The National Institutes of Health (NIH) has always carefully limited its responsibilities to biomedical research and knowledge development, including clinical trials, dissemination of results of research, and training. Ten years ago, NIH undertook to examine its possible role in the evaluation of medical technologies.

In 1976, the U.S. Congress became alarmed over the increase in health care costs: in particular, that a number of expensive technologies, such as coronary artery bypass surgery and electronic fetal monitoring, had entered the delivery system without adequate study of their safety, efficacy, cost, or other implications. At the time, there was no formal structure or forum in either the executive branch of the government or in the private sector for seeking a consensus that a medical innovation was actually safe, beneficial, and ready to be transferred into the health care delivery system. Similarly, there was no structured process through which the parties who comprise the delivery system could meet with representatives of the research community to examine the medical-scientific issues surrounding a given innovation along with cost and cost- effectiveness, ethics, and other societal issues of importance to the system.

This paper offers a theory to explain the diffusion of new medical technologies into local practice. Based on several hundred interviews with community hospital physicians, it anchors technology decisions in the norms and relationships of local practice. Physician descriptions of their use of different types of assessment information provide insight into the way in which local consenses on appropriate practice are formed, guide behavior, and change. To understand new technology adoption, it is necessary to (a) differentiate “formed” (complete) and “dynamic” (still developing) technologies, and (b) appreciate the extent to which medical practice is locally organized. Concepts from organizational literature, then, become useful in explaining the penetration of these medical communities and the circumstances under which a new modality takes hold in them. Within the framework presented, previously puzzling findings regarding variations in local practice and the poor relationship between practice behavior and the published literature become understandable.

Though technology assessment and quality assessment have much in common, they differ significantly in emphasis. Technology assessment judges technology itself; quality assessment examines the extent to which a technology is used well in its various settings. This article explores the nature of quality assessment–including the performance of individual practitioners as they care for individual patients and the care received by communities–and examines its interrelationship with technology assessment.

This article chronicles the adoption of medical technology in twentieth-century Korea. The author suggests that the structure of the present health care delivery system has relied predominantly on small clinic practice and has resulted in a shortage of highly capitalized hospitals and a maldistribution of modern technology. In addition, the author argues that medical practice in small unconnected clinics and hospitals isolate physicians from academic medicine and hamper research. Finally, the highly decentralized structure of Korean medicine is a weak basis for controlling the diffusion of medical technology and leaves most acquisition judgments in the hands of individual hospital owners.

This article describes and explains the impact of the National Health Service bureaucracy on the diffusion of medical technology in the United Kingdom. Through case studies of six medical technologies, the author demonstrates how health care authorities may exercise significant control by using the central financing system to dampen the general diffusion of technology. However, the United Kingdom has less control in specific cases due to the absence of a bureaucratic body to coordinate the evaluation and introduction of new technology.

A rapidly evolving technology, percutaneous transluminal coronary angioplasty, is increasingly favored over bypass surgery for treating some types of coronary stenosis because of its less traumatic invasion, better recovery response, and lower initial cost. However, substantially higher failure rates in initial procedures offset PTCA's savings to an unknown extent and cloud analysis of its overall impact. Lack of randomized clinical data precludes valid cost-effectiveness comparison of the technologies at this time. Criteria for establishing valid data and evaluations of currently available data are described in this paper.

Programs that disseminate information to health care practitioners often do so partly to encourage appropriate changes in practice. However, merely providing information is seldom enough to accomplish such changes. If information transfer programs are to influence practice, they must be designed to maximize the conditions facilitating change. Reliance on a diffusion model for thinking about how information reaches practitioners has led researchers to over-emphasize the importance of exposure to information and ignore other factors that determine whether change will occur, such as practitioners' motivation to change, the context in which clinical decisions are made, and how information is presented. The fact that successful dissemination will not necessarily produce change also has implications for how information transfer programs should be monitored and evaluated.

This article reviews the diffusion of western medical technology in China since 1978. The author demonstrates how medical organization and financing at both the national and hospital levels have contributed to a relatively rapid diffusion. The example of the CT scanner is used to evaluate the financing, distribution, and utilization of medical technology in China. The author concludes with an examination of the policy implications and practical impact of current trends.

The authors provide a detailed overview of how the national and provincial health systems of Canada exercise control over the diffusion of medical technology. In particular, they examine the diffusion of CT scanning and the adoption of non-ionic radio contrast media. While the nature of the parliamentary system theoretically aflows the government, especially the executive, to exert more control over its policy agenda than in the United States, the authors believe that effective control is hampered by a lack of political will and insufficient “teeth” in the Ministry of Health' mandate and policy. The authors also conclude that the manipulation of reimbursement systems to encourage or discourage the diffusion of various medical technologies is not always effective, and that political clout often triumphs over rational decision making.

