Fifty-three deaf patients were screened psychologically and medically for suitability to receive an intracochlear implant. After initial screening for psychological normalcy, candidates were assessed again 1 year postimplant. Isolated deleterious psychological effects were found, and certain aspects of psychological functioning were enhanced. Overall evidence suggests that the implant is not psychologically damaging.

This article is based on the report, Anticipating and Assessing Health Care Technology, written in the Netherlands between 1985–1988. The project was carried out because of increasing concern in the Dutch Ministry of Health (STG, then WVC) about the costs and benefits of new technologies for health care. At that time, there were no established models for early identification, so the project was not only the most extensive such effort to that date, but had to develop its own methods. Overseen by a special commission, the project staff identified many future and emerging technologies in health care and assessed selected technologies. Although the actual information produced was quickly dated and the project was discontinued in 1988, it did stimulate the Ministry of Health to ask the Dutch Health Council (Gezondheidsraad) to continuously identify important new technologies. The reports also demonstrated the potential usefulness of such an effort to Dutch policy makers, and probably to those in other countries as well.

A breast cancer screening program mainly aims at reducing mortality. However, it also has an effect, often not assessed, on the utilization of health care resources that is relevant to health care policy making. Using a simulation model, this paper forecasts the impact of introducing a breast cancer screening program on the utilization of resources for the primary therapy of breast cancer. The most important consequences from a health care point of view will be an increased use of breast-conserving therapy and an increased need for postoperative radiotherapy; there will also be a higher number of women diagnosed with noninvasive breast cancer. The results of this study could provide support for health care decision making by showing the consequences of policy decisions on the introduction of screening programs for health care utilization.

High-flux dialysis is a new method for providing routine-maintenance hemodialysis to patients with endstage renal disease. It promises to shorten the duration of the dialysis session, but poses potential clinical risks to patients and financial risks to dialysis centers because of the high unit cost of purchasing new dialysis equipment. We retrospectively evaluated the cost-effectiveness of high-flux dialysis compared to conventional dialysis in a hospital-based center. The center provided only conventional dialysis until March 1989, when it initiated high-flux dialysis. The estimated annual costs of treatment were US $31,249 (high-flux) and $32,562 (conventional). The rate of hospital admissions was almost identical in both groups (conventional, 1.29 admissions per year; high-flux, 1.24 admissions per year; p = 0.23). Predicted prolongation of life expectancy with high-flux dialysis was significantly higher after statistical adjustment for observable patient characteristics (1.8 to 4.5 years; p <0.01). The cost-effectiveness ratio was $28,188 per life-year saved for high-flux compared to conventional dialysis. These findings suggest that the added capital expense of purchasing high-flux equipment can be justified from the perspective of its societal cost-effectiveness.

The ability to extract information on resource use from randomized controlled trials can provide the groundwork for systematically compiling health economic reviews of health interventions. A review of the brief smoking interventions in general practice demonstrates that not all the necessary information can be extrapolated from these trials, and cost data will have to be supplemented from other sources.

Deapite the importance of understanding factors related to physician adoption and use of diagnostiv technologies, relatively few studies have been published. Results of a two-year study of the adoption of magnetiv resonance imaging (MRI) and its substitution for computed tomography scanning (CT) are presented. The literature on physician adoption and use of technologu is used to provide a frame-work for this study. Differences in adoption and substitution among medical specialties, early versus late adopters, and high versus low users of MRI are examined. Results show that neuerologists and internists more rapidly adopt MRI and substitute it for CT than do orthopedists and other surgical specialists. Referral of higher number of patients is the best predictor of more rapid substitution. Physicians who were late adopters more quickly substituted MRI for CT. The cost and social implications of empirical versus “ideal” substitution rates are discussed along with various regulatory, technology assessment, and finicial strategies influence substitution. The role of individual physicians, radiologists, and specialty societies in determining substitution rates is also discussed.

In order to explore the diffusion of the selected technologies in one Canadian province (British Columbia), two administrative data sets were analyzed. The data included over 40 million payment records for each fiscal year on medical services provided to British Columbia residents (2,968,769 in 1988) and information on physical facilities, services, and personnel from 138 hospitals in the province. Three specific time periods were examined in each data set, starting with 1979–80 and ending with the most current data available at the time. The detailed retrospective analysis of laboratory and imaging technologies provides historical data in three areas of interest: (a) patterns of diffusion and volume of utilization, (b) institutional profile, and (c) provider profile. The framework for the analysis focused, where possible, on the examination of determinants of diffusion that may be amenable to policy influence.

A common criticism of high technology is that therapeutic objectives are sometimes secured at too high a price in loss of quality of life. Certainly some interventions serve only to prolong life that is already of unacceptable quality to the patient (some rescues in intensive care and salvage surgery for cancer). Others leave the patient with less good quality of life than he enjoyed before treatment, either because the crisis that called for rescue had lasting effects (incomplete recovery from severe head injury) or because the intervention itself had inevitable adverse effects (mastectomy, laryngectomy, colostomy). Yet some life-extending technologies can improve dramatically the quality of a patient's life (renal and heart transplantation), while others are directed primarily at improving quality of life (hip replacement and coronary bypass surgery). When the ultimate result of technological intervention is improved quality of life or a reasonable extension of life of quality, then some temporary impairment of life's quality may be justifiable. The problem is to discover in which clinical circumstances the benefits expected from high technology are both great enough, and are also likely enough to be realized, to justify the resources that have to be expended by society and the inevitable burdens that have to be borne by the patient (11).

Large registries have been used by the National Heart, Lung, and Blood Institute to evaluate a number of medical procedures. Two of these, the Coronary Artery Surgery Study (CASS) and the Balloon Valvuloplasty Registry (BVR), are described to illustrate potential problems in using registry data to compare medical procedures.

Objectives: The current and past situation of health technology assessment (HTA) in Catalonia is presented in this study.

Methods: The approach used here is a historical review of facts and landmarks.

Results: Spain has undergone radical change in many aspects, but the changes in healthcare provision have been major indeed. Catalonia has had the ability to benefit from these changes and has been able to build upon professionals' experience and expertise to development a consistent HTA network and continuous evaluation paradigm. The early involvement of the Catalan Agency for Health Technology Assessment (CAHTA) in several relevant HTA international initiatives and the relationship of CAHTA and Research with other HTA agencies in Spain is also stressed.

Conclusions: HTA is currently of common use in Catalonia for decision making at different levels. Now emphasis has to be put on the coming challenges that the HTA community will have to face in the coming years: uncontrolled demand, capacity scarcity, a rapidly evolving knowledge frontier, and insufficient input from the economic sphere into evaluations.

Objective: To assess the influence of physician specialty and the way in which patient data are presented in the treatment recommended for patients with coronary artery disease.

Methods: In a prospective study, 3,628 patients with significant coronary artery disease who had been referred to 1 of 10 heart centers in the Netherlands as possible candidates for either percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft surgery (CABG) were recruited. Within each center, the recommended treatment is determined by a team consisting of cardiologists only, cardiovascular surgeons only, or cardiologists and cardiovascular surgeons (i.e., composite teams). The main outcome measures are the proportions of patients for whom PTCA, CABG, or noninvasive (medical) therapy was recommended.

Results: Composite teams made 71% of recommendations, surgeon-only teams, 12%, and cardiologist-only teams, 17%. Cardiologist-only teams primarily recommended patients to PTCA, surgeon-only teams to CABG, while combined teams made more evenly distributed recommendations (p < .001). Although the patients discussed by the three types of teams were clinically different, the recommendation patterns remained significant after adjusting for these differences (p < .001). For patients with recent myocardial infarction, direct presentation of the case to the team by the referring cardiologist reduced the likelihood that CABG would be recommended.

Conclusions: The treatment recommended to patients with coronary artery disease is affected by the composition of the team providing the recommendation. These findings have important implications for clinical decision making for patients with cardiovascular disease.

Evaluations of telemedicine have sought to assess various measures of effectiveness (e.g., diagnostic accuracy), efficiency (e.g., cost), and engagement (e.g., patient satisfaction) to determine its success. Few studies, however, have looked at evaluating the organizational impact of telemedicine, which involves technology and process changes that affect the way that it is used and accepted by patients and clinicians alike. This study reviews and discusses the conceptual issues in telemedicine research and proposes a fresh approach for evaluating telemedicine. First, we advance a patient pathway perspective, as most of the existing studies view telemedicine as a support to a singular rather than multiple aspects of a health care process. Second, to conceptualize patient pathways and understand how telemedicine impacts upon them, we propose simulation as a tool to enhance understanding of the traditional and telemedicine patient pathway.

Objectives: In a resource-constrained reality, physicians are facing polar demands—those of healthcare managements to adopt cost-conscious behaviors and those of ethical standards that obligate physicians to consider only their patients' best interests. In our study, we aimed to determine the attitudes, practices, and knowledge of healthcare costs among Israeli physicians.

Methods: A questionnaire was developed and mailed to a representative sample of physicians in Israel. The overall response rate was 51 percent. The study reviewed self-reported levels of cost consciousness in practice, attitudes, obstacles related to cost containment, and knowledge of the costs of medical resources.

Results: Forty-two percent of the physicians reported high levels of cost consciousness in their daily practice; 70 percent reported greater current cost consciousness in comparison to 5 years ago; 76 percent of the responses legitimized institutional demands for cost containment. Although 83 percent of the physicians that responded expressed the belief that economic thinking was inherently the role of management, only 39 percent thought it was part of the physician's role. It was found that predominant predictors of agreement to cost consciousness concepts were employment by a community health plan, a managerial position, participation in health economics seminars, and male gender.

Conclusions: Cost consciousness among physicians is related to a broad array of parameters. Interventions must emphasize the benefits of evidence-based medicine as an anchor for both cost containment and quality care, as well as providing assistance to physicians in accepting economic decision-making as part of their professional role.

Objectives: Learning effects may have considerable influence on the performance of new health technologies, thereby on cost-effectiveness and ultimately on resource allocation. In the area of radiotherapy, equipment is becoming increasingly costly and the analysis of learning effects is complex given that sequential treatments are necessary, with multiple sessions for each patient. Our study aimed at analyzing learning effects in radiotherapy at an early stage of innovation.

Methods: We used multilevel analysis to separate out the different learning effects of the new technique. Statistical analysis of observational data collected in a French National prospective survey was performed using an individual growth model. Intrapatient learning was modeled at level 1, and two types of interpatient learning were considered at level 2, regarding possible influences of professional experience on (i) the duration of each patient's first session in a given setting and (ii) the rate of change of session duration over time for a given patient. Conventional radiotherapy was also considered for comparison.

Results: Our results demonstrate a substantial type-1 interpatient learning effect and an even higher intrapatient learning effect. No type-2 interpatient learning was at work: professional experience did not impact intrapatient learning. Moreover, some intrapatient learning was also reported with conventional radiotherapy and was not significantly modified by innovation. Session duration was in any case strongly influenced by disease.

Conclusions: Because professionals highly underestimated the learning phenomenon, assessment of learning cannot be based on professional statements and it requires careful analysis of observational data.

Objectives: Health Technology Assessment (HTA) is a relatively new concept in Latin America (LA). The objectives of this exploratory study were to identify HTA programs in LA, review HTA documents produced by those programs, and assess the extent to which HTA aims are being achieved.

Methods: An electronic search through two databases was performed to identify HTA programs in LA. A content analysis was performed on HTA documents (n = 236) produced by six programs between January 2000 and March 2007. Results were analyzed by comparing document content with the main goals of HTA.

Results: The number of HTA documents increased incrementally during the study period. The documents produced were mostly short HTA documents (82 percent) that assessed technologies such as drugs (31 percent), diagnostic and/or screening technologies (18 percent), or medical procedures (18 percent). Two-thirds (66 percent) of all HTA documents addressed issues related to clinical effectiveness and economic evaluations. Ethical, social, and/or legal issues were rarely addressed (<1 percent). The two groups most often targeted for dissemination of HTA information were third-party payers (55 percent) or government policy makers (41 percent).

Conclusions: This study showed that while HTA programs in LA have attempted to address the main goals of HTA, they have done so through the production of short documents that focus on practical high-technology areas of importance to two specific target groups. Clinical and economic considerations still take precedence over ethical, social, and/or legal issues. Thus, an integrated conceptual framework in LA is wanting.

Methods of meta-analysis, computer modeling, and issue analysis are used to answer four key questions related to efficacy, cost, and political feasibility of legislating insurance coverage for mammography. The findings are presented, and the strengths and weaknesses of the combined use of these methods to inform policy debate at the regional level are discussed.

Technical innovations have enormous potential for enhancing the lives of people with disabilities, often providing means for substantial independence and contributing to their dignity. This paper uses a framework related to the personal needs of individuals throughout the hours of waking and rest. Examples of various potentialities are provided and discussed.

This article describes issues that are clinically significant when assessing quality of life of patients whose organ disease can be treated only through transplantation or reliance upon an artificial organ. Emphasis is placed on stresses that affect the family as well as the immediate patient, because, over time, these are inextricably interwoven. The transplant recipient who experiences a “good” medical outcome may perceive that he has little to live for if his family is severely disrupted or broken apart by the strain of the illness. The family of a patient who dies after unremitting complications while being sustained by an artificial organ may experience both relief at the lifting of an unmanageable burden, and continuing guilt that they were unable to provide unconditional love and support to a dying family member.