EDITORIALS
ANNALS of Internal Medicine
Medical Technology Policies and Computed Tomography C O M P U T E D TOMOGRAPHY (CT) has been a cause celebre in the American
Volume 9 0 • Number 1 January 1 9 7 9
P U B L I S H E D monthly by the American College of Physicians under t h e direction of the Publications Committee of the Board of Regents; see advertising page 1-5 for listing of the Committee, the Editorial Staff, the Editorial Board, and the Business Staff. Editorial Policy A N N A L S O F I N T E R N A L M E D I C I N E pub-
lishes original articles, case reports, topical reviews, editorials, book reviews, and medical news for internal medicine and related fields. Further details on the kinds of manuscripts that will be considered for possible publication are given in " I N F O R M A T I O N F O R A U T H O R S " on advertising page 1-6. Selected books will be critically reviewed or briefly described monthly. Review copies should be sent to the Assistant Editor. T h e content of A N N A L S O F I N T E R N A L
M E D I C I N E is protected by copyright. Manuscripts are accepted for publication with the understanding that their contents, all or in part, have not been published elsewhere and will not be published elsewhere, except in abstract form or by the express consent of the Editor. A N N A L S O F I N T E R -
NAL M E D I C I N E accepts no responsibility for statements made by contributors. Subscriptions A N N A L S O F I N T E R N A L M E D I C I N E is is-
sued monthly; new volumes begin with the January and July issues each year. Subscription price per year, net postpaid, A R E A I (North and Central America, Puerto Rico, Canal Zone): Students, $12.50; physicians out of medical school 4 years or less, $18.75; all others, $25.00. A R E A II (all countries not in Area I): Students, $14.00; physicians out of medical school 4 years or less, $21.00; all others, $28.00. Single copies of recent issues: $3.00 in North and Central American countries, Puerto Rico, and Canal Zone; $3.25 in other countries; price of supplements provided on request. Checks should be made payable to the American College of Physicians and remitted to the Circulation Manager. Communications to the Editor or the Circulation Manager should be sent to
Annals of Internal Medicine 4 2 0 0 Pine St. Philadelphia, PA 19104 USA Phone: 2 1 5 / 2 4 3 - 1 2 0 0
114
January 1979
health care community since it was introduced into the United States in 1973. The CT scanner was then a dramatically new and expensive imaging device. Like a seed crystal dropped into a supersaturated solution, it became the focus of a rapidly expanding controversy over the value and cost of new medical technology. In August 1978, the Office of Technology Assessment (OTA) of the Congress of the United States published its report on the policy implications of computed tomography (1). This wide-ranging and wellorganized document describes the principles of computed tomography, summarizes literature on its evaluation, details growth in the number and distribution of scanners, discusses the type of patients that are examined by CT, and reviews reimbursement practices. The document is one of the most extensive treatments of policy issues related to any new medical technology. Although this report is about computed tomography, its general aim is to reveal policy problems in the evaluation, dissemination, and use of medical technology. The OTA report is intentionally descriptive rather than judgmental. It makes no recommendations but culminates in a series of broad policy alternatives for Congress to consider. These policies address three areas: the development of information on efficacy and safety; changes in regulation including restricting the use of technology, linking reimbursement to efficacy, and regulating expenditures for equipment in physicians' offices; and new reimbursement methods aimed at encouraging efficiency. The report accomplishes its purpose, giving the physician reader, no less than the congressional staffer, much to contemplate. One central finding deserving attention is that CT scanners were installed widely before well-designed efficacy studies were conducted. Although hospital administrators calculated the financial implications of CT for their institutions (and scanners have been profitable, according to the OTA), no one was responsible for estimating the resource costs to society associated with their widespread use. The OTA report suggests that Congress might establish a formal process to identify technologies meriting special assessment, conduct evaluations, synthesize evidence from all sources, and disseminate conclusions. The general problem of assessing efficacy and safety is described in more detail in a second recent OTA publication (2). Formal evaluation of the efficacy of a new diagnostic technology brings special problems. Computed tomography is a diagnostic procedure, but diagnosis is not an end in itself. The clinical value of CT rests on what it contributes to decisions about the care of patients and on the extent to which those decisions affect the patients' health. Before we can measure such effects, however, we must address matters of definition. What do we mean by "health"? How do we measure "information"? The ultimate effect on health depends as much or more on the nature of the patients' diseases and on available treatments as on the information provided by the diagnostic examination. How much of the same information could be
• Annals of Internal Medicine • Volume 90 • Number 1
Downloaded from https://annals.org by Tulane University user on 01/13/2019
acquired by alternative means? To what extent does the value of CT depend on the presenting complaints or final diagnoses of the patients? Data on ultimate health effects may take years to accumulate. In the meantime, physicians gain experience with the technique, and CT technology evolves, as do other diagnostic methods and available therapies. While we frame evaluation questions and await the results of clinical trials, decisions about the purchase and use of CT scanners continue to be made. The aim in evaluating an evolving technology such as computed tomography is not to achieve a final assessment, which would be impossible, but to expand our base of knowledge continually, making possible the most informed judgment in the face of remaining uncertainty. The OTA report properly identifies appropriate use as a fundamental concern with CT scanning but does not attempt to develop utilization review criteria or planning guidelines. At the time of the OTA literature review, only a limited number of studies analyzing effects beyond diagnostic information had been published. On the basis of more recent studies (see, for example, the special section on medical efficacy of CT in the American Journal of Roentgenology, July 1978), initial guidelines for appropriate use can be developed. A few state PSROs, including those in Colorado and North Carolina, have developed review criteria for CT scanning. In September 1978, the national PSR Council adopted model criteria for distribution to local PSROs. Given the evolving nature of CT and information about its value, such criteria will themselves need periodic review and amendment. Whether they can be implemented successfully remains to be seen. Proscribing CT in cases where it offers no benefit is easy, but such circumstances are relatively rare. Appro-
priate use is much more difficult to determine when CT offers only a small chance of diagnostic gain. In such cases, practicing physicians decide, consciously or not, whether a small potential benefit is worth the price. No physician wants to make such value judgments— why deny any patient even the most remote chance at a more accurate diagnosis, better treatment, and improved health? Physicians do knowingly deny resources to some patients every day, but only when resource limits and alternative choices are clear. (For example, only one of two patients with symptoms of myocardial infarction can be admitted to the last intensive care unit bed.) Doctors will not, and should not, withhold health resources unless alternative allocations of the same resources will accomplish greater benefits. Arranging medical decision-making so that alternative resource uses can be considered clearly and explicitly is a task for physicians and policymakers alike. Computed tomography continues to receive so much attention because it epitomizes new medical technology, at once technically advanced, costly, and variably beneficial. As CT becomes more commonplace, it also serves to remind us how many existing medical practices have similar features. In our zeal to evaluate new technology, we should not neglect established practices that are costly and of questionable efficacy. ( H A R V E Y V. FINEBERG,
M.D.; Center for the Analysis of Health Practices, Harvard School of Public Health; Boston, Massachusetts) References 1. O F F I C E OF T E C H N O L O G Y ASSESSMENT, CONGRESS OF T H E U N I T E D
STATES: Policy Implications of the Computed Tomography (CT) Scanner. Washington, D.C.; U.S. Government Printing Office, August 1978. 2. O F F I C E OF T E C H N O L O G Y ASSESSMENT, CONGRESS O F T H E U N I T E D
STATES: Assessing the Efficacy and Safety of Medical Technologies. Washington, D.C.; U.S. Government Printing Office, September 1978. ©1979 American College of Physicians
Editorials
Downloaded from https://annals.org by Tulane University user on 01/13/2019
115
ANNALS of Internal Medicine
Medical Technology Policies and Computed Tomography C O M P U T E D TOMOGRAPHY (CT) has been a cause celebre in the American
Volume 9 0 • Number 1 January 1 9 7 9
P U B L I S H E D monthly by the American College of Physicians under t h e direction of the Publications Committee of the Board of Regents; see advertising page 1-5 for listing of the Committee, the Editorial Staff, the Editorial Board, and the Business Staff. Editorial Policy A N N A L S O F I N T E R N A L M E D I C I N E pub-
lishes original articles, case reports, topical reviews, editorials, book reviews, and medical news for internal medicine and related fields. Further details on the kinds of manuscripts that will be considered for possible publication are given in " I N F O R M A T I O N F O R A U T H O R S " on advertising page 1-6. Selected books will be critically reviewed or briefly described monthly. Review copies should be sent to the Assistant Editor. T h e content of A N N A L S O F I N T E R N A L
M E D I C I N E is protected by copyright. Manuscripts are accepted for publication with the understanding that their contents, all or in part, have not been published elsewhere and will not be published elsewhere, except in abstract form or by the express consent of the Editor. A N N A L S O F I N T E R -
NAL M E D I C I N E accepts no responsibility for statements made by contributors. Subscriptions A N N A L S O F I N T E R N A L M E D I C I N E is is-
sued monthly; new volumes begin with the January and July issues each year. Subscription price per year, net postpaid, A R E A I (North and Central America, Puerto Rico, Canal Zone): Students, $12.50; physicians out of medical school 4 years or less, $18.75; all others, $25.00. A R E A II (all countries not in Area I): Students, $14.00; physicians out of medical school 4 years or less, $21.00; all others, $28.00. Single copies of recent issues: $3.00 in North and Central American countries, Puerto Rico, and Canal Zone; $3.25 in other countries; price of supplements provided on request. Checks should be made payable to the American College of Physicians and remitted to the Circulation Manager. Communications to the Editor or the Circulation Manager should be sent to
Annals of Internal Medicine 4 2 0 0 Pine St. Philadelphia, PA 19104 USA Phone: 2 1 5 / 2 4 3 - 1 2 0 0
114
January 1979
