Health care technology assessment and the biomedical engineer - where do we go from here?

Since the IFMBE established a Division for Health Care Technology Assessment (DHCTA) in 1991, there has been an extremely rapid development in the field.

The pressure on decision makers in health care is steadily increasing due to the innovation rate which contributes to effectiveness in health care. Now, comfortable, patient-friendly technologies give rise to demands from patients whose suffering we could not so easily alleviate previously. Consequently, the increasing demands are in troublesome conflict with the limited resources.

Various measures are taken to handle the situation in different countries. Over the years, methods of technology assessment have been refined. Several countries have organised systematic health technology assessment to find ways of allocating resources based on knowledge and reasoning and not on random choice.

What is the role of engineers in this process? What has the IFMBE DHCTA done and what is the impact? Where should we go in the future? The reason for raising these questions is that biomedical engineers are stil much too invisible in HCTA and policy making.

Let us have a quick look at the history. Dealing with the impact of technology in a society needs a broad approach encompassing social and economic consequences. In 1972 the US Congress established an Office of Technology Assessment (OTA) which published a report on HCTA in 1976.

Following this, but with delay, several countries now have national programs for HCTA. A scientific society, the International Society of Technology Assessment in Health Care (ISTAHC) was established in 1985. The discipline is well established now (remarkably, the OTA closed down last year in spite of this), several textbooks have been published, there is a scientific journal (International Journal of Technology Assessment in Health Care), HCTA results are available in databases, and issues as clinical effectiveness and evidence-based medicine have got broad recognition.

Several organisations have interests in HCTA, e.g. governmental agencies in permitting a technology, professionals about the effective use of technologies, hospital administrations about procurement, payers (insurance companies) about coverage and reimbursement (Goodman, 1993). Trends that have been seen include: -

  • more and more groups become involved
  • the starting point in assessments is often the health problem, not the technology
  • while efficacy of an intervention is defined as the degree to which favourable outcomes are achieved under ideal circumstances, it is generally recognised that reality (everyday conditions, disease severity, a.o.) 'modifies' the efficacy
  • it is recognised that, in using HCTA results, the strength of recommendations is explicitly coupled to the kind of trials they are based on (from single case studies to randomised controlled trials)
  • the methods for syntheses of studies have been improved (NHS Centre for Reviews & Dissemination 1996)
  • the methodology for achieving outcome measures (health-related quality of life) has reached a high level
  • HCTA has been subjected to widened interest in prioritisation
  • the medical device industry shows increased interest in cost-effectiveness issues.

The Division

The DHCTA was established with the goals of: promoting comprehensive assessments and the participation of biomedical and clinical engineers, encouraging multidisciplinary co-operation, stimulating the biomedical and clinical engineering communities to strive for appropriate and cost-effective technologies, and enriching the biomedical and clinical engineers' understanding of policy-making and encouraging their participation in these processes.

The Division should bring together expertise from areas such as technology assessment, quality assurance and quality assessment, biomedical and clinical engineering, medical informatics, regulatory affairs, technology transfer, epidemiology and biostatistics, technology innovation, industry, health economics, payment and reimbursement, ethical/social/ legal affairs, medicine and health services research (Persson, 1991).

What has been done?

The HCTA immediately established collaboration with the International Society of Technology Assessment in Health Care (ISTAHC) and ISTAHC members were co-opted to the Division Board. Over the years many meetings have been arranged in co-operation, for example the IFMBE 1991 World Congress in Kyoto and Rio de Janeiro in 1994. Furthermore, sessions were set up at the ISTAHC annual meetings (Vancouver 1992, Stockholm 1995, Barcelona 1997) and at other meetings. These cross-border meetings have been very stimulating.

Various publications have been initiated in order to create awareness of the area, in the ISTAHC as well as the IFMBE journals. I anticipate that the contribution by BMEs will increase in the near future.

The Division decided to focus attention on the field of rehabilitation engineering and participated in the IFMBE/UN-ECE study 1989 - 1992. This study was followed by a workshop in the Czech Republic in 1995 on technology assessment in rehabilitation engineering for European countries with economies in transition.

Where do we go?

I would like to see the IFMBE strengthen its efforts to

  • increase the involvement of BMEs in policy making, with information on costs, effectiveness and ethical issues regarding medical devices
  • encourage BMEs to make use of assessment results available through various databases (e.g. the Internet)
  • increase the engineer's knowledge of health economics and ability to read assessment reports critically
  • continue to stimulate collaboration across borders with health care professionals and other groups in collecting data for effective and cost-effective use of medical technology.

The Federation should continue to build bridges between the biomedical and clinical engineers and health care professionals in order to achieve the most proper use of medical technology with regard to the resources available, the health status of the population and the quality of life of the patient.

JAN PERSSON

References

J. Persson (1991): 'Technology assessment and biomedical engineering' in H. Abe et al. (Eds.) 'A new horizon on medical physics and biomedical engineering' (Elsevier Science Publishers), pp.179-186

C. Goodman (1993): 'Literature searching and evidence interpretation for assessing health care practices'. Swedish Council on Technology Assessment in Health Care, Stockholm NHS Centre for Reviews & Dissemination (1996): 'Undertaking systematic reviews of research on effectiveness'.

NHS CRD Report 4, University of York, UK, January 1996

Jan PerssonWhat should the DHCTA do to better serve you and fulfil its goals? Please send your comments to Jan Persson, Chairman, IFMBE Division for Health Care Technology Assessment, email: jan.persson@cmt.liu.se