Healthcare innovations often represent important improvements in population welfare, but at what cost, and to whom? Health technology assessment (HTA) is a multidisciplinary process to inform resource allocation. HTA is conventionally anchored on health maximization as the only relevant output of health services. If we accept the proposition that health technologies can generate value outside the healthcare system, resource allocation decisions could be suboptimal from a societal perspective. Incorporating “broader value” in HTA as derived from social values and patient experience could provide a richer evaluative space for informing resource allocation decisions. This article considers how HTA is practiced and what its current context implies for adopting “broader value” to evaluating health technologies. Methodological challenges are highlighted, as is a future research agenda. Ireland serves as an example of a healthcare system that both has an explicit role for HTA and is evolving under a current program of reform to offer universal, single-tier access to public services. There are various ways in which HTA processes could move beyond health, including considering the processes of care delivery and/or expanding the evaluative space to some broader concept of well-being. Methods to facilitate the latter exist, but their adaptation to HTA is still emerging. We recommend a multi-stakeholder working group to develop and advance an international agenda for HTA that captures welfare/benefit beyond health.

In this issue of the Journal, Panteli et al. (6) provide insight into the extent to which a gender-sensitive approach is adopted by sixty health technology assessment (HTA) agencies worldwide. Their findings should make all of us involved in the production of HTA take pause: less than a handful of the agency Web sites that were examined by Panteli's team made any mention of gender as an explicit consideration in priority setting processes or in the HTA methods used (6). This is despite the fact that gender is recognized as a social determinant of health (1) and despite best practices that acknowledge the need to account for equity issues—of which gender is one—in the design, conduct, and reporting of HTA (3;4). Assuming we take the findings of Panteli et al. at face value, this does seem to be a case of “do as I say, not as I do.”

In 1979, maternal and child health issues were discussed during the annual meeting of the 33 Member States of the European Region of the World Health Organization. During this discussion many countries expressed concern about the services offered for pregnancy, birth and the period following birth. The countries recognized that, as yet, unsolved problems remain which must be examined and they asked the European Regional Office of WHO to mount activities to study and report on these problems surrounding birth and birth care. In response to this request, the maternal and child health unit of the European Regional Office organized a Perinatal Study Group. The Group's 15 members came from 10 countries and spanned 10 professional disciplines: economics, epidemiology, health administration, midwifery, nursing, obstetrics, pediatrics, psychology, sociology, and statistics. For five years the Group conducted surveys, reviewed the literature and brought its own personal and professional experience to discussions of the health services for women and their babies, during pregnancy and birth, and after birth. The entire group met together at least once a year, at which time findings from the previous year's work were presented, followed by lengthy, sometimes heated, open and free discussions.

Since 1982, the Medical Research Council of the Academy of Finland, together with other interested parties, has tried to develop systematically the evaluation research of medical technology. The broadly based working group set up by the Council is preparing a program dealing with this issue to promote research work and the training of researchers. The arrangement of consensus development conferences, held on various topics in many countries, is another means of reaching these goals. In Finland, the arrangement of such conferences has been the responsibility of the Medical Research Council.

Economic evaluations can be used to compare alternative antenatal care programs in terms of cost and outcome. The cost of routine antenatal care is small compared to the total cost associated with pregnancy and childbirth. The main problem in economic evaluations is related to outcome measurement.

The first consideration must be an agreed-upon definition of asphyxia. We cannot determine outcome of a condition if some observers are referring to apples and others to pears. Asphyxia is a pathophysiological event comprising both hypoperfusion and hypoxia, and these events result in compromise at a cellular level with the production of metabolic acids. This can be due to a wide number of insults, but a complication of the birth process is the most important cause. Asphyxia is not like intraventricular hemorrhage (IVH) or periventricular leukomalacia (PVL), as these are conditions that can be diagnosed with a reasonable degree of precision with imaging techniques.

Cochlear prostheses are beginning to be implanted regularly to restore hearing in profoundly deaf patients, but there is little agreement on the relative merits of the many different designs and rehabilitative procedures. We report on the responses to a technology assessment questionnaire that was sent to 120 researchers and clinicians worldwide who have been at the forefront of research in this field.

The author examines the Australian health care system by surveying the financing techniques, physical organization, and government activity. He explains the impact of the public and private sectors and comments on the effectiveness of current evaluation procedures. While the author believes that the system is relatively healthy and cost effective, he recognizes a need for more comprehensive and scientific oversight. Using regression analysis and focusing on the installation of medical technology in hospitals, the author attempts to determine the specific factors that influence technology diffusion. He concludes by stressing that further studies analyzing the actual use of specific technologies are vital.

