role of a particular technology in relation to its possible use, purchase
or reimbursement in current medical practice.
It should include efforts
to assess the safety, effectiveness, efficiency and appropriateness of
devices, medical and surgical procedures, and pharmaceuticals promoted
as improving a patient’s condition or quality of life.
Considers these in regards
to maximizing quality – the most effective health care services that medical
science can provide.
Also includes the assessment
of costs to determine whether equipment is appropriate and excluding any
that does not provide any benefit to the patient and promoting that which
does.
Claims of superiority should
be investigated to assure that appropriate experimental testing has been
completed to uphold manufacturer’s claims, or those claims of health care
scientists in improving the treatments.
Categories of technology:
1. Devices
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Diagnostic devices (MRI, CAT,
SPECT, etc.) which help in improving the diagnosis for the patient.
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Treatment devices (lasers, arthroscopes,
angioplastis, etc.) which help limit the invasiveness of surgery and improve
patient outcomes.
2. Procedures
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Medical and surgical procedures
such as radial keratotomy used to improve vision.
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Chorionic villus sampling, a
genetic testing technique.
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Bone marrow transplantation
-
Other examples include the way
we treat head injuries, cancers, joint replacements, etc.
3. Pharmaceuticals
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Determination of efficient and
appropriate uses for drugs approved by the U.S. Food and Drug Administration.
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Procedural aspects of this include
labeling – the exact language used to delineate the clinical use of a drug
(indications, dosage, adverse effects, etc.).
-
Also includes the need to understand
the long-term affects of uses of some drugs, or uses alternative uses for
drugs (e.g., manoxodil) which can also have benefits for other areas.
-
Increased importance of investigating
drug uses are also indicated due to drug resistant strains of viruses which
may be use to overuse of certain antibiotics and allowing the viruses to
build resistance to these medications.
Technology Life Cycle
Investigation – laboratory and
clinical studies to discover or create, refine and package a new diagnostic
or treatment modality.
Promotion – introducing the
technology into the buying community.
Acceptance and utilization –
incorporating the technology into practice.
Decline – as the technology
is increasingly supplanted by superior new technology.
Obsolescence – when the new
technology is obsolete and no longer appropriate.
Targeting Technologies
for Assessment
As recommended by the Council
on Health Care Technology of the Institute of Medicine, selection criteria
should include:
-
Improve individual patient outcome
-
Positively affect a large population
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Reduce treatment costs
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Reduce unexplained treatment
variation.
Other organizations involved
include HCFA, NIH, National Institutes of Health Office of Medical Applications
and Research.
Essentially, these look at
3 components:
1. High Utilization
-
Rapidly increase uses of a technology
may signal inappropriate or excessive utilization. (e.g., Cesarean births
rates)
-
Uses of high technology for
common conditions may be inappropriate
-
E.g., use of mammography for
women under the age of 50 has sparked controversy on the practice of high
technology.
2. High Potential for Harm
-
Requires different standards
and assessment priorities for different risk factors in patients.
3. High Cost – payers may be
unwilling to pay form some technological procedures or diagnoses.
How Technology Assessment
is Performed
1. Literature Review and
Synthesis – review of primary medical literature is a requirement for every
evaluation effort.
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Consider quantitative measures
(statistically significant findings; e.g., p. <.05).
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Consider
the source of the reviews
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How and
why the study was performed?
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What interventions
were made during the study?
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Who were
the study subjects?
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How was
the study analyzed?
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Were the
results meaningful?
2. Consensus
Panels – experts review testimony from the scientific literature and seek
input from consumers and medical professionals.
-
Standards
may be adopted by a number of review boards for specific specialties or
national associations (NCQA)
3. Meta-Analyses
– summarizes the treatment effect obtained from a comprehensive determination
of the pool of available published studies. This compares the findings
and methodologies for similarities. Takes the information and pools it
into statistical analyses.
4.
Outcomes Assessment – compares the performance of a technology against
standards established or recommended by expert bodies.
-
Different
organizations are developing their own standards by which to measure treatment
procedures (AMA today announced that they will be keeping statistical analysis
on the outcomes of physicians which will be open for review for everyone
but the public.
-
Agency
for Health Care Policy Review is at the forefront of this information.
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Comparing
consequences of doing nothing against the potential benefits of doing something.
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Summarizing
the harmful effects of the technology (side effects and toxicity)
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Identifying
patients who are at high risk and those most likely to respond to therapy.
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Incorporating
measures that allow clinicians and their patients to evaluate directly
the benefits and risks of alternative therapies.
5. Randomized
Clinical Trials – focused randomized, controlled, clinical trials are the
"gold standard" of assessment. Should include "blinding" of physicians
and patients regarding treatment assignment (double blind), hard end points
not susceptible to other treatments, and other assessment factors pertinent
to the methodology used in the study.
Agencies
Conducting Technology Assessment
U.S. FDA
Agency
for Health Care Policy and Research (DHHS)
American
College of Physicians
American
Medical Assn.
Blue Cross
and Blue Shield
ECRI
Office
of Health Technology Assessment
Office
of Technology Assessment
University
Hospital Consortium
Problems
in Performing Technology Assessment
Lack of
Evidence (not enough literature or patients to study, or poorly conducted
research)
Lack of
Agreement on How to Perform the Assessment (may lead to different results
using different techniques)
Inconsistent
Evidence (may result from different or inconsistent research methods)
Legal
Interference (can be influenced from biased resources)
Breadth
of Topics (difficult to successfully study or assess all technologies)
New Information
(assessment process must be ongoing to adequately compare new uses)
Technology
and Health Care Reform
Ever-changing
technology contributes to the turbulence or "white water change" of health
care. While technology has contributed to greater success in diagnosis
and treatment of diseases, it has also contributed to the rapid growth
of health care expenditures.
Higher
rate of technology has also resulted by an increase in the specialty professions
of physicians who are likely to use the tools available to them to perform
the greatest maximum of health care services. But at what cost?
The
challenge for health care organizations and professionals will be how to
control the effective use of this technology.
Clinical
decisions and protocols are likely to be developed as to what types of
patients will warrant use of high cost technology.
In
the recent past, physicians and health care providers were likely to practice
defensive medicine to avoid litigious complications. This practice led
to unnecessary and expensive diagnostic procedures. While the introduction
of managed care has impacted that to some extent, there are some out there,
physicians included, who claim that managed care has gone too far and has
resulted in denying necessary treatments or diagnostics to patients.
Only
through continual review by reliable organizations can the appropriate
allocation of scarce resources be determined. These reviews will result
in clinical guidelines and protocols on the appropriate uses of technology.
Terms
Technology
Assessment Defined
Relationship
to Quality
Categories
of Technology (Devices, Procedures, Pharmaceuticals)
Technology
Life Cycle
Factors
for determining the use of technology
Tools
to assess technology and assessment problems
Examples
of agencies assessing technology
Technology
and Health Care Reform
Be
able to identify at least 2 technology devices from COMA Video
What
organization is likely to consider the procedure in COMA Video
Major
benefit of the procedure used in COMA Video