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Design and development of a conceptual and quantitative framework for health technology decisions : a… Kazanjian, Arminee, 1947-; Cardiff, K. (Karen), 1953-; Pagliccia, N. (Nino R.), 1942- Oct 31, 1995

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DESIGN AND DEVELOPMENT OF A CONCEPTUAL AND QUANTITATIVEFRAMEWORK FOR HEALTH TECHNOLOGY DECISIONS: A MULTI-PROJECTCOMPENDIUM OF RESEARCH UNDERWAYBCOHTA 95:30B.C. Office of Health Technology AssessmentCentre for Health Services & Policy ResearchS 184 - Koerner Pavilion2211 Wesbrook MallVancouver, BCCanada V6T 1Z3A. KazanjianK. CardiffN. PaglicciaOctober 1995CANADIAN CATALOGUING IN PUBLICATION DATAKazanjian, Arminee, 1947-Design and development of a conceptual and quantitative framework for healthtechnology decisions"BCOHfA 95:20."ISBN 1-896256-06-61.Medical technology-Evaluation. 2. Medical technology-Decision making. 3.Technology assessment.I. Cardiff, K. (Karen), 1953- II. Pagliccia, N . (Nino R.), 1942- m. BritishColumbia Office ofHealthTechnology Assessment. IV. Title .R855.3 .K39 1996 610'.28 C96-910110-4iiFOREWORDThe British Columbia Officeof HealthTechnology Assessment (BCOHTA) was established on December 1,1990 by a grant to the University of BritishColumbia 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. 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.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. One or more of the following criteria are used to determine the priorityof an assessment and the level of analysis: 1) number of users and potential change in quality of life; 2)acquisition and operating costs to the health care system; 3) potential to influence provider and consumerbehaviour as a resultof a review; and 4) availability of accurate information and appropriate researchskills.Electronic bibliographic databases and fugitive literature (that is not indexed or distributed publicly) aresearchedusing predefined inclusion and exclusion criteriabased on the specific search strategy. The criticalappraisal of the retrieved evidence includes the formulation of logical and defensible conclusions about thetechnology understudy.This report, however, differs in two ways: it doesnotinclude a criticalappraisalof the literature, and it does.:-. not pertain to a specific health technology. The focus of this study is to develop a rational approach forhealth technology decisions, mapping a route for the practical application of usually complex, sometimesvoluminous, and oftenconfounding researchevidence from various fields and disciplinary perspectives.Arminee Kazanjian, Dr. Soc.Chair, BCOHTASteering CommitteeCopies may be obtained from:B.C. Officeof HealthTechnology AssessmentCentre for Health Services & PolicyResearchS 184- Koerner Pavilion, 2211 Wesbrook MallThe University of British ColumbiaVancouver, BCCanada V6T 1Z3Tel. (604) 822-7049iiiTABLE OF CONTENTSForeword iiiTable Of Contents vList Of Figures viiList Of Tables viiSection AIntroduction And Background A - 1Section BFramework For Technology Decisions: Literature Review B-11. Introduction B-12. Background B-13. Framework For Technology Decisions B-24. Objective And Scope Of Study B - 75. Methodology B - 85.1 North American Databases B - 85.1.1 ABlllnform B - 85.1.2 US Political Science Documents (UPSD) B - 85.1.3 Management Contents B - 95.1.4 Economic Literature Index B - 95.1.5 Public Affairs InformationService (PAIS) B - 95.1.6 Sociological Abstracts B-105.1.7 MEDLINE B -105.1.8 Health Planning And Administration (Health Database) B-1 05.1.9 Biobusiness B-105.1.10 NTS Bibliographic Database B -105.1.11 Mathsci B - 115.1.12 Health Periodicals Database B - 115.1.13 CUADRA B -115.2 European Databases B - 125.2.1 FRANCIS B - 125.2.2 Bioethics B - 125.2.3 PASCAL B - 126. Results B - 136.1 Descriptive Analysis B -166.2 Convergence Of Findings B - 237. Concluding Remarks B - 24vSection CFramework For Technology Decisions: A Quantitative Model1. Project Summary C - 12. The Quantitative Model. C - 2Section DA Framework For Health Technology Decision Making: A Uterature Review1. Background D - 12. The Literature Review D - 32.1 Objective D - 32.2 Methodology D - 32.3 Results D - 42.4 Conclusions D - 72.5 The Quantitative ModeL D - 7References D - 10Section EDoing The Right Thing, Not Just Doing Things Right: A Framework For Technology Decisions1. Introduction: The Challenge Of Technological Choices And Policy E - 11.1 Policy Formulation And The Decision-Making Process E - 22. Conceptual Framework: Description, Application And Gender Implications E - 22.1 Population At Risk E - 42.2 Population Impact E - 52.3 Economic Concerns E - 82.4 Social Context (Including Ethical, Legal, And Political Concerns) E - 112.5 Technology Assessment Activity E - 153. Making Choices Without Taking Chances E - 174. Future Research Needs E - 18References E - 21Appendix To Section B B - 37Appendix To Section C C - 7viLIST OF TABLESSection BTable 1 Matrix ForDecisions On Health Technology B - 5Table 2 ABlllnform Database Search B - 13Table 3 MEDUNE Database Search B - 14Table 4 Health Database B - 15Table 5 Analysis Of Articles Reviewed B - 17Section DTable 1 Matrix For Decisions On Technology In Health Care D - 2Section ETable 1 Framework ForHealth Technology Decisions E - 7LIST OF FIGURESSection 0Figure 1Figure 2Figure 3Figure 4.......................................... ............................... .................................. D - 4.............. ............ ................................ ....... .......................................... D - 5........................................................................................................... D - 6........................................................................................................... D - 6viiSECTION AIntroduction and BackgroundThe 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. The earliest work, published elsewhere, is discussed briefly in thissection.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 andFriesen, 1990). The development of a taxonomy to classify emerging and existing technologies wasdeemed an important first step in the compilation of useful information for policydecisions. While it wouldbe prohibitive to undertake health technology assessment work every time a resource allocation or otherpolicy decision had to be made, it is desirable to make such decisions based on informedjudgments aboutthe clinical, economic, and social impacts of the technology under consideration. A taxonomy would servetwo purposes:a) it would provide a priorizationoftechnologies that could serve as a guide for further evaluativeresearch;b) this, in itself, would providesufficientdetail to indicatethe regulatoryapproach most appropriateto each technology.In summary, our pilot study described the changing patterns of diffusion of two selected categories:imagingdevices and commonlaboratory tests. 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. Two importantpointswarranted noting. 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. Second, thisinformation, incomplete as it may be in breadth, is of a technical nature that is not easily retrievable andconcerns a singletechnologyat a time.The policy maker confronted with an allocation decision has very little use for such highly-technicalinfonnation specific to the attributes of one or another technology. A decision tool that quantifies, in aclear and replicable way, the relative merits of the technologies under consideration would be of greatassistance. In conclusion, a decision framework that reflects current socialvalues, and rationalizes choicesbetween technologies in terms of equity (needs-based) as well as utility (cost-effectiveness) is arguablymore useful than a priority classification scheme that is divorced from considerations of healthconsequences ofthe technology.Further analysis of technological diffusionwas undertaken in 1991, using population-based utilization dataon CT scans and MRI in the province. This study is published elsewhere (Kazanjian and Friesen, 1991)and an abstract is given below.B.C. Office of HealthTechnologyAssessment A- 1Design and Developmentof a Conceptual and QuantitativeFrameworkforHealth Technology Decisions: A Multi-Project Compendium of Research UndelWayIn order to explore the diffusion of the selected technologies in one Canadianprovince (BritishColumbia), two administrative data sets were analyzed. 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. Threespecific time periods were examined in each data set, starting with 1979-80 andending with the most current data available at the time. The detailed retrospectiveanalysis of laboratory and imaging technologies provides historical data in threeareas of interest: (a) patterns of diffusion and volume of utilization; (b)institutional profile; and (c) provider profile. The framework for the analysisfocused, where possible, on the examination of determinants of diffusion that maybe amenable to policyinfluence.A more extensive and systematic review of the literaturewas undertaken in 1992, as part of a report to theRoyal Commission on New Reproductive Technologies. Section B contains this report with a detailedappendix containing the resultsof the literature searchfrom tenNorth American and Europeandatabases.Further analysis of the literature pertinent to the development of a rational framework was prepared forposter presentation at the International Society for Technology Assessment in Health Care conference in1993,and is contained in Section D.More recently, efforts are being directed toward the development of a quantitative model. Much workremains to be done, however. An outline of howto validatethe conceptual model (framework) throughthequantification of each of the dimensions is contained in Section C. The proposedapproachwould yieldanempirical model to estimate the weighted indexof the technology (WIT) under consideration. The (type of)model will directdecision makerstowardsa moreglobal viewof the issues relatedto healthtechnology andits assessment, and will highlight the weak linksin that assessment process.Finally, SectionE contains the most recenteffort on this subject; this work was undertaken for the UnitedNations Commission on Science and Technology for Development (UNCSTD). In addition to a thoroughdiscussion of the framework, this paper elaborates on how the framework may be applied(in a hypotheticalsituation) to examine the diffusion of ultrasonography in a developing country and possible ensuingconsequences of such technological diffusion.The chronicle of research studies stops here. However, more work is underway; we have paused only toreplenish our resources.A - 2 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwaySECTION BFramework for Technology Decisions: Literature ReviewReport Submitted to The Royal Commission onNew Reproductive Technologies, May 1992Also published in: Royal Commission on New Reproductive Technologies,Volume 11, Chapter 2, Canada Communications Group, 19931. INTRODUCTIONDecisions regarding technology are made daily by practitioners. administrators and policy makers. Ideally.decisions regarding health technology should be based on evidence from comprehensive assessment, that is.information on the safety. effectiveness. costs and ethicalllegallsocial implications of the particulartechnology under consideration. Reality proves otherwise; the large majority of technological innovationsin health care are in use long before any systematic assessment has taken place. Sometimes at the secondor third generation level, technologies are found to be ineffective, or even unsafe. after belated assessment.The Canadian Standards Association safety tests medical devices, and the Canadian Food and DrugAdministration polices the safety testing of pharmaceutical products (acting as the regulator) . 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 role governments play in the development and diffusion of technology is clearly an influential one,especially in health care. It spans a wide range of levels of involvement: from supporting the developmentof technologies through funding of research in basic sciences, to regulating the marketing of certaintechnologies and licensing offacilities for the provision of certain technological services, to paying for suchservices through public funds (medical insurance). Yet, these policy decisions are most often made in theabsence of accurate information on the specific as well as general implications of such technologicaldevelopment or diffusion.2. BACKGROUNDDecisions about who will get how much of what in health care are made mostly in an ad hoc, oftenpartisan, fashion with different motives operating for the different levels of decision makers. 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. Moreover, it is unlikely that prospective assessment of the consequencesofthese technology decisions has ever been part ofthe decision-inaking process.The determination of whether decisions pertaining to new reproductive technologies are more rationalizedthan decisions for other health technologies is an important research question, but one beyond the scope ofthis study. The popular assumption, however, is that the consequences - especially ethical - of newreproductive technologies are potentially more serious than those of the .average' health technologydecision. Therefore. a general understanding of how allocative decisions regarding resources fortechnology are made would be extremely helpful in understanding specific decisions regarding reproductivetechnologies.B.C. Office of Health Technology Assessment B-1. Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayWhile 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. Thus, in a pilot study on technology adoption and diffusion(Kazanjian and Friesen, 1990) we examined the feasibility of developing a taxonomy to classify emergingand existing technologies. The purpose of taxonomy is: identification of the object. recognition of itsspecific limits, grouping it into natural groups, and constructing classifications which as near as possibleshow the course of evolution within a group (Cain, 1959). We reviewed a vast and rapidly increasingliterature in the area of technology assessment, and in a more limited fashion the clinical literaturepertainingtwo broad categories, laboratory tests and imagingdevices, as well as the literature on taxonomydevelopment. Part of the conclusion from that study was that neither the inherent characteristics of healthcare technologies nor their assumed properties lend themselves to taxonomic classification. The decisionmaker confrontedwith an allocation or other technology decision has very little use for the highly technicalinformation specific to the attributes of one or other technology; clearly, a decision tool that quantifies therelative merits of technologies under consideration was needed.3. FRAMEWORK FOR TECHNOLOGY DECISIONSConfronted with a choice to make from among several technologies, the policy maker has a number ofpossible alternatives (Churchill, 1987):a) to refuse to considerthe particular merits of each technology, and simplydividethe resourcesequally, that is, each gets equal shares of most likelyinadequateresources;b) to consider resource requirements of each technology and give each an equalpercentageof itsrequest; that is.relative resource requirements are allocated to all;c) to chose the technologythat will assist the neediest or the most ill; that is, the technologythatwould seek to rescue those nearest to death;d) to chose the technologythat promises long-range efficiency and effectiveness; that is, a technologywith a preventionemphasis whichdoes not entail expensive or ineffective rescue efforts;e) to chose the technologythat will effectively help the largest number of persons; that is, thetechnologythat seeks "thegreatest good for the greatest number";f) to chose the technologyof greatest value to those whose conditionis causedor exacerbatedbyprevious social or economicinjustices; that is, on the principleof restorative justice;g) to chose the technology of serviceto those who have previouslybeen treated or t~ whomone owesfidelity due to past obligations; that is, to honour long-standing obligations;h) use the lottery approach and draw the "winner" from a hat.B-2 B.C. Office of Health Technolgy AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayGiven the high stakes involved (in the sense that the entire population in a jurisdiction is affected) ingovernment policy decisions, selecting the alternative that includes notions of equity and utility and isgrounded in principles of social justice is the most appropriate. A decision framework that reflects theseattributes and rationalizes choices between technologies in terms of equity and utility is arguably moreuseful than a priority classification scheme that is divorced from considerations of health consequences ofthe technology.The rationale for the development of our health technology decision framework was centred around basicprinciples of justice in health care: equitable access to all effective health care which society can afford.This implies that the decision maker employs norms of utility as well as equity in making a decision.Neither of these lend themselves to easy formulation of policy. Some adjudication and interpretation isneeded to translate principles into action: How much technology and for whom?The practitioner is most motivated by clinical efficacy, the administrator by fiscal and other resourceimplications that impact quality of care, and the government agency by budgetary restrictions (economicefficiency). While each of them is engaged in what would be considered proper or "ethical" behaviour, allof these behaviours are based on principles of ethical individualism which are deeply rooted in our NorthAmerican culture (Churchill, 1987). These principles are operant in all Canadian health care decisionmaking.Yet, the individual and society cannot be treated separately, or given different moral priorities, because theyare comp'lementary realities. Individuals develop a socially defined sense of selfhood and, as socialcreatures, no one person has a prior entitlement to health (services) based on social differences . However,given society's finite resources, an equitable health systemis concerned with the provision of effective carewhich it can reasonably afford. This humanist perspective for the provision of health services evolves frombasic principles of social justice pertaining to the collective welfare of society.Using the humanist perspective as theoretical underpinning, and the empirical evidence from the pilot studyindicating the futility of any attempt to consistently link either inherent attributes of the technology to itsdiffusion, or health care technology diffusion to the prevalence of disease, a preliminary decisionframework was developed using five key dimensions (fable 1). The first four, population at risk,population impact, costs, and ethicaIllegaVsociaVpolitical implications, are societal responses to theparticular technologies of concern; the fifth component, technology assessment activity, is a descriptiveelement included to provide a "quality ofmedical knowledge" perspective, incorporating information on thequality ofthe assessment evidence and its degree of convergence.The purpose of this conceptual model is to provide an empirical, evidence-based foundation to technologydecisions, thus de-mystifying a heretofore undefined and generally misunderstood phenomenon.Population at risk takes into account the magnitude of the health concern related to the technologies,indicated by prevalence, severity of illness, and other such epidemiological measures in that jurisdiction.B.C. Office of Health Technology Assessment B-3Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayFor example, AIDS affects a relatively small proportion of the population (prevalence), but its effect isfatal (severity); in comparison, arthritis affects a much larger proportion of people but the debilitatingeffectsare generallymildto moderateto severe.Population impact takes into account the known expected health consequences of the technologicalintervention indicated by comprehensive general health status measures. While a person suffering fromheart disease will experience various levels offunctional disability, an HIV positive person may have yearsof symptom-free and disability-free existence. Thus, a measure of qualityof life overthe life-expectancy ofthe respective cohorts affectedby each of the technologies provides anotherpolicy component. This seconddimension ofthe framework, combined with the first, expressesconsiderations of utility - the greatest goodfor the greatest number - the selection being made not between individuals but among categories of healthconcerns.B - 4 B.C. Office of Health Technolgy AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayTABLEtMATRIX FOR DECISIONS ON HEALTH TECHNOLOGYDIMENSION METHOD TOOL SOURCE1.2.3.4.5.POPULATION AT RISK(problemldiseaseJhealth issues)POPULATION IMPACT(problemldiseaselhealth issues)COSTETIllCALILEGALISOCIALIPOLmCAL IMPLICATIONSTECHNOLOGY ASSESSMENTACTIVITY(i) Epidemiologic Orientation(ii) DescriptiveEpidemiology(iii) Indicesof CommunityHealthHealth Status MeasuresEconomic analysisof net cost to thehealth care systemDescriptionsynthesisof issues fromliteratureLocal situationFrameworkof Major Emphasis ofTechnology AssessmentActivities(i) Natural History/Severity of illness scale(ii) IncidencelPrevalence rates, Mortalityrates(iii) Life Expectancy, SocialDeviance,SummaryIndex(i) FunctionalAssessmentInventory(ii) Sickness ImpactProfile(iii) NottinghamHealth Profile(iv) Qualityof Well-BeingScale(i) Aggregate Cost(ii) Cost of Alternatives(iii) Cost-UtilityAnalysisScorefor current or potential importanceof issue(on Likert-typescale)(i) Score for comprehensiveness of assessmentactivity(ii) Score for congruityof fmdings(i) ClinicalEpidemiology Litemture(ii) LocalDatabases (from Vital Statistics,HMRI,MSP, Census Surveys, etc.)