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BCOHTA review 1991 & 1992 British Columbia Office of Health Technology Assessment 1993

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British Columbia Office ofHealth Technology AssessmentBCOHTA Review1991 & 1992Centre for Health Services and Policy ResearchThe University of British ColumbiaContentsMessage from the ChairAbout BCOHTAResearch liaisonsTechnology assessment processResearch activitiesOther activitiesLooking ahead to 1993BCOHTA productsBCOHTA faculty and staffAcknowledgmentsCommitteesIn Fond MemoryThis Review isdedicated to the memory ofDr. Lionel E. McLeod, afounding memberofthe BCOHTA. His gentle guidance and clear vision ofwhat BCOHTA should be shapedliS inmany ways.MESSAGE FROM THE CHAIRI am pleased to present the first Review ofthe B.C. Office of Health TechnologyAssessment reporting on almost two years ofresearch-related activity. Establishing theOffice, planning a successful internationalconference as well as undertaking researchprojects have been particularly excitingchallenges; it has been a productive period.Decisions regarding technology are madedaily by practitioners, administrators andpolicy makers; these decisions are onlyoccasionally based on evidence from com­prehensive assessment that incorporatesknowledge about the safety, effectiveness,and cost and the ethical, legal and socialimplications of technology. While suchresearch information may be available, thefield of policy research has only recentlyfocused attention on how to link the scienti­fic evidence to decision-making at all levelsand in various sectors.BCOHTA is funded by the provincialMinistry of Health through a grant to theUniversity of British Columbia to developand promote the use of scientific evidence inhealth care decisions. The number andvariety of projects and requests for informa­tion processed by the Office indicate notonly the great demand for such information,but also the usefulness of the interdiscipli­nary collaborative approach. The depth andbreadth of the activities undertaken by theOffice demonstrate that clear and meaning­ful communication can occur betweenresearchers, policy-makers, administrators,clinicians and the public. BCOHTA iscommitted to facilitating all such communi­cation.,2Arminee Kazanjian, Dr. Soc.Chair, Steering CommitteeB.C. Office ofHealth Technology AssessmentHealth TechnologyAssessment AdvisoryCommitteeAcademic Facultles& Schools (U.B.c.)- Medic7U! -School of NUTSing- his - School of Social Work- Commerce & Business AdministrAtionMinistry of Health Centre for Health Services& Policy ResearchM . Berer, Director!Steering CommitteeA. Kazanjian. (CIuUT). Associate Director, CHSPRG. Anderson. AssodIlleDirector, CHSPRL Mcl.eod, President & CEO.UniTlersity Hospit/1.lS.Sheps. Head, Dept.Hesalth CI1.Te & EpidemiologyB.C. Office of Health Technology AssessmentTechnology ResearchGroup- O inic:ians-R=chas- AdministriUarsIProgramAssistantIResearchers& librarianK. Friesen. ProgrAm M/1.nIlgaIMedicalConsultants- Prooincial- N/1.tional- InternationalResearch LiaisonsThe R.C. Office ofHealth Technology issupported by aSteering Committee composed offaculty and staff of the Centre for Health Services andPolicyResearch.The process ofestablishingresearch priorities iscollabonuive,invoivinginput and discussion from both the SteeringCommitteeand BCOHTA. The Office has also de~'eloped ateam ofexpertsfrom avarietv ofdisciplines whocomprise the TechnologyResearch Group.Theyassist BCOHTA on aconsultative basis.2indicates reporting relat ionshipsindicates advisory or consultancy relationsh ipsAbout BCOHTAThe British Columbia Office of HealthTechnology Assessment (BCOHTA) wasestablished by the government of BritishColumbia to promote and encourage the use ofassessment research in policy and planningactivities at the governmental level and in policy,acquisition and utilization at the clinical andoperations levels. It was officially opened in thefall of 1990 by the then Minister of Health, theHonorable Bruce Strachen.Located at the University of British Columbia,BCOHTA is a component of the Centre forHealth Services and Policy Research. The Centreserves as a focus for cross-disciplinary research,database development, and consultation in theareas of health policy and health servicesresearch. BCOHTA complements the activitiesof the Centre by providing evaluative researchrelevant to health technologies and improvingthe exchange and utilization of technologyassessment information among academicresearchers, health professionals, and decision­makers at the governmental, clinical andoperational levels.Our research activities focus primarily onassessing the effectiveness of health caretechnology with the goal of providing informa­tion in a timely manner for more effectivedecision-making among policy makers, indus­tries, health professionals and consumers. Weaim to critically re-examine technology atdifferent stages of diffusion, the results whichmay be seen to show the adoption of emerging ornew technologies or foster better resourceallocation decisions for new, established oroutmoded technologies.In addition to this research component,BCOHT A provides guidance and direction inconsultation to individuals and external organi­zations interested in conducting technologyassessment research and answering questionsrelated to the field. We have developed acommunication program to disseminate theresults of technology assessment and to highlightissues in evaluative research. In this respect,BCOHTA sponsors and/or organizes confer­ences, workshops, seminars , and circulatesdiscussion papers, research reports, publicationreprints , scientific papers, health technologyreviews, and proceedings from research events.More formal educational opportunities are alsoincorporated into BCOHTA's agenda . BCOHTAco-ordinates with the Department of Health Careand Epidemiology and the Faculty of MedicineCommunity Medicine Residency Program toprovide opportunities for graduate level educa­tion and