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HEALTH TECHNOLOGY ASSESSMENT VISITED
INTERVIEW WITH A GURU IN TECHNOLOGY ASSESSMENT
Professor David Banta was in Singapare in February
to conduct a short course on Health Technology Assessment. The editor took
the opportunity to interview him on this area of medical science to find
out more about the subject. The course was opened by Prof Chee Yam Cheng.
TECHNOLOGY AS A MIXED BLESSING
Q. Prof Banta, technology has been viewed as a mixed blessing. Would
you comment on this observation?
A. The perception of a mixed blessing has probably arisen because technology
makes us uncomfortable what action to take. The attitude towards technology
takes a different turn the moment we look at technology as a tool. We have
to be able to decide what technology can be put to good use, what is of
no use and what technology is still uncertain.
In the real world technology has enormous
benefits, costs and also side effects which can be awesome and frightening.
As a result, technology may be viewed positively or negatively. It can
be seen as a mixed blessing. With appropriate use, the benefits will outweigh
the costs.
WHAT IS TECHNOLOGY ASSESSMENT (TA)
Q. Thank you. Could you give our readers a thumbnail sketch as to what
is technology assessment and its place in the health care delivery system?
A. TA emerged at the time when policy makers, politicians, medical leaders,
heads of professional organisations were concerned with technology as it
was used. TA was born in that context. It helps to put a halt to useless
technology.
TA may be misconstrued as anti-technology. For example,
it counter-balanced the excessive operations in the 1960s. This is a misconception.
TA grew up with a need for information and understanding of technology
for policy decision making. It is a multi-disciplinary. TA addresses issues
in epidemiology, symptomatology, social aspects and ethical issues in the
context of costs and benefits. It has to be multidisciplinary.
TA is not new but rather it makes use of the information
in epidemiology, social science, health economics to put together information
for the pragmatic decision maker.
TA is a synthesis of knowledge. Before TA came,
this was done in an ad hoc fashion - in an editorial, a review by an expert
or a chapter in a book. Basically TA puts quality control into synthesis.
It examines all literature, position statements and based on best evidence
method synthesises scientific knowledge both for the physician and the
health economist.
In health care delivery, TA began in US and afterwards
spread to Europe by relating itself to formal health policy making, public
health regulation, clinical services regulation, regulation of placement
of services in specialist hospitals and payment, although that came later.
Basing payment on technology is a major issue in TA today.
All that said, formal policy making is still not
adequate to affect practice behaviour. There is a need for a framework
for decision formed by the individual physician and the individual patient.
It has taken 20 years’ development in the
field to have a method to put evidence together that will be helpful for
clinicians. We now have that information that can be available immediately
when needed. It is now possible to track developments in health care delivery.
One can be instantly on-line to find out the results of ongoing random
controlled trials and get those results even before they are published.
It would not be possible for this to happen
if not for the computer, modern data processing, the Internet, registration
of studies, online retrieval and modern information processing. Twenty
years ago there was no information on the computer. Now there is quite
a lot. Managing information has now become necessary.
GREATEST IMPACT
Q. Prof Banta, where would health tachnology assessment make its greatest
impact?
A. Rationalisation of available service is where TA can make the greatest
impact. TA can point out what is totally useless and that can be thrown
out and what is useful. The mechanism of control of useless technology
can be through payment. With a payment entry barrier, useless technology
will be curtailed.
In the real world, basically efficacious technology
is often used for inappropriate circumstances and on wrong people, wrong
setting, and without adequate support. lnformation dissemnisation of the
results of TA can influence what doctors do, provide more decision support
to administrators, clinic doctors and even department heads.
There is a concern by doctors that they are
not providing what patients want. With the information from TA, one should
be confident to say, “I have nothing to offer; it does not work.” Acute
backache is a classic example that treatment has little to offer. At most
10% of patients need more than reassurance that the condition will almost
always feel better in 2-3 weeks with symptomatic medicine and judicious
exercise.
There is a Iegitimate place for watchful waiting
in many of the common problems that the doctor encounters each day. This
requires a trust in the physician and a good doctor-patient relationship.
The doctor should be able to say, “See me a week from now, when it would
be appropriate to look at it again.”
What has gone wrong is doctors have become
too paternalistic and not developing a partnership. The doctor should be
prepared for the patient to reject his advice. He gives advice based on
information from TA. The patient can always change his mind and come back,
provided of course, the situation will not be irreversible in the meantime.
INTEREST LEVEL
Q. Prof Banta, what is the interest level as gauged by
you by doctors in this region?
A. I have conducted a course in November 1995 in Malaysia and that
may give me some idea. In Malaysia, the doctors have a background of several
number of years in fostering QA and health services research. They have
now throughout the system certain skills and infrastructure that made them
ready for adoption of TA. I do not have a knowledge of the background of
doctors in Singapore. Nevertheless, I can observe that there was also a
strong level of interest and participation by the course participants in
Singapore in the short course.
For TA to develop there is need for national
effort and for several factors to be present – money, Ieadership, and willingness
for assessment of issues of national concern e.g., gamma knife technology.
BECOMING ACQUAINTED WITH TA
Q. Prof Banta, how does one become acquainted with TA?
A. There are several aspects. On methodological techniques, there are
several books on measurement of quality, analysis tools and on structured
review or meta-analysis. Specialised abstracts on existing technology can
be obtained from the HSTAT database on the lnternet. The US Preventive
Task Force, NIH and AHCPR also have useful website information on TA.
The Cochrane Collaboration database is aIso
usefuI. For example, the database of studies on obstetric and perinatal
care. It is up-to-date and comprehensive. Probably in 10-20 years the Cochrane
Collaboration will be able to pull together all RCTs needed for making
some sort of synthesis. The database is available for purchase.
Then there is the International Network of
Agencies in Health Technology Assessment (lNAHTA) that one can tap into.
They have websites on the Internet.
There are also some journals in this area,
such as “Effective health care” from UK and “Evidence based medicine” published
by the BMJ. JAMA too, has enormous amount of evidence based medicine papers.
At Ieast one article in each issue is directly related to methodology and
high quality RCTs.
The International Journal of TA is published
4 times a year. Each issue is based on a theme looking at technical issues
in different areas such as, TA in dentistry, and primary care. It is peer
review based and tells what the world is thinking. Subscription is $95
US. Membership plus journal subscription plus society newsletter for those
who join the society. It now has a membership of 1000 from 30 countries.
THE FUTURE OF TA
Q. Prof Banta, what do you see is the future of TA?
A. TA was viewed as a passing fad in the 1970s and even as recently
as 7-8 years ago. With 22 years history of medical experience, building
on the RCTs in the UK and cost effective studies. With its development
in the US and Europc, one can say TA is now firmly rooted.
It is now necessary that practice should be
guided by information on what is efficacious, cost effective, and what
works well. One can see the potential of development in East Asia.
Finally, non directed research and basic research results in one form of knowledge. There is also a need for another type of information on a more immediate basis – the impact on policy and practice guided by ethical principles. This is what technology assessment is all about.
Prof Banta, thank you very much for sharing the subject of health technology
assessment with us.