health care community since it was introduced into the United States in 1973. The CT scanner was then a dramatically new and expensive imaging device. Like a seed crystal dropped into a supersaturated solution, it became the focus of a rapidly expanding controversy over the value and cost of new medical technology. In August 1978, the Office of Technology Assessment (OTA) of the Congress of the United States published its report on the policy implications of computed tomography (1). This wide-ranging and wellorganized document describes the principles of computed tomography, summarizes literature on its evaluation, details growth in the number and distribution of scanners, discusses the type of patients that are examined by CT, and reviews reimbursement practices. The document is one of the most extensive treatments of policy issues related to any new medical technology. Although this report is about computed tomography, its general aim is to reveal policy problems in the evaluation, dissemination, and use of medical technology. The OTA report is intentionally descriptive rather than judgmental. It makes no recommendations but culminates in a series of broad policy alternatives for Congress to consider. These policies address three areas: the development of information on efficacy and safety; changes in regulation including restricting the use of technology, linking reimbursement to efficacy, and regulating expenditures for equipment in physicians' offices; and new reimbursement methods aimed at encouraging efficiency. The report accomplishes its purpose, giving the physician reader, no less than the congressional staffer, much to contemplate. One central finding deserving attention is that CT scanners were installed widely before well-designed efficacy studies were conducted. Although hospital administrators calculated the financial implications of CT for their institutions (and scanners have been profitable, according to the OTA), no one was responsible for estimating the resource costs to society associated with their widespread use. The OTA report suggests that Congress might establish a formal process to identify technologies meriting special assessment, conduct evaluations, synthesize evidence from all sources, and disseminate conclusions. The general problem of assessing efficacy and safety is described in more detail in a second recent OTA publication (2). Formal evaluation of the efficacy of a new diagnostic technology brings special problems. Computed tomography is a diagnostic procedure, but diagnosis is not an end in itself. The clinical value of CT rests on what it contributes to decisions about the care of patients and on the extent to which those decisions affect the patients' health. Before we can measure such effects, however, we must address matters of definition. What do we mean by "health"? How do we measure "information"? The ultimate effect on health depends as much or more on the nature of the patients' diseases and on available treatments as on the information provided by the diagnostic examination. How much of the same information could be
• Annals of Internal Medicine • Volume 90 • Number 1
Downloaded from https://annals.org by Tulane University user on 01/13/2019
acquired by alternative means? To what extent does the value of CT depend on the presenting complaints or final diagnoses of the patients? Data on ultimate health effects may take years to accumulate. In the meantime, physicians gain experience with the technique, and CT technology evolves, as do other diagnostic methods and available therapies. While we frame evaluation questions and await the results of clinical trials, decisions about the purchase and use of CT scanners continue to be made. The aim in evaluating an evolving technology such as computed tomography is not to achieve a final assessment, which would be impossible, but to expand our base of knowledge continually, making possible the most informed judgment in the face of remaining uncertainty. The OTA report properly identifies appropriate use as a fundamental concern with CT scanning but does not attempt to develop utilization review criteria or planning guidelines. At the time of the OTA literature review, only a limited number of studies analyzing effects beyond diagnostic information had been published. On the basis of more recent studies (see, for example, the special section on medical efficacy of CT in the American Journal of Roentgenology, July 1978), initial guidelines for appropriate use can be developed. A few state PSROs, including those in Colorado and North Carolina, have developed review criteria for CT scanning. In September 1978, the national PSR Council adopted model criteria for distribution to local PSROs. Given the evolving nature of CT and information about its value, such criteria will themselves need periodic review and amendment. Whether they can be implemented successfully remains to be seen. Proscribing CT in cases where it offers no benefit is easy, but such circumstances are relatively rare. Appro-
priate use is much more difficult to determine when CT offers only a small chance of diagnostic gain. In such cases, practicing physicians decide, consciously or not, whether a small potential benefit is worth the price. No physician wants to make such value judgments— why deny any patient even the most remote chance at a more accurate diagnosis, better treatment, and improved health? Physicians do knowingly deny resources to some patients every day, but only when resource limits and alternative choices are clear. (For example, only one of two patients with symptoms of myocardial infarction can be admitted to the last intensive care unit bed.) Doctors will not, and should not, withhold health resources unless alternative allocations of the same resources will accomplish greater benefits. Arranging medical decision-making so that alternative resource uses can be considered clearly and explicitly is a task for physicians and policymakers alike. Computed tomography continues to receive so much attention because it epitomizes new medical technology, at once technically advanced, costly, and variably beneficial. As CT becomes more commonplace, it also serves to remind us how many existing medical practices have similar features. In our zeal to evaluate new technology, we should not neglect established practices that are costly and of questionable efficacy. ( H A R V E Y V. FINEBERG,
M.D.; Center for the Analysis of Health Practices, Harvard School of Public Health; Boston, Massachusetts) References 1. O F F I C E OF T E C H N O L O G Y ASSESSMENT, CONGRESS OF T H E U N I T E D
STATES: Policy Implications of the Computed Tomography (CT) Scanner. Washington, D.C.; U.S. Government Printing Office, August 1978. 2. O F F I C E OF T E C H N O L O G Y ASSESSMENT, CONGRESS O F T H E U N I T E D
STATES: Assessing the Efficacy and Safety of Medical Technologies. Washington, D.C.; U.S. Government Printing Office, September 1978. ©1979 American College of Physicians
Editorials
Downloaded from https://annals.org by Tulane University user on 01/13/2019
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