training in the area of health technologyassessment.BCOHTA's Goalso Select and carry out assessment research on health technologies; 0 Review and analyzeavailable information and prepare reports and discussion papers; 0 Disseminate the resultsofresearch and analysis by reports, newsletters, workshops and seminars; 0 Organize aprogram of frequent workshops/seminars directed attarget audiences toexamine the issues oftechnology; 0 Provide assistance and guidance toresearchers in the development ofresearch proposals relevant totechnology assessment which are submitted to traditionalsources offunding; 0 Provide financial support inthe jorm ofbursaries toqualified studentspursuing closely related research.34Research Liaisons / Partnerships / AffiliationsThe volume of information exchanged with representatives from other organizations is on the rise. As aresult, BCOHT A has become instrumental in developing and packaging key information on technologyassessment. Much effort has been dedicated to fostering our contacts. The listing on this page is arepresentation but not an exhaustive compilation of these liaisons which have involved consultation ,membership in committees or advisory groups including local, national and international groups,professional associations, technology assessment organizations, health facilities , academic andgovernmental organizations.Academic Research InstitutionsBritish Columbia Institute of TechnologySchool of Health SciencesHealth Research and Development Technology CentreSimon Fraser UniversityGerontologyCentre for Policy Research on Science and TechnologyThe University of British ColumbiaBiotechnology Research CentreClinical Engineering ProgramCentre for Applied EthicsFaculty of MedicineDept. of MedicineDept. of Health Care and EpidemiologyDept. of Obstetrics and GynecologySchool of NursingUniversity of VictoriaSchool of Health Information ScienceUniversity of WashingtonHealth Policy Analysis ProgramHealth Care FacilitiesB.C. Children's HospitalChildren's Hospital of Eastern OntarioLion's Gate Hospital .Surrey Memorial HospitalSt. Paul's HospitalUniversity Hospital, UBC SiteUniversity Hospital, Shaughnessy SiteVancouver General HospitalVictoria Cancer ClinicVictoria General HospitalProvincial AffiliationsArthritis SocietyB.c. Cancer AgencyB.C. Health AssociationB.C. Health Management ReviewB.c. Health Research Foundat ionB.C. Heart Health CoalitionB.C. Medical AssociationB.c. Medical Services CommissionB.C. Ministry of HealthHealth Economics and Planning, Policy Planning and LegislationProgram Monitoring and Education, Medical Services PlanB.C. Ministry of Advanced Education, Technology and TrainingB.C. Rehabilitation SocietyClinical Management Resource Advisory CommitteeCollege of Physicians and Surgeons of B.C.Council of University Teaching HospitalsGreater Vancouver Regional Hospital DistrictMedical Device Development CorporationP.A. Woodward's FoundationRegistered Nurses Association of B.C.Science Council of B.C.Vancouver FoundationNational AffiliationsConseil d'evaluation des technologies de la Sante du QuebecCentre for Health Economics and Policy AnalysisCanadian Coordinating Office of Health Technology AssessmentNational Health Research and Development ProgramNational Science and Engineering Research CouncilSaskatchewan Health Services Utilization and Research CommissionTechnology Assessment Specialty Services Branch, Alberta HealthInternational AffiliationsAgency-for Health Care and Policy Research, U.S. Dept. of Health and Human ServicesAustralian Institute of HealthCOMETT - ASSESS, FinlandDepartamento de Sanidad, Vitoria-Gasteiz, SpainDepartament de Sanitat i Seguretat, Barcelona, SpainEmergency Care Research Institute, PA, U.S.A.Erasmus Universiteit, The NetherlandsGeorgetown University School of Medicine, U.S.A.International Society of Technology Assessment in Health CareInstitute of Medicine, Washington, D.C., U.S.A.King's Fund Centre, United KingdomNational Library of Medicine, Washington, D.C.Office of Health Technology Assessment, Agency for Health Care Policy and ResearchOffice of Technology Assessment Congressional Office, Washington, D.C.SBU, Swedish Council on Technology Assessment in Health CareSubdireccion General de Prestaciones y Evaluacion de Technologias Sanitarias, Madrid, Spain .Te Tari Ora, Department of Health, New ZealandWorld Health Organization, Division of Noncommunicable Diseases5Technology Assessment Process6BCOHT A performs assessments in response torequests from the public sector such as hospitals,physicians, professional associations, regionaldistricts , and government; private sector groupssuch as manufacturers; and individuals from thegeneral public. The types of technologiesconsidered for assessment include phannaceuti­cals, devices, medical or surgical procedures,organizational/administrative and supportsystems. The methodology used to evaluatetechnologies is as follows:Explicit criteria are applied first to select (seeopposite page) and then to critically appraiseliterature on the safety, efficacy, and effective­ness of a technology; its ethical, legal and socialimplications as well as its economic impact onthe health care system are taken into considera­tion.The collection of information for assessment isdone in a systematic way to locate all data fromtraditional sources such as libraries as well asfugitive information from other sources. Ofinterest is literature using a wide range ofmethodology including: laboratory testing,clinical trials, epidemiological and other obser­vational methods , simulation/modeling,quantitative synthesis and group judgment,expert opinion , literature synthesis, cost-effec­tiveness, cost-benefit analysis. A comprehensivesearch of the literature is done through bothnational and international electronic databasesand social science literature, publications ofvarious patient advocacy groups and from verbalreports given by patients to public enquiries.Explicit inclusion and exclusion criteria areapplied equally to all