(i) Crewe & Athelson (1981)(ii) Bergner et al (1981)(iii) Martini & Hunt (1981)(iv) Kaplan & Anderson(1988 revision)StandardMeasuresMSPIHSIIHS21HMRIInternationalJournalslExpertsLocalExpertsMedia CoverageLobbyGroupsInstitute of Medicine (1985)B.C. Office of Health Technology Assessment B - 5Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayThe cost component of the decision framework considers what society can reasonably afford. Aggregatecosts of each of the technologies, costs of alternatives to the technologies and more specific measures ofcosts per well-year of life. How society arrives at decisions about what it can afford is a very importantbut opaque question. How a government agency arrives at that same decision appears to be less opaque.Finite financial resources set the parameters; principles of distributive justice serve to eliminate any socialordering.No rational health technology policy decision can be taken without at least cursory consideration of thesocial, political, ethical, and legal ramifications of that decision. While it may be possible to clearlydelineate legal implications, the other three are not as clearly identifiable. Conversely, once identified, theweight carried by political considerations may be enormous. Rational decisions then would be made byweighing the political consequences of making a choice versus not making that choice. Social implicationsare generally more difficult to define than the political and less likely to incite prompt government action,yet they tend to yield longer term consequences and can be considerably more serious than any of theothers. Perhaps the least well understood, and therefore the most neglected, sub-eomponent is the ethicalconsequences of decisions on health technology. While the field of bioethics is recently becoming morehigh profile, ethical considerations are not routinely incorporated in official guidelines or protocols of useofhealth technologies.The final component, technology assessment activity, is different from the other four in that it indicates thelevel of scientific knowledge about the technology which acts as backdrop to the decision. Whereas most ofthe research in technology diffusion assumes that the mere existence of technology assessment willinfluence diffusion, generally it fails to separate the three levels of stakeholders in technology assessmentwho affect diffusion in different ways (Fodor, 1988; McGivney, 1988; Peddecord, 1988). Physicians,facility administrators and government officials all look to technology assessment for different reasons and,therefore, assessment has a different function for each ofthe groups (the role of the public is omitted fromthis discussion for the sake of brevity). New information from technology assessment may affectphysicians' clinical behaviour, could help the administrator in acquisition decisions, and should assist thegovernment agency in reimbursement or regulatory policy making .Thetemporal order ofevaluation-decision is also very different for each ofthe stakeholders. For the policymaker, ideally, the assessment should precede policy formulation but it rarely, if ever, does. For theadministrator, the information is sought only when it affects that particular institution. For the physician,the information is useful when it affects medical practice (appropriate care to patients) . Thus, it isreasonable to argue that clinical evaluation ofmedica1Jsurgical procedures should precede their widespreaduse. This order also holds true for regulatory bodies such as the Canadian Standards Association andCanadian Food and Drug Administration, whose mandate is to establish safety and efficacy beforereleasing devices and drugs. But it is quite unreasonable to suggest that all government financing andinsurance coverage policies should be based on locally undertaken primary assessment of each technologyB - 6 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underwaywhen that information may already exist in other jurisdictions (Davis, 1986). There are ten identifiedsources of influence in the adoption or abandonment of healthtechnology (Institute of Medicine, 1985), ofwhichenvironmental constraints and incentives are the major ones susceptible to policy influence. It maytherefore be more efficient for the policy maker to develop such incentive/disincentive policies first, basedon a synthetic evaluation of available knowledge, and subsequently call for more serious primaryassessment efforts, if required. It is unrealistic to believe that technology diffusion would stop whileextensive evaluation is beingundertaken.In summary, this last dimension ofthe decision framework is usedto qualifythe four preceding componentsand alerts the policymakerto the relative assessment status of eachtechnology.4. OBJECTIVE AND SCOPE OF STUDYThe objective of this study is to provide a critical appraisal of the literatureon each of the five dimensionsdeveloped in the preliminary health technology decision model, which would, ultimately, provide aframework to analyze decision making pertaining to the allocation of resources for health technologies.The critical appraisal of the literature examines the quality and volume of the evidence pertaining to theconceptual model and establishes the feasibility of its empirical application. In addition, the literaturereview delineates the evidence on how decision making processes evolve, and what type of information issoughtby the individual making clinical, administrative, or public policydecisions.While beyond the scope of the present study, the extension of this work would lead to the development ofquantitative measures - newor alreadyexisting - whichcan be combined to develop a simplemathematicalmodel to estimate "Global Score" for health technologies under consideration, whenever a decisionnecessitating a choice between technologies has to be made. The purpose of the mathematical model, onceit is developed, is to facilitate the ways in which priorities can be established around health technologiesthrough the application of this Global Score. Such a measure would indicate the broader socio-medicalvalueof onetechnology relative to others which, although unrelated, may be competing for the same limitedresources.B.C. Office of Health Technology Assessment B- 7Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underway5. METHODOLOGYThe literature review proceeded in four phases. The first phase involved identifying relevant sources ofinformation on literature related to decision making in health care. To do this, a group of librarians from avariety of disciplines were selected and interviewed to determine which databases would yield bothcomprehensive and relevant results . Fifteen databases representing social science, bio-medical, scientific,feminist' and business literature were recommended. Twelve of these are North American databases andinclude the following: ABI\INFORM, US Political Science Documents (UPSD), Management Contents,Economic Literature Index, Public Affairs Information Service (pAIS), Sociological Abstracts,MEDLINE, Health Planning and Administration (HEALTH Database), Biobusiness, NTS BibliographicDatabase, MathSci, and Health Periodicals Database. The other three databases are European and include:FRANCIS, PASCAL and Bioethics. A concise description of each database follows:5.1 North American Databases5.1.1 ABI/InformContains more than 480,000 citations, with abstracts, to the periodical literature in the areas of businessand management. Covers over 800 international periodicals in these subject areas: accounting andauditing; economics; electronic data processing systems and information science; engineering management;finance and financial management; health care; law and taxation; management science; marketing;advertising and sales management; personnel, employee benefits, and labour relations; banking; insurance;public administration and government.A hierarchical classification system allows users to create broad topical subsets before applying specificsearch terms. Five areas are covered by the classification codes: business environment (e.g., economicconditions, social policy), management function (e.g., public relations, planning, information management),industries and markets, article treatment (e.g., company specific, product specific), and organization does(e.g., small business, non-profit institution).5.1.2 US Political Science Documents (UPSD)UPSD provides detailed abstracts and indexing from approximately 150 of the major American journalspublishing scholarly articles in the broad area ofpolitical science. Coverage includes such specific areas asforeign policy, international relations, behavioral sciences, public administration, economics, law andcontemporary problems, world politics, and all areas of political science, including theory andmethodology. This database is of particular interest to the academic community, providing a centralsource from which to access significant research results in the political, social, and policy sciences.1 A search on 'CUADRA' On-LineDatabaseindicated that Sociological Abstractswould best capture the feministliterature.B - 8 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underway5.1.3 Management ContentsThe Management Contents database provides current information on a variety of business andmanagement-related topics to aid individuals in business, consulting firms, educational institutions,government agencies or bureaus, and libraries in decision making and forecasting. Articles from over 140US and international journals, as well as conference proceedings, transactions, business course materials,newsletters, and research reports, are fully indexed and abstracted to provide up-to-date infonnation in theareas of finance and economics (including accounting, banking, and managerial economics); industry(including commodities and goods, production, industrial relations); and management and administration(including public administration, planning, decision science, human resource development, managementphilosophy, operations research, and marketing).5.1.4 Economic Literature IndexEconomic Literature Index is an index of journal articles and book reviews from 300 economics journalsand from approximately 200 monographs per year. Covers general economic theory, history, and systems;economic growth, development, planning and fluctuations; quantitative economic methods and data;international economics; domestic monetary and financial theory and institutions; administration, businessfinance, marketing and accounting; industrial organization, technological change and industry studies;agriculture and natural resources; manpower, labour, and population; welfare programs; consumereconomics; and urban and regional economics. Since June 1984, abstracts from selected journals havebeen added to approximately 25% of the records in the file. The descriptive abstracts are approximately100 words in length and are written by the author or editor of the journal article; all are in English. Thedatabase corresponds to the index section ofthe quarterly Journal of Economic Literature and to the annualIndex ofEconomic Articles.5.1.5 Public Affairs Information Service (pAIS)PAIS is a bibliographic index to the public policy literature of business, economics, finance, law,international relations, government, social sciences and political issues and the making and evaluatingof public policy. It provides references in English to material published worldwide in any of six languages:English, French, German, Italian, Portuguese, and Spanish. Approximately 60% ofthe items indexed wereoriginally published in English. It covers printed material in all formats: periodical articles; books, state,local, federal, and non-US government documents; committee hearings, pamphlets; and the reports ofpublic and private organizations. PAIS provides comprehensive coverage of all issues of public policyrelating to social, economic or political problems, including taxation, multinational corporations, banking,labour, insurance, crime, health, international relations, international trade, and specific industries. It is anenhanced compilation oftwo print publications: PAIS Bulletin and PAIS Foreign Language Index.B.C. Office of Health Technology Assessment B - 9Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A MUlti-Project Compendium of Research Underway5.1.6 Sociological AbstractsSociological Abstracts covers the world's literature in sociology and related disciplines in the social andbehavioral sciences. Over 1600 journals and other serial publications are scanned each year to providecoverage of original research, reviews, discussions, monographic publications, panel discussions, casestudies, conference papers, and dissertations.5.1.7 MEDLINEMEDLINE produced by the US National Library of Medicine provides access to the worldwide biomedicalliterature, including research, clinical practice, administration, policy issues, and health care services.MEDLINE corresponds to three print indexes: Index Medicus, Index to Dental Literature, and InternationalNursing Index. MEDLINE covers virtually every subject in the broad field of biomedicine, indexingarticles from over 3000 international journals published in the United States and 70 other countries.Citations to chapters or articles from selected monographs are also included from May 1976 through 1981.5.1.8 Health Planning and Administration (Health Database)Health Planning and Administration, produced by the US National Library of Medicine, contains about500,000 citations to the worldwide literature on health care delivery. Covers health care planning andfacilities, health insurance, and the aspects of financial management, personnel administration, manpowerplanning, and licensure and accreditation that apply to .the delivery of health care. References in HealthPlanning and Administration are drawn in part from MEDLINE and from the American HospitalAssociation's Hospital Literature Index. Documents from the National health Planning Information Centerare included, as well as additional journals of special importance to the health care field5.1.9 BiobusinessContains about 164,000 citations, with abstracts, to the worldwide periodical literature on businessapplications of biological and biomedical research. Covers agriculture and forestry, food technology,genetic engineering, pharmaceutical products, and other industries affected by biotechnologicaldevelopments. Also covers patents in such areas as immunological testing, food processes, and fishing .For each patent record, includes inventor's name and address, patent title and number, patent classes, dategranted, and assignee. Sources include journals, books, newsletters, monographs, and conferenceproceedings.5.1.10 NTS Bibliographic DatabaseContains about 1.4 million citations, most with abstracts, to unrestricted technical reports from U.S. andnon-U.S . government-sponsored research, development, and engineering analyses. The unpublished U.S.reports are prepared by federal, state, and local agencies and their contractors or grantees. Major areascovered include the biological, social, and physical sciences, mathematics, engineering, and businessB-10 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underwayinformation, Includes announcements of computer-readable software and data files, U.S. government­owned inventions available for licensing, selected reprints, federally sponsored translations, and some non­English-language reports. Corresponds to the biweekly publication Government Reports Announcement &Index (GRA&I) and in part to the weekly AbstractNewsletters.5.1.11 MathSciMathSci contains evaluative reviews and abstracts of the international research literature in mathematics,computer science, statistics, econometrics, and applications in areas such as physics, engineering, biology,and information systems. MathSci has seven subfiles on-line: Mathematical Reviews (MR) and CurrentMathematical Publications (CMF), published by the American Mathematical Society; ACM Guide toComputingLiterature (GCL) and Computing Reviews (CR), published by the Association for ComputingMachinery; Technical Reports in Computer Science (STR), compiled by Stanford University; CurrentIndex to Statistics (CIS), published by the American Statistical Association and Institute of MathematicalStatistics; and Index to Statistics andProbability (Tukey), by Tukey and Ross. The combined coverage ofthe seven subfiles is very comprehensive. Approximately 600 journals are reviewed cover-to-cover and2,500 journals are covered selectively. In addition, over 10,000 monographs, conference proceedings,theses, and technical reports are reviewed annually .5.1.12 Health Periodicals Database-Health Periodicals Database provides indexing and full text of journals covering a broad range of healthsubjects and issues . Subjects covered include pre-natal care, dieting, drug abuse, AIDS, biotechnology,cardiovascular disease, environment, public health, safety, paramedical professions, sports medicine,substance abuse, toxicology, and much more. Articles are collected from core health, fitness, and nutritionpublications. The database provides a valuable resource for corporate, medical, and legal librarians,human resources professionals, and product analysts.5.1.13 CUADRAThe CUADRA database contains descriptions of about 5,000 databases worldwide, including over 4,500on-line databases and over 950 "portable" (i.e., databases available on CD-ROM, diskette, and magnetictape.Each entry provides the database name, type classification (Audio, Bibliographic, Full Text, FullTextlImages, Images, Numeric, Referral, Software, Textual-Numeric, Video), database producer orinformation provider, on-line services or vendors through which the database can be accessed or purchases,content description, subject, language, geographic coverage, time span, frequency of updating, and, asapplicable, conditions of access or price. For portable databases, CUAD also covers format (e.g., HighSierra or ISO 9660 for CD-ROMs, number and size for diskettes), hardware and software requirements,and corresponding on-line and printed information sources. CUAD includes addresses and contactB.C. Office of Health Technology Assessment B - 11Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underwaynumbers for database producers/information providers and on-line services/vendors. It corresponds to theprintedDirectory of On-lineDatabases and Directoryof Portable Databases.5.2 European Databases5.2.1 FRANCISA leading bibliographical database of the human, social and economic sciences. Coverage includes boththe human sciences and the social sciences. The database language is French with English, German andSpanish descriptors.5.2.2 BioethicsInternational database on biomedical ethics, including coverage of health policy, neonatology, doctor­patient relationships, reproductive contraception, abortion, reproductive technology, geneticengineering, experiments on humans, artificial and implanted tissue and problems related to death andviolence. Database is in Englishand French.5.2.3 PASCALContains about 8 million citations, with abstracts, to the worldwide literature in science, technology andmedicine. Covers applied science, biomedicine, chemistry, computer science, earth sciences, engineering,fundamental and applied biology, marine science, mathematics, medicine, physics, psychology, and spacescience. Sources includebooks, theses, reports, conference proceedings, and more than 4500 periodicals.During the second phase of the review listsof key words were created, using the controlledvocabulary ofthe respective databases. Next, search strategies for each database were developed. Following from this,extensive searches were executed using Boollean logic'. It should be pointed out that the terms decisionmaking, health policy and public policy are the subject ofmany literatures; to ensure the applicabilityoftheliterature to our particular needs we limited our searching to articles where decisionmaking, health policyand public policy were the focus of the article. The details of the search strategies, and the results ofsearches for ten databases can be found in the Appendix (seeAppendix to SectionB).The final stage of the literature review involved selection of relevant articles and critical appraisal of theliterature. The appraisal considered a variety of factors including theoretical grounding, empiricalevidence, methodological rigour, clarity offindings, and convergence offindings withother work.2 Online database searching employs Boolean logic, a method oflogicdeveloped by the mathematician andlogician George Boole. Boolean operators combine setsor terms in various relationships. The major logicaloperators are: 'and', 'or' and 'not'. 