Eleven percent of the U.K. population holds private health care insurance, and £2.2 billion are spent annually in the acute sector of private health care. Although isolated from policy discussions about new medical technology in the National Health Service, the private sector encounters these interventions regularly. During 18 months in one company, a new medical technology was encountered on average every week; 59 leading edge technologies were submitted for authorization (18 on multiple occasions). There are certain constraints on purchasers of health care in the private sector in dealing with new technology; these include fragmentation of the sector, differing rationalities within companies about limitations on eligibility of new procedures while competing for business, the role and expertise of the medical adviser, and demands of articulate customers. A proactive approach by the private sector to these challenges is hampered by its independence. Poor communication between the public and private sectors, and the lack of a more inclusive approach to policy centrally, undermine the rational diffusion and use of new medical technology in the U.K. health care system.

The current medical environment makes information retrieval a matter of practical importance for clinicians. Many avenues present themselves to the clinician, but here we focus on MEDLINE by summarizing the current state of the art and providing an innovative approach for skill enhancement. Because new search engines appear rapidly, we focus on generic principles that can be easily adapted to various systems, even those not yet available. We propose an idealized classification system for the results of a MEDLINE search. Type A searches produce a few articles of high quality that are directly focused on the immediate question. Type B searches yield a large number of articles, some more relevant than others. Type C searches produce few or no articles, and those that are located are not germane. Providing that relevant, high-quality articles do exist, type B and C searches may often be improved with attention to search technique. Problems stem from poor recall and poor precision. The most daunting task lies in achieving the balance between too few and too many articles. By providing a theoretical framework and several practical examples, we prepare the searcher to overcome the following barriers: a) failure to begin with a well-built question; b) failure to use the Medical Subject Headings; c) failure to leverage the relationship between recall and precision; and d) failure to apply proper limits to the search. Thought and practice will increase the utility and enjoyment of searching MEDLINE.

The aim of this paper is to demonstrate the use of conjoint analysis (CA) in health services research. Conjoint analysis is first explained, with emphasis on the history of the technique, followed by an explanation of how to carry out such a study and how the results from such a study can be used. The technique is demonstrated with reference to a study that looks at the benefits of in vitro fertilization. It is shown how CA can be used to estimate the relative importance of attributes, the trade-offs individuals make between these attributes, willingness to pay if cost is included as an attribute, and utility or benefit scores for different ways of providing a service. The paper then considers the potential advantages of CA over other, more commonly used benefit assessment instruments. Finally, there is discussion of the issues raised in the design and analysis of CA studies. It is concluded that these issues must be addressed before the technique becomes an established instrument for technology assessment.

The cultural and emotional importance of having and raising healthy children is undisputed. Cross-cultural solutions to problems resulting from involuntary childlessness have included such strategies as adoption, finding new partners, and dissolving marriages that do not produce offspring. While both males and female infertility may result from heritable factors, environmental exposures, and disease, it is usually the result of functional incapacity in youth and in old age. The high value attached to reproduction is not puzzling. Human reproduction is protected by strong basic instincts. Childlessness is seldom met with stoicism by those who wish to have children. The happiness that follows the successful birth of a wanted child must not be discounted. Traditional definitions of “family” imply “offspring” before the acknowledgment of other memberships.

Objectives: To develop and evaluate a new model of continuing medical education (CME) for general practitioners (GPs). The study is part of the joint European Drug Education Project (DEP). This paper presents the Swedish part regarding the design of the evaluation study, the educational methodology, and the participants' evaluation.

Methods: An educational model was developed. Two peer group discussions (facilitated by a GP/pharmacist team), including individual feedback on the GPs' judgments of written simulated cases and prescribing, were main components. The model was tested in a parallel randomized controlled study including 36 GP groups, allocated to education on asthma or urinary tract infections. Background and outcome data were knowledge and attitudes (K/A) assessed by a questionnaire and prescribing practices for actual and written simulated cases. The GPs' evaluation of the model was captured through a questionnaire.

Results: All 36 groups completed the program. The mean participation rate in the group discussions was 75%. The response rates were 82–98% regarding background, 60–83% regarding outcome data (K/A questionnaire and written cases), and 80% regarding the evaluation questionnaire. Prescribing data were captured for 99% of the GPs. Both group discussions were considered important by 84–89%. Eighty-seven percent wished to take part in similar CME activities for other conditions. About 80% reported that their purpose in participating had been fulfilled.

Conclusions: It was feasible to evaluate the developed educational model by using a two-armed parallel study design. The model was well received by the participants.

The Human Fertilisation and Embryology Act of the United Kingdom was passed in 1990, leading to the formation of the Human Fertilisation and Embryology Authority (HFEA), the first statutory body to regulate and control assisted conception anywhere in the world. The principal function of the HFEA is to license and monitor clinics that carry out in vitro fertilization (IVF), donor insemination (DI), and embryo research. Information on over 135,000 treatment cycles, 20,000 pregnancies, and 25,000 babies following IVF has now been collected as part of the regulatory process, and these data have permitted unbiased and accurate evaluation of treatment efficacy using pregnancy and live-birth rates. The treating clinics are required by law to provide information on the outcome of all births, including neonatal mortality and congenital malformations, but there is no systematic validation of these data using medical records or any follow-up of treated women, or babies, over time. In addition, the strict confidentiality of data supplied to the HFEA means that outside researchers have been unable to access the database for research projects. Thus, at the present time, it is not possible to evaluate the long-term safety of assisted conception procedures using HFEA data. There is reasonable scientific evidence to justify full investigation of the health of both treated women and resulting children. Particular health outcomes requiring evaluation include obstetric complications, preterm births, cerebral palsy, and cancer. The HFEA has recognized the need for follow-up studies and is currently investigating ways of enabling research projects using HFEA data to be undertaken.

Objective: Even though gastrointestinal complaints are among the most frequent reasons to contact general medical practioners, little is known about the actual care of these patients, especially the use of diagnostic imaging technologies.

Methods: In a network of 57 family practitioners and 29 general internists in Lower Saxony, Germany, 1,217 contacts with patients with gastrointestinal diseases (16%, gastritis; 12%, gastroenteritis; 6%, cholelithiasis; 5% each, ulcus ventriculi and duodeni, and 14%, no final diagnosis) were documented. The effects of patient and physician/practice side factors on the use of ultrasonography and radiography were modeled using multivariate logistic regression.

Results: For ultrasonography, diagnosis and ownership of an ultrasound unit (odds ratio [OR] = 3.33) were highly significant predictors (p < .0001), followed by unknown diagnosis at beginning of contact (OR = 1.92; p = .0019), physician specialty (OR for internists = 1.89; p = .0025), and severity (p = .0085). For radiography, ownership of an ultrasound unit was the most significant factor (OR = 0.34; p < .0001), followed by severity (p < .0009), ownership of x-ray apparatus (OR = 2.56; p = .0025), physician specialty (OR for internists = 1.98; p = .0358), and unknown diagnosis at beginning of contact (OR = 1.79; p = .0451). Not significant were age and sex of patient and diagnosis for radiography.

Conclusions: Physicians use diagnostic imaging technologies for patients with gastrointestinal complaints according to severity and knowledge about the diagnosis, but ownership of technology is the most predictive factor.

Biomedical databases are an important source of information for health technology assessment. However, there is considerable variation in the costs of accessing commercial databases. We sought to measure the quality, amount of overlap, and costs of information retrieved from two of the main database sources — MEDLINE and EMBASE. Librarians at two health technology assessment agencies ran a total of eight literature searches on various medical technologies, using both databases. All search results were independently reviewed by two researchers. The researchers were asked to identify relevant references and to rank each of these according to a level of evidence scale. The results were tabulated to show the number of references identified by each database, the number of relevant references ranked by level of evidence, and the number of these references that were unique to one or the other database. The cost of retrieving references from each source was also calculated. Each database contained relevant references not available in the other. Because of the longer time lag for indexing in MEDLINE, many of the references that originally appeared to be unique to EMBASE were subsequently available in MEDLINE as well. Since our study was conducted, MEDLINE has been made available worldwide, free of charge, via the Internet. Hence, the cost difference between the databases is now even greater. However, notwithstanding the costs, it appears that literature searches that rely on only one or the other database will inevitably miss pertinent information.

The Centers for Disease Control and Prevention published the first Assisted Reproductive Technology (ART) Pregnancy Success Rate Report in 1997. This article presents a description of the law that initiated the public report, a description of the surveillance system used to accumulate data for the report, and some of the results from ART cycles intitiated in 1995.

Objectives: To evaluate the characteristics, methods, and results of the Dutch Investigative Medicine Program (“ontwikkelingsgeneeskunde”) in policy and health care.

Methods: Project database analyses of the initial 9 years of the program; description of characteristics, methods, and effects of the program.

Results: By the end of 1997, 53 projects had been completed, including implementation in health care policy. In 20 of 53 cases the program worked as an instrument to prevent the introduction of ineffective, inefficient, or even harmful medical interventions. In most other cases the program assisted with proper placement or appropriate application of new technologies. Apart from new or emerging technologies, already existing technologies are evaluated.

Conclusion: The Dutch Investigative Medicine Program (“ontwikkelingsgeneeskunde”) of the Sickness Funds Council is an effective collaboration of health care providers, medical science, health economics, and a regulatory body in empirical technology assessment. It is also an example not only of a substantial contribution of technology assessment to decision making in practice and policy but also of a means of regulation of health care by the very activity of technology assessment itself. It appears that the program has evolved into an instrument to rationalize health care and health care policy, although some further possible improvements are identified.

Meta-analysis is commonly used in reviews of the effectiveness of medical technologies, but this approach has not been used in direct support of guidelines development groups. This paper describes the approach of the North of England Guidelines Development Project in describing the evidence using meta-analyses that were conducted explicitly to address questions on the choice of therapy raised by the guidelines development groups. Particular emphasis is placed on the context within which the contributing trials were conducted and the extent to which systematic differences between trials (heterogeneity) was observed, described, and explained. There is a trade-off between internal and external validity for different metrics when presenting the results of trials. More interpretable metrics, such as risk differences or weighted mean differences, are confounded by study design issues and strong assumptions. More robust measures such as odds ratios or standardized weighted mean differences are difficult to interpret physically. Individual patient data may prove particularly helpful in addressing pivotal questions on the magnitude of effects of interventions, though accessing and reanalyzing these data requires a substantial investment in time and other resources.

Objectives: To examine the distribution of interventional cardiac catheterization laboratories, their case load, the time trends, and the regional variation of percutaneous transluminal cutaneous angioplasty (PTCA) utilization in Italy.

Methods: Analysis of data was provided by the annual reports of the Italian Group of Studies and Interventional Cardiology over the period from 1983 to 1996.

Results: The number of PTCA facilities and their use steadily increased, mainly in the North. In 1996 the utilization rate was 34 per 100,000 population, but only 60% of labs performed 200 or more procedures.

Conclusions: Dramatic time trends and regional variations often took place without an epidemiology and technology assessment-based planning process.

Objectives: The purpose of this review was to examine whether studies from the medical literature focusing on efficiency of diagnostic facilities reported economic evaluation methods appropriately, following guidelines for conducting and reporting economic evaluations.

Methods: A Medline search was conducted, and studies that concerned a diagnostic technology and fulfilled the Drummond criteria were selected for methodological review. The reliability of selection and methodological review based on the abstracts was determined by scoring a random sample of both abstracts and full articles. lnterrater reliability was determined by scoring a random sample of abstracts by both authors. Kappa values were calculated. Nine methodological aspects were reviewed: study design, the type of economic evaluation, the comparison made, the study's perspective, the cost-effectiveness ratio used, the definition of cost-effective, the types of costs analyzed, the cost calculation method, and the use of sensitivity analysis.

Results: Two hundred fifty studies published between 1992 and 1997 were found regarding efficiency of diagnosticfacilities; 134 studiesfulfilled the Drummond criteriaand were selected for methodological review. Kappavalues showed reliability of selection and methodological review and interrater reliability. The existing literatue on the economic evaluation of diagnostic facilities does not adhere well to guidelines for economic evaluation. In 95%, no perspective was mentioned, in 50% of the cases no ratio was given, in 82% the cost calculation method was not mentioned, and in 66% no sensitivity analysis was reported.

Conclusions: Our review suggests that to improve the quality of reporting economic evaluations, editorial boards could issue and enforce guidelines for standard reporting of such studies.

Objectives: To examine whether screening and eradication of Helicobacter pylori by population-based invitation or opportunistic screening by general practitioners reduces costs to the National Health Service (NHS) of treating dyspepsia.

Methods: A limited dependent, variable, two-step regression analysis was used to explore the baseline annual health care costs of dyspepsia for men and women aged 40–49 enrolled in the Leeds H. pylori screening and eradication trial.

Results: Epidemiological and clinical questionnaires, general practitioner notes, and 13C urea breath test results were available for 4,754 individuals. After adjusting for covariates, H. pylori was associated with a 6.7% increased probability of incurring gastrointestinal-related NHS costs (p < .0001) in the population aged 40-49. Additionally, H pylori increased average costs in those who seek medical care (p = .001). In consequence, H. pylori is associated with an average increased cost to the NHS of £0.30 per year (95% CI: £0.17 to £0.45) per adult aged 40–49. In those consulting for dyspepsia, the increased cost to the NHS was £1.04 per year (95% CI: £0.42 to £1.75) per patient. The cost of population screening and treatment would not be recovered in reduced dyspepsia costs in the lifetime of those screened. Assuming laboratory-based serology screening is used opportunistically in patients presenting with dyspepsia, it is estimated that costs would be recouped in 18 years.

Conclusions: This observational data set suggests that the costs of screening and treatment in all individuals aged 40–49 or in those presenting in primary care with dyspeptic symptoms are unlikely to be attractive on the basis of cost savings alone.

After 25 years of debate about privacy of automated personal health data, the U.S. Congress has set a deadline of August 1999 for enacting health information privacy legislation. The urgency to establish national policy in the United States re-emerges with implementation of a 1996 law mandating a unique identifier for each participant in the U.S. medical care system and the use of a uniform electronic data set for all health information transmitted in financial and administrative transactions. The impact of electronic data storage and transmittal on privacy, health outcomes, and medical care is unclear. A three-step analytic scheme can clarify the issues in the policy debate and for future assessment. The first step is intended to elicit, for the first time, a precise, accurate, and reproducible description of personal health data transactions and chains of transactions, independent of the policy preferences of any interested party. The second step allows the reader to analyze these transactions according to who benefits first and foremost from each. This scrutiny clarifies the reasons why parties to the debate tend to disagree. The third step characterizes how Congress is likely to perceive the policy process and consider its options before enacting any particular set of compromises. Understanding the policy deliberations and potential effects of evolving information technologies and new national privacy rules should aid assessment of results.

The process of technology assessment is evolving. The process of policy development for technology is the least understood in the cycle of technology assessment. The process of policy development, which should involve extensive consultation and a broad-based research and evaluation program, is often fraught with difficulties and can cause further analysis or the assessment process to come grinding to a halt. This article reviews some social, political, and ethical issues and the role of civil society in influencing the technology assessment process for new reproductive technologies in Canada. It is written from the perspective of one of the Deputy Directors of Research and Evaluation for the Royal Commission on New Reproductive Technologies and highlights the strengths and difficulties of technology assessment when civil society and technology assessment come face to face. A brief update by a policy analyst in Health Canada on the current situation of legislation on new reproductive technologies has been provided and is included at the end of this article.

Objectives: To provide information to health authorities and others on the effectiveness of hyperbaric oxygen treatment (HBOT) and the impact on health services should an additional HBOT facility be established in the provincial health care system.

Methods: A literature review on the clinical use of HBOT was conducted, drawing on MEDLINE, EMBASE, and HealthSTAR. For each of 13 conditions, the effectiveness of HBOT was assessed, with reference to a widely used classification of level of evidence. Cost implications were considered for each condition for which there was sufficient evidence of effectiveness. The perspective was that of the payer.

Results: Good evidence of effectiveness exists for HBOT for four conditions and HBOT is established as the clinical standard of care for two others. Available evidence did not support the routine use of HBOT for a further seven indications. An additional 59–87 patients per year would be eligible for HBOT if a second facility were established in the province. Improvement in quality of life could be expected for 30–60 persons per year. A new facility would result in identified additional annual expenditure of $108,000. Capital costs could exceed $600,000.

Conclusions: On the basis of the available evidence on benefits and costs to routine health care, there did not seem to be a particularly strong case for establishing a second HBOT center in the province. Following the assessment, the health authority made a decision not to provide funding for this additional service.

In vitro fertilization (IVF) stands out as one of the contemporary period's most extraordinary technologies, and its social and ethical consequences among the most far reaching. Despite its uncertain effectiveness and medical consequences, IVF has contributed significantly to the medicalization of infertility and the increasingly imperative character of reproductive technology. New developments in IVF, particularly oocyte donation, have created new definitions of treatable infertility and new social needs for IVF; when the technology does not result in pregnancy or healthy babies, these developments have created profound new disappointments. IVF and the commodification of the extracorporeal embryo have also confused the social meaning and legal definition of parenthood. Ultimately the relationship between prospective parents, infertility specialists, and the embryos that they create is a highly ambiguous one. This ambiguity is likely to be a long-term characteristic of efforts to develop, use, and assess assisted reproductive technologies.

Objectives: To examine the influence of a picture archiving and communication system (PACS) on the length of stay (LOS) for patients receiving total hip replacement (THR) or total knee replacement (TKR) procedures.

Methods: A before-and-after design was used. Data were collected on all THR and TKR procedures at Hammersmith Hospital from 1993–96. A regression approach was used to examine the influence of PACS on LOS. Factors such as patient age, sex, and physician were controlled for.

Results: Type of admission and discharge, month of procedure, complications, and number of procedures all significantly influenced LOS for patients undergoing THR. For patients receiving TKR, age, sex, admission, prosthetic complications, number of procedures, and PACS significantly influenced LOS.

Conclusions: While this study shows an apparent reduction of 25% in the average LOS for TKR patients at the time PACS was introduced, this is unlikely to be a true PACS effect and no similar reduction in LOS was shown for THR patients.

The need to choose among alternatives instead of allowing the market to make choices has led health care professionals to rely on scientific information as an aid in decision making. Mathematical modeling is one of the increasingly common tools used over the past three decades to produce new information. But we have used almost exclusively noncomplex models to help analyze complex systems problems. The need to integrate the complexity of the interactions of clinical, quality of life, and economic attributes into such models can no longer be ignored. The opportunity is available to use existing complex systems modeling techniques for health care questions to improve the quality of study outputs, which can, in turn, help produce more rational decisions.