October 2000 Bulletin

HTA studies treatment costs, risks, benefits

Seeks to narrow gap between what is known from research and ‘real world’ clinical setting

By James S. Breivis, MD

One of the charges or obligations we have professionally is to determine what or which of our actions, such as diagnostic testing, operative interventions, health promotion and prevention, work best for our patients. Another obligation is the ongoing effort to acknowledge and reduce errors. For the health technology assessor, all of this type of effort is more like a mission statement.

Health Technology Assessment is a profession that reviews the scientific basis of methods used in health care and evaluates their cost, risks and benefits. It consists of organizations and individuals searching for comprehensive evidence reviews on health conditions, treatments and technologies. Their intention, simply stated, is to narrow the gap between what is known from research about effective clinical care and what is practiced in "the real world or clinical settings."

This definition for HTA can still leave my colleagues quite puzzled as to what exactly is meant by the term and how the scientific findings might effect them. Perhaps it will clarify things if I listed some of the main agenda topics discussed and debated at the June 2000 annual meeting of The International Society of Technology Assessment in Health Care (ISTAHC). These include: Measuring Quality of Life; The Consumers Perspective in Health Care; Musculoskeletal Disorders: From Trials to Guidelines; Cost of Illness; Drugs and Cost Containment; and Wait Lists: Clinical and Social Issues. This is just a sampling. The HTA field, like the AAOS, is becoming quite multifocused and multifaceted.

Many say that HTA started in the United States. However, its influence is seen predominately where large health care systems exist, and therefore, has a strong niche in the national programs of Canada and Europe. Decision-makers internationally seek out the HTA reports on the effectiveness and economic aspects of technologies.

To emphasize its importance in the overall picture of health care delivery, the Netherlands has made courses in HTA mandatory for all of their medical students. More than ever, the parties dealing with health delivery in developing countries, including our colleagues who volunteer for Orthopaedics Overseas, acknowledge that there is a desperate need for HTA. Hopefully, through the application of methodologies used in HTA, health care personnel will be better able to determine how to spend their very limited resources. For example, a situation that certainly needs HTA attention is that reportedly 30 percent of the world’s population has no access to 100 of the most recognized successful drugs.

The processes and methods used in HTA are many and can be complex. Nevertheless, they are "what makes the HTA engine run." In the past, when I discussed or wrote articles about this phase of the field and elaborated upon terms such as cost utility analysis, incremental analysis, cost benefit analysis and others, the eyes of the audience and I am sure of the reader would begin to glaze over. I hope to avoid this, first, by emphasizing that the details, definitions and applications of the complex methodologies are in the literature and otherwise out there. Secondly, by presenting two examples of "HTA in action" in which these methodologies were used to come to the conclusions.

Following are two conditions or situations pertinent to the musculoskeletal caregiver work performed by SBU, the Swedish Council on Technology Assessment in Health Care. For each example the pre-study fundamental question was the same. What is the evidence, if any, to support the existing clinical practice? It should be emphasized that this a fundamental mission for health technology assessors–the promotion of evidence-based medicine.

Example 1. Pre-Operative Routines–In 1989, SBU published their report examining "routine" pre-operative chest X-rays, laboratory tests and EKG’s as a norm. Their scientific findings revealed no health care benefit to this practice or protocol. Testing should be done if clinically appropriate. With proper dissemination of their findings, the Swedish physicians, and then those in other countries, abandoned the routine ordering of multiple pre-op tests, reducing costs.

Example 2. Back Pain and Neck Pain–SBU just completed a 13 person, five-year technology assessment on Back Pain and Neck Pain. It included a metanalysis of over 2,000 references in the literature with nearly 1,000 clinical trials. Their two-volume report will be published in English in late 2000.

The first Back Pain and Neck Pain volume addresses how one’s work situation and social, psychological and individual factors can influence back pain. It also discusses what is known about the origins of pain, the potential for preventing back and neck pain and how often they appear in different populations and age groups.

The second volume presents scientific facts on the results of conservative, surgical and psychological treatment methods and their cost effectiveness. The reports are now being distributed throughout Sweden. SBU leaves it up to others in their national health system (such as physicians and health authorities) to use the evidence from such research as they deem appropriate. It may or may not shock you to hear that in the SBU review of the treatment of either acute or chronic neck pain, only a few studies had any scientific quality.

SBU published an excellent summary booklet. The two-page listing in their booklet in which they noted the common treatments for both chronic and acute back and neck pain deserves particular attention. They make declarations based on their search for evidence as to whether or not each treatment listed was backed by strong, limited and moderate– or no scientific information. For some treatments they even declared that there was evidence against its use.

It turns out that most of the treatments for these conditions have minimal to no supporting scientific evidence. Examples include: no evidence to support the treatment of acute or chronic low back pain with ultrasound and no evidence to prescribe acupuncture for acute back or neck pain.

In the U.S., HTA has had a great influence in the pharmaceutical industry with assessments performed internally or through private technology assessment firms. There is also the Agency for Healthcare Research and Quality (AHRQ) and its division called the Center for Practice and Technology Assessment (CPTA). As a part of the U.S. Department of Health and Human Services, there are four programmatic activities.

  1. Evidence-Based Practice Centers (EPC’s)–12 in the U.S. that develop evidence reports and technology assessments on clinical topics for the Medicare and Medicaid populations.
  2. National Guidelines Clearinghouse (NGC)–a public/private collaboration, which is a comprehensive Internet-based source for clinical practice guidelines (www.guideline.gov).
  3. U.S. Preventive Services Task Force (USPSTF) –Its mission is to evaluate the scientific evidence for effectiveness of a range of clinical preventive services.
  4. Research and Evaluation–To oversee research grants that deal with methodologies used in HTA as well as how to implement the results in the clinical setting.

The Academy has supported and participated in HTA for many years. The time-consuming and expensive (and excellent) work on treatment outcomes measurement, musculoskeletal care guidelines and the recent efforts on the burden of disease for musculoskeletal conditions are key examples.

With globalization and the Internet, many of the barriers and borders that separated our health care delivery systems are fading. The future of Health Technology Assessment is bright and its influence upon you and your treatment of patients will only grow–and it should.

James S. Breivis, MD, is a consultant on the Biomedical Engineering Committee.

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