'And' is used to combine concepts. It will retrieve records containing bothtermsor sets in a combination. 'Or' is used to search on all or anyconcepts. It willretrieve records containing all or anyterms in the statement. 'Not' is usedto exclude information.B - 12 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underway6. RESULTSIn total, the literature reviewyielded approximately 1300 abstracts relatedto decisionmaking in health care(this is the result after overlap in articleshas beeneliminated). Tables 2 - 4 outlinethe results fromthree ofthe database searches respectively. In Table 2 the results from the search of ABI\INFORM indicatethatalthoughthere are a total of28,214 articleswith a focus on decision making, only 1502 (5%) of the articlesare related to decisionmaking in health care. In Table 3 the results from the search of MEDLINE showthere are 3658 articles related to decision making or policy and the results from the HEALlli Databasesearch in Table 4, show there are a total of 5434 articles relatedto decision makingor policy.TABLE 2ABI/Inform Database SearchDATABASE SEARCH WORD(S) # ARTICLESABI/Inform Decision/Policy 28214(1986 - Nov 1991)Decision/Policy related toHealth Care 1502Decision/Policy related toHealth Care 'and' Population Health!Population Impact 149Decision/Policy related toHealth Care 'and' Economics 61Decision/Policy related toHealth Care 'and' Technology Assessment 48Decision/Policy related toHealthCare 'and' Law 200Decision/Policy related toHealthCare 'and' Politics 29Decision/Policy related to HealthCare 'and' Ethics 28B.C. Office of Health Technology Assessment B - 13Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A MUlti-Project Compendium of Research UnderwayTABLE 3MEDLINE Database SearchDATABASE SEARCH WORDCS) # ARTICLESMEDLINE Decision/Policy 3658(1987 - Jan 1992)Decision/Policy related to Delivery ofHealth Care 33Decision/Policy relatedto Costs/CostBenefitAnalysis 107Decision/Policy related to Health 16Decision/Policy related to HealthCareRationing 43Decision/Policy related to HealthFacilities 19Decision/Policy related to HealthPlanning (search limitedto 1990-92) 17Decision/Policy related to HealthPriorities(search limitedto 1990-92) 11Decision/Policy related to HealthResources (searchlimitedto 1990-92) 19Decision/Policy related to HealthServices (searchlimitedto 1990-92) 26Decision/Policy related to HealthServices Research 35Decision/Policy relatedto HealthStatusIndicators (searchlimitedto 1990-92) 14Decision/Policy relatedto Health Surveys 16Decision/Policy related to TechnologyAssessment 50Decision/Policy relatedto PopulationSurveillance 4Decision/Policv related to medical ethics 149B -14 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A MUlti-Project Compendium of Research UnderwayTABLE 4Health Database Seareh"DATABASE SEARCH WORD(S) # ARTICLESHealthDatabase DecisionIPolicy 5434(1975 - Jan1992)DecisionIPolicy related to Delivery ofHealth Care 33DecisionIPolicy relatedto Costs/CostBenefitAnalysis 69DecisionIPolicy related toHealth 14DecisionIPolicy related toHealth CareRationing 11DecisionIPolicy related toHealthFacilities 11DecisionIPolicy relatedtoHealthPlanning (searchlimitedto 1990-92) 28DecisionIPolicy relatedtoHealthPriorities(searchlimitedto 1990-92) 16DecisionIPolicy relatedto HealthResources (searchlimitedto 1990-92) 25DecisionIPolicy related to HealthServices (searchlimited to 1990-92) 4DecisionIPolicy relatedtoHealthServices Research 27DecisionIPolicy relatedtoHealth StatusIndicators (searchlimitedto 1990-92) 4DecisionIPolicy relatedtoHealth Surveys 4DecisionIPolicy relatedto TechnologyAssessment 49DecisionIPolicy relatedtoPopulationSurveillance 8DecisionIPolicv relatedto medicalethics 25... Overlap between Health Database and MEDLINE has been eliminated in this searchB.C. Office of Health Technology Assessment B - 15Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underway6.1 DescriptiveAnalysisAll of the abstracts were reviewed; however, only a small proportion (13%) were actually relevant to theparticular focus of this study. The final review examined, in depth, 173 (13%) of the total number ofabstracts (1,300) captured by the original search. Entire articles were retrieved for the majority (160) ofthe analysis; however, in 13 of the cases we only had access to abstracts.The appraisal took place in several stages. First, we looked at the quality of evidence; articles werecategorized as being either theoretical/analytical, empirical, or editorial/personal viewpoint. Table 5describes the results of these processes. About 51 percent of the articles were theoretical/analytical innature and 44 percent were editorial or personal viewpoints. Only 5 percent ofthe articles were empiricallybased. With respect to focus it should be pointed out that the majority ofthe literature addressed more thanone dimension. The results are as follows: 55 of the articles (32%) discussed the role of economics; 88 ofthe articles (51%) discussed the role of ethics/equity; 42 ofthe articles (24%) discussed the role of politicaland legal factors; 57 of the articles (33%) discussed the role of social factors; 41 (24%) of the articlesdiscussed the role of epidemiological factors (population at risk, population impact); and, 54 (31%) of thearticles discussed the role oftechnologyassessment activities.B - 16 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayTABLE 5ANALYSIS OF ARTICLES REVIEWEDAUTHOR(S) ETHICAU LEGAU EPIDEMIO- TECHNOLOGYECONOMIC EQUITY POLITICAL SOCIAL LOGICAL ASSESSMENTAaron, Henry and William B. Schwartz (1990) PAdams, Orvlll (1988) PAllen, Anne (1991) P PAyry, M. (1991) TBalk, Roger A. (1990) T TBanta, H. David and Per Buch Andreasen (1990) TBanta, H. David etaI. (1987) TBatUsta, Renaldo (1989) TBegin, Patricia (1989) T T TBehrens, Cornelia and Klaus-Dirk Henke (1987) PBenjamin, M. (1990) TBerman, Gary D.,T. E. Kottke and D. J, Ballard (1990) PBerwick, Donald M. (1988) PBinney, Elizabeth A. and Carroll L. Estes (1988) T TBjork, Stefan and Per Rosen (1991) PBlank, Robert H. (1988) TBlank, Robert H. (1984) TBloche, M, Gregg and Francine Coumos (1990) T T T T TBlumstein, James F, (1976) TBowie, Robert D. (1991) PBozeman, Barry and Frederick A. Rossini (1979) TBrehm, Henry P. and Ross M, Mullner (1989) TBrody, Baruch etal. (1991) EBrody, Baruch A. (1988) P P PBrown, Lawrence D. (1991) T T T T TBucci, Vincent A. (1991) PCallahan, Daniel (1991) P PCallahan, Daniel (1988) P P P P PLegend:T=Theoret/caVAna/ytica/P=Personal Viewpoint/EditorialE=Empirical...IcontinuedB.C. Office of Health Technology Assessment B - 17Design and Development of a Conceptual and Quntitative Framework forHealth Technology Decisions: A MUlti-Project Compendium of Research UnderwayTABLE 5(continued)ANALYSIS OF ARTICLES REVIEWEDAUTHOR(S) ETHICAU LEGAU EPIDEMIO- TECHNOLOGYECONOMIC EQUITY POLITICAL SOCIAL LOGICAL ASSESSMENTCalltolp, Johan (1966) ECapron, Alexander Morgan (1969) P P PChana, Harjinder S. and Ka~ J. Lundstrom (1990) P PChapman, Fern Schumer (1965) P PConnelly, Michael D. (1991) P P PCouncil on Ethical and Judicial Affairs (1991) E ECrane, Vicki S. (1966) TCrichton, A. (1969) TDanis, Marion and Larry R. Churchill (1991) T Tde Wachter, Maurice A.M. (1966) TDeber, Raisa B. and Vivek Goel (1990) T TDeber, Ralsa B., G. G. Thompson and P. Leatt (1966) T TDetsky, Allan S. and I.Gary Naglie (1990) T T TDrane, J.F. (1988) T T T T TDrummond, Michael F. (1990, a) TDrummond, M. (1969, b) T TDrummond, Michael F. (1987) T TDrummond, Mlcahel F. (1967) PDuff, Raymond S. and A.G.M. Campbell (1980) P PDuggan, J.M. (1969) P P P PEddy, David M. (1990, a) PEddy, David M. (1990, b) PEddy, David M. (1990, c) P P PEllencweig, Avi Y. (1966) TEmery, Danielle Dolenc (1969) T TEmson, Harry E. (1991) P P P PEtzioni, Amitai (1991) P PEtzioni, Amitai (1975) P P PLegend:T=TheoreticaVAnalyticalP=Personal Viewpoint/EditorialE=Empirical...IcontinuedB -18 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayTABLE 5(continued)ANALYSIS OF ARTICLES REVIEWEDAUTHOR(S) ETHICAU LEGAU EPIDEMIO- TECHNOLOGYECONOMIC EQUITY POLITICAL SOCIAL LOGICAL ASSESSMENTEvans, Robert G. (1990) T TEvans, Roger (1983) TFeeny, David and Greg Stroddart (1988) TFeldstein, Paul J. (1990) T T T TFox Daniel M. and Howard M. Leichter (1991) T T TFrance, George (1988) TFriedman, Emily (1989) PFriedman, Emily (1987) P PFuchs (1990) PGafnl, Amiram (1991) TGarber, Alan M. and Judith L. Wagner (1991) T T TGemmette, Bizabeth Villiers (1991) T T TGlnzberg, Eli (1982) PGoldberg, Allen I. (1988) E E E EGolding, A.B.M. (1984) PGrannemann, Thomas W. (1991) T T TGula, RM. (1990) T T THaan, Ger (1991) T T THadom, David C. (1991, a) T T T T THadom, David C. (1991, b) T THakullnen, Timo and Matti Hakama (1991) THalstead, Scott B., P. Tugwell and K. Bennett (1991) TIkegami, Naoki (1988) TJacobson, Peter D. and C. John Rosenquist (1988) TJennett, Bryan (1988, a) T TJennett, Bryan (1988, b) TKaplan, Robert M. and John P. Anderson (1988) TKelly, Lucie S. (1990) P P PKelsey, Beverly (1975) P P P P PLegend:T=TheoreticaVAna/ytica/P=Personal Viewpoint/EditorialE=Empirical.../continuedB.C. Office of Health Technology Assessment B -19Design and Development of a Conceptual and auntitative Framework forHealth Technology Decisions: A MUlti-Project Compendium of Research UnderwayTABLE 5(continued)ANALYSIS OF ARTICLES REVIEWEDAUTHOR(S) ETHICAU LEGAU EPIDEMIO· TECHNOLOGYECONOMIC EQUITY POLITICAL SOCIAL LOGICAL ASSESSMENTKilner, John F. (1988) T T TKing. John R. (1990) PKlein. Rudolf (1969) PKlein, Rudolf (1990) TKoska. Mary T. (1991) PKrahn. Murray D. and Allan S. Detsky (1992) P Ptamm Richard D. (1990) PLarnm, Richard D. (1989) PLamm, Richard D. (1987) P Ptan,Chung-Fu (1987) TLarson. Eric B. (1987) TLaupacls. Andreas (1992) T T TLevey. Samuel (1990) PLevkoff. Sue and Terrie WeUe (1989) E E ELomas, Jonathan (1990) TLoomes, Graham and Lynda McKenzie (1989) TMaher. Walter B. (1991) T TMarmor, Theordore R. (1990) PMcCormack, Thelma (1988) T T TMcGivney, William T. and Andrea L.Schneider (1988) TMorey. Dennis A.J. (1988) PMurphy. Donald J. and David B. Matchar (1990) T T T TMyers. Beverlee A. (1977) PNatiello, Thomas A. (1988) P PNeuhauser, Duncan and Klrstine Napier (1989) PO'Malley, Nora C. (1991) E EOmenn, Gilbert S. (1990) T TOster, Gerry (1988) TParis, John J. and Kevin O'Connell (1991) P P P P PParker, Bamett R. (1990) TPena-Mohr. Jome (1987) TLegend: ...IcontinuedB - 20 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth TechnoloClY Decisions: A Multi-Project Compendium of Research UnderwayT= TheoreticaVAnalyticalP =Personal Viewpoint/EditorialE=EmpiricalTABLE 5(continued)ANALYSIS OF ARTICLES REVIEWEDAUTHOR(S) ETHICAU LEGAU EPIDEMIO- TECHNOLOGYECONOMIC EQUITY POLITICAL SOCIAL LOGICAL ASSESSMENTRead, Kevin (1990) P P- PReagan, Michael (1989) PReiser, Stanley J. (1992) T TReiman. Amold S. (1990) PRettig, Richard A. (1989) T TReynolds, R. Larry (1989) T T T T TRice. Dorothy P. (1989) T TRodin, Judith andAila Collins, ed. (1991) T T T TRoss, John Jr. (1991) P P P PRossiter, Louis F. (1990) PRothschild, lIa S. (1990) PRussell, Louise B. and Jane E. Sisk (1988) TRutten, Frans and H. David Banta (1988) TSabatino, Frank (1991) P PSalter, B. (1991) P P P P PSchweitzer. Stuart O. (1990) PShannon. Thomas A. (1987) P PSidel, Victor W. (1987) PSiegler, Mark (1985) P P PSisk. Jane E. (1987) PSmith, Lee (1989) P P PStarr. Paul (1975) PSteinwachs. Donald M. (1989) TSvanstrOm. Leif (1988) PTanneberger. Stephan (1988) TThompson. Mark and Aubrey Mllunksy (1979) T T TTokarski. Cathy (1990) PTorrance, George W. (1987) TTugwell, Peter. etal. (1986) TTymstra Tleerd (1989) TLegend:.../continuedB.C. Office of Health Technology Assessment B - 21Design and Development of a Conceptual and Quntitative Framework forHealth Technology Decisions: A MUlti-Project Compendium of Research UnderwayT=TheoreticaVAnalyticalP =Personal Viewpoint/EditorialE=EmpiricalTABLE 5(continued)ANALYSIS OF ARTICLES REVIEWEDAUTHOR(S) ETHICAU LEGAU EPIDEMIO- TECHNOLOGYECONOMIC EQUITY POLITICAL SOCIAL LOGICAL ASSESSMENTVilnius, Douglas and Suzanne Dandoy (1990) T T T TWagstaff, Adam (1991) T TWeinstein, Milton (1990) TWeinstein, Milton C. (1989) T TWeinstein, Milton C. and William B. Stason (1977) P P PWennberg, John E. (1990) PWetle, Terrie, Julie Cwikel, and Sue E. Levkoff (1988) E E EWhite, Gladys B. (1989) P PWikler, Daniel (1991) TWilliams, Alan (1988) T T TWilliams, Alan (1987) P P P P PWissema, Johan G. (1981) PWray, Nelda etal. (1988) E EWright, Richard A. (1991) TZajac, Barry M. (1989) PZeckhauser, Richard and Donald Shepard (1976) T T TZiporyn, Terra (1983) PLegend:T=TheoreticaVAnalyticalP=Personal Viewpoint/EditorialE=EmpiricalB - 22 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underway6.2 Convergence ofFindingsThat rational analysis and systematic planning ought to be the norms governing health technology decisionsappears to be a consensus statement. There is appreciable convergence of research findings regardingpolicy decisions pertaining to health technologies, regardless of source, disciplinary perspective, ormethodology. Some differences emerge, however, when the criteria and/or factors that constitute the focusof rational planning are being considered. The proposed decision framework, described in Section 3 ofthisreport, was used to provide focus to the critical appraisal of the literature reviewed. The identification ofthe model's key dimensions, addressed by each of the selected articles, provides a measure of convergenceofthought that was heretofore unmeasured.As indicated in Table 5, very few articles addressed only a single dimension; generally these pertained tothe economic issues of health technology or the role of technology assessment in decision making. Thelarge majority of the reviewed articles examined ethical concerns regarding health care technology, mostfrequently discussed as questions of equity. Related closely to this were issues of the social impact ofhealth technologies and, therefore, social costs. In particular, questions regarding experimental, expensive,and/or newly introduced technologies are raised, especially in tenus of the need to understand how theyaffect social relations, current and future, for the patient and family/friends as well as the health careproviders. The emotional costs of new choices, its paradoxical effects on individuals and stake-holdergroups and the often false sense of freedom arising from it, are postulated to be at least as important as thefinancial costs. The literature also indicates that the burden of illness is ultimately shared by the society at­large; while one individual may be the recipient of a public good - in the form of a technologicalintervention paid for through universal health insurance - other individuals have to forego other publicgoods in health care or other public services.There is also appreciable convergence in the literature on the political aspects of resource allocation. Theevidence indicates that beyond establishing the safety, efficacy and effectiveness of technologies, scientificknowledge does not provide the answer to "how much technology and for whom?" These types of decisionsshould be made by officials elected to represent the public interest, accountable to a legislative body.While it is generally obvious that public policy-makers are responsible for the public interest, it is oftenassumed that health professionals, as providers, are responsible only to the individuals under their care.There is growing literature, however, to indicate that providers do bear some public responsibility asstewards ofthe common wealth.While the field oftechnology assessment is a relatively new one, fraught with the usual problems of multi­disciplinary work, the research evidence indicates that the usefulness of scientific evidence would be limitedifproduced in a vacuum, that is, divorced from the decision-making processes. The value of integrating thetechnology assessment research with public policy was recognized more than a decade ago (Bozeman,B.C. Office of Health Technology Assessment B - 23Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A MUlti-Project Compendium of Research Underway1979); it was suggested that the research process should include the interplay of values, making it part ofthe bureaucratic-political environment. The importance of linking research findings to clinical,administrative, or policy decisions is clearly a point of convergence in our findings. Regardless ofdisciplinary perspective, researchers agree that political considerations must be an important dimension oftechnology assessment, and increasing the involvement of the decision makers in the research processwould increase the latters' commitment to use the research evidence (Banta, 1990; Drununond, 1990).Slowly emerging, is the literature on evaluatingthe researchevidence, whether this is economic evaluationor clinicaltrials (Laupacis, 1992; Larson, 1989). Furthermore, as the integration of technologyassessmentand decision-making becomes better coordinated, attention should be paid to eliminating the structuralbarriers to such integration, usually through the clarification of long-standing ambiguities regardingdecision-making authority. As well, the attenuation of chronic border disputes between government andmedicine, or betweengovernment and hospitals, over who decides what issues, wouldclarify who should bethe target audience for the information generatedthrough technology assessment(Lomas, 1990).Finally, it is reasonableto conclude that health care systems are grounded in societal norms and propelledby culturallydefined value systems whichare not immutable over time. Thus, changing values in Canadiansociety (as well as in the rest of the Western world) have altered the traditional relationships betweengovernment, medical practitioner, and health care consumer with a consequent shift in their respectiveauthority to manage the system. The public is now less likely to endow the medical practitioner withpaternalistic attributes, and at the sametime, less likelyto unquestionably transfer these attributes to publicofficials. In addition, since views of the human condition, concepts of health and disease, approaches tomedical practice, and notions of distributive justice are all culturally defined, incorporating underlyingparadigms in research may shed better light on outcomes of care than simply studying the technicalcapacity of the health care system.The tabular presentation of the quality of research evidence in Table 5 indicates that much more empiricalwork needs to be undertaken on how decisions regardingpublic policy, that best serve the public interest,oughtto be made.7. CONCLUDING REMARKSThe purpose of the proposed decision framework (see Table 1) is the creation of a clear, precise,manageable, and replicableprocess designed to generate information about the consequences ofthe variousdecision options. Modelsare fundamental to policy analysis; whilethey may not predict consequences withthe same assurance as the best scientific models, policy models tell us what the possibilities are, based onvarious assumptions about the factors of concern. Decisions are often made intuitively, without explicitmodels. However, in that case, a tacit model or an unconsciously calculated decision is being developed.Facedwith a phenomenon that is too complex and too expensive to study directly, a natural inclinationis toB - 24 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underwaystudy a model, which resembles the phenomenon of framework interest in its essential features but is moremanageable, less expensive, easier to study.It is possible to test the predictionsbased on a model and determine the correctnessand relevance of thesepredictions for real-world decisions. Our proposedconceptual model providedthe broad parameterswithinwhich this literature review was conducted. A critical appraisal of the literature has provided anexamination of the quality and volume of the evidence pertaining to health technology decisions; evidencepertaining to the attributes of health care technologies was not investigated. This literature review wasundertaken primarily to establish the feasibility of the model's empirical application. Two general findingswarrant brief discussion.First, the literature we reviewed for this project clearly indicated that the dimensions of the proposedframework were the appropriate ones to include in a health technology decisionmodel. While these factorswere not always grouped similar to our particular grouping, singly or in multiples the same factorsappeared in most of the literature we examined. In addition, the evidence from this literature reviewindicated that the decision making process, as described by the studies referenced here, is receptive tosystematic inputs of information which enhance the potential for better decisions. Several of the articlesreviewed proposed decision models with similar, but usually less comprehensive characteristics (see, forexample, Balk 1990; Deber & Goel, 1990; Eddy, 1991c; Hadorn, 1991a; Kaplan and Anderson, 1988;Murphy, 1990)..The second general comment about our findings pertains to the technical feasibility of developing themathematical model based on the suggested conceptual one. The degree of difficulty in developingquantitative measures for each of the model dimensions will vary appreciably from one dimension to thenext, but the task is not an impossible one. Economic and epidemiological measures are easier to compilefrom already existing ones than developing measures for ethical and social concerns, quantification of thepolitical milieu may prove to be a challenging exercise. However, these methodological hurdles do notappear to be insurmountable, in light of the evidence on the importance of using norms of utility as well asequity in makinghealthtechnology decision.B.C. Office of Health Technology Assessment B - 25Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayREFERENCESAaron, Henryand William B. Schwartz. "Rationing HealthCare."Across the Board 1990;27(7-8): 34-39.Adams, Orvill. "Rational Decision-making in Health Care: Is ThereHope?" Canadian MedicalAssociation Journal 1988;138(April):591.Allen, Anne. "Rationing Health Care Resources: WhoWill Set Limits?" Journal ofPost AnesthesiaNursing 1991;6(4):294-295.American Medical Association. 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"Medical Technology and the Poor.II Technology Review 1987(May/June):24-25.Siegler, Mark. "Another Form ofAgeDiscrimination."Across the Board 1985;22(2):7-10.Sisk, Jane E. "Discussion: Drummond's "Resource Allocation Decisions in Health Care: A Role forQualityofLife Assessment?" Journal ofChronical Disease 1987;40(6):617-619.Smith, Lee. "What Do We Oweto the Elderly?" Fortune 1989;119(7):54-62.Starr, Paul. IIA NationalHealth Program: Organizing Diversity." Hastings Center Report 1975;5(1):11-13.Steinwachs, DonaldM. "Application of Health StatusAssessment Measures in PolicyResearch. II MedicalCare 1989;27(3): SI2-S25.Svanstrom, Leif. "CurrentTrends in Sweden: Implications for PublicHealth Policy. II Journal ofPublic 'Health Policy 1988;9(3):429-433.Tanneberger, Stephan. "When Must a New Approach to Treatmentbe Introduced?" International JournalofTechnology Assessment in Health Care 1988;4:113-120.Thompson, Mark and AubreyMilunksy. 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IIQALYs and the Equity-Efficiency Trade-Off.II Journal ofHealth Economics1991;10:21-41.Weinstein, MiltonC. "Principles ofCost-Effective Resource Allocation in Health Care Organizations."International Journal ofTechnology Assessment in Health Care 1990;6:93-103.Weinstein, MiltonC. "Methodologic Issues in Policy Modeling for Cardiovascular Disease.II Journal oftheAmerican College ofCardiology 1989;14(3):38A-43A.B.C. Office of Health Technology Assessment B - 35Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayWeinstein, Milton C. and WilliamB. Stason. "Allocating Resources: The Case of Hypertension." HastingsCenterReport 1977;7(5):24-29.Wennberg, John E. "Outcomes Research, Cost Containment, and the Fear ofHea1th Care Rationing." NewEnglandJournal ofMedicine 1990;323(17):1202-1204.Wetle, Terrie, Julie Cwikel, and Sue E. Levkoff. "Geriatric Medical Decisions: Factors InfluencingAllocation of Scarce Resources and the Decision to WitholdTreatment." The Gerontologist1988;28(3):336-343.White, GaldysB. "EthicalAnalyses in the Development of Congressional PublicPolicy." TheJournal ofMedicne and Philosophy 1989;14:575-585.Wikler,Daniel. "What Has Bioethics to OfferHealthPolicy?" The Milbank Quarterly 1991;69(2):233-251.Williams, Alan. "Priority Settingin Publicand PrivateHealth Care. A GuideThroughthe IdeologicalJungle." Journal ofHealth Economics 1988;7:173-183.Williams, Alan. "Who is to Live? A Question for the Economist or the Doctor?" WorldHospitals1987;23(2-4):34-36.Wissema, Joban G. "PuttingTechnology Assessment to Work." Research Management 1981;24(5):11-17.Wray, Nelda et aI. ''Withholding Medical TreatmentFrom the Severely Demented Patient. Cost Processesand Cost Implications."Arch InternMed 1988;148(September):1980-1984.Wright, Richard A. "Clinical Judgment and Bioethics: The Decision MakingLink."TheJoumal ofMedicine and Philosophy 1991;16:71-91.Zajac, Barry M. "LegalIssues in NeonatalIntensive Care."Hospital& HealthServicesAdministration1989;34(4):578-590.Zeckbauser, Richard and DonaldShepard. 'Where Now for Saving Lives?" Law & ContemporaryProblems 1976;40(4):5-45.Ziporyn, Terra. "MedicalDecision Making: Analyzing Optionsinthe Face of Uncertainty."Journal oftheAmericanMedical Association 1983;249(16):2133-2141 .B - 36 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayAPPENDIX TO SECTION BSEARCH STRATEGIES AND RESULTS1. ABNnform2. US Political Science Documents3. Economic LiteratureIndex4. Sociological Abstracts5. MEDLINE6. HealthPlanningAndAdministration (Health Database)7. Biobusiness8. Mathsci9. HealthPeriodicals Database10. FRANCISABVInform1986-Nov 1991 12345decision making modelsdecision theorydecision making models'or' decision theorystrategic planningtechnological planning184strategic planning 'or'technological planningpublicpolicysocialpolicypublicpolicy'or'socialpolicydecisionpolicydecision 'or' policysearches 1 'or' 2 'or' 3'or' 4 =decision4974338504,6604,8171,5686802,2248,59815,57723,70028,214B.C. Office of Health Technology Assessment B - 37Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underway6 searches 1 'and' 2 'and' 3'and' 4 =decision 17891011121314151617health 7,877medical devices 266hospitals 4,238health 'or' medical devices'or' hospitals=health care 10,921searches 5 'and' 7 =decisionsrelatedto health care 1,502epidemics 37diseases 427epidemics 'or' diseases 440illnesses 228population 639illnesses 'or' population 867incidence 12prevalence 0incidence 'or' prevalence 12population 639impact 8,145population'and' impact 64demography 1,197searches 12 'or' 13 1,249searches 9 'or' 10 'or' 11 'or'14 2,335lifetables 0statisticaldata 15,446searches 15 'or' 16=populationhealth/population impact 17,303B - 38 B.C. 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Office of Health Technology Assessment B - 39Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A MUlti-Project Compendium of Research Underway28 government 5,40029 searches 27 'or' 28 =law 21,53430 searches 8 'and' 29 =decisionsrelated to health care and law 20031 politics 700political risk 320politics 'or' political risk 1,00532 power 2,21733 searches 31 'or' 32 3,18334 publicopnuonsurveys 161polls 63public opinion surveys lor' polls 19635 advocacy 44consumerism 115advocacy lor' consumerism 15436 searches 34 'or' 35 34937 searches 33 'or' 36 =politics 3,52538 searches 8 'and' 37 =decisionsrelated to health care and politics 2939 ethics 1,684social impact 131ethics 'or' social impact 1,81040 quality of life 11541 searches 39 'or' 40 =ethics 1,92242 searches 8 'and' 41 =decisionsrelated to health care and ethics 28B - 40 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayUS Political ScienceDocuments (1975-1991) 12345678910111213Administrative policymakingIDECommittee decisionmakingIDEAdministrative policymakingIDE 'or' decisionmaker perceptionIDECommunity decisionmakingIDEDecision makerperceptionIDECommunity decisionmakingIDE 'or' decisionmaker perceptionIDEDecision makinganalysisIDEDecision makingtheory/DEDecision makinganalysis/DE 'or' decisionmaking theory/DEDecision makingprocessIDEJudicial decisionmakingIDEDecision makingprocess/DE 'or' judicialdecision makingIDELegislative decisionmakingIDE76501261183754937583749497602891,045139B.C. 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Office of Health Technology Assessment B - 43Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayEconomic LiteratureIndex (1969 -December 1991) 1 Decision 0 making 1,4242 Search 1 'and' healthO care 33 Search 1 'and' assess? 'and'technolog? 34 Search 1 'and' medic? 215 2 'or' 3 'or'4 246 Search 1 'and' model? 3797 Search 6 'and' (cost? 'or'fund? 'or' spend?'or' expend? 'or' financ?) 848 Search 6 land' (rationaliz?'or' equitable 'or'inequitable 29 7 'not' 8 8410 Search 1m, DE 1,046Search 10 'and' model? -Search 10 1,046Search 10 'and' model?-Model? 38,20211 Search 10 'and'model? 22911 2297 8412 11 'and' 7 23Sociological Abstracts(1963- December 1991) 123Decision0 makingSearch 1 'and' feminis?Search 1 'and' female8,006199300B - 44 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayB.C. Office of Health Technology Assessment B - 45Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A MUlti-Project Compendium of Research Underway27 26 'not' 5 38Assess(search limited to 64-85) 3,651Technolog? 25,26128 Assess (3N) technolog? 16Search 28 'and' decision -Search 28 16Search 28 'and' decision -Decision? 14,64429 Search 28 'and' decision? 2MEDLlNE(1987 - January 1992) 1 Decision making (all) 2,302Decision making (focus) 8932 Decision making,organizational (all) 319Decision making,organizational (focus) 1453 Decision theory (all) 101Decision theory (focus) 444 Decision support Techniques(all) 424Decision support Techniques(focus) 2755 searches 1 'or' 2 'or' 3 'or' 4=decision 1,3346 Health Policy (all) 3,234Health Policy (focus) 1,8847 Public Policy (all) 860Public Policy (focus) 4588 searches 6 'or' 7 =policy 2,3389 searches 5 land' 8 =decisions related to policy 1410 Delivery ofHealth Care 3,049B -46 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-ProjectCompendium of Research Underway11121314151617181920212223242526272829303132searches5 'and' 10searches8 'and' 10(searchlimited to 1991 - 1992)Health Expendituressearches 5 'and' 13searches 8 'and' 13Healthsearches 5 'and' 16searches 8 'and' 16Health Care Rationingsearches5 'and' 19searches8 'and' 19Health Facilitiessearches 5 'and' 22searches8 'and' 22HealthPlanningsearches 5 'and' 25searches 8 'and' 25(searchlimited to 1990 - 1992)HealthPrioritiessearches 5 'and' 28searches 8 'and' 28 (searchlimited to 1990 - 1992)Health Resourcessearches5 'and' 3120133401101,12631341616277227129244134063865312B.C. Office of Health Technology Assessment B - 47Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underway33 searches 8 'and' 31 (searchlimited to 1990 - 1992) 734 Health Services 1,70235 searches 5 'and' 34 236 searches 8 'and' 34 (searchlimited to 1990 - 1992) 2437 Health Services Research 1,67038 searches 5 'and' 37 1439 searches 8 'and' 37 (searchlimited to 1990 - 1992) 2140 Health Status Indicators 75541 searches 5 'and' 40 442 searches 8 'and' 40 1043 Health Surveys 1,47344 searches 5 'and' 43 445 searches 8 'and' 43 1246 Technology Assessment,Biomedical 47347 searches 5 'and' 46 1448 searches 8 'and' 46 1149 ethics, medical 4,41150 searches 5 'and' 49 8651 searches 8 'and' 49 6352 Population Surveillance 1,55453 searches 5 'and' 52 0B - 48 B.C. 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Office of Health Technology Assessment B - 49Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underway3 DecisionTheory (all) 153Decision Theory (focus) 614 DecisionSupportTechniques (all) 250DecisionSupportTechniques (focus) 1495 searches 1 'or' 2 'or' 3 'or' 4=decision (limited toarticles with 'focus') 2,6916 Health Policy (all) 7,721Health Policy (focus) 4,8357 Public Policy (all) 2,854Public Policy (focus) 4,8358 searches 6 'or' 7 =policy(limitedto articles with'focus') 6,4349 searches 5 'and' 8 3310 searches 5 'or' 8 9,09211 Deliveryof Health Care 12,20912 searches 11 'and' 10 599 (all)searches 11 'and' 10 33 (searchlimitedto87 - 92;MEDLINEeliminated)13 Health Expenditures 2,76914 searches 13 'and' 10 193 (all)searches 13 'and' 10 54 (searchlimitedto87 - 92;MEDLINEeliminated)15 Health 3,483B - 50 B.C. 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Office of Health Technology Assessment B - 51Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underway26272829303132333435searches 25 land' 10searches 25 land' 10HealthServicessearches 27 land' 10searches 27 land' 10Health Services Researchsearches 29 land' 10searches 29 'and' 10HealthStatus Indicatorssearches 31 'and' 10searches 31 'and' 10Health Surveyssearches 33 land' 10searches 33 land' 10Technology Assessment,Biomedical214 (all)25 (searchlimited to87 - 92;MEDLINEeliminated)5,777196 (all)4 (searchlimited to87 - 92;MEDLINEeliminated)4,273198 (all)27 (searchlimited to87 - 92;MEDLINEeliminated)1,59138 (all)4 (searchlimited to87 - 92;MEDLINEeliminated)3,94938 (all)4 (searchlimited to87 - 92;MEDLINEeliminated)1,4068 - 52 8.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A MUlti-Project Compendium of Research Underway363738394041424344454647searches 35 'and' 10searches 35 land' 10Ethics, Medicalsearches 37 land' 10searches 37 'and' 10Population Surveillancesearches 39 'and' 10searches 39 'and' 10Technology, Medicalsearches 41 'and' 10searches 41 land' 10Technology, Pharmaceuticalsearches 43 land' 10searches 43 land' 10Technology, Radiologicsearches 45 land' 10searches 45 'and' 10United States Office ofTechnology Assessment (OTA)92 (all)34 (searchlimited to87 - 92;MEDLINEeliminated)8,045 (all)278 (all)25 (searchlimited to87 - 92;MEDLINEeliminated)1,3148 (all)o(eliminatedMEDLINE)221884 (all)3 (searchltd to 87 - 92;MEDLINEeliminated)2118 (all)2 (eliminatedMEDLINE)1,2154 (all)1 (eliminatedMEDLINE)32B.C. Office of Health Technology Assessment B - 53Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayBiobusiness484950I234569101112searches 47 'and' 10searches 47 'and' 10Cost BenefitAnalysissearches 49 'and' 10searches 49 'and' 10EquitableDecision/Tl, DEMakingfTI. DEDecision 0 makingfTI, DEI 'and'2 - II 'and'2 - 2I 'and'2Search2 'and' (legislate?'or' government? 'or'rationalize 'or' inequitable'or' spending 'or' financ?) ­Search2Legislat?Government?RationalizeSpendingFinane?Search2 'and' (legislat? 'or'government? 'or' rationalize'or' inequitable 'or' spending'or' financ?)Search2 'and' expend ­Search2Expend?4 (all)o(eliminatedMEDLINE)7,007249 (all)15 (searchlimited to87 - 92;MEDLINEeliminated)432,4402,11871343713I71350,08625,650221,8504,743375713644B - 54 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underway13 Search 2 'and' expend? 213 'or' 11 - 13 213 'or' 11 - 11 37514 13 'or' 11 375Search 14 'and'health 0care - Search 14 37515 Health 33,92916 Care 9,08317 Health (W) care 4,09418 Search 14 'and'health 0care 6Search 14 'and'drugs -Search 14 37519 Drugs 6,32420 Search 14 'and' drugs 5Search 14 'and' technolog?- Search 14 37521 Technolog? 22,63322 Search 14 'and'technolog? 28Search 14 'and'health 0policy - Search 14 37523 Health 33,92924 Policy 8,24625 Health (W) policy 5126 Search 14 'and'health 0policy°Search 14 'and'health (3N)(policy 'or'policies'or'projects) - Search 14 37527 Health 33,92928 Policy 8,246B.C. Office of Health Technology Assessment B- 55Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: AMulti-Project Compendium of Research Underway29 Policies 1,40330 Projects 1,02131 Health(3N) «policy 'or'policies) 'or' projects) 9532 Search14 'and'health (3N)(policy 'or' policies'or'projects) 018 'or' 20 - 18 618 'or' 20 - 20 533 18 'or' 20 11Mathsci 1 Decision 0 makingfTI, DE 1,3362 Search1 'and' model?m, DE 2593 Search2 'and' (cost? orfund? or spending orexpend? or financ?) 134 Search2 'and' health 15 Search2 'and' medi? 116 Search2 'and'medic? 97 Search 2 'and' fund? 'and'projects 18 Search2 'and' assess? 'and'technology 09 Assess? (F) tecbnology 10610 Search9 'and'decision? 18HealthPeriodicals 123Decision adj making.de.Reproduct$7073,04610B - 56 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayFRANCIS456789101112345678TechnologS.TI, DE.I 'and'43 'or'SI 'and' investment1 'and'feminisSTechnology adjassessment.de.1 'and'99 'and'decisionS.TI,DE.Decision W makingDecisionfTIDecision/ITHealth 'or' medicineHealth 'or' medicalDecision (W) making 'and'healthDecision (W) making 'and'medical8 'not' 74,685132313171131,3832,2143,37931,82026,488272414,229B.C. Office of Health Technology Assessment B- 57Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwaySECTION CFramework for Technology Decisions: A Quantitative Model1. PROJECT SUMMARYDecisions regarding technology are made daily by practitioners, administrators and policy makers. Ideally,decisions regardinghealth technology should be based on evidence from comprehensive assessment, that is,information on the safety, effectiveness, costs and ethical/legal/social implications of the particulartechnology under consideration. Reality proves otherwise; the large majority of technological innovationsin health care are in use long before any systematic assessment has taken place. While it would beprohibitive to undertake extensive technology assessment work every time a resource allocation or otherpolicy decision had to be made, it would be desirable to make these decisions based on informedjudgements about the clinical, fiscal, and social impact of the specifichealth technology before it is widelyadopted and extensively used. While there are many knowncriteria for rational decisionmaking, these arerarely used systematically for priority-setting in the health sector and there is no evidence to suggest thatmultiple criteria are used in concert. We suggest that even ifhealth technology policy decisions are basedon a sequence of eventsand informationinputs, the parts are not usually integrated and consolidated into acumulativeprocess.The overall purpose of this research is to delineate a process which will provide a rational, systematicapproach to policy decisions about health technology. The outcome should yielda simple empirical modelto estimate the weighted index for health technologies under consideration, whenever decisionmakers needto make choices in technology policy development. The proposed model is based on a framework (seeAppendix) whereby the evidence on each dimension of a technology decision may be quantified andconsolidated into a singleweighted score. The application of the model to differenttechnologies will allowthe decision maker to rank the technologies in terms of their contribution to society along the above­discussed dimensions. It is hypothesized that decisions are most appropriate when supported by amultidimensional frameworksummarizing the sociomedical meritofthe technologies under consideration.The main focus of this project is the initial validation of the conceptual model, i.e. the gradual process ofquantifying each of the dimensions, where possible, in a way to allow the estimation of their cumulativeimpact. This is a necessary first step in establishing the usefulness of the model to decisions about healthtechnology.The specific objectives ofthis project are to: 1) compile a list of indicators for the selecteddimensions; 2)appraise the relevance of each indicator to decision-making; 3) develop a process to rank the relativeimportance of different indicators within each dimension; 4) identify appropriate quantitative andqualitative measures for each indicator; 5) consolidate the rank-ordered indicators into a measure for eachdimension; 6) develop a process to define stakeholder-specific priority weights; 7) test the model fordecisions on two technologies.Methodological principlesdrawn from epidemiology, sociology, decision analysis and system dynamics areused to develop the study design. A combination of quantitative and qualitative measures, and objectiveand subjective approaches are used throughout all phases of this project. A comprehensive list ofB.C. Office of HealthTechnology Assessment C - 1Design and Development ofa Conceptual and Quantitative FrameworkforHealth Technology Decisions: A Multi-Project Compendium ofResearch Underwayindicators for each dimension of the model will be compiled and appraised regarding volume and strengthofthe scientific evidence, relevance to decision-making, and ease ofapplication in modelling. Next, using amodified Delphi technique, expert opinion will be used to determine the relative merit of each indicatorwithin the respective weights for each dimension. Finally, the model will be applied to two specificdecision making contexts for separate technologies. The outcomes of these decision making processes willbe validated from the perspective ofexpert decision makers.2. THE QUANTITATIVE MODELThe development of a quantitative model within the framework described in the Appendix is part of theprocess of technology assessment. As suggested in our framework, health technology decisions are notviewed as having only epidemiological and financial implications, but as affecting the broader socialcontext. The immediate consequence of this fact is that a quantitative model would have to includemeasurements of qualitative and subjective variables. This is recognized to be a very arduous task(Duncan, 1984) .A quantitative model will be developed capable of estimating a technology index denoting the sociomedicalmerit of each technology. The application of the model to different technologies will allow the decisionmaker to rank the technologies in terms of their contribution to society along