Surfactant deficiency has come to be understood as equivalent clinically to lung immaturity, except in situations of extreme prematurity or lung hypoplasia. Thus, surfactant deficiency and the diagnosis respiratory distress syndrome (RDS) have been applied quite uniformly to preterm infants with respiratory distress who have no other identifiable problems. While the diagnosis can be made more specific by assay of surfactant phospholipid composition (12), such measurements are seldom made in clinical practice. Perinatal discussions of the premature with respiratory distress also have been focused toward surfactant by the availability of multiple tests of “lung maturation” based on the assay of surfactant components in amniotic fluid (19). While surfactant is necessary for normal lung function, adequate surfactant is not sufficient to assure normal gas exchange in the preterm. There are no simple ways to separate surfactant deficiency states clearly from other aspects of lung development, such as airway development, alveolarization, and the development of the pulmonary vasculature in the preterm infant. The anatomic data of Hislop et al. (13) and Langston et al. (22) indicate a considerable variability in the number of alveoli in the preterm infant at each gestational age, resulting in large differences in potential gas exchange surfaces in different infants. Airway development also differs between infants of comparable gestational ages, as is evident clinically by susceptibility to the development of pulmonary interstitial emphysema. Assuming that surfactant treatments for RDS fully correct the surfactant deficiency, a realistic expectation based on animal studies (16), surfactant treatments should be useful in the near future to eliminate the surfactant deficiency component of lung immaturity syndromes. Any residual lung disease can then be better characterized.

The purpose of this study was to examine differences in the way Britain and the United States invest in and deploy a new medical technology. We used structured interviews to obtain information on the technical sophistication and approximate replacement value of all hospital-based obstetrical ultrasound machines in every maternity hospital in Washington state and Wales. The supply of hospital-based ultrasound machines—approximately two machines per 1,000 births—was similar in both countries. Wales had fewer advanced ultrasound machines than Washington state, and they were based exclusively in high-volume district general hospitals; there were no obstetric ultrasound machines in the private sector. In Washington state, the majority of advanced machines were in small and medium-sized hospitals, and many private offices had ultrasound machines. The approximate replacement value of hospital-based machines was three times as high per birth in Washington state as in Wales. In the case of obstetrical ultrasound, centralization of facilities, a relatively small private sector, and global budgeting lead to lower expenditures per patient within the National Health Service without compromising access to care.

This article first examines data bases available to assess the risk of vaccine-preventable diseases (VPD). In the second part, immunization recommendations and practices are briefly evaluated in view of the risk of exposure to VPD and of the efficacy and safety of available vaccines.

The majority of technologies in use in perinatal care were organized into 45 technological functions. Forty-six experts from 19 different regions of Brazil and other Latin American countries then selected a “basic package” (BP) of 15 technological functions. Considering the 12 main causes of perinatal mortality in Brazil, the experts estimated the number of preventable deaths, assuming universal coverage by the BP and the additional reductions that could be obtained by gradually adding other technological functions to the BP. A simulation was performed for the 26 states of Brazil to identify regional priorities for the diffusion of technological functions. For most regions, the BP appears to be the most effective intervention, with the potential of reducing perinatal mortality by 33%, followed by “coordination of services and referral of pregnant women” (14%), and “treatment of respiratory conditions” (11.8%).

The development and assessment, over a 10-year period, of a technology for group treatment of patients with chronic pain and anxiety is described. Positive results, such as a decrease of symptoms and improved self-confidence, have stimulated diffusion of the technology to colleagues and have increased our own involvement in the organization of services.

During 1984–1985, laminectomy rates in Massachusetts demonstrated a 2.2-fold variation among districts. Thirty-five percent of laminectomies occurred in 7 of the 108 hospitals studied. Approximately 81% of laminectomies were performed by neurosurgeons. Rates of laminectomy decline with increasing age after 65, while rates of hospitalization for lower-back pain rise.

Medical education in the United States is torn between its allegiance to the Newtonian biomolecular paradigm of medical science that made it so successful in the past and a growing sense, both within academia and without, that medicine needs to become more interdisciplinary and population based. This article explores the potential of the Oxford Perinatal Care model as a useful tool for medical educators to bridge the curricular gap between these two paradigms. The Oxford model is based upon ongoing meta-analysis of all randomized control trials relating to perinatal medicine; interventions and technologies are placed into one of four categories, ranging from “forms of care that reduce negative outcomes” to “forms of care that should be abandoned.” This article proposes a strategy for the inclusion of this information into the U.S. medical school curriculum.

Policy makers in the United States have increasingly recognized the deficiencies in information related to technology assessment and quality assessment. This growing consensus resulted in the passage of legislation in 1989 to create a new Agency for Health Care Policy and Research and to expand substantially funding for assessment activities.

We analyzed the cost-effectiveness of nonemergent treatment for esophageal varices commonly used in Japan (endoscopic injection sclerotherapy, nonshunting direct interruption procedure, and selective shunt). We assessed the cost per survivor from the perspective of the Japanese government and other payors. Epidemiologic and economic data from published Japanese literature and from Japanese hospital-cost information were applied in decision analysis. While sclerotherapy is the most cost-effective treatment, the popular surgical procedures save the most lives, thus raising difficult ethical issues regarding trade-offs of cost and quality.

The aim of the present study was to compare the factual results with the perception of results by the expert investigators involved in a major epidemiological study on risk factors for hip fracture, the Mediterranean Osteoporosis Study (MEDOS), and to do so before the actual results were known. A selection of 30 questions were used from the original MEDOS questionnaire to obtain estimates of selected key risk factors from the 14 participating experts. Ten investigators participated, six of whom filled out the questionnaire completely; these six questionnaires were used for the analysis. The population was estimated to be younger, to have better functional capacity, and to be more subjected to preventive activities than the actual survey data showed. Several methodological problems are explored.