Economic forces and hospital technology. A perspective from Europe

Focal therapy for localised prostate cancer: are we asking the correct research questions?

The goals of focal therapy are laudable, namely reducing morbidity of treatment while ensuring at least equivalent oncological outcomes when compared with established interventions for localised prostate cancer, e.g. RP and external beam radiotherapy. While progress has been made towards better identifying the index lesion in these patients, there is much yet to be done to establish the validity of the index lesion theory as the metastatic focus and to establish that current targeting and ablative platforms are adequate to deliver the goals outlined above. The correct research questions have not yet been asked to establish either of these key principles underpinning focal therapy for localised prostate cancer.

Has NICE got it right? An international perspective considering the case of Technology Appraisal No. 98 by the National Institute for Health and Clinical Excellence (NICE)

BACKGROUND

The National Institute for Health and Clinical Excellence (NICE) has been widely recognised as setting an international standard for high-quality health technology assessments (HTAs) including economic evaluation.

SCOPE

A previous critical analysis of NICE Technology Appraisal No. 98 (TA98), evaluating methylphenidate, dexamphetamine and atomoxetine for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children, revealed a number of issues, which must cast doubt on the robustness of the NICE approach when addressing a complex clinical decision problem. The exploration of potential underlying problems will be followed by a discussion of lessons for international healthcare policy-makers, and is intended to be an invitation to further debate and inquiry, not a presentation of definitive conclusions.

SYMPTOMS

Pertaining to the technology assessment report, potential problems were identified relating to an unnecessarily narrow scope, data search and selection strategy, the distinction between efficacy and effectiveness, data synthesis across studies and clinical effect measures, and limitations of the economic model. The appraisal process moderated the asserted 'clear conclusions' of the assessment but could not compensate for some of its gaps.

CONCLUSIONS

It is suggested that key issues contributing to these problems may have included a separation of clinical and economic perspectives, a highly standardised reference case analysis that was followed schematically, the absence of an effective system for quality assurance of technology assessments, and transparency deficits of the economic evaluation. Further considerations for international policy-makers looking at NICE as a potential role model for HTAs are discussed, such as institutional context, the objectives of collectively financed healthcare and related value judgments, the reliance on QALYs as a universal and comprehensive measure of health benefits, the appropriate perspective for analysis, and process-related implications.

Which are the best information sources for identifying emerging health care technologies? An international Delphi survey

The purpose of this survey was to assess potential information sources for identifying new health care technologies. A three-round Delphi study was conducted, involving 38 selected experts who suggested and assessed potential sources by applying agreed criteria. Twenty-six potential information sources were considered. Timeliness, time efficiency, and sensitivity were important criteria in determining which were the most important sources. The eight recommended sources were: pharmaceutical journals, pharmaceutical and biotechnology companies, specialist medical journals, key medical journals, medical engineering companies, private health care providers, newsletters and bulletins from other health technology assessment agencies, and groups of expert health professionals. There is a need to use a combination of sources because the most useful sources will vary according to the type of technology under consideration.

Managing new technology: economics research and practical decisions

Rapidly advancing health technology poses problems for managers. Although clear conceptual frameworks exist for economic evaluation, in practice severe problems remain in carrying out timely research that is locally appropriate to the needs of managers. This paper explores some of these problems in the context of the policy analysis interface between economic research and the management of technology. In the light of experience gained from recent evaluation research it indicates how researchers and managers can each contribute to the provision of a stronger empirical basis for policy making and policy management. An earlier version of this paper was presented at the joint meeting of the Health Economists Study Group and Institute of Health Service Management, University of York, 6-8 July 1987. The author would like to thank Christopher Spry and Mike Drummond for helpful comments.