the above-discusseddimensions. The maindesirable feature of such a quantitative model is that it should be an instrument easyto understand and to use, not requiring specialized technical background, nor complicated calculations.Also, the model should provide a quantitative measure capable ofranking technologies on some scale.The model design is similar to the design ofthe priority score model suggested by the Institute of Medicine(1992) in that it is a multiplicative model but differs in purpose. Our proposed model is used in two stagesand provides a technology index as opposed to a priority score for technology assessment. The advantagesof a multiplicative model and its equivalent logarithmic expression have been described by the 10M (1992).The model will be developed within the framework of that described in the Appendix, that is, it will takeinto account all the policy dimensions addressing different aspects ofthe health technology.C - 2 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayAt the first stage, a policydimension score is calculated usingthe following logarithmic expression:IiDi= (1:j=1 Vij In Sij) IIi for i=1,2,3,4,5where is the estimated scorefor policydimension iis the numberof indicators used in the calculation of Diindicates summation overall indicators jis the valueof indicator j for dimension iis the relative valueof indicatorI withindimension iindicates the natural logarithm of SijThe equivalent multiplicative expression is givenby]-M' - II' ~ (S··) vijlIi1 - :J=I IJwhereDi=In(Mj}i=1,2,3,4,5In a more generalform, when, for example, preventive and treatment technologies are compared, the Ii arerescaling factors whose specific expressions are to be determined, To the extent that suitable rescalingfactors are successfully developed, considerably different technologies willbe susceptible to comparison.At a secondstage,the valuesDi are aggregated to a single weighted indexof technology WIT:5WIT = 1:i= I WiDiwhereWi is the assigned weight of dimension iSinceDi=In(Mi), WIT is also a logarithmic expression and the equivalent multiplicative expression is5 W'T = IIi=l (OJ) 1whereWIT=In(T),For each technology to be assessed, Di are calculated first and then aggregated to obtainWIT.B.C. Office of Health TechnologyAssessment C - 3Design and Development ofa Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayThe Weighted Index of Technology should be the necessary and sufficient tool for decision making.However, technologies could be compared at the level of each policy dimension in order to understand theissues that are ofmore or less relevance to a certain technology or to identify technologies that are more orless sensitive on a given issue. For instance, technology A may have a more favourable score thantechnology Bin terms ofthe economic concern, but it could be more controversial (sensitive) in terms of itsethical ramifications.The relative abundance of indicators, certainly in the area of epidemiologic and economic concerns, will bediscussed below. Our task will be to obtain a comprehensive list of indicators describing their nature,source and relevance to the proposed model. In this process the quantitative model may be adjusted toaccommodate the new findings. .The major challenge of the proposed project will be to reconcile the methodological concerns expressed inthe literature (porter, 1980). The goal of a comprehensive model, for example a model that could begeneralized across the range of technologies, might be in conflict with the goal of objectivity andreproducibility. We take this challenge within the more recent view of the tenets of scientific inquiry(Barlas, 1990). According to this view, a model cannot be proved valid in an absolute sense but can bejudged to be so within a given social context. In other words, model building and validation is consideredto be an on-going process; models are not viewedto be true or false but to where they lie on a continuum ofusefulness.Finally, an algorithm similar to those used in decision analysis will be developed to guide the decisionmaker through the process of indexing the technology under consideration. The algorithm should besufficiently detailed to cover all the necessary steps leadingto the implementation ofthe quantitative model.While many measures relevant to these dimensions are available in the literature, the selection of thoseappropriate to easy implementation ofthe model is the main concern ofthe study design. A comprehensiveinventory of available indicators and their critical appraisal is a proposed objective ofthe study.C - 4 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayREFERENCESBarlas, Y., Carpenter, S. (1990) Philosophical roots of model validation: Two paradigms. SystemsDynamic Review, 2 (summer): 148-166.Battista, R. (1992). Healthcare technology assessment: Linking science & policy-making. CanadianMedical Association Journal, 146(4): 461-462.Beauchamp, T. and Childress, IF. (1989)Principles of Biomedical Ethics. 3rd Edition. New York, OxfordUniversity Press.Bowie, R. (1991) "HealthEconomics: A Framework for Health Services Decision-Making", New ZealandMedJ. 104(March): 99-102.Drummond, M.F., Stoddart, G.L. (1984) "Economic analysis and clinical trials", Controlled ClinicalTrials. 5: 115-128.Duncan, O.D. (1984) Notes on Social Measurement - Historical and Critical. New York, Russel SageFoundation.Eisenberg, lM. )1989) "Clinical Economics: A Guide to the Economic Analysis of Clinical Practice",JAMA, 262(20): 2879-2886.Fenny, D. and Torrance, G. (1992) Principles of Economic Evaluation for Health Care Technologies.Centrefor HealthEconomics and PolicyAnalysis. McMasterUniversity.Fink, k, Kosecoff L, Chassin, M. and Brook, R. (1984) "Consensus Methods, Characteristics andGuidelines for Use" Am.J. Pub. Health74(9): 979-983.Frenk, Julio (1992) Balancing relevance and excellence: Organizational responses to link research withdecision making. Social Science andMedicine. 135(11): 1397-1404.Garland, Michael J. (1992) "Light on the Black Box of Basic Health Care: Oregon's Contribution to theNationalMovement toward Universal HealthInsurance", Yale Law and PolicyReview, 10(2): 409-430.Kazanjian, A., Cardiff,K. (1992)Framework for Technology Decisions: LiteratureReview. Report to theRoyal Commission on New Reproductive Technologies. Ottawa, Canada.Kazanjian, A., Friesen, K. (1990) "Technology Diffusion: The Troll Under the Bridge. A Pilot Study ofLow and High Technology in British Columbia", Health Policy Research Unit, The University of BritishColumbia.Kleinbaum, D.G., Kupper, L.L., Morgenstern, H. (1982) Epidemiologic Research: Principles andQuantitative Methods. Belmont, CA: Lifetime Learning Publications.McDowel, I. and Newell, C. (1987) Measuring Health: A Guideto Rating Scales and Questionnaires. NewYork, OxfordUniversity Press, 1987.B.C. Office of Health Technology Assessment C - 5Design and Development ofa Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayMausner, 1.S. and Kramer, S. (1985) Epidemiology: An Introductory Text. Philadelphia, W.B. SuandersCompany.Medical Care, Supplement (1990) Quality of life: Bibliography and Indexes. 28(12): 77 pages.Nord, Erik (1992) "Methods for Quality Adjustment ofLife Years", Soc. Sci. Med. 34(5): 559-569.Porter, A.L. et al (1980) A Guidebook for Technology Assessment and Impact Analysis . New York, NorthHolland.Sisk, J. (1987) "Discussion: Drummond Resources Allocation Decisions in Health Care: A Role forQuality ofLife Assessment? 1. Chronic Diseases 40(6): 617-619.Stewart, A.L. et al (1989) "Functional Status and Well-being of Patients with Chronic Conditions: Resultsfrom the Medical Outcomes Study", JAMA 262(7): 907-913.Torrance, G.W., Feeny, D. (1989) Utilities and Quality-adjusted life years. International Journal ofTechnology Assessment in Health Care 5(4): 559-575.Torrance, G .W. (1992) Multi-attribute Health Status Classification Systems and Utility Functions . Centrefor Health Economics and Policy Analysis . McMaster University.C - 6 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayAppendix to Section CMatrix for Decisions on Technology in Health CareDIMENSIONS INDICATORS SOURCE1. POPULATION AT RISK(of problemldiseaselhealth i) Mortality: Death rates; cause-specificdeath rates; LocalDatabases (from Vital Statistics,HMRL MSP,issue): proportionatemortalityratio; case-fatalityratio Census Surveys,etc.)- Epidemiologic orientation ii) Potentialyears of Life Lost (PYLL)iii) Morbidity: Incidencerates; Prevalencerates2. POPULATION IMPACT(of problemldiseaselhealth i) Disability: i) Medical Care, Supplement,December 1990issue): a) Functional ii) McDowelland Newell (1987)- Epidemiologic orientation b) Psychological or Quality of Well-Being iii) Kleinbaum,P.G., Kuper, L.L.,The measures can be generic or disease-specific, Morgenstern,If. (1982)ExamplesInclude: FunctionalAssessmentInventory,SicknessImpactProfile, NottinghamHealth Profile,Qualityof Well-BeingScaleii) Potential Impact; "EtiologicFraction"3. ECONOMIC CONCERN: Cost analyses Standardmeasures from literature, e.g.- Comparesthe inputs of an interventionwith CEA i) Feeny and Tormnce(1989)somecombinations of the outputs CBA ii) Drummondand Stoddart(1984)CUA iii) Torranceand Feeny(1992)4. ETInCALlLEGAL/SOCIALlPOLmCAL Current or potential importanceof issue value systems. i) Expert opinionRAMIFICATIONS FOR: Social indicators ii) Stakeholderparticipation- Individuals iii) Public participation- Communities- Organizations and groups- Institutionsand systems5. TECIfNOLOGY ASSESSMENT ACTIVITY: i) Comprehensiveness of assessment activity Adapted fromthe Institute of Medicine (1985)- Role of scientificevidence ii) Convergence of resultsB.C. Office of Health Technology Assessment C -7Design andDevelopment of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwaySECTION DA Framework for Health Technology Decision Making:A Literature ReviewPresentation at The International Society of Technology Assessmentin Health Care Conference Sorrento, Italy, June 19931. BACKGROUNDDecisions regarding technology are made daily by practitioners, administrators and policy makers. Ideally,decisions regarding health technology should be based on evidence from comprehensive assessment, that is,information on the safety, effectiveness, costs and ethical/legaVsocial implications of the particulartechnology under consideration. Reality proves otherwise; the large majority of technological innovationsin health care are in use long before any systematic assessment has taken place. While it would beprohibitive to undertake extensive technology assessment work every time a resource allocation or otherpolicy decision had to be made, it would be desirable to make these decisions based on informedjudgements about the clinical, fiscal, and social impact ofthe specific health technology before it is widelyadopted and extensively used. While there are many known criteria for rational decision making, these arerarely used systematically for priority-setting in the health sector and there is no evidence to suggest thatmultiple criteria are used in concert. We suggest that even ifhealth technology policy decisions are basedon a sequence of events and information inputs, the parts are not usually integrated and consolidated into acumulative process.Using the humanist perspective as theoretical underpinning a preliminary decision framework wasdeveloped using five key dimensions (see Table 1 below - 'Matrix for Decisions'). The first four,population at risk, population impact, economic concern, and ethical/legaVsociaVpolitical ramifications, aresocietal responses to the particular technologies of concern; the fifth component, technology assessmentactivity, is a descriptive element included to provide a 'quality of medical knowledge' perspective,incorporating information on the quality ofthe assessment evidence and its degree of convergence.The rationale for the development of our health technology decision framework was centred around basicprinciples of justice in health care : equitable access to all effective health care which society can afford.This implies that the decision maker employs norms of utility as well as equity in making a decision.Neither of these lend themselves to easy formulation of policy. Some adjudication and interpretation isneeded to translate principles into action: How much technology and for whom?The purpose of this conceptual model is to provide an empirical, evidence-based foundation to technologydecisions, thus de-mystifying a heretofore undefined and generally misunderstood phenomenon .B.C. Office of Health Technology Assessment D - 1Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A MUlti-Project Compendium of Research UnderwayTable 1Matrix for Decisions on Technology in Health CareDIMENSIONS INDICATORS SOURCE1. POPULATIONAT RISK (i) Mortality: Death rates, cause-specific death Local Databases(of problem/disease/health issue) rates; proportionatemortality ratio; (from Vital Statistics, HMRI, MSP, Censuscase-fatalityratio. Surveys,etc.)- Epidemiologicorientation (ii) Potentialyears of Life Lost (PYLL).(iii) Morbidity: Incidence rates;Prevalencerates.2. POPULATION IMPACT (I) Disability: (I) Medical Care, Supplement,(of problem/diseaselhealth issue) (a) Functional December 1990- Epidemiologicorientation (b) Psychological or Qualityof Well-Being (ii) McDowell and Newell (1987)The measurescan be generic or disease-specific. (iii) K1einbaum, P.G., Kuper, L.L.,Examples include: Functional Assessment Morgenstern, H. (1982)Inventory; Sickness Impact Profile; NottinghamHealth Profile; Qualityof Well-Being Scale.(ii) Potential Impact: "EtiologicFraction"3. ECONOMIC CONCERN Cost analyses Standard measures from literature,e.g.:- Compares the inputsof an intervention with CEA (i) Feeny and Torrance (1989)some combinations of the outputs. CBA (Ii) Drummond and Stoddard (1984)CUA (iii) Tolerance and Feeny (1992)4. ETHICAULEGAUSOCIAUPOLITICAL Current or potential importance of issue/value (i) Expert opinionRAMIFICATIONSFOR: systems. (Ii) Stakeholder participation- individuals Social indicators. (iii) Public participation- communities- organizations and groups- institutions and systems5. TECHNOLOGY ASSESSMENT ACTIVITY (i) Comprehensiveness of assessmentactivity Adapted from the Instituteof Medicine(1985)- Role of scientific evidence (ii) Convergenceof resultsD - 2 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forU ..alth T .....hnnlnnu n .....lelnne· 4 1\1l1l1.I_Drnl ...... r.n",n..ntilllrn nf ~..e ..ar,.h I Inti..nAI::Iv2. THE LITERATURE REVIEW2.1 ObjectiveThe objective of the literature review was to provide a critical appraisal of the literature on each of the fivedimensions described above, which will potentially, provide a framework to analyze decision makingpertaining to the allocation of resources for health technologies. The critical appraisal of the literatureexamined the quality and volume of the evidence pertaining to the conceptual model and established thefeasibility of its empirical application.While it was beyond the scope of this particular study, the extension of this work will lead to thedevelopment of quantitative measures - new or already existing - which can be combined to develop asimple quantitative model to estimate a 'Weighted Index of Technology' for health technologies underconsideration, whenever a decision necessitating a choice between technologies has to be made. Thepurpose of the quantitative model, once it is developed, is to facilitate the ways in which priorities can beestablished around health technologies through the application ofthis Weighted Index ofTechnology. Sucha measure would indicate the broader socio-medical value of one technology relative to others which,although unrelated, may be competing for the same limited resources (see 'quantitative model' in a latersection).2.2 MethodologyThe literature review proceeded in three phases:Phase I: Identification of relevant sources of information about literature related to decision makingin health care. Fifteen data-bases representing social science, biomedical, scientific,feminist and business literature were identified - twelve of these were North Americandata-bases and three were European.Phase IT: Execution of extensive literature searches using Boollean logic. It should be pointed outthat the terms decision making, health policy and public policy are the subject of manyliteratures; to ensure the applicability of the literature to our particular needs we limitedour searching to articles where decision making, health policy and public policy were thefocus of the article.Phase ill: Selection of relevant articles and critical appraisal of the literature. The appraisalconsidered a variety of factors including theoretical grounding, empirical evidence,methodological rigour, clarity offindings, and convergenceoffindings with other work.B.C. Office of Health Technology Assessment D - 3Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underway2.3 ResultsIn total, the literature review yielded approximately 1300 abstracts related to decision making in health care(this is the result after overlap in articles was eliminated). Only a small proportion of these (13%) wererelevant to the particular focus of this study i.e. decision making related to health policy and social policy .The final review examined, in depth 173 (13%) of the total number of abstracts captured by the originalsearch. This presentation describes the results ofthis analysis for literature covering the five year period of1987 - 1991 (N=149).The appraisal took place in several stages. Figures 1 - 4 describe the results of the analysis. First, welooked at the quality of evidence; articles were categorized as being either theoretical, empirical, orpersonal opinion/editorial (See Figures 1 and 2). Overall, the majority of literature was either theoretical orpersonal opinion with only a very small proportion being empirically based. Figure 2 shows that the yieldof articles for the years 1988, 1990 and 1991 was similar (n=33; n=38); however, the quality or type ofliterature varied considerably. In 1988 almost 70% of the literature was theoretical and only 20% of theliterature was based on opinion. In 199147% of the literature was theoretical, 42% was based on opinionand 11% was empirical.Figure!Literature Categorized by Type1987 -1991(N=149)41%6%lite1'3ture 1Jpe:• Empiricalo Theoreticalo OpinionD - 4 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underway.