articles reporting primarydata to avoid the perception of bias in theselection of research reports.The literature is reviewed by BCOHT A staff,medical residents or consultants. BCOHTAdraws on research using all analytical methodsbut employs primarily literature synthesis, expertopinion and cost analysis. The evaluat ion of thetechnology is based upon the analysis of theinformation for quality of evidence and strengthof findings . The power of an assessment isimproved when methods of assessment such asmeta-anal ysis or reports of expert committees areused in the synthesis of the information, Logicaland defensible conclusions about the technologyare formulated,Research that has been conducted using rigorousmethods is generally viewed as producing strongerevidence than research using weaker methods ofstudy. For example, randomized controlled trialsare regarded as the strongest method of assessingthe efficacy of a new technology. It is appreciated,however, that randomized clinical trials cannotalways be undertaken and other methods must bedepended on.PROCESS FOR THE SELECTION AND APPRAISAL OF TECHNOLOGIESIdentification of possible technologiesExternal formal requestsRequests from members ofBCOHTA's Steering Committee oraffiliate boards/groupsTopic evaluation & prioritizationPotential topics are considered following application of BCOHTA's selection criteria:• broad potential impact and potential change in quality oflife• acquisition and operating costs tothe health care system• potential to influence provider and consumerasaresult ofareview• availabilityofaccurate information and appropriate research skills• ability ofresearchers/reviewers to produce definitive resultsSteering Committee approvalComprehensive information collection• National Library ofMedicine databases. • other specialty databases• review ofdata fromother technologyassessment agencies (national, international)• fugitive data collection (medical specialty associations, manufacturers. committee repons,consensus statements, task force repons)Critical appraisal/analysis of the scientific literatureEvaluative analysis based on the quality and strength of the evidenceReview process• ltuemai and external reviewers• Steering Committee approvalProduction and dissemination of the technology assessment document78Research ActivitiesCollagen Implant Therapy in theTreatment of Urinary IncontinenceIncontinence is an important health problemaffecting an estimated one million Canadians .Medical and surgical therapies as well asbehavioral techniques have been developed in anattempt to alleviate or ameliorate the physical,social, and emotional morbidity associated withincontinence. Collagen implant therapy appearsto be a promising treatment for some forms ofurinary incontinence, however, it has not beenevaluated by means of a properly conductedrandomized clinical trial. Three published andone unpubl ished case series are reviewed. Thepaucity of scientific evidence on this modalitydoes not allow the proper assessment of itstherapeutic merits relative to other forms ofintervention. Certainly no conclusions can bedrawn regarding its economic benefits until dataon the durability or longevity of its effect isavailable. Thus the current clinical and economicdata do not yet support its use, even in selectedpatients. However, we would recommend the useof this unproven technology is, not only costlybut clinically inappropriate except in the contextof strictly controlled experimental situations .This project was completed in December 1991.The Use of Desk-Top Analyzers forCholesterol ScreeningSince the association between an elevated totalserum cholesterol and an increased risk ofcoronary heart disease (CHD) was establishedthere has been much interest in cholesterolscreening as a public health measure to identifyhigh-risk individuals. Concurrent with thisinterest has been the development of portabledesk-top analyzers which can rapidly measuretotal cholesterol in the blood by means of asimple finger prick. This new technology offersthe advantages of minimal patient discomfort,more convenient testing sites , and the availab ili­ty of the test results within minutes.It is evident , however , that even with a perfecttest for total serum cholesterol, there are manyuncertainties associated with using such mea­surements as guides to further work-up andtreatment in an attempt to reduce CHD.Extensive research is currently underway onother serum lipids (most notably high densitylipoprotein) to find measurements that are morepredictive of CHD.Added to this problem of poor predictive valueof a truly high total serum cholesterol for CHD,is the problem of the accuracy of this measure­ment. Even in large laboratories staffed byprofessionals, there are difficulties in obtainingreliable, valid total serum cholesterol results.Using desk-top analyzers to estimate the labora­tory measurements may increase thismisclassification at the initial screen.There may be a place for desk-top analyzers as aconvenient preliminary total cholesterol screen­ing test. Additional data are needed, however.regarding the precise diagnostic test characteris­tics of desk-top analyzers relative to laboratorytesting, quality control of the analyzers, and thecost of desk-top versus laboratory analysisbefore any final conclusions can be drawn. Thisproject was completed in December 1991 andupdated in 1993.Home Uterine Monitoring: A Review ofthe Scientific EvidenceThe intent of home uterine activity monitoring(HUAM) is early detection of preterm labourwhich would allow early medical intervention tostop the uterine contractions (tocolysis). Intheory, earlier diagnosis leads to earlier treat­ment, a better chance to prolong gestation, andultimately healthier newborns. The estimatedcost for British Columbia to monitor high riskpregnancies with HUAM could range between$873,810 and $10.46 million per year. The B.c.Office of Health Technology Assessment(BCOHTA) conducted a review of the medicalliterature between 1986 and June 1992 