The evaluation of innovations which use old technology poses different problems than does the evaluation of new technologies. The main necessity is the targeting of its use rather than the technology itself. The need to evaluate the extent of use and its problems is illustrated by the example of progestin use among menopausal and postmenopausal women in the United States. There progestins are not of ficially approved for use in menopause, even though they have been on the market for a long time with other indications. Estrogen-replacement therapy was widely used from the early 1960s until 1975, when the claim that estrogens cause endometrial cancer notably decreased their use. The use of estrogens increased again in the early 1980s, and one reason for this revival was the claim that progestins offered protection against endometrial cancer. When recommendations for combined estrogen-progestin therapy have been made, other health effects have been ignored. Two consensus conferences as well as the drug control authority have recommended against combined estrogen-progestin therapy until further research is completed. Absence of good research, specialization in medicine, and advantages for prescribers and the drug industry may have contributed to the wide use of this unassessed treatment. Possible solutions for prevention of the diffusion of these kinds of innovations are discussed.

This presentation provides an overview of the process of information transfer in a typical area of the medical device industry, that of medical imaging. The medical device industry must translate technological trends into ideas for new methods for diagnosis and treatment. The feasibility of such ideas has to be evaluated carefully, inasmuch as large amounts of money are sometimes invested in product development. Moreover, the knowhow obtained from research must be protected long enough to enable the industry to complete development and market the product.

The authors of the paper argue that Norway's national health service, despite public perceptions, is both inexpensive and technologically advanced. Norway has a highly regulated medical system at both the national and local levels, and many distribution issues take the form of political debate. As a result, the authors believe that medical care and equipment is equitably distributed, but perhaps over-densely, throughout the country. Although the overall picture is optimistic, there is some concern that technologies, health care priorities, and decision-making processes should be more carefully examined by consensus conferences, advisory groups, and experts in technology assessment.

This article begins by sketching out the constitutional arrangements in Italy for the distribution of powers among different levels of government. The more important characteristics of the health system are then examined in some detail, the aim being to provide a sufficient basis for understanding the analysis of technology policy which follows later. The mechanisms used for funding medical technology are next described, after which data available on the diffusion of medical equipment are illustrated. Medical technology policies at the national and regional level are examined and an attempt made to appraise their effectiveness. The article concludes with a brief analysis of the possible role played by private medicine in the diffusion of medical technology in ltaly.

Biomedical research plays a great part in promoting not only advances in scientific knowledge but also in the continuous flow of technological innovations in health care. One of the first conditions for the successful transformation of research into an innovation is overcoming the divisions between science and technology, between the researchers and their partners in the innovation process.

Biomedical Research Councils (BMRCs) have an important role in the transfer of information. To improve the chances of successful developments and transfers of scientific breakthroughs, the BMRCs must adopt new, comprehensive strategies for such transfer. They must learn to recognize as early as possible which new opportunities hold promise, at which stage of development information should be transferred to other areas of expertise, and which target groups in which fields should be made partners in the research.

This article reviews milestones in the technological development of mammography since 1970. Mammography is particularly underutilized as a screening procedure for breast cancer and the reasons for its continued inappropriate and under use are explored. Although there are some known barriers to increased utilization among the female adult population, the majority of barriers reside within the domain of referring physicians. Remedies to address the low referral rates for screening mammography are outlined for federal agencies, radiology groups, mammography equipment companies, medical schools, and philanthropic groups. Until the developers of technological procedures such as mammography appreciate that the application of a technology and its appropriate utilization by professionals and the public are important to consider when the technology is developed, utilization rates may not do justice to the technology's potential.

This article argues that while health care and government authorities in the Netherlands in the last decades have attempted to rationalize the diffusion of medical technology, much work remains to be done. The authors contend that though a mix of direct government regulation and economic incentives will be needed, regulation by incentive is more effective than regulation by directive in achieving cost effective use of technology. Generally, bureaucratic structures provide only limited opportunities for tight control of the diffusion of medical technologies. The article offers possible future strategies for directing the adoption and use of medical technologies and stresses the importance of reliable infor mation culled from comprehensive technology assessments.

This article surveys attempts by the Finnish government to plan and budget health care since the Primary Health Care Act of 1972. A national board of health allocates approved resources to local authorities who develop plans for preventative and primary health care and hospital services. The acquisition of expensive technologies are debated at the national level. The author presents studies which suggest that there is a considerable need for expansion of both diagnostic and therapeutic technologies in Finland. These adjustments will be necessary to meet the needs of an economically, socially, and demographically changing country.