~oI10<Jl1o90%80%7CfJIo60%50%4Q01o3CfJIo2CfJIo1CfJIo0%Figure 2Literature Categorized by Type and Year1987 -1991(N=149)literature Type:o Empiricalo Theoretical• Opinion1987(n=14)1988(n=B3)1989(n=26)isso(n=€l8)1991(n=$8)With respect to focus, the majority of the literature that we reviewed addressedmore than one dimension.Figure 3 describes the breakdown of literature by the dimensions described earlier. It is important to pointout that there has been a steady growth in the quantity of literature which discusses decision making inhealth and social policy. Interestingly, there has also been a shift in the focus of the literature itself. Forexample, in 1987 there were only 14 articles which discussed decision making in health/social policy;however, by 1991 there were 31 articles - this represents almost a threefold increase. However withrespect to focus, during this same time frame there was a 6 fold increase in the number of articles whichaddressed issues related to ethics (most frequently discussedas questionsof equity) and there was a 10 foldincrease in the number of articles which addressedlegal issues. Finally, comparing 1990 (n=38) to 1991(n=38), Figure 3 shows that there was almost a 50% increase in the number of articles which addressedethical issues.Figure 4 describesthe literature by both dimension and type.B.C. Office of Health Technology Assessment D - 5Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underwayr-"WHI'-30255oFigure 3Literature Categorized by Dimension and Year1987 -1991(N=149) literature Type:• Economico EthicalJEquity• LegalIPoliticaloSocialoEpidc:miologicalTA1987(n=14) 1988(n=$3) 1989(n=i!6) 1990(n=€l8) 1991(n=illl)1000/08<Jl/o'"s 6<Jl/o0.:::Jl-<0e- 4(Jl/o~2CJl/oFigure 4.0Literature Categorized by Type and Dimemion1987 -1991(N=149)literature Type:oEmpiricalo Theoretical• OpinionEconomic Ethicall Legal! Social Epidemio- Techno-Equity Political logical logy AssessD - 6 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underway'.2.4 ConclusionsThe purpose of the proposed decision framework (see Table 1) is the creation of a clear, precise,manageable, and replicableprocess designed to generate information about the consequences of the variousdecision options. Models are fundamental to policyanalysis;whilethey may not predict consequences withthe same assurance as the best scientific models, policymodels tell us what the possibilities are, based onvarious assumptions about the factors of concern. Decisions are often made intuitively, without explicitmodels. However, in that case, a tacit model or an unconsciously calculated decision is being developed.Faced with a phenomenon that is too complex and too expensive to study directly, a natural inclination is tostudy a model, which resembles the phenomenon of framework interest in its essential features but is moremanageable, less expensive, easier to study.It is possible to test the predictions based on a model and determine the correctness and relevance of thesepredictions for real-worlddecisions. Ourproposed conceptual model providedthe broad parameterswithinwhich this literature review was conducted. A critical appraisal of the literature has provided anexamination of the quality and volume of the evidence pertaining to health technology decisions; evidencepertaining to the attributes of health care technologies was not investigated. This literature review wasundertakenprimarilyto establishthe feasibility of the model's empirical application. Two general findingswarrant brief discussion.First, the literature we reviewed for this project clearly indicated that the dimensions of the proposedframework were the appropriate ones to include in a health technology decision model. Whilethese factorswere not always grouped similar to our particular grouping, singly or in multiples the same factorsappeared in most of the literature we examined. In addition, the evidence from this literature reviewindicated that the decision making process, as described by the studies referenced here, is receptive tosystematic inputs of information which enhance the potential for better decisions. Several of the articlesreviewed proposed decision models with similar, but usually less comprehensive characteristics.The second general comment about our findings pertains to the technical feasibility of developing thequantitative model based on the suggested conceptual one. The degree of difficulty in developingquantitative measures for each of the model dimensions will vary appreciably from one dimension to thenext, but the task is not an impossible one. Economic and epidemiological measures are easier to compilefrom already existing ones than developing measures for ethical and social concerns, quantification of thepolitical milieu may prove to be a challenging exercise. However, these methodological hurdles do notappear to be insurmountable, in light of the evidence on the importance of using noons ofutility as well asequity in makinghealth technology decision.2.5 The Quantitative ModelA quantitativemodel will be developed capable of estimating a technology index denotingthe sociomedicalmerit of each technology. The application of the model to different technologies will allow the decisionmaker to rank the technologies in terms of their contribution to society along the above-discussedB.C. Office of Health Technology Assessment D - 7Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A MUlti-Project Compendium of Research UndelWaydimensions. The maindesirable featureof such a quantitative model is that it should be an instrument easyto understand and to use, not requiring specialized technical background, nor complicated calculations.Also, the model shouldprovide a quantitative measurecapableof ranking technologies on some scale.The model design is similarto the design of the priorityscoremodel suggested by the Institute of Medicine(1992) in that it is a multiplicative model but differs in purpose. Our proposed model is used in two stagesand provides a technology indexas opposed to a priorityscore for technology assessment. The advantagesof a multiplicative model and its equivalent logarithmic expression havebeendescribed by the 10M (1992).At the first stage, a policydimension score is calculated using the following logarithmicexpression:J;D; =(~:>if InSit> /.l; i - 1,2,3,4,5j=lwhere D;J;1:S··yt.Inis the estimated scorefor policydimension iis the number of indicators usedin the calculation of D;indicates summation overall indicators jis the valueof indicator j for dimension iis the relative valueof indicator j within dimension iindicates thenatural logarithm of SijThe equivalent multiplicative expression is given byJ;~ =II(Sif /ijIJ/j=lwhere D; =In (M;)i =1,2,3,4,5D - 8 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A MUlti-Project Compendium of Research UnderwayIn a more general form, when, for example, preventive and treatment technologies are compared, the Ji arerescaling factors whose specific expressions are to be determined, To the extent that suitable rescalingfactors are successfully developed, considerably different technologies will be susceptible to comparison.At a second stage, the values Di are aggregated to a single weighted index of technologyWIT:5WIT =LT¥,D,;=1where Wi is the assigned weight of dimension iSince Di = In(Mi), WIT is also a logarithmic expression and the equivalent multiplicativeexpression is5T= IlCDY";=1where WIT= In(T).For each technology to be assessed, Di are calculated first and then aggregated to obtainWIT.The Weighted Index of Technology should be the necessary and sufficient tool for decision making.However, technologies could be compared at the levelof each policy dimension in order to understand theissues that are of moreor less relevance to a certaintechnology or to identify technologies that are more ofless sensitive on a given issue. For instance, 'technology AI may have a more favourable score than'technology B' in terms of the economic concern, but it couldbe more controversial (sensitive) in terms ofits ethical ramifications.B.C. Office of Health Technology Assessment D- 9Designand Development of a Conceptual and Quantitative Framework forHealthTechnology Decisions: A Multi-Project Compendium of Research UnderwayREFERENCESInstitute of Medicine. Settingpriorities for health technology assessment: A modelprocess. NationalAcademy Press,Washington, D.C. 1992. .Kazanjian, A., Cardiff, K. Frameworkfor Technology Decisions: Literature Review, in NewReproductive Technologies andthe Healthcare System: The Casefor Evidence Based Medicine. RoyalCommission on New Reproductive Technologies, Volume 11, Chapter 2, Canada Communications Group,1993.Kazanjian, A., Friesen, K. Defusing technology: Technology diffusion in British Columbia. InternationalJournalof Technology Assessment in Health Care 1993;9(10):46-61.D - 10 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwaySECTION EDoing the Right Thing, Not Just Doing Things Right:A Framework for Technology DecisionsReport to The United Nations Commission on Science andTechnology for Development (Gender Working Group)September 1994Also published as: "Doing the Right Thing, Not Just Doing Things Right:A Framework for Decisions about Technology" in Missing Links - Gender Equity inScience and Technology for Development, lORe & UNIFEM, Ottawa & New York, 19951. INTRODUCTION: THECHALLENGE OF TECHNOLOGICAL CHOICESAND POLICYInterest in technological choices and their effects on health has accelerated in recent years; this ismanifested through a global trend in bringing about health reform. Marked decline in overall economicgrowth and the consequent increased pressure on public budgets has been cited by public policy makers asreasons for reforminitiatives pertaining to the appropriate and effective delivery ofhealth care. Due to theglobalization of world economies all countries have simultaneously experienced this phenomenon, albeit indifferent degrees. However, health reform is variously perceived (and implemented) by countries, states,and other jurisdictional levels. Governments have sought to deal with such pressures on health carebudgets in different ways, often undertaking (or contracting) evaluative studies and technology assessmentto provide them with direction in reducing publicly funded service costs. In contrast, changing publicexpectations and the proliferation of medical technology, two important "external" pressures frequentlycited by health policy makers, are rarely examined in the broader context of technological development anddiffusion. A critical approach and feminist analysis as expounded in this paper provide a different frame ofreference .New health technologies (drugs, devices, and procedures) are becoming available at an increasing rate.Unfortunately, the development and diffusion of technology is neither associated with its inherent attributesnor with the prevalence of disease. Furthermore, not much is known about the diffusion of healthtechnology - new or old. Technology does not dictate its own range of applications, nor its price; societalreaction to the technology is a key determinant of its use. Electronic fetal monitoring provides aninteresting elaboration. It was pointed out over 10 years ago that it had been adopted in the absence ofanyevidence as to its effectiveness and substantial evidence of harm to pregnant women. Subsequentepidemiological research confirmed that the device was of no specific value in improving fetal outcomewhile doubling the cesarean section rate (Bassett, 1993). The technique remains firmly established inobstetrical practice. This example also points out the vulnerability of all women in the health sector asnurses, midwives, technologists continue to use it, as well as birthing mothers, who expect it to be part ofthe obstetric routine .The role of national governments in the development and diffusion of health technology is an influentialone, and numerous opportunities exist for adopting a theoretical Framework with which technologydecisions can be guided. In the absence of a national technology policy, decisions regarding healthtechnology are often contradictory. How much technology and for whom? These decisions are usuallymade intuitively, without systematic consideration of possible alternatives and consequences of variousdecision options. A framework which puts technology in a social context and provides a critical analysis ofthe broad range ofpotential issues and interests would make the decision making process more transparentand equitable.B.C. Office of Health Technology Assessment E - 1Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A MUlti-Project Compendium of Research Underway1.1 Policy Formulation and the Decision-Making ProcessDecision support models are used to make explicit the process of thinking about alternatives and to maketransparent to the decision maker available choices and consequences of such choices. Unless the decisionprocess is made explicit and a stepwise activity. limited rationality will prevail; since the human mind islimited in attention, memory. calculation, and imperfect in perception, we tend to simplify. use limitedviewpoints. highlight some not all aspects. Policy makers respond to situations as they interpret them. notas they exist in some objective reality; the same problem in a different frame can elicit a very differentresponse. As well. decision making often involves making difficult trade-offs, and most people adopt asimple decision rule that does not require trading off incommensurables. Finally. the policy maker veryrarely finds out the broad consequences of hislher decision or whether the decision was considered "good"or "bad" (Carroll and Johnson, 1990).2. CONCEPTUAL FRAMEWORK: DESCRIPTION, APPLICATION ANDGENDER IMPLICATIONSThe proposed conceptual Framework focuses on how alternative choices may have diverse consequencesthat stretch beyond immediate outcomes. The Framework provides a synthesis of the social dynamics ofeach situation; it adopts a critical perspective which delineates issues of power and dominance. as well asdescribing technological impact. Policy researchers erroneously assume that decision making alwaysoccurs in a series of fairly well-defined stages (that could also repeat and backtrack): 1) recognition ofproblem. 2) formulation of possible intervention. 3) generation of alternatives. 4) information search, 5)judgment or choice. 6) action. 7) feedback. Most often. however. decision making comprises onlyinformation search and choice (payne et al, 1978; Svenson, 1979). A broader "problem solving" approachis the one adopted for the proposed Framework to ensure a comprehensive understanding of the specificproblem/deficit as well as a thorough examination of the consequences of alternative courses of action.The Framework can be used during policy formulation as a proactive analytic tool that explicitly considerspossible alternative courses of action and their respective consequences. This application also facilitatespublic consultation as well as solicitation of expert opinion. Alternatively. the Framework can be used toanalyze and understand how a past (or current) situation has occurred. especially in the case of a "wrong"technology. delineating the reasons for the negative consequences ofthe technology.Few would disagree that society seems to be unable to manage technological change to respect and servethe broad range of human interests and needs. On a global level, historic and continuing efforts to includewomen's needs and concerns in the way science and technology is developed and evaluated have not yieldeddiscernible results. Over the last two decades. many official documents containing long lists ofrecommendations have been produced. In a 1979 United Nations document - The Vienna Program ofAction on Science and Technology for Development - it was recognized that "modern technologicaldevelopments do not automatically benefit all groups of society equally....and may have a negative impacton the condition of women and their bases for economic. social and cultural contributions to thedevelopment process". An appeal was made to strengthen support of national government efforts toE - 2 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underwaypromote full participation of women in the application of science and technology for development. Someyears later, the Report ofthe United Nations Panel of the Advisory Committee on Science and Technologyfor Development in 1984, postulated that the absence of women form the highest policy - and decision­making ranks in science and technology "affects the process, quality, and outcomes" of the latter. ThePanel concluded that, although it is not clear how this would take shape, women should be given access tothe process. Furthermore, "inadequacies of existing indicators of the impact of technological change onwomen" were noted and the need for better measurement of relevant concepts was identified.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. 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. The Frameworkdeveloped in this paper stimulates the articulation of goals, enabling the systematic monitoring and broadassessment oftechnological change.While most decisions do not follow the explicit stage-by-stage process, implicit rules of decision makingare, nevertheless, operant. The literature in decision research indicates that, in making important decisions,general, formal, or complex rules of decision making are usually desirable. Furthermore, a combinationand mix of general and specific, simple and complex rules give the best results in terms of better decisions(Gustafson, et al. 1992). The proposed Framework meets these criteria. Consistent dimensions, identifiedas policy concerns, are developed for application to all technology decisions. Clearly defined, accuratelymeasured indices of each dimension may be combined with less specific ones, or qualitative measures, todevelop composite measures, for each of the dimensions. The proposed model is comprised of severalcomponents (dimensions) and provides a comprehensive approach to decision making. However, it isdesigned with ease of application in mind and should not be too onerous to use.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). The first four dimensions, population at risk, population impact, economicconcerns and broad social context (including ethical, legal, and political concerns) are descriptive elementsofthe health problem in question and the social environmental context within which the problem is defined.The fifth component, technology assessment activity, is the scientific evidence about the health problemand/or the technologies used to alleviate the problem. It represents a "quality of scientific knowledge"perspective which provides information on the strength and quality of the evidence on a technology orhealth program. In order to elaborate, in a clear fashion, how the Framework can be applied to a healthtechnology decision, a hypothetical situation for a policy decision is presented and examined. 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. Thus, its discussionshould be relevant to most countries (developed and developing). The hypothetical decision of concern iswhether it should be publicly funded and under what circumstances. Ultrasonography is the imagingB.C. Office of Health Technology Assessment E - 3Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underwaytechnique that permits "seeing with sound" (Yoxen, 1987). Ultrasonography during pregnancy is a major(albeit not exclusive) application of this technology. Sound waves sent through amniotic fluid bounce offstructures to produce a two-dimensional and cross-sectional picture of the woman and the fetus on a videodisplay screen (Gold, 1984). It is used to assess the duration of pregnancy, position of the fetus in thewomb so as to assist fetal/maternal diagnosis.The first two dimensions of the Framework, population at risk and population impact, represent theepidemiological orientation in health research. Epidemiology may be defined as the study ofthe distributionand determinants of diseases and injuries in human populations. It is concerned with the extent and typesof illnesses and injuries in groups ofpeople and with the factors which influence their distribution (Steineret al, 1989). Epidemiology is concerned primarily with three major variables: person, place, and time.Person characteristics include such factors as gender, age, race, marital status, and socio-economic status,among others. The place or geographic distribution of a health-related outcome of interest can also beimportant in understanding causal relationships or planning health services to meet the needs of a particularcommunity. Geographic differences can suggest a role for factors such as climate or cultural practices,including diet, method offood preparation and food storage, in the incidence and prevalence of a particulardisease. Alternatively, geographical differences may be due to differential access to health services.Variations in the time ofoccurrence of a particular disease can also indicate causal relationships along withthe other factors that can account for the changes in disease distribution over time. 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 RiskPopulation at risk takes into account the magnitude of the problem. In health research this population isusually defined within epidemiological terms such as the number of new cases of the disease or problem(incidence), the numbers of existing cases with the disease/problem (prevalence) which are known asmorbidity rates (Mausner and Bahn, 1974) . These rates are usually available in varying degrees ofprecision in developed countries and may be more crudely estimated in developing countries; statistics maybe compiled at national or local levels. Population at risk can also be defined in different terms such asgeneral death rates or cause-specific death rates, known as mortality statistics. A comprehensiveconsideration of the population at risk includes relevant measures such as age, sex, socioeconomic status,access to health programs to mention a few individual characteristics, as well as natural history of thedisease or health problem and relevant social indicators such as measures of income disparity or illiteracyrates, to describe collective characteristics.The first step in this explicit process is to establish the population of interest. It is important to be inclusiveat this stage in order to recognize the magnitude of the phenomenon under examination. In the case ofultrasound, for example, it is perhaps best to consider all women of childbearing age (say, 15 - 45) ratherthan only those who are pregnant.E - 4 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayTo 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. More elaborate estimates of the potentialpopulation of interest could also be obtained by factoring in average family size, number of multiparouswomen, etc. with assistance from population demographers. The important point is to determine the levelof empirical precision required then to seek this evidence with or without assistance from empiricists in thefield. While accuracy and precision of data are desirable objectives, variations in data availability andaccuracy should not become a major detriment to this approach. For example, the geographic or ethnicdistribution of the population of interest are only important if services are delivered in a decentralizedfashion, or if cultural factors contribute to risk. Otherwise, aggregate statistics, expressed as actual countsor estimated rates, are sufficient.Other statistical indicators may be of interest depending on the intended use of the technology, that is,whether ultrasound will be made available as a screening tool to all pregnant women (current practice indeveloped countries), or whether (to contain costs) it will be used only as a diagnostic tool and availableonly to women identified by primary care providers as high risk pregnancies. Obviously, the issue underconsideration would appear to be of a different magnitude if the technology were to be available only tocertain sub-populations of interest.In summary, the decision maker would raise two basic questions as a first step: who is the population atrisk (i.e. those who need this technology) and what qualitative and quantitative empirical evidence isavailable to describe that population in epidemiological terms? The extent to which answers to thesequestions can be answered will indicate the clarity with which the problem at hand is defined, and thedegree to which an empirical appreciation of the problem exists . Finally, a statistical profile of currentservice utilization and (ifavailable/possible) the demand for such services completes the picture. All along,the decision maker may consult with researchers in this field to establish the relative quality of theempirical evidence, as well as consult with interested parties for assistance with broad or specificdefinitions ofpopulation at risk.2.2 Population ImpactThe purpose of this step is to examine and understand the burden of illness, and determine the knownexpected consequences of the intervention. The population impact is often measured by examining bothfunctional ability (physical and social) and psychological status (quality of well-being) . Measures offunctional status and well-being can be either generic or system-specific (see Table 1, second column) . Awide range of narrowly defined health status measures have been documented in the literature, and thediscussion generally includes information about the purpose, reliability and validity of the measurementinstrument (McDowell and Newell, 1987). However, these particular measures are not usually gender­specific and there is no feminist critique of such measures . Special effort would be required to address thisobvious research gap .B.C. Office of Health Technology Assessment E - 5Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayIn additionto the measurement of population impact described above, other measures of impact which areuseful include Quality-of-Life, and the measurement of "potential" impact. Measures of potential impactreflect the expected effect of changing the distribution of one or more risk factors in a particularpopulation. Although the utility of this measure may be somewhat limited, it has important value indecision makingrelated to public health issues. For example, this measurewould be valuable for proactiveassessmentof public healthprogramsaimedat eliminating riskfactors in a population.Ifultrasound is being used as a screening tool, then what are the expected consequences of this screening?Once again, it is more important to raise the appropriate question and attempt to obtain some quantifiablemeasure for its answer than to seek to be particularly precise in that answer. For example, if reliablestatistics exist on matemaVinfant morbidity then all the better informed the decision maker would be. Theright question to consider is: how much of the burden of illness may be reduced by using ultrasoundtechnology? Often, expert clinical opinion or consensus statements may be the only available information,therefore, this should be noted but the more important proper question should not be lost. 10' the case ofultrasound, goodepidemiological information is available (Anderson, 1994).E - 6 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayTable 1 Framework for Health Technology DecisionsDIMENSIONS INDICATORS TARGET/GOAL1. POPULATION AT RISK i) Mortality: Death rates;cause-specific rates; e.g. Minimizethe numberat risk(ofproblem/disease/health issue): proportionate mortality ratio; case-fatality ratio- Epidemiologic orientation ii) Potentialyearsof LifeLost (pYLL)iii) Morbidity: Incidence rates; Prevalence rates2. POPULATION IMPACT i) Disability: e.g. i) Improve functional status(ofproblem/diseaselhealth issue): a) Functional ii) Arrestfurther deterioration- Epidemiologic orientation b) Psychological or Qualityof Well-BeingThe measures can be genericor disease-specific.ExamplesInclude: Functional Assessment Inventory,Sickness ImpactProfile, Nottingham HealthProfile,Qualityof Well-Being Scaleii) Potential Impact: "Etiologic Fraction"3. ECONOMIC CONCERN: Costanalyses e.g. i) Capitaland operatingcosts- Compares the inputs of anintervention i) Cost-effectiveness ii) Opportunity costswith somecombinations of the outputs ii) Cost-benefitiii) Cost-utility4. ETHICALILEGAL/SOCIAL/POLITICAL i) Currentor potential importance of issue/value e.g. i) Increased autonomyRAMIFICATIONS FOR: systems. ii) Equity- individuals ii) Social indicators- communities- organizations and groups- institutions and systems5. TECHNOLOGY ASSESSMENT ACTIVITY: i) Comprehensiveness of assessment activity. e.g. Improved relevance of research- Roleof scientific evidence ii) Convergence of resultsB.C. Office of Health Technology Assessment E - 7Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UndelWayAnother important impact-related query for a screening or diagnostic intervention is about the availabilityof therapeutic or curative intervention. Once problems have been identified by ultrasound, are therepossible health care or other measures able to attenuate the burden of illness? Does ultrasonographyprovide the type of diagnostic information that, if acted upon (treatment), would make a difference towomen's and babies' health and quality of life? As direct intervention to treat the fetus in utero is unusual,identification of abnormalities may not be of great value except to offer abortion. Finally, questionsregarding the potential health risk of the technology, and whether that is offset by potential benefits, shouldbe raised. This is similar to undertaking risk assessment; for example, there are no known major medicalor health risks associated with the use of ultrasound imaging itself; but problems of false diagnosis (due tomachine or human error, or both) and subsequent investigation and treatment cannot be overlooked.It is also important to note that the particular statistical indicators and quantitative measures chosen byresearchers to depict the epidemiological dimension can portray the same situation very differently. Forexample, maternal mortality rates are usually cited, expressed as maternal deaths per 100,000 (or 10,000)live births; rates at between 100 -200 (in the late 1980's) which are considered very high pale incomparison to a different expression of the same situation, expressed as Years-of-Life Lost (YLL). TheYLL statistic would take into account age at death and the average life expectancy for women of that ageand present the cumulative figure for the 200 women at, roughly, 7 - 8,000 Years-of-Life Lost.2.3 Economic ConcernsThe economic component of the decision Framework considers what society can reasonably afford. Howsociety arrives at decisions about what it can afford is a very important but opaque question. How agovernment agency arrives at that same decision appears to be based on the fact that finite financialresources set the parameters. Those who plan, deliver and pay for health services are constantly faced withthe fact that the supply of professionals, hospitals and other facilities, and technologies cannot meet thedemands or needs of all patients (Sackett et al, 1985). The question for decision makers is how to applylimited resources where the most good will be the result . This question involves both costs andconsequences, and because it implies a choice between alternative courses of action, it constitutes aneconomic evaluation. In such a comparative analysis, money may be the unit of measurement but the,realor "opportunity" cost of any health program or technology is the sum of effects or benefits foregone bycommitting resources to this program rather than to another one.E - 8 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayThe economic dimension of the decision Framework compares the inputs to a health care program withsome combination ofthe outputs. The inputs ofa health care program usually include:a) Direct costs to the health care sector and to patients and their families; in aggregate, theycorrespond to the portion ofthe gross national production spent on health care.b) Indirect costs are expressed in terms ofproduction losses because of morbidity, mortality, and useof health care.c) Intangible costs are costs of pain, suffering, grief, etc., they correspond to any non-financialoutcomes of disease and medical care.The outputs of a health technology can be summarized into three categories:a) Conventional clinical outcomes such as number of cases treated or number of life years saved.When compared with inputs, this type of analysis is referred to as cost-effectiveness analysis(CEA). It considers the possibility of improved outcomes in exchange for the use of resources. Itcannot be used to choose between technologies with different outcomes, or to determine whatweights should be put on human life, but gives an indication about the quantity of life of a personwith a given health condition (Eisenberg, 1989; Bowie, 1991; Feeny and Torrance, 1992).b) Monetary value of different health effects. When technology costs are compared with its effectsdefined in monetary terms, it is referred to as cost-benefit analysis (CBA) . This type of analysisattempts to link cost information with medical evidence on the outcomes of treatment, but forcesan explicit decision about whether the costs are worth the benefits by measuring both in the sameunit of currency (Drummond and Stoddart 1984, Sisk 1987).c) Outcome is expressed not only in terms of quantity of life, but also in terms of quality of life, andincludes such indices as Quality-adjusted-life-years (QALYs) and Disability-adjusted-life-years(DALYs). Cost-utility analysis is yet another method of weighting for quality of life variations(Drummond, 1987).The choice ofmeasure would depend on the health outcome of interest. A cost-effectiveness ratio would beused when there is only one health outcome of interest. For example, comparing two technologies in termsof their costs per life-years gained, such as in an immunization program. A cost-benefit ratio would beapplied when there are multiple health outcomes of interest such as level of hypertension versus cholesterolmeasure. Monetary values are given to outcomes in order to be able to compare the merits of eachintervention. Finally, a cost-utility ratio would be used when the interest is on quality of health outcomeand not just on quantity.There are several problems with economic analysis, related to both theory and measurement. Thetheoretical underpinning of cost-benefit analysis is based withinnew welfare economics, and is designed toB.C. Office of Health Technology Assessment E - 9Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underwayidentify those conditions in the economy which will maximize the social welfare under various resourcerestrictions. Changes in social welfare are not easily amenable to evaluation; CBA cannot tell whether theobjective is worth achieving, it just examines the much narrower question pertaining to payoff of using atechnology. Similarly, for measures of cost, social costs are usually omitted from consideration due tomeasurement problems. As CBA for a single technology can be undertaken from the different perspectivesof each interested party (or constituency), the decision maker will possibly be able to identify potentialopposition but will not have an understanding of the reasons . Cost-effectiveness is not grounded in theory,and does not assist in the identification of policy direction. It does provide a comparison of cost for aselected outcome or desired effect. Thus, neither CEA nor CBA are advisable as primary tools for decisionmaking.However, efficiencies in health and health care are particularly important during times of economicconstraint. Society and public funds can pay only what they can afford. To apply limited resources whereat least some good will result, the decision maker has to raise the question of cost-effectiveness. However,it is often very difficult to arrive at this information, as discussed above. A number of fundamental costand benefit questions should, nevertheless, be raised and empirical measures examined carefully.To begin a narrow fiscal analysis, costs beyond that of capital or acquisition costs should be ascertained:operating costs vis-a-vis various levels of throughput (productivity). For example, once ultrasonographsare purchased what are the costs for services provided in hospitals (public or private), in communityclinics, in urban centres only or across country to reach remote areas? What are the costs for serviceprovision during regular business hours and for additional hours of service, and multiple shifts? The higherthe acquisition cost, the higher the level ofproductivity required to offset such costs . Further to operatingcosts, costs associated with human resource requirements should also be carefully considered. Forexample, payment of technologists and specialist physicians are important expenditures. But, additionalcosts incurred to the system may include those for credentialing of professionals, academic researchinterests of clinicians, continuing education for staff etc.Once costs of a single imaging unit are ascertained, estimates of total cost can be computed for the entirepopulation at risk and for sub-populations. This information coupled with non-priced (human) costinformation on population impact can begin to provide the decision maker with a sketch of the economicdimension of possible decision options. Of course, in some situations, full scale cost-effectiveness or cost­utility evidence would be possible, which would examine costs for alternative and complementaryinterventions, and health outcomes. To fully appreciate cost implications, opportunity costs should also beexamined. The key question to be raised in this instance is: for equivalent expenditures, what otherservices can be purchased or are being forgone. This can be articulated either in terms of other services tothe population of interest or to another population. For example, what level of services can be purchasedand what results can be obtained if the same amount of money was allocated to nutrition or to infectioncontrol for pregnant women? The evidence on theeffectiveness ofprenatal care with a focus on nutrition isindisputable Or, what would be the yield on a monetary investment similar in amount to that for ultrasoundtoward assistive devices for handicapped women?E - 10 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayThe final synthesis ofempirical cost-estimate data should at least strive to establish the value-for-resourcesexpended ratio to women, service agencies, and to the health care system for a specified quantity of fetalultrasonography services. It should be noted that value couldbe expressedin other than monetary or healthoutcomemeasures and pertinent socioeconomic factors may also be appropriate indicesfor such analysis.2.4 Social Context (including ethical, legal, andpolitical concerns)As the health care system is a sub-system of the larger social system,the diffusionofa technologyin healthcare should be analyzed in that context. The development or diffusion of a single health technology hasimplications for consumers, health professionals, public payers, service agencies, educational institutions,and industry but also for social institutions such as the family, the community, and the economy (to nameafew). The reason and directionofthese relations have not beenwell investigated in health assessment.Social impact analysis is a method used to understand, explain, and predict the potential impact oftechnology on social systems. Social indicators are the quantitative measures of interest and they can beexpressed at the individuaVfamily unit, community, organization, or systemlevel. However, the boundariesbetween social and ethical, or ethical and legal, or legal and political are not always clear and certainlythere are interactive effects among these dimensions (Duncan, 1984). For example, the use of healthtechnology could result in a demographic change which may interact with an altered economic base in aregionto changethe power of the regionalpolitical institutions. Conversely, understanding the relationshipbetween social structure or social values and health technology is equally important in the assessment ofthat technology. For example,why is the Electronic Fetal Monitor firmly establishedin obstetrical practicedespite the evidence of harm to pregnant women? Legal implications are often cited; yet, does litigationinfluencemedical practice or is it vice versa? The value of a "perfect" child from every birth is a sociallydetermined phenomenon; technology that is perceived to promote such "perfection" is wholeheartedlyadopted. Ethical implications are focal points in all reproductive technologies, as often questions are raisedabout the commodification ofwomenand babies. In addition, ethical implications ofgenetic testing andtheenormous powers vested in that type of knowledge are of ultimate importance from a social policyperspective as well as from a health care delivery perspective.An increasingly important component of health care evaluation concerns the anticipated effects of newtechnologies, or technology transfers, within the spheres of medical ethics and social justice. Appropriateindicators within each of these dimensions can be compiled from the literature and ranked for relativeimportance using panels of experts, then taken to the community (or interested parties) for consultation.This approach considers the role of social values and technical expertiseto be complementary in a processthat strives for justice and fairness (Garland, 1992).Specifically, constituencies and interested parties should be consulted for their input on the relativeimportance of the four major tenets of medicalethics; autonomy, beneficence, non-malfeasance, and justice(Beauchamp and Childress, 1989). Autonomy refers to the extent to which patients and their families areable to remain in meaningful control of their care, including decisions about which interventions to undergoB.C. Office of Health Technology Assessment E - 11Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underway(or to refrain from undergoing) as part of their care plan. Beneficence refers to the extent to whichtechnologies provide true health benefits in the areas most favoured by patients, such as enhanced qualityof life and prevention of disease. Non-malfeasance refers to the potential for certain technologies toproduce a net harmful effecton patients. Certain painful or risky procedures of dubiousor minimal benefitmay fall into this category. Finally, considerations of justice are increasingly important in the health caretechnology assessment arena because of the growing tension in some countries between a tradition ofegalitarianism in health care delivery (universal public coverage) and the shrinking pool of resourcesavailable to pay for all effective services. This consideration is of particular importance when newtechnologies are expected to be very expensive and of potential benefit to small numbers of patients, orspecific subpopulations.While severaldistinct dimensions are subsumedunderthis one categoryof social context, it is not the intentof the Framework to simplify these complex phenomena. For the sake of parsimony, and because allprovide the context within which public policy decisions ought to be examined, these dimensions arepresented collectively. Depending on the situation, some permutation among these may be relevant. Morelikely, all theseconcernsmay be of relevance in varying degrees.To illustrate, in the case of fetal ultrasonography, the social as well as the ethical dimensions may be moreimportant thanthe legal and political. A basic question, for groundingthe technology in its social context,is to ask: To what social uses will this technology be put? In obtaining an answer to this query bothempirical (objective) and subjective information should be sought. For example, social scientific researchon whetherultrasoundtechnology socialvalues characterizethe use ofultrasound in the care and welfare ofpregnant women. In the Western world, for example, ultrasonography, by providing visual access to thefetus, fits with a growing trend in obstetrics to give the fetus patient status, somehow separate from itsmother (Mattingly, 1992). This mayor may not be the case in the developing world. Ultrasound has alsobe used to make a "media spectacle" of pregnancy (petchesky, 1987), and has contributedto a change inwomen's and men's experience of pregnancy and expectant motherhood and fatherhood (Sandelowski,1994). The impact of technological changeon social relations can vary greatly from one group to another,instigatingdifferent degrees of social change. At the sametime, the inversemay be the case; differenttypesof social change can culminate in different levels of technological development. Critical feminist