on theefficacy, effectiveness and cost effectiveness ofHUAM used for pregnant women at increasedrisk for preterm labour and birth. Clinical paperswere critically appraised using the methodologyof Chalmers; economic papers using the method­ology of Drummond . The evidence suggests thatHUAM may detect preterm labour when thecervix is less than 2 ern, however , cervicaldilation measurements are limited in their abilityto reliably measure small differences betweengroups. The possible subsequent impact ofdetection of preterm labour with less cervicaldilation on the incidence of pre term birth andthen neonatal outcomes is unclear. The evidenceto date is not sufficient to establish the efficacy .effectiveness or cost effectiveness of this newtechnology even for selective use during preg­nancy. This project was completed in October1992.Hyperbaric Oxygen for Osteomyelitisand OsteoradionecrosisHyperbaric oxygen (HBO) therapy is in currentuse in British Columbia for chronic osteomyelitis(COM) and osteoradionecrosis (ORN). Theseconditions are both anoxic infections. thus. it isbelieved that the antibiotic properties ofincreased levels of oxygen pressure provided byHBO may aid in their resolution. The literaturewas systematically searched to obtain anoverview of the available scientific evidence onthe efficacy and effectiveness of HBO for COMand ORN. With two exceptions. all the papersidentified were either review articles . case series.case reports. or animal studies (the latter are notincluded in this assessment). Two trials. onenon-randomized in COM and one randomized inORN, were found. The paucity of well designedclinical trials makes assessment of HBO forCOM and ORN difficult as do data from caseseries because of poor descriptions or methodol­ogy (e.g. patient selection), and mixed results:success rates ranging from 50% to 100% bothwith and without HBO.In conclusion, there is insufficient evidence thatHBO clearly makes a difference in the outcomesof patients with COM. With regard to ORN, thecomplex nature of the condition, the resultsreported in the case series and the single random­ized trial suggest stronger support for HBO use.The lack of evidence based on well designedtrials makes this, at best, a tentative conclusion.One conclusion, however. is clear: HBO isregarded by all authors as an adjunct to adequatesurgical and antibiotic treatment.Conclusions regarding the value of HBO. interms of costs versus benefits, are currently notpossible since these relationships for COM andORN are complex. No formal economic evalua­tions were found in the literature. This projectwas completed in October 1992.The Erythrocyte Sedimentation Rate: AnExamination of the EvidenceThe erythrocyte sedimentation rate (ESR) test isan example of an old technology whose continu­ing clinical usefulness is uncertain. The ESR iscommonly referred to as a "sickness index"because almost any disease can lead to anelevation of the rate. A critical appraisal of theliterature as it relates to the clinical utility,effectiveness. and indications for appropriate useof the erythrocyte sedimentation rate wasundertaken by the B.C. Office of HealthTechnology Assessment. Research from 22studies published from 1988 through 1991reporting primary data on the ESR werereviewed. The obvious drawback to ESR as adiagnostic test is that it is not specific to anydisorder. Consequently. ESR is not useful as adisease-specific indicator or as an independentdiagnostic test. The limited number of appropri­ate indications for ESR testing supported by theresearch suggest that current utilization is basedon a broader set of indications. In 1991/92.376.000 ESR tests were performed in BritishColumbia at a cost of S811,000. The questionremains as to whether ESR is sufficiently useful. clinically to warrant its continued widespreadand increasing use. This project was completedin May 1992.Percutaneous Transluminal CoronaryAngioplastyIn order to provide an overview of the efficacyand effectiveness of percutaneous transluminalcoronary angioplasty (PTCA) in the populationsfor which it is currently used. the literature wasreviewed with a focus on methodologicallysound, prospective studies published after 1985.Where such studies were meager or absent , theywere supplemented with data from earlierstudies. The evidence for efficacy and effective­ness of PTCA is scanty at best despite the factthat it has diffused rapidly into clinical practice .The one RCT completed found that PTCAprovides better short-term functional andsymptomatic outcomes than medical treatment insingle-vessel disease. but with a higher incidenceof untoward outcomes. Furthermore, PTCA mayimprove better long-term freedom from anginaand cardiac events. Because much remainsunknown about the merits of this procedure, theappropriate role of PTCA in the treatment of910coronary heart disease is not clear. Prospectivecontrolled studies are urgently needed to evalu­ate this procedure adequately. This project willextend into mid 1993.Framework for Technology Decisions:Report to the Royal Commission onNew Reproductive TechnologiesGovernments playa major role in the develop­ment and diffusion of health technology.However, decisions are often made in theabsence of accurate information, with decisionmaking being partisan, fragmented and ad hoc.Assessment of the technologies and their effectshas followed development; however, it isunrealistic to assume that development anddiffusion of technologies will pause till theresults are in. Using the humanistic perspectiveand some empirical evidence from a previousstudy, a preliminary framework for health caredecision making was developed using thefollowing dimensions: population impact, cost,ethical/legal, social and political implications.The objective of this paper was to present theresults of a critical appraisal of the literature oneach of these dimensions. The appraisal exam­ined the quality and volume of the evidencepertaining to the conceptual model, establishingthe feasibility of its