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Clifford S. Goodman, Ph.D., Senior Scientist, The Lewin Group, Falls Church, VA.
This session addressed the importance of health technology assessment (HTA). Given the proliferation of health technology and its impact on healthcare costs, there is a growing demand for assessment of drugs, devices, procedures, and systems used in healthcare. Dr. Goodman noted that technologies must be understood broadly, in terms of not only their physical nature but also their clinical applications and stage of maturity or diffusion. According to Dr. Goodman:
"Health technology assessment is the systematic evaluation of the properties,
effects, or other impacts of health technology. Its main purpose is to inform policymaking for healthcare interventions involving medical technology."
Dr. Goodman demonstrated the importance of identifying and interpreting studies according to their methodological rigor and relevance to the clinical problem or coverage decision at hand. Just as there is a hierarchy in methods of primary data collection, ranging in strength from large randomized controlled trials to cross-sectional studies, to single case reports, there is also a hierarchy to levels of evidence:
- Meta-analysis of multiple, well-designed controlled studies (strongest).
- Well-designed experimental studies.
- Well-designed quasi-experimental studies.
- Well-designed non-experimental studies.
- Collections of case reports and clinical examples (weakest).
Depending upon the policy to be informed, HTA can address the following issues regarding a given technology:
- Technical properties.
- Efficacy or effectiveness.
- Costs and other economic attributes.
- Other social, legal, ethical, and political impacts.
Coverage decisionmakers and other policymakers must seek out HTA information to meet their particular needs.
Dr. Goodman offered a 10-step framework for conducting HTA:
- Identify assessment topics.
- Specify assessment problems.
- Determine locus or responsibility of assessment.
- Retrieve evidence.
- Collect new primary data.
- Interpret evidence.
- Synthesize evidence.
- Formulate findings and recommendations.
- Disseminate findings and recommendations.
- Monitor impact.
He noted that shifts in the application of technologies, new uses for old technologies, and other adaptations present a "moving target" problem for HTA. To manage this challenge, Dr. Goodman suggests that researchers and policymakers have prospective approaches for determining when assessing or re-assessing a technology is necessary. He stressed that the ability to identify, access, and interpret data and information sources in the field is essential for conducting a well-founded HTA. Also, understanding the target audiences and how to influence them are necessary for HTA to be effective.
Current trends in HTA methods include:
- More systematic priority-setting and transparent HTA processes.
- Higher standards for evidence on safety and effectiveness.
- Development and wider use of improved instruments for assessing health-related quality of life.
- Emphasis on improving and standardizing economic analysis.
- Development and wider use of synthesis methods (e.g., meta-analysis, decision analysis).
- Greater reliance on informatics resources (e.g., computer databases, electronic patient records, Internet).
Recent trends in the application of HTA include:
- Greater emphasis on HTA in technology industries.
- Wider demand for HTA for technology investment, acquisition, practice guidelines, and patient/consumer use.
- Increase in the number of HTA agencies.
- Greater HTA collaboration.
Croghan TW, Johnstone BM, Buesching DP, et al. Information needs for medication coverage decisions in a State Medicaid program. Med Care 1999 Apr;37(4):24-31.
Eisenberg JM. Ten lessons for evidence-based technology assessment. JAMA 1999 Nov 17;282(19):1865-9.
Goodman CS. Healthcare technology assessment: methods, framework, and role in policy making. Am J Man Care 1998 Sep 25;4(SP):200-16.
Steiner CA, Elixhauser A. Managed care, technology assessment and coverage of medical technology. Today's Internist 1998 Jan/Feb; 22-27.
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