analysishas provided important information on general issues of power, control and dominance common to allcountriesand cultures (Wajeman, 1991;Lindenbaum and Lock, 1993).In addition to the empirical evidence, the decision maker should consult with women and/or women'sgroups to obtaintheir assessment of the issues and their particular perspective on the subject of ultrasound.Again, using the Framework facilitates this process of consultation because the decision maker canapproach the interested parties with a set of criteria (the previously discussed dimensions) alreadyelaborated and documented. Those being consulted can follow the decision maker's process of thoughtthrough the materialpresented and can take issue with any or all ofthe foregoing logicalarguments, iftheywish. Without an explicit decision Framework, it is simply a guessing (and outguessing) game whencommunication occurs between policymakers and others.E -12 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayAnother important aspect of the social context is the concern with equity: would all those who wouldbenefit from the technology have equal access to it? In the case of fetal ultrasonography, two basicquestions regarding equity can be raised. First, a question ofeligibility: would this technology be availableto all pregnant women? If so, particular attention should be given in designing a service delivery structurethat will reach all pregnant women and allow equal access. Secondly, if the decision is to make thispublicly funded technology available only for certain medical indications, i.e. previously defined high riskpregnancy, the question on equal access becomes even more important, especially for rural or isolated areasor disadvantaged groups. In this instance, since a gatekeeper to the technology has to be consulted first,requiring perhaps initial travel or forgone earnings, and further displacement for the subsequent services ofinterest.For ethical concerns, two of the major tenets of medical ethics are particularly relevant for the decision onultrasound: autonomy and beneficence. The recent social scientific literature on ultrasound indicates thatthis technology can be used to commodify the fetus and pregnant woman (Sandelowski, 1994) while itmaximizes the male role and expectant fatherhood. Seeing and getting a picture of the fetus is made to beas significant as carrying the fetus, thus reducing a woman's control over the situation. This is a hindranceto the pregnant woman's autonomy, as defined by medical ethics.The extent to which ultrasonography provides true health benefits to the pregnant woman and her fetus hasbeen seriously challenged (Oakley, 1986). Ultrasound use becomes even more problematic if it isconsistently and routinely misused or abused. The use ofultrasound for sex selection (undertaken routinelyin some countries) has now been documented (Wertz and Fletcher, 1993; Global Child Health News andReview, 1994; Canadian Royal Commission on New Reproductive Technologies, 1993). The ensuingabortion of female fetuses raises serious questions regarding beneficence as well as morality. Theavailability of a technology that is potentially exploitative of women and contributes further to theirsubjugation should be curtailed immediately until further policy action to stop such undesirable practice isfully implemented. If there is evidence of potential and possible abuse by the health care provider, or theconsumer of the services, regulatory mechanisms to remedy this situation should be concurrentlydeveloped, and legal implications fully explored and documented.General and specific questions regarding government regulation of facilities and service organizations, aswell as the professionals who provide these services are often desirable and always necessary steps in thedecision making process. Speaking at the opening of the 19th Session of the Program Committee of theWHO Executive Board, Dr. Nakjima, the Director-General, stated that "in the field of health, technologycannot be left to govern ethics on an empirical basis. Decisions must be made consciously by us all"(Global Child Health News and Review, 1994).Political concerns may vary widely among health care systems and countries. However, in arational stepwise approach to decision making, political implications of technological development andchange should be raised and considered as one among the many concerns. If the political imperative will,ultimately, be the only factor driving the decision, at least the decision maker should be fully aware of theB.C. Office of Health Technology Assessment E -13Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underwayconsequences of the decision along all the other dimensions. Finally, it may be desirable to weight eachdimension as opposed to attributing equal importance to all ofthem.2.5 Technology Assessment ActivityHealth technology assessment is the systematic evaluation of a technology. In a narrow sense, it involvesthe evaluation or testing of a technology for safety and benefits when used under ideal conditions (efficacy).In a broader sense, it is the process for policy research that examines the short- and long-term consequencesof the technology in question. Health technology has been defined (US Institute of Medicine, 1985) toinclude the drugs, devices and medical/surgical procedures used in health care and theorganizational/administrative and support systems within which health care is delivered.The assessment of a technology sometimes combines concerns from the clinical, epidemiological, economicand socio-Iegal perspectives. These aspects are usually specific to the technology in question as comparedto the broader context ofthe aforementioned dimensions of thedecision model. The assessment would takeinto consideration:a) the safety ofthe technology which is a judgment ofthe acceptability of risk in a specified situationwhich may include comment on the quality of provider or type of facility within which thetechnology is used;b) the benefit of using a technology or procedure for a particular clinical problem under idealconditions of use (efficacy) such as within a study environment in a laboratory or at a teachinghospital;c) the benefit of using a technology or procedure for a particular clinical problem under general orroutine conditions of use (effectiveness) such as in a field situation or within a rural or non­teaching hospital;d) considerations of costs, volume of services and benefits in terms of cost savings and other factorssuch as lives saved or serious illness prevented; ande) the implications of using the technology in the context of societal norms and cultural values andsocial institutions and relationships.Some (and on rare occasion, all) of these concerns form part of the analytic frame which is used toapproach the technology assessment activity.Assessments usually incorporate one or more evaluative methods into the research design. The first step isa thorough search of the published literature through library databases as well as a search for all fugitiveinformation - that which does not appear in peer-reviewed scientific sources. The information is thenexamined for strength and quality. Research which has been conducted using rigorous methods is generallyE -14 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underwayseen as producing stronger evidence than research using weaker methods of study. For example, evidenceobtained from at least one properly designed randomized controlled trial is seen as stronger than evidencefrom non-randomized studies or descriptive studies. The power of an assessment can be improved whenmethods of assessment such as meta-analysis or reports of expert committees are used in the synthesis ofthe information. Systematic evaluation of a technology can draw on research using any assessmentmethod, but most technology assessments that currently exist use primarily literature synthesis, expertopinion and cost analysis.Most technology falls under one of six categories of application: prevention, screening, diagnosis,treatment, rehabilitation and palliation. The application of the technology is particularly important as theassessment usually focuses all efforts on this aspect. Clear criteria exist for evaluating technologies orhealth programs for screening, diagnosis and treatment and the application of these criteria would becentral to the technology assessment activity. Technologies may be assessed at different stages ofdiffusion. Technology diffusion is defined as the process by which a technology enters and becomes part ofthe health care system (OTA, 1976). These stages include: emerging, new to practice, established, almostobsolete or outmoded.Under ideal conditions, a technology should be assessed prior to diffusion into the social system. However,in the realworld, most technology is adopted prior to examination of its efficacy and/or effectiveness. Thecosts to the system and society are sometimes enormous as was the case with the drug thalidomide for thetreatment ofnausea in pregnancy. Health technology assessment attempts to make sense of the informationavailable. on technology regardless of its source. An evaluation of the technology is based upon theanalysis of the evidence and strength of the findings. Logical and defensible conclusions about thetechnology are formulated in reports prepared usually for the decision makers. Generally, assessment isundertaken to examine only the effectiveness of health care and to provide information in a timely mannerfor more informed decision making by policy makers, industries, health professionals, and consumers. It isalso undertaken to critically re-examine technology at different stages of diffusion. Technology assessmentmay be used to slow the adoption of emerging or new technologies but, most often, it is to assist decisionmakers in better resource allocation decisions among established technologies.The technology assessment dimension incorporates into the decision process a different type of factor: theweight of scientific evidence specific to the health technology. Methodologic rigour and the application ofrules of evidence to what is known about the technology under consideration provides arguably the mostreasoned of decisions. However, it is very rare when such complete scientific evidence is available, or evenpossible to undertake concurrent with the decision making effort. The d.i:ffusion of health technologyproceeds at a rate much faster than the time-frame required to undertake good, scientific research. Theinclusion of this dimension in the Framework yields new information about the interplay betweenresearch/scientific evidence and health technology diffusion.B.C. Office of Health Technology Assessment E - 15Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayWhile this dimension of the Framework introduces an objective scientific component into the overallinformation package, its importance is dependent on its preference weight, which is subjectively assignedby the decision maker. As a final step in the proposed rationalprocess, the decision maker shouldconsiderthe availability and quality of scientific evidence regarding the technology under consideration,ultrasonography. Althoughthere is appreciable researchon the efficacy ofthis medicalimaging technologyin prenatal care, information on its effectiveness and cost-effectiveness is very scant and may be much lessconclusive.All the above mentioned dimensions of the Framework are dependent on reliable indicators (empiricalmeasures) to define and accurately describe the specific policy issues of importance to the decision maker.The potential contributionof research to policy making in the health sector is made more evidentthroughthe use of the Framework and its explicit deliberation of each policy dimension separately, as well as ofoverall, integral consequences from a societal perspective. The availability and quality of the scientificevidence are, therefore, important factors for using a critical approach; the lack of accurate data, however,shouldnot lead to the abandonment of the conceptual Framework, since raisingsome appropriate questionsabout the broader contextofhealthand humanneeds is itselfa desirable objective.3. MAKING CHOICES WITHOUT TAKING CHANCESThe dominantinstitutions whichstructure technological options in health, historically, have been controlledby the church, the state, the medical profession, researchbodies and :funding agencies, and drug companies.These technologies develop within a science culture that defines women by their biological :function (childbearers) and their social function (child rearers), and scientific research priorities are identified by malescientists. For example, research on contraceptive technologies has examined only clinical efficacy and. effectiveness; the question of why particular contraceptive technologies have been developed in preferenceto others remains unanswered. Also, we know very little about the influence of social institutions on thedevelopment of reproductive and other health technologies. Decisions about who will get how much ofwhat in health care are made daily, mostlyin an ad hoc fashion that tends to be biased in favour ofthose inpower; women are absent from these circles Policy mechanisms pertaining to health technology and itsdiffusion are neither coordinated between local, regional, national, and international levels, nor appliedconsistently to ensure allocative efficiency (that is, doing lithe right thing") in addition to technicalefficiency ("doingthings right"). Women's concerns and needs wouldbe bettermet iftechnological choicesare moreinformedchoices.The Framework provides the guidelines within which the appropriate information is sought and examined.This is achievedthrough raising several questions for whichthere mayor may not be answers at the time.Due to the Framework's explicit and stepwise approach, it can expose the ideological and social power ofthose who make decisions duringthe development and diffusion of technology. By focusing on the analysisof the dynamics of the social context, women's technological concerns as well as their absence fromdecision making rolesbecomesevidentandcan be corrected.E - 16 B.C. Office of Health Technology AssessmentDesign and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research UnderwayWhere there is any evidence indicating possibility of harm to women's health and wellness, the analysisusing the Framework exposes conflicting interests that may attempt to mask that situation. In addition,even where the technology of concern is not directly related to women's health, the consultative capacity ofthe Framework invites the participation ofwomen in the decision process.That decision process, in the hypothetical example of ultrasound imaging for pregnant women, can berapidly demystified. To begin with, the policy maker will become aware of the bias in the language ofclinical practice, where ultrasound measurements during pregnancy are known as "fetal" measurements, notpregnant women measurements, showing a male, medical bias. The information gleaned fromepidemiological evidence indicates that screening of all pregnant women through ultrasound imaging, onbalance, does more harm than good. While it is desirable and necessary to reduce matemaVinfantmorbidity and mortality rates, such evidence is not forthcoming in developed countries where there iswidespread use ofthis technology. The evidence indicates that programs of prenatal care, such as nutritioneducation and food distribution, are effective in reducing slow development and other problems ofpregnancy. As for economic concerns, the adoption of inappropriate technology at any cost isunacceptable.Within the social context, the evidence points to altered social relations, not just between mother/child andfather/child units, but among members of larger groups: health care providers, facilities and communities.The autonomy ofthe expectant mother is appreciably reduced by the use of this technology, disregarding amajor tenet of medical ethics. Finally, the overt misuse of the technology for sex selection is regarded asimmoral and would incur political costs to the present authorities.The right decision for the policy maker (in a developing country, most likely, where this technology isstarting to push its way) would clearly be not to purchase ultrasound technology.In summary, the Framework is being proposed not as a substitute for Health Technology Assessment(HTA), but in conjunction with it. Others have discussed the methods and limitations ofHTA (Banta andLuce, 1993; Morgall, 1993); they observe that there is almost unanimous agreement on the need fortechnology assessment in general. However, there is very little mainstream HTA that is context-orientedand gender-specific; technology is rarely viewed in a social context of conflicting human interests; and anattempt to make HTA more directly relevant to policy-making is very recent (Battista, 1992). Theproposed theoretical Framework addresses these important issues.For its theoretical grounding, the Framework draws on a number of disciplinary perspectives, incorporatingtheories of epidemiology, sociology, economics, and systems science; and combines a critical feministapproach with that of health services research. Application of the Framework generates a package ofinformation which includes social values. The Framework identifies possible choices by providing anevaluation ofthe relative sociomedical merits oftechnological alternatives under consideration; the decisionmaker still makes the choice, cognizant of its many and often far-reaching consequences.B.C. Office of Health Technology Assessment E • 17Design and Development of a Conceptual and Quantitative Framework forHealth Technology Decisions: A Multi-Project Compendium of Research Underway4. FUTURE RESEARCHNEEDSThe recognition that empirical evidence can contribute enormously to health policy and planning has notbeen uniformly espoused and promoted across time as well as across countries. Funding available forhealth systems research has been very small relative to that spent on health services, and has not beenforthcoming in a predictable, stable pattern. This paper, through a detailed discussion of health policyissues, highlights the many areas where there is a lack of knowledge and lack of understanding ofpopulation health needs in general, and in women's health issues in particular. This information deficit canbe appreciably reduced through special, targeted funding of priority areas and continued, stable funding ofall areas.Three thematic areas, or types of research, can be delineated from the discussion of issues and decisionmakingcontainedin this paper:1) Epidemiological research which expounds on the distributionand types of illnesses and injuries inhuman populations and the factors which influence their distributions. Particularly lacking arestudies on women's health, as previouslydiscussed.2) Health systems and population health research which are multidisciplinary fields of research andrecognize that health is more than medicine. For health systems research the focus is on systemorganization and deliveryofcare recognizing that these are at least as important as the content ofcare. Research on the social indicators of health and illness constitute the major focus forpopulation health research; both would contribute enormously to understanding women's healthissues.3) Health policy development and analysis research which expounds specifically on how healthdecisions are made, who makes decisions, and how best to incorporate empirical evidence intohealth policy decisions, given a better understanding of the process and the people. Research ondecision support models or frameworks that facilitate a rational and integrated approach to healthpolicy is a relativelynew field. A rational, explicit approach to health policy would, at least in thelong-term,be useful by bringingwomen's experiences to the policy-making arena.Some official international efforts do exist to promotethe use of research evidence in the health sector. Aninternational consultation convened by the WHO in 1993, in Geneva, discussed and presented studiesidentified as "health futures" research. This area of research is beingpromotedand supported by the WHObecause it is perceivedto be essential to evolveand developnew approaches that will assist in formulatingpublic health action aimed at accelerating progress toward health for all. The importance of futuresresearch in this context was recognized by the WorldHealth Assemblyin 1990 (Taket, 1993).While the "health futures" label is a comparatively recent phenomenon, the studies identifiedas such by theWHO are concerned with the future of health or health servicesusing methodologies more broadly definedas epidemiology, systems research, strategic planning, or modeling. The major internationalnetwork in thefield of health futures is the International Health Futures Network (IHFN). This body of work containssome projects on modeling futures; however, these are generally described as projection or simulationE - 18 B.C. 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