empirical applicat ion.In conclusion, the literature has indicated that thedimensions of the proposed framework are theappropriate ones to include in a health technolo­gy decision model. Some differences emerge,however, when the criteria and/or factors thatconstitute the focus of rational planning areconsidered. More such work needs to be under­taken to determine how decisions regardingpublic policy should be made to better serve thepublic interest. The literature review phase ofthis project was completed in March 1992.Defusing Technology: TechnologyDiffusion in British ColumbiaIn order to explore the diffusion of the selectedtechnologies in one Canadian province (BritishColumbia), two administrative data sets wereanalyzed . The data included over 40 millionpayment records for each fiscal year on medicalservices provided to British Columbia residents(2.968,769 in 1988) and information on physicalfacilities, services, and per~onnel from 138hospitals in the province. Three specific timeperiods were examined in each data set, startingwith 1979-80 and ending with the most currentdata available at the time. The detailed retrospec­tive analysis of laboratory and imagingtechnologies provides historical data in threeareas of interest : (a) patterns of diffusion andvolume of utilization , (b) institutional profile,and (c) provider profile. The framework for theanalysis focused , where possible, on the exami­nation of determinants of diffusion that may beamenable to policy influence. This project wascompleted in June 1992.Prostate Specific Antigen in the EarlyDetection of Prostate CancerProstate specific antigen (PSA) is a blood serumprotein produced only by the epithelial cells ofthe prostate . Relatively high levels of PSA inblood serum are associated with not onlyprostate cancer but the even more commoncondition of BPH and other benign conditionsaffecting the prostate . Thus, PSA is not a specificindicator for cancer and consequently producesnumerous false positive test results which requireincreasingly invasive and expensive diagnosticprocedures to rule out the diagnosis of cancer.Furthermore, only a small proportion of prostatecancers result in illness or premature death. Theprostate cancers which progress quickly andcause premature death cannot be distinguished inthe early stages from the more common 'silent'ones with our current state of knowledge . Theprimary purpose of this report is to review andcritically appraise research data on the clinicalutility of prostate specific antigen (PSA) forearly detection of prostate cancer. A secondarypurpose of this report is to identify and clarifythe major issues surrounding adoption of thisnew technology. Conclusions are drawn basedon the ability of the available research to supporta recommendation for the use of PSA for earlydetection of prostate cancer. This project willextend into mid 1993.Anticoagulation for Stroke Prevention inNon-valvular Atrial FibrillationNon-valvular atrial fibrillation occurs in approxi­mately 5% of the population over age 60. It isassociated with an increased risk of stroke(estimates range from I% to 8%). Therefore, thehealth care implications of anticoagulating largenumbers of relatively elderl y patients is pro­found. The results of five published randomizedcontrolled trials provide strong and consistentevidence on the efficacy of warfarin in theprevention of stroke in non-valvular atrialfibrillation. However, warfarin use also results ina number of bleeding complications necessitat­ing careful estimation of competing risks andbenefits . Aspirin is also being considered as analternative to anticoagulation with warfarin,however, the efficacy of aspirin has not beenverified. An analysis of reported outcomes isbeing undertaken to estimate the magnitude ofhealth effects (benefits and consequences) of thispreventive strategy. This data will be presentedin a BCOHTA report along with Canadian andU.S. cost estimates. This project will extend intomid 1993.INVENTORY OF TECHNOLOGY RESEARCH (MINOR) REQUESTS1991-1992Assessment of vascular surgery technologyBone mineral measurement/densitometryBreast implantsCandela laser for the treatment of pigmented and vascular dermatologic lesionsCardiac catheterizationCat-scan: Indications for utilizationComputerized digital radiology - economic evaluationCongenital abnormalities associated with new reproductive techniquesConsensus paper by Canadian Cardiovascular society on indications for bypass surgeryDiasonic sonablate technologyDuplex ultrasound in vascular surgeryDwell time of peripheral catheters related to thrombophlebitis in the home-care settingEconomic evaluation protocol for Midwifery Services in a community hospitalEffective methods of influencing physician consumer adherences to practice guidelinesEfficacy/effectiveness of laparoscopic surgery and anticipated effect on hospital use/buildingErythropoietin (EPO) in the treatment of hereditary hemorrhagic teangiectasia (HHT)EchocardiographyExosurf neonatal for surfactant replacement therapyGallstone therapiesImplanted electrodes in the spine for ambulationInformation on how to make technology obsolescence disposal decisionsIntrathecal baclofen for the treatment of spasticityIntra-urethral collagen injections - treatment for urinary stress incontinenceJoint arthroplasty: accessibilityLaparoscopic cholecystectomyLaser lysis of adhesions by carbon dioxide laserLiver function tests - technology assessment reportsManagement information systems - operating room scheduling systems in a pediatric settingMethotrexate in rheumatoid arthritis and auto-immune diseases - utilizationMinimal access surgeryMRI vs arthroscopy in back, shoulder and knee injuriesNew medical devices. Procedures and evaluation criteriaOsteoporosis literature scanPatient controlled analgesiaPatient lifting devicesPeriodic health exam concensus developmentProstatron utilizationRe-use of single-use cardiac cathetersRight ventricle ejection fraction catheterUltrasound use in the paediatric setting - economic critiqueVentilators by small acute care hospitalsYag laser literature scanXero-mammogram use for mammography1112Other ActivitiesHighlights on the Eighth Annual Meetingof the International Society ofTechnology Assessment in Health CareThe Eighth Annual Meeting of the InternationalSociety of Technology Assessment in HealthCare (ISTAHC) was held at the WaterfrontCentre Hotel in Vancouver, June 14-17th, 1992.BCOHTA organized the conference in co­operation with the British Columbia Ministry ofHealth, the British Columbia Health Associationand the Council of University TeachingHospitals . The meeting was designed to providea forum for the exchange of information andideas in the growing field of technology assess­ment and attracted over 400 delegates from avariety of professional groups including healthcare administrators, practitioners, policy makersand researchers. Twenty-five countries wererepresented at the meeting.Delegates had an opportun ity to attend severalsessions throughout the conference. Four pre­conference sessions focused on specific issuesrelated to health care technology, its use andevaluation. The pre-conference sessions includ­ed: 'Drug Use in the Elderly: Research Issues' ;'The TechnologylLabor Spectrum: Defining aPragmatic Research Agenda ' ; 'DevelopingTechnology Assessment Curricula and TeachingMaterials'; and 'Evaluating TechnologyAssessment Performed by GovernmentAgencies ' . In addition , pre-conference work­shops provided a forum for researchers to sharetechnical information and knowledge on avariety of topics including: meta-analysis;improving of clinical practice guidelines;introducing technology assessment into hospitalsettings; and linking economic evaluation withclinical research.Opening the conference, the Honorable ElizabethCull, B.C. Minister of Health and MinisterResponsible for Seniors presented an overviewof the role of health care technology assessmentin guiding health policy decisions toward ahealthier British Columbia. Following a similartheme, Jane Sisk delivered the Presidentialaddress discussing the challenges associated withsuccessfully implementing the results of technol­ogy assessment.A wide range of topics were presented in panelsessions and concurrent sessions and a series ofposter sessions. Keynote speakers shared theirthoughts on technology assessment: RobertEvans (Centre of Health Services and PolicyResearch, D.B.C.) spoke about the role ofeconomic evaluation in technology assessment,and Robert Brook, of the Rand Corporation,spoke about the relationship between qualityassurance and technology assessment activities.The conference closed with a panel session thataddressed the issue of linking technologyassessment to clinical practice and public policy.The panel featured four prominent speakers ­David Hailey of the Australian Institute ofHealth ; Stanley Reiser , of the University ofTexas, Houston; Illka Vohlonen of HealthServices Research Limited, Finland; and AlanWilliams of the University of York.The conference was followed by a 2 1/2 dayeducation program at the Whistler Resort, B.C.,on 'Economic Evaluation of Health CareTechnology'. The program offered a variety ofcourse topics including: principles of economicevaluation with technology assessment applica­tions; health-related quality of life measurement;incorporating economic evaluations into clinicaltrials; and policy, ethics and economic evalua­tion. The education session featured faculty fromthe Centre of Health Services and PolicyResearch, McMaster University, University ofYork, BruneI University , and the BritishColumbia Ministry of Health.BCOHTA Seminar SeriesAs part of the BCOHT A Seminar Series, Dr.John Wennberg, Director of the Centre forEvaluative Clinical Sciences, DartmouthMedical School , spoke to the Ministry of Healthin Victoria, B.c. and on campus at U.B.C. on thetopic of 'Learning what works and what patientswant' . Dr. Wennberg is the pioneer of small areavariation analysis and has more recently been atthe forefront of the development of interactivevideos as a means to getting patients involved intheir own clinical decisions . This was the focusof his talk using the example of treatmentchoices in benign prostate disease. The purposeof the videos is to educate patients in theirchoices with view to shifting the environmentfrom one where doctors choose the treatment todemocratizing the doctor-patient relationship.Early experience indicates that at one site of 250patients, demand for surgery fell by 44% thefirst year after showing the video. Other siteshave shown a 60% decrease in surgical ratesillustrating how powerful the informed patientcan be in driving medical decisions .Information ResourcesBCOHTA has become the province's primaryresource centre for data gathering, storage andretrieval of technology assessment information.Our goal has been to collect literature thatsynthesizes and analyzes primary data orprovides opinion such as informal technologyassessment reports, technical reports , consensusstatements , and task force reports and otherfugitive literature. At times, this information isnot easily accessed by more traditional sourcessuch as university libraries or library electronicdatabases.We have the facilities in place to networkremotely with both local and national electronicdatabases. Medical, technical , scientific andbusiness databases can be accessed and we haverecently connected with the INTERNET. Theseelectronicsources, in conjunction with thelinkages BCOHT A has developed with provin­cial, national, and international organizationsalso provide access to a broader network ofinformation systems and databases relevant tohealth technology.In total, our library collection houses approxi­mately 600 items including books. reports .conference proceedings and article reprints.During 1992, software for the library cataloguedatabase was purchased. This computerizedcatalogue is now up and running and has becomea rich resource in facilitating access to ourexpanding collection.In the context