K39 1996 610'.28 C96-910110-4ii FOREWORDThe British Columbia Officeof Health Technology Assessment (BCOHTA) was established on December 1,1990 by a grant to the University of British Columbia from the Province to promote and encourage the use ofassessment research in policy and planning activities at the government level and in policy, acquisition andutilization decisions at the clinical, operations and government levels. D - 5........................................................................................................... D - 6........................................................................................................... D - 6vii SECTION AIntroduction and Background The purpose of this report is to incorporate several papers written on the same topic, a tool for decisionmaking in health care; the chronological presentation of this material delineates the evolution of thoughtand analysis inherent to each project. Yet, science and technology policy, at national and intemationa11evels, remains unresponsive to women andtheir needs although there is recognition in these documents and in others that assessment, monitoring andmeasurement ofthe impact of science and technology on development is desirable.This study is published elsewhere (Kazanjian and Friesen, 1991)and an abstract is given below. The dataincluded over 40 million payment records for each fiscal year on medical servicesprovided to British Columbia residents (2,968,769 in 1988) and information onphysicalfacilities, services and personnel from 138hospitals in the province. "Priority Setting: A Sensible Approach to Medicaid Policy? "The International Clinical Epidemiology Network(INCLEN): A Progress Report." Journal of Clinical Epidemiology 1991;44(6»:579-589. The use ofultrasound during pregnancy is the chosen example; it is widely used in developed countries and rapidlydiffusing in developing countries with a moderate acquisition (purchase) price-tag.While somemechanisms exist for influencing technological adoption and/or diffusion, such as regulation under specialprograms for the purchase of expensive technologies (Deber, Thompson, & Leatt, 1988), or fee-for-serviceschedules that signal what services can be provided and how much the payment will be (Evans, 1982),policy mechanisms at present are neither coordinated nor applied consistently to ensure predefined andpublicly articulated health goals. "The Fiscal Management of Medical Technology: the Caseof Canada." In Resources for Health: Technology Assessmentfor Policy Making. The first step in this explicit process is to establish the population of interest.Moreover, it is unlikely that prospective assessment of the consequencesofthese technology decisions has ever been part ofthe decision-inaking process. Design and Development of a Conceptual and Quantitative Framework for Health Technology Decisions: A Multi-Project Compendium of Research Underway While it would be prohibitive to undertake extensive technology assessment work every time a resourceallocation or other policy decision had to be made, it would be desirable to make these decisions based oninformedjudgements about the clinical, fiscal, and social impact of the specific health technology before itis widely adopted and extensively used. "Health Care Rationing: A Critical Evaluation." Commentary in Health Affairs1991;10(2):88-95. "Public Policy Issues Raisedby a Medical Breakthrough." Policy Analysis 1975;1(1):6976. "Tension, Compression, and Shear: Directions, Stresses, and Outcomes of Health Care Cost Control.' Journal of Health Politics, Policy and Law 1990;15(1):101-128. It is important to be inclusiveat this stage in order to recognize the magnitude of the phenomenon under examination. Office of Health Technology Assessment Design and Development of a Conceptual and Quantitative Framework for Health Technology Decisions: A Multi-Project Compendium of Research Underway To identify the size of this group, simple empirical evidence can be sought, such as the proportion ofwomen in the age-groups of interest, and the fertility rates.The (type of)model will directdecision makerstowardsa moreglobal viewof the issues relatedto healthtechnology andits assessment, and will highlight the weak linksin that assessment process. Person characteristics include such factors as gender, age, race, marital status, and socio-economic status,among others.
Howevereffectiveness studies made available to health care providers are usually undertaken by the research staffofthe manufacturer or the pharmaceutical company, seriously compromising the credibility ofthe evidence. The variables ofperson, place, and time are important in understanding the nature ofperson-environment fit, a key constructin assessing the risk and protective factors that determine health status in groups ofpeople .2.1 Population at Risk Population at risk takes into account the magnitude of the problem.
Second, thisinformation, incomplete as it may be in breadth, is of a technical nature that is not easily retrievable andconcerns a singletechnologyat a time. Building on two previous studies on this subject (Kazanjian and Friesen, 1993; Kazanjian and Cardiff1992), the Framework for Technology decisions in health care was developed incorporating five keydimensions (see Table 1).
In the course of this research, we also reviewed the rapidlygrowing clinical literature pertainingto the two selected categories of health care technology as well as theliterature on taxonomy development. First, the literature on healthcare technology covers only a small number of technologies, is most frequently based on the less-rigorousmethods, and provides very little information about the consequences of such technology. However, it isdesigned with ease of application in mind and should not be too onerous to use.
British Columbia Office of Health Technology Assessment. Assessments are performed in response to requests from the public sector such as hospitals, physicians,professional associations, health regions, government; private sector groups such as manufacturers; andindividuals from the generalpublic. The genesis of this work dates back to 1989 when a pilot project, funded by the NHRDP (grant #66101772-55) was undertaken to explore developing a taxonomy for health care technology (Kazanjian and Friesen, 1990). "AGeneral Health Policy Model: Updateand Applications."Health Services Research 1988;23(2):203-235. "Survey of Health Care Executives Reveals Priorities for Allocation of Care." Nursing Outlook 1990;38(3):110. The Frameworkdeveloped in this paper stimulates the articulation of goals, enabling the systematic monitoring and broadassessment oftechnological change.
It is important to note that the role ofthe Office is to appraise the scientific evidence only, without involvement in actual policy development forthe requesting agency. The earliest work, published elsewhere, is discussed briefly in thissection. At present, it has to berecognized that any change in this regard can only occur as part of an intentional prescriptive processwhere goals are clearly defined at various levels and decisions are intended toward goals.