Health-care technology assessment: a clinical perspective

Priority setting in Swedish health care: are the politicians ready?

BACKGROUND

Resource allocation in public health care principally involves politicians, administrators, and physicians. They all have their different roles, agendas and ambitions when it comes to how public health care resources should be spent. Previous studies on attitudes among health-care stakeholders have mainly focused on views and preferences among clinical decision-makers, while less attention has been paid to the views of health care politicians.

AIM

The study aimed to investigate if the health care politicians' views on priority setting and decision-making in health care differed from other stakeholder groups.

METHOD

The study was based on a questionnaire conducted among health care politicians, administrators, and physicians in four county councils in Southern Sweden.

RESULTS

The findings show significant differences between the politicians and the other two groups in their views on health-care resources, financing, priority setting and decision-making.

CONCLUSIONS

The findings could, at least partly, be explained by the special situation it means for the politicians to be forced to be re-elected every fourth year to stay in power.

The usefulness of NICE guidance in practice: Different perspectives of managers, clinicians, and patients

Objectives: The UK National Institute for Health and Clinical Excellence (NICE) has been widely hailed as an international leader in health technology assessment. The objectives of its guidance are to ensure uniformity in healthcare provision, and promote a systematic and accountable way to allocate resources. However, research relating to the implementation of guidance is limited, and little is known about how it influences decision making at the consultation level or how useful it is to individual patients.

Methods: In-depth interviews were undertaken with professionals involved in healthcare provision at the community level, and with clinical professionals and patients providing or receiving care for morbid obesity and breast cancer (n = 52).

Results: Although NICE guidance was generally well-regarded, in practice it was of more importance and usefulness to managerial than clinical professionals. Clinicians used a patchy approach to implementation depending on whether recommendations accorded with their personal interpretation of the evidence available, and whether funding was available locally. Many patients had not heard of NICE, and clinical professionals did not alert them to its existence. Even where patients knew about relevant guidance, they were rarely able to use it to assert their right to treatment.

Conclusions: These findings challenge the perception that NICE guidance results in consistent and accountable decision making, and the limited accessibility and usefulness of guidance to patients suggests more information and support is needed at the point of provision if these objectives are to be achieved.

Medical education needs to teach health technology assessment

Health technology assessment evaluates the effects of drugs, devices, procedures and policies on patients and the healthcare system. Because of its potential to optimize healthcare resources and patient care, health technology assessment is becoming increasingly important in healthcare systems at national and local levels. This article provides an explanation of health technology assessment and an example of its application in residency education.

Cost-benefits associated with social outcome from neurobehavioural rehabilitation

PRIMARY OBJECTIVE

To carry out a clinical and cost-outcome evaluation of a neurobehavioural post-acute rehabilitation programme in the UK.

RESEARCH DESIGN

The study was a multi-centre prospective cohort study of adults with acquired brain injury admitted for residential rehabilitation. Comprehensive data were collected on type of residence, amount and type of care, functional independence, engagement in constructive occupation and participation in social roles.

PROCEDURES

Data were gathered on admission relating to individuals' levels of care and functioning, both pre-morbidly and at the time of admission (pre-rehabilitation). Additional information about functioning was collected upon discharge (post-rehabilitation). Follow-up data was collated in person, by telephone or by post after an average of 18 months by a researcher who was blind to the rehabilitation outcomes. The data were analysed in terms of clinical outcomes and support costs. Savings in costs of care or support were calculated on the basis of difference between pre-rehabilitation and follow-up support costs minus the costs of rehabilitation.

RESULTS

Significant gains were evident at discharge and follow-up in virtually all indices of social outcome. Improvements were recorded in type of accommodation, levels of care, functional ability, productive occupation and performance of social roles. Patients admitted within 1 year of injury made the most progress, but improvements were made regardless of time since injury. Patients continued to benefit from rehabilitation well beyond the period when most natural recovery would take place. Economic calculations suggested that the initial costs of rehabilitation are generally offset by savings in care costs within 2 years. Sensitivity analysis on estimated savings in care costs yielded projected lifetime savings of between Pounds 1.1-0.8 M for persons admitted for rehabilitation within 12 months of injury, Pounds 0.7- Pounds 0.5 M within 2 years of injury and Pounds 0.5-0.36 M for admissions after 2 years.

CONCLUSIONS

Specialist rehabilitation for neurobehavioural disability produces comprehensive and sustainable improvements in the life of individuals with brain injury. The initial costs associated with neurobehavioural rehabilitation are offset by savings in costs of support in the medium and longer term.

Assessment of the quality of mini-HTA

Objectives:Mini-HTA (health technology assessment) is increasingly being applied in Denmark as an input for decisions on the use of health technologies. Mini-HTA is a form or check list with questions concerning the prerequisites for and consequences of health technologies. At the national level, the National Board of Health uses mini-HTA when hospitals apply for permission to introduce new treatments. Mini-HTA is also compulsory in Danish Regions' annual collection of early warnings. At the local level some hospitals have made mini-HTA compulsory when clinical departments apply for funding for new technologies. The objective of this study is to assess the quality of the information included in mini-HTA used at Danish hospitals and to discuss the consequences of this to decision making.

Methods:The quality of mini-HTA is assessed by use of an INATHA checklist for HTA reports. Data consists of reviews of the quality in fifty-two mini-HTAs produced by Danish hospitals in 2008.

Results:The mini-HTAs generally include descriptions of the assessed technology and the comparator, but information about the selection and interpretation of the clinical literature and other data is often missing. The level of evidence for the clinical effects and the main references are generally included. Only 25 percent of the mini-HTAs include a quantitative estimate of the size of the clinical effects. Organizational consequences inside the clinical department is described in 81percent of the cases and 92 percent includes a cost estimate.

Conclusions:The results show that the quality of the information in many cases is insufficient. There is a strong need for quality assurance of mini-HTAs to improve the accuracy of the information, however, without harming the timeliness and the limited use of resources in producing the reports.

Technology Assessment in Radiology: Putting the Evidence in Evidence-based Radiology

In this review, which is part of a larger series on evidence-based practice in radiology, the relationship between technology assessment (TA) and the practice of evidence-based radiology (EBR) is discussed. TA guides researchers in the methods required to be reliable providers of unbiased and relevant evidence. Meanwhile, EBR equips radiologists with the skills needed to be discerning consumers of that evidence. Both paradigms aim to improve the effectiveness of health care spending. In this review, it is argued that EBR can be only as good as the TA on which it is based. However, TA is particularly complex in regard to diagnostic radiology because of the many links in the chain between the interim objective (to make the correct diagnosis) and the ultimate goal (to improve patient health). In this article, the development of TA in medicine in general and, more specifically, the TA hierarchy for the evaluation of diagnostic imaging are described. Some of the improvements in the pool of evidence during the past 30 years are documented, and some of the remaining tensions between TA and EBR are highlighted.