EDITORIALS * EDITORIAUX
Helhcr.eholg
seset
Healt care teehnology assessment: linking science and policy-making
Renaldo N. Battista, MD, ScD, FRCPC
He ealth care technology assessment has gathered momentum in Canada in recent years. The creation in 1988 of Le Conseil d'evaluation des technologies de la sante du Quebec, in 1989 of the Canadian Coordinating Office for Health Technology Assessment and in 1990 of the British Columbia Office of Health Technology Assessment testifies to the growing importance of this field of activity in Canadian health care policy-making. It is no coincidence that Canada will host the eighth conference of the International Society for Health Care Technology Assessment, to be held in Vancouver in June 1992. In this context the article by Drs. Andreas Laupacis, David Feeny, Allan S. Detsky and Peter X. Tugwell (see pages 473 to 481 of this issue) is a timely and useful contribution to the debate on how best to assess health care technology. Laupacis and associates have built on the pioneering methodologic contributions of the Canadian Task Force on the Periodic Health Examination,1 which were later adopted and amended by other recommending bodies.2'3 They have expanded the system that assesses the evidence for the effectiveness of technologies to include guidelines for evaluating cost-effectiveness. The authors raise a critical question: Should an economic evaluation become part of any clinical trial of effectiveness, or should it be done only for those interventions found to be effective? The problem is complex and entails a delicate trade-off. A full analysis of cost-effectiveness takes up many resources and much time; furthermore, few people in Canada can competently carry out such analyses. Hence, it might not be feasible to require that all clinical trials include an economic
evaluation, and even if it were feasible the strategy itself might not prove cost-effective. An alternative is to perform a cost-effectiveness analysis after a health care technology has been proven clinically effective. Unfortunately the diffusion of technologies is not a linear process.4 It is difficult enough to contain their spread before effectiveness has been established, and it might prove totally unrealistic to expect, while awaiting cost data, to curb the use of a technology that has been proven effective. A workable solution would be to make it mandatory that a cost-effectiveness analysis be planned concurrently for any clinical trial of effectiveness but that the actual gathering of the cost data be timed with the interim analysis. The cost analysis itself would then be carried out only after evidence of a technology's effectiveness has been found in the analysis. Laupacis and associates rightly point out that "the guidelines are proposed as a necessary but not sufficient step in making decisions about the adoption and utilization of new technologies" and that the "introduction of a new technology is influenced by a combination of effectiveness, economics, ethics and politics." Despite these assertions the proposal of Laupacis and associates as it now stands implies that the policy-making process that introduces new technologies into the health care system could become a very rational and scientifically driven one. Of course, the contribution of rational thinking to policy formulation should be increased, but policymaking will always be a much more complex process than research, because it attempts to integrate many more dimensions, beliefs and values. Scientists and policy-makers do not always un-
Dr. Battista is director of the Division of Clinical Epidemiology, Department ofMedicine, Montreal General Hospital, Montreal,
Que.
Reprint requests to: Dr. Renaldo N. Battista, Division of Clinical Epidemiology, Department of Medicine, Montreal General Hospital, 1650 Cedar Ave., Montreal, PQ H3G 1A4 -
For prescribing information see page 641
CAN MED ASSOC J 1992; 146 (4)
461
derstand each other and at times display a mutual Conferences lack of confidence if not hostility. The fundamental continuedfrom page 457 reason for this difficulty in communication is that 25-29,1992: 12th International Congress of Hospital science and policy-making use very different para- May Engineering (in concurrence with the Hospital-Health digms. Science unfolds according to a positivist Care International Exhibition) paradigm that posits the existence of some "truth," Congress Hall, Bologna, Italy which it seeks to uncover with the use of sophisti- Organizing Secretariat, SENAF, Via Michelino 69, 40127 cated methods concerned with issues of validity, Bologna, Italy; telephone 011-39-51-503318, fax 011reliability and generalizability. Policy-making is an 39-51-505282 interpretive process based on multiple iterations and the integration of several factors. In this context May 26-31, 1992: 5th International Conference on the Cell and Molecular Biology of Chlamydomonas "truth" as such does not exist but, rather, results Asilomar Center, Pacific Grove, Calif. from a complex social interaction. Some authors Dr. GeorgeConference Witman, organizer, Worcester Foundation for have referred to this process as "the science of Experimental Biology, Shrewsbury, MA 01545, muddling through."5 The difficulty with technology (508) 842-8921, fax (508) 842-3915; or Genetics Society assessment is that it tries to bridge the gap between of America, 9650 Rockville Pike, Bethesda, MD 20814, science and policy-making: its roots are in science, (301) 571-1825, fax (301) 530-7079 its foliage is in policy-making. This position is not a comfortable one for the assessors, who can easily be May 29, 1992: Cancer Care in the 90s: a Community Perspective (sponsored by the Canadian Cancer Society accused by scientists of lacking rigour in their [Alberta/Northwest Territories Division], the Alberta methods while being chided by policy-makers for Cancer Board and the University of Calgary) lacking relevance. Orange Health Sciences Centre, University of Theatre, Physicians have realized that their practice enCalgary vironment is being reshaped; making informed Office of Continuing Medical Education, University of choices is unavoidable. There is indeed a new Calgary, 3330 Hospital Dr. NW, Calgary, AB T2N 4N1; "world order" in health care, and physicians are (403) 220-7240, fax (403) 270-2330 being challenged to evolve and adapt to it. This is a time for creative thinking. Scientific information June 2-4, 1992: Bio-Recognition: an International Industrial Biotechnology Conference will always be only one piece (an important one, it is Montreal hoped) of the policy-making puzzle. Our aim as scientists is to make that piece as large as possible. David Smith, Ottawa-Carleton Economic Development Corporation, 111 Lisgar St., Ottawa, ON K2P 2L7; The work by Laupacis and associates is an important (613) 236-3500 step in that direction. June 5-7, 1992: Ontario Fitness Council Conference I thank Drs. Steven Grover and Vivian H. Hamilton for Harmony in Motion providing helpful comments and Ms. Diane Telmosse for Hamilton, Ont. preparing the manuscript. Applications to present, letters of interest and resumes to: Dr. Battista is a research scholar with the National Judi Savage, Chair Program, 7 Alba St., Stoney Creek, Health Research and Development Program, Ottawa. ON L8G lN9
References 1. Canadian Task Force on the Periodic Health Examination: The periodic health examination. Can Med Assoc J 1979; 121:
1193-1254 2. Sackett DL: Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest 1986; 89: 25-35 3. US Preventive Services Task Force: Guide to Clinical Preventive Services, Williams & Wilkins, Baltimore, 1989 4. Rogers EM: Diffusion of Innovations, 3rd ed, Free Pr, New York, 1983
June 8, 1992: 2nd International Symposium on Perinatal Asphyxia Westin Bayshore, Vancouver Mrs. Joan Beards, Perinatal Asphyxia Conference, Education Department, Canadian Medical Protective Association, PO Box 8225, Ottawa, ON KIG 3H7; (613) 236-2100, ext. 238, fax (613) 236-5588 June 9-10, 1992: IMHE - International Meeting on Hospital Economy (in conjunction with the International Symposium on the Planning of Radiological Departments [ISPRAD] VI) Grieg Hall, Bergen, Norway
Official language: English IMHE/ISPRAD VI, c/o Lilly Hausberg, PLUSreiser, PO Box 946, N-5001 Bergen, Norway; fax 011-47-5-47590-20-91
5. Lindblom CE: The science of muddling through. Public Admin
Rev 1959; 19 (spring): 79-88 462
CAN MED ASSOC J 1992; 146 (4)
continued on page 508 LE 15 FEVRIER 1992
Helhcr.eholg
seset
Healt care teehnology assessment: linking science and policy-making
Renaldo N. Battista, MD, ScD, FRCPC
He ealth care technology assessment has gathered momentum in Canada in recent years. The creation in 1988 of Le Conseil d'evaluation des technologies de la sante du Quebec, in 1989 of the Canadian Coordinating Office for Health Technology Assessment and in 1990 of the British Columbia Office of Health Technology Assessment testifies to the growing importance of this field of activity in Canadian health care policy-making. It is no coincidence that Canada will host the eighth conference of the International Society for Health Care Technology Assessment, to be held in Vancouver in June 1992. In this context the article by Drs. Andreas Laupacis, David Feeny, Allan S. Detsky and Peter X. Tugwell (see pages 473 to 481 of this issue) is a timely and useful contribution to the debate on how best to assess health care technology. Laupacis and associates have built on the pioneering methodologic contributions of the Canadian Task Force on the Periodic Health Examination,1 which were later adopted and amended by other recommending bodies.2'3 They have expanded the system that assesses the evidence for the effectiveness of technologies to include guidelines for evaluating cost-effectiveness. The authors raise a critical question: Should an economic evaluation become part of any clinical trial of effectiveness, or should it be done only for those interventions found to be effective? The problem is complex and entails a delicate trade-off. A full analysis of cost-effectiveness takes up many resources and much time; furthermore, few people in Canada can competently carry out such analyses. Hence, it might not be feasible to require that all clinical trials include an economic
evaluation, and even if it were feasible the strategy itself might not prove cost-effective. An alternative is to perform a cost-effectiveness analysis after a health care technology has been proven clinically effective. Unfortunately the diffusion of technologies is not a linear process.4 It is difficult enough to contain their spread before effectiveness has been established, and it might prove totally unrealistic to expect, while awaiting cost data, to curb the use of a technology that has been proven effective. A workable solution would be to make it mandatory that a cost-effectiveness analysis be planned concurrently for any clinical trial of effectiveness but that the actual gathering of the cost data be timed with the interim analysis. The cost analysis itself would then be carried out only after evidence of a technology's effectiveness has been found in the analysis. Laupacis and associates rightly point out that "the guidelines are proposed as a necessary but not sufficient step in making decisions about the adoption and utilization of new technologies" and that the "introduction of a new technology is influenced by a combination of effectiveness, economics, ethics and politics." Despite these assertions the proposal of Laupacis and associates as it now stands implies that the policy-making process that introduces new technologies into the health care system could become a very rational and scientifically driven one. Of course, the contribution of rational thinking to policy formulation should be increased, but policymaking will always be a much more complex process than research, because it attempts to integrate many more dimensions, beliefs and values. Scientists and policy-makers do not always un-
Dr. Battista is director of the Division of Clinical Epidemiology, Department ofMedicine, Montreal General Hospital, Montreal,
Que.
Reprint requests to: Dr. Renaldo N. Battista, Division of Clinical Epidemiology, Department of Medicine, Montreal General Hospital, 1650 Cedar Ave., Montreal, PQ H3G 1A4 -
For prescribing information see page 641
CAN MED ASSOC J 1992; 146 (4)
461
derstand each other and at times display a mutual Conferences lack of confidence if not hostility. The fundamental continuedfrom page 457 reason for this difficulty in communication is that 25-29,1992: 12th International Congress of Hospital science and policy-making use very different para- May Engineering (in concurrence with the Hospital-Health digms. Science unfolds according to a positivist Care International Exhibition) paradigm that posits the existence of some "truth," Congress Hall, Bologna, Italy which it seeks to uncover with the use of sophisti- Organizing Secretariat, SENAF, Via Michelino 69, 40127 cated methods concerned with issues of validity, Bologna, Italy; telephone 011-39-51-503318, fax 011reliability and generalizability. Policy-making is an 39-51-505282 interpretive process based on multiple iterations and the integration of several factors. In this context May 26-31, 1992: 5th International Conference on the Cell and Molecular Biology of Chlamydomonas "truth" as such does not exist but, rather, results Asilomar Center, Pacific Grove, Calif. from a complex social interaction. Some authors Dr. GeorgeConference Witman, organizer, Worcester Foundation for have referred to this process as "the science of Experimental Biology, Shrewsbury, MA 01545, muddling through."5 The difficulty with technology (508) 842-8921, fax (508) 842-3915; or Genetics Society assessment is that it tries to bridge the gap between of America, 9650 Rockville Pike, Bethesda, MD 20814, science and policy-making: its roots are in science, (301) 571-1825, fax (301) 530-7079 its foliage is in policy-making. This position is not a comfortable one for the assessors, who can easily be May 29, 1992: Cancer Care in the 90s: a Community Perspective (sponsored by the Canadian Cancer Society accused by scientists of lacking rigour in their [Alberta/Northwest Territories Division], the Alberta methods while being chided by policy-makers for Cancer Board and the University of Calgary) lacking relevance. Orange Health Sciences Centre, University of Theatre, Physicians have realized that their practice enCalgary vironment is being reshaped; making informed Office of Continuing Medical Education, University of choices is unavoidable. There is indeed a new Calgary, 3330 Hospital Dr. NW, Calgary, AB T2N 4N1; "world order" in health care, and physicians are (403) 220-7240, fax (403) 270-2330 being challenged to evolve and adapt to it. This is a time for creative thinking. Scientific information June 2-4, 1992: Bio-Recognition: an International Industrial Biotechnology Conference will always be only one piece (an important one, it is Montreal hoped) of the policy-making puzzle. Our aim as scientists is to make that piece as large as possible. David Smith, Ottawa-Carleton Economic Development Corporation, 111 Lisgar St., Ottawa, ON K2P 2L7; The work by Laupacis and associates is an important (613) 236-3500 step in that direction. June 5-7, 1992: Ontario Fitness Council Conference I thank Drs. Steven Grover and Vivian H. Hamilton for Harmony in Motion providing helpful comments and Ms. Diane Telmosse for Hamilton, Ont. preparing the manuscript. Applications to present, letters of interest and resumes to: Dr. Battista is a research scholar with the National Judi Savage, Chair Program, 7 Alba St., Stoney Creek, Health Research and Development Program, Ottawa. ON L8G lN9
References 1. Canadian Task Force on the Periodic Health Examination: The periodic health examination. Can Med Assoc J 1979; 121:
1193-1254 2. Sackett DL: Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest 1986; 89: 25-35 3. US Preventive Services Task Force: Guide to Clinical Preventive Services, Williams & Wilkins, Baltimore, 1989 4. Rogers EM: Diffusion of Innovations, 3rd ed, Free Pr, New York, 1983
June 8, 1992: 2nd International Symposium on Perinatal Asphyxia Westin Bayshore, Vancouver Mrs. Joan Beards, Perinatal Asphyxia Conference, Education Department, Canadian Medical Protective Association, PO Box 8225, Ottawa, ON KIG 3H7; (613) 236-2100, ext. 238, fax (613) 236-5588 June 9-10, 1992: IMHE - International Meeting on Hospital Economy (in conjunction with the International Symposium on the Planning of Radiological Departments [ISPRAD] VI) Grieg Hall, Bergen, Norway
Official language: English IMHE/ISPRAD VI, c/o Lilly Hausberg, PLUSreiser, PO Box 946, N-5001 Bergen, Norway; fax 011-47-5-47590-20-91
5. Lindblom CE: The science of muddling through. Public Admin
Rev 1959; 19 (spring): 79-88 462
CAN MED ASSOC J 1992; 146 (4)
continued on page 508 LE 15 FEVRIER 1992