of developing a resource centre . anumber of other projects have been undertaken:A Review ofthe Literature on TechnologyAssessment was published in early 1992covering the period 1988-1991. Its pur­pose: 1) to help determine the state ofcurrent knowledge in health technologyassessment; and 2) assist in definingpriorities for BCOHTA. (This will beincorporated in a future publicationentitled 'Handbook of TechnologyAssessment for Health Care Providers').The Directory ofHealth TechnologyResearch Projects in RC. As the primaryoutput of an expanding database ofprovincial health technology researchprojects initiated and ongoing since 1988,this report assists the Office in identifyinggaps in research and development, facili­tates the exchange of information amongstakeholders in health care, and assists inthe dissemination of health technologyinformation for the province.Educational opportunities at BCOHTAOver the past two years, student researchpositions at BCOHTA have been filled by threeresidents in the Community Medicine Programwithin the Faculty of Medicine at U.B.C. and aco-operative Health Information Sciencesstudent from the University of Victoria. BCOH­TA has offered these opportunities to providestudents with 'hands on' experience in thecritical appraisal of medical technologies and theprocess and methodology involved.1314Looking ahead to 1993The past two years have seen BCOHTA emergefrom a developmental phase into full operationwith all of its originally planned programs nowin place. During this time, BCOHTA has focusedon establishing research priorities, refiningassessment methods and explaining and promot ­ing the concept of technology assessment inhealth care. The success with the organization ofthe 8th Annual Meeting of the InternationalSociety of Technology Assessment in HealthCare in 1992 has given us the opportunity toparticipate and develop an international perspec­tive in the field. This, and the undertaking of amultitude of technology assessment projectshave helped build the foundation for furtherresearch initiatives and collaboration with fellowresearchers and other individuals involved inevery aspect of health care in the province.Our research activity in the coming years willfocus on projects that are both timely andrelevant. We will continue to expand both ourindependent and collaborative research activities.Two major projects are nearing completion(Prostate Specific Antigen for the EarlyDetection of Prostate Cancer andAnticoagulation for Stroke Prevention in Non­valvular Atrial Fibrillation). A third majorassessment, Prenatal Genetic Screening in B.C.is currently underway. In addition, the Office isproposing two other projects : the 'EconomicEvaluation of Digital Imaging ' and a 'HealthTechnology Decision Model' which are subjectto grant funding .We will also continue to develop our communi­cation program in an effort to disseminate ourfindings through presentations, newsletters anddiscussion papers. We recognize the need tostrengthen our liaisons with healthcare providersand enhance their awareness of technologyassessment. Developing and expanding ourinformation resources will continue as a centralpriority; it has already become a rich resourceand with easier accessibility to more diversedatabases, the collection of technology assess­ment-specific information will broaden .Prenatal Genetic Screening in BritishColumbiaThe purpose of this report is to assess theprenatal genetic screening program proposed forBritish Columbia and to compare it with theprogram currently operating in the province.Prenatal genetic screening in British Columbia iscurrently limited to a single program designedprimarily to detect Down's syndrome in womenover the age of thirty-five. Over the past eight toten years, the provincial health ministry inconjunction with various committees andprofessionals concerned with genetic services,have moved towards introducing a more compre­hensive prenatal genetic screening programdirected at all pregnant women in the province.In contrast to the existing program, whereamniocentesis or chorionic villous sampling(CVS) are used on all women over the age ofthirty-five, entry into the new program would bedetermined by a maternal serum screening testfor various markers known to be indicative of anincreased risk of genetic disorders. In selectedwomen, further diagnostic evaluation would beoffered, first using ultrasound and possiblysecond using amniocentesis. Movement towardsthis new program reflects rapid development inboth basic science and clinical research knowl­edge regarding maternal serum markers, as wellas rising professional interest and publicdemands for this type of service. In view of thesedevelopments and this interest, an assessment ofthis prenatal genetic screening program isconsidered timely. (Ken Bassett, ProjectDirector)Economic Evaluation of Digital ImagingBCOHTA in consultation with Dr. DavidStringer , Head of Sections of Ultrasound andGeneral Radiology at BC Children' s Hospital,will assess and compare cost, cost reduction, andeffects of photostimulable technology (digitalimaging) and conventional film-screen technolo­gy in a pediatric environment. The assessmentwill consider capital and operating costs. Amatrix displaying important players and benefitseach player may receive from digital imaging incomparison to conventional imaging will also bedeveloped. The costing will be closely integratedwith clinical trials carried over. Submitted forfunding. (N. LeMire, Project Director)Health Technology Decision ModelThis is a long term research project submittedfor funding by BCOHTA and the Centre forHealth Services and Policy Research. The teamis composed of Arminee Kazanjian, principalinvestigator, and collaborators from the staff andfaculty of the Centre. The overall purpose of thisresearch is to delineate a process that willprovide a rational , systematic approach to policydecisions about health technology. The outcomeshould yield a simple empirical model toestimate the weighted index for health technolo­gies under consideration whenever decisionmakers need to make choices in technologypolicy development. Submitted for funding.(Arminee Kazanjian . Principal Investigator)1516BCOHTA ProductsPublicationsBCOHTA 91:1D "Collagen Implant Therapy for the Treatment ofStress Incontinence." Originallyreleased in December, 1991. (M.M. Johnson)BCOHTA 91:2D "A Review ofResearch on the Use ofDesk-Top Analyzers for CholesterolScreening." Originally released in December, 1991. (c. Archibald)BCOHTA 92:1D Review of the Literature on Health Technology Assessment (1992). Originallyreleased in January, 1992.BCOHTA 92:2D "Home Uterine Activity Monitoring: A Review ofthe Scientific Evidence."Originally released in October, 1992. (C.J. Green, S.B. Sheps, K.D. Friesen, R.Parker, A. Kazanjian, N. LeMire)BCOHTA 92:3D "Hyperbaric Oxygenfor Osteomyelitis and Osteoradionecrosis." Originallyreleased in October, 1992. (S.B. Sheps)BCOHTA 92:4D "The Erythrocyte Sedimentation Rate: An Examination of the Evidence."Released January, 1993. (C.J. Green, S.M. Wai, G.M. Anderson, K.D. Friesen, A.Kazanjian)BCOHTA 92:5R "Defu sing Technology: Technology Diffusion in British Columbia." InternationalJournal of Technology Assessment in Health Care, 9:1 (1993),46-61. (A.Kazanjian, K.D. Friesen)D =Discussion Paper R =ReprintPapers Presented"Technology assessment in health: The B.C. Office" by A. Kazanjian at theWorkshop of health research funding jointly sponsored by British ColumbiaHealth Research Foundation and the B.C. Heart and Stroke Foundation,Vancouver, B.C.• March 1992."Defusing technology: A study of low and high technology in British Columbia"by A. Kazanjian and K. Friesen at the Eighth Annual Meeting of the InternationalSociety of Technology Assessment in Health Care, Vancouver, B.C., June 1992."Modeling health care technology decisions: A systems approach" by A.Kazanjian at the Fifth International Conference on System Science in Health Care,Prague, Czechoslovakia, July 1992.Conferences AttendedCanadian Association of Radiology Conference, Halifax, Summer, 1992Canadian Coordinating Office of Health Technology Assessment - DevelopmentWorkshop, Ottawa, Ontario, January 1992Centre for Health Economics and Policy Analys is Conference (CHEPA) ,Hamilton, Ontario, January 1992Technology Assessment: National and International Perspectives on Research andPractice, June 1992International Health Systems Conference, Prague, Czeckoslovakia, June 1992International Heart Health Conference, Victoria, B.C., Spring 1992ISTAHC 7th Annual Conference, Helsinki, Finland, May 199117BCOHTA FACULTY AND STAFFSteering Committee18Geoffrey M. Anderson currently conductsevaluative research at the Institute for ClinicalEvaluative Sciences at Sunnybrook Hospital inNorth York, Ontario . Prior to this, he held thepositions of Associate Director of the HealthPolicy Research Unit, Assistant Professor in theDepartment of Health Care and Epidemiologyfrom 1988 - 1992, and served on the SteeringCommittee for BCORTA. Dr. Anderson com­pleted his medical training at the University ofOttawa. He has an M.Sc . in CommunityMedicine from the University of Toronto and aPh.D. in Public Policy Analysis from the RandGraduate School.Arminee Kazanjian is the Chair of theBCOHTA Steering Committee. In addition , sheis the Associate Director of the Centre for HealthServices and Policy Research and an AssistantProfessor in the Department of Health Care andEpidemiology. Dr. Kazanjian has an M.A. inSociology from the University of Toronto and aDoctorate in Sociology from the Sorbonne.The focus of Dr. Kazanjian 's research has beenhealth human resource planning and policy,including modelling of nurse supply and require­ments; gender and professional dominance;changing roles of health personnel; highereducation and professional attachments ofnurses; practice location decisions and retentionof rural physicians. Current areas of interestinclude technology assessment and diffusion, thepolicy making process pertaining to technologydecisions, and women's health issues. She haspublished extensively and has acted as a consul­tant to provincial and federal governments onhealth human resource issues.Lionel E. McLeod to whom we have dedicat­ed this review, was a nationally renownedclinician and administrator; sadly, Dr. McLeodpassed away April lath, 1993.Dr. McLeod was the Past-President of theAlberta Heritage Foundation for MedicalResearch, Past-President of the Royal College ofPhysicians and Surgeons of Canada, Past­President of the Association for CanadianMedical Colleges, and Past-Chairman of theCanadian Council on Hospital Accreditation. Hismost recent appointment was as the Presidentand C.E.O. of University Hospital - UBC andShaugnessy Sites. In addition to his distin­guished administrative career, Dr. McLeod hadmaintained an active research interest in theareas of clinical decision making, technology.assessment, quality assurance and broader healthpolicy issues.Sam Sheps is the Head of the Department ofHealth Care and Epidemiology. Dr. Sheps'primary research interests are in health servicesresearch, particularly utilization managementand health care policy analysis , issues related toservices for severely handicapped children;trends in the influence of increasing survival onhandicapping conditions and perinatal and infantmortality; and epidemiological applications inclinical practice. Research has included programevaluation, and the application of explicit criteriato measure quality of care.Specific recent interests have included both theevaluation of utilization management programs,technology assessment, and the evaluation oftheir implementation within hospital settings. Ingeneral , his interests surround the application ofepidemiological principles and methods in theevaluation of health care services and policyanalysis which guides the development of thoseservices and the establishment of prioritiesamong competing services.BCOHTA Program StaffKen Bassett joined BCOHTA as a MedicