In this issue investigators and commentators from Australia, the United Kingdom, the Netherlands, Sweden, and the United States consider some of the many issues being studied and discussed by advocates of appropriate technology in obstetrics.

The objective of this article is to describe and analyze the decision-making process and its consequences for medical technology transfer in China. Data were obtained in 1987 from 35 elite teaching hospitals affiliated with 13 medical universities, directly supervised by the Ministry of Health in the People's Republic of China. This article focuses on three kinds of diagnostic equipment: computerized tomographs, ultrasonic diagnostic units, and high-power x-ray diagnostic apparatuses. Decision-making on the transfer of medical technology in China is decentralized. Most hospitals rely on foreign medical sales representatives and medical exhibits, and their decisions on the acquisition of equipment rely more on the services available than on the price of the product. Chinese hospitals also encounter serious infrastructure problems when buying medical equipment. A number of alternatives are suggested for improving the efficiency of medical technology transfer in China.

The rising costs of health care and interest in the evaluation of health services and systems have sparked an increased need for technology assessment. A variety of available methods of assessment are described in the Institute of Medicine's book Assessing Medical Technologies (1). Although such methods as the randomized controlled trial (RCT) are widely accepted and used, obtaining information by such methods often takes a considerable amount of time, expense, and sophistication in study design. These costs suggest that a broader range of methods for collecting information about health care technologies should be considered. A vast resource of data collected on patients, ranging from a provider's practice records to national data sets, might be useful for technology assessment if it could be properly appraised.

We evaluated the cost-effectiveness of (a) a vaccination program for the prevention of hepatitis B; and (b) the two commercially available vaccines (Merck Sharp and Dohme; Pasteur Institute) in Greece, a country of intermediate endemicity. We examined cases of hepatitis-B infection prevented and the expected medical costs among the high-risk groups of medical and nursing students, hospital personnel, and the general population. Employing a vaccination program reduces considerably the risk of infection, especially in the high-risk groups, while it increases the total cost. The vaccines are very comparable in terms of both health and economic outcomes. Sensitivity analysis indicated that vaccine cost, incidence of hepatitis B, and compliance were the key factors for the choice of (a) whether to undertake an extensive program to prevent hepatitis-B infection and its chronic sequelae; and (b) which vaccine to administer.

A search of literature using the Connecticut Tumor Registry (CTR) for technology assessment produced eight articles. These articles represent a small but apparently increasing percentage (2%) of total CTR publications. By keeping pace with the development and dissemination of medical technologies, the population-based CTR has been useful for assessing them, especially their adverse effects.

Many people believe that cost-effectiveness (CE) and cost-benefit (CB) analyses require different assumptions. However, when CE analysis supports decisions to use medical resources, it makes the same assumptions that CB analysis requires. They are mathematically equivalent. Differences between CE and CB hinge more on reporting style than on fundamental assumptions.

The two components of low birth weight — preterm delivery and fetal growth retardation — lead singly or in combination to a heavy burden of mortality, short- and long-term morbidity, and high medical and social costs. Although different types of long-term morbidity are still being identified, the primary focus of concern has been neurodevelopmental disability resulting from the cerebral palsies, hydrocephalus, and visual and auditory deficits among survivors of very low birth weight. Additional special risks in such infants include chronic lung disease, acute lower respiratory infections, and rehospitalization in infancy and early childhood.

This article describes one approach to assessing the effects of perinatal care–that adopted by the National Perinatal Epidemiology Unit in Oxford, England. The unit's research has been based primarily on a combination of simple, descriptive analyses of observational data and statistically robust analyses of evidence derived from randomized controlled trials.

Screening for human immunodeficiency virus (HIV) antibodies as a means of preventing both the progress and spread of acquired immunodeficiency syndrome (AIDS) is problematic in terms of efficacy, effectiveness, and ethics. The few desired effects are mostly offset by greater and more certain undesirable effects on individuals and society.

The Surveillance, Epidemiology, and End Results (SEER) cancer registry contributed to technology assessment by providing population-based samples for detailed case-control studies, by serving as the control group in comparisons with various experimental groups, by allowing an assessment of selection bias in clinical trials, and by facilitating evaluations of classification and coding systems.

The use of 53 different technologies was studied in 82 patients in a neonatal intensive care unit. Using a coefficient of similarity based on the utilization pattern of these technologies, it was possible to identify five clusters of patients that can be correlated with the primary diagnostic groups and such other variables as birth weight (BW), gestational age, length of stay (LOS), and weight gain. Four interdependent models were identified by multiple regression analysis. The number of different therapeutic technologies applied to these patients can be explained (r = 0.67) by their Apgar scores, gestational age, and an index of severity of illness based on the diagnostic group. The number of different diagnostic technologies used is directly related to the number of therapies delivered (r = 0.63) and, jointly with BW, determines LOS (r = 0.73). Finally, weight gain is explained by LOS and BW (r = 0.65).

It is well known that signs of respiratory distress or disease (RD), such as high breathing frequency, chest wall retractions, grunting, and cyanosis, are common in newborn infants. The signs may be very transient or develop into a potentially life-threatening condition. When they are first observed, they often have a very ambiguous prognostic significance.

In the past decade the prevention and management of prematurity have begun to be addressed with more appropriate designs. A few strategies—very few—can now be recommended. A few, some widely implemented, can be abandoned. The risks and benefits of most interventions still require clarification.

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.

Both observational studies and nonrandomized controlled trials have found the presence of support during pregnancy to be associated with superior outcomes in terms of preventing abortion, extending the length of gestation, and reducing interventions in labor. However, randomized controlled trials of supportive interventions in pregnancy have not demonstrated any physical benefits from the interventions. It is also unlikely there are any significant adverse effects. Psychological benefits do appear to result from supportive interventions, including better enjoyment of the pregnancy and better postnatal status.

In a pretest-posttest panel survey of 595 eligible Maryland physicians practicing family or general medicine, internal medicine, cardiology, or nephrology, perceptions of consensus reports designed to alter medical practice are examined. On a 7-point scale, physicians reported positive or neutral views of descriptors, most favorably rating credible (mean = 2.25) and reliable (mean = 2.41), and least favorably rating biased (mean = 3.79). In a regression analysis of factors influencing changes in practice behavior congruent with consensus recommendations before and 1 year after the release of a consensus report on hypertension (8), these perceptions were not significant determinants. The strongest predictor of congruent practice behavior a year after the report was published was congruent practice behavior just prior to the report's release, and the second strongest predictor was perceived influence of the report's sources/sponsors.

Screening has a relevant role in and is likely to become an increasingly important instrument for cancer control in the near future. This overview summarizes some of the available evidence on the issue. Some of the opinions are well established. The apparent absence of consensus on other issues should be critically evaluated, too, because the evidence on some procedures is substantially more convincing than that on others. High costs, low compliance, poor curability, and substantial false positive rates, in a disease as relatively rare as cancer, often counterbalance in practice the theoretical benefits of diagnostic anticipation. In screening as well as in treatment for cancer, it is unlikely that major technical breakthroughs will occur in the near future. The evaluation of whether the benefits likely to be achieved by the screening program outweigh its disadvantages by a sufficient margin, therefore, should rely on large and carefully planned controlled studies.

This review of publications based on data from the Veterans Affairs Normative Aging Study identified four articles that were considered assessments of health care technologies. Three evaluated methods for research on body composition, the fourth studied ventricular size in patients with presenile dementia. Several additional articles are discussed that provided data on baseline values or risk factors for disease that might be useful in generating hypotheses to be tested in later assessments of technologies.