A GLOBAL PERSPECTIVE ON HEALTH TECHNOLOGY ASSESSMENT

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A GLOBAL PERSPECTIVE ON HEALTH TECHNOLOGY
ASSESSMENT

• H. David Banta, MD, MPH

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Some problems with health technology

• Efficacy (benefits)
• Safety
• Financial costs (and cost-effectiveness)
• Social
• Ethical
• Institutional

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The case of the computed tomography (CT) scanner

• Rapid diffusion beginning in 1972
• No well-designed studies of efficacy until later
• Excellent and exciting pictures of the inside of
  the human body
• High profits to be made (USA)
• Magnetic resonance imaging (MRI) had a similar
  pattern 15 years later
• Positron emission tomography (PET) repeating the
  story now

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The case of electronic fetal monitoring (EFM)

• Rapid diffusion into health care during 1970s
• Claims of substantial benefits in terms of fetal
  deaths and injuries not backed by studies
• Synthetic studies (systematic reviews) in 1970s
  and 1980s showing no benefits
• Use has continued without much change

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The case of diethylstilbesterol (DES)

• Synthetic estrogen introduced in late 1930s
• Claims of substantial benefits to mother and
  child, especially in terms of averted
  miscarriages
• Claims not supported by studies
• From 1973, cases of clear-cell adenocarcinoma of
  the vagina in DES daughters
• Other complications gradually emerged (sons,
  mothers)
• Use continues in many parts of the world,
  although not North American or Europe

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Changes since the time of these cases

• Greatly expanded number of randomized clinical
  trials (RCTs)
• Frequent systematic reviews of the literature,
  following established standards
• Data bases making studies more available
  (Cochrane, HTA database, many others)
• Evidence-based medicine seems to be the norm (in
  terms of lip-service?)

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Problems with health technology continue

• Health systems filled with unproven, dangerous
  and costly technology
• Some examples
• Machines for physiotherapy
• Occupational therapy
• Many drugs with marginal or few benefits
  Alzheimer drugs a current example
• Overuse of traditional surgical procedures
  tonsillectomy, hysterectomy

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Health technology assessment is not only for the
purpose of keeping technology out of the system
also should facilitate entry when this is
justified

• Prevention is an undervalued and underused set of
  technologies
• Therapies also not always used properly -
  thrombolysis

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Health technology assessment is a structured
analysis of a health technology, a set of related
technologies or a technology-related issue that
is performed for the purpose of providing input
to a policy decision. It encompasses safety,
efficacy (benefits), costs and cost-effectiveness,
organizational implications, and social and
ethical issues.
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Health Technology

• Drugs
• Devices
• Medical and surgical procedures
• And the organizational and support systems within
  which health care is delivered

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Purposes of health technology

• Prevention
• Diagnosis
• Treatment
• Rehabilitation.

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Health policies that may be related to HTA

• General public health policies
• Research and development
• Regulation of pharmaceuticals and equipment
• Payment for services
• Quality assurance
• Education and training of providers
• Consumer education

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Establishment of public programs for HTA

• 1970s the USA was the leader later, changes
  in health care emphasis
• 1987 Swedish Council for HTA (SBU)
• 1990 Canada, Australia and Western Europe
• Gradual spread throughout the world All of the
  European Union, Latin America, Asia, Israel
• Africa only continent where HTA almost does not
  exist

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Important international supporters for HTA

• World Bank China, Malaysia, Poland and other
  Eastern European countries
• World Health Organization many useful
  conferences and consultations
• PAHO (WHO for Americas) - promoted HTA in
  individual member states since mid-1980s

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The Present

• HTA is institutionalized at the national policy
  level in about 50 countries, plus some regional
  and provincial programs
• HTA an important force in (perhaps) 10 countries
• HTA is growing in importance in all of these
  areas, and spreading into middle-income countries
• BUT poorer countries essentially left out

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Concerns for the future

• Apparent lack of will of governments to intervene
  in health care to improve the health of their
  populations
• National focus on costs of care (and not quality)
  although costs is a legitimate concern
• Role of industry a pervasive force in health
  care. Partnerships? With firms whose primary
  motivation is profits?

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Trends in the future

• New and continued efforts to assure
  implementation of HTA results example of UK,
  also point to Sweden, the Netherlands, France,
  Malaysia
• More emphasis on financial mechanisms, especially
  payment for services to assure appropriateness
  and high quality

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Closing points

• Development of HTA is becoming an important force
  in the world today - movement toward HTA and
  evidence-based medicine has been called the
  third revolution in health care
• Slow but steady rate of change
• Aggressive policies toward health technology
  using HTA results are the path to more effective
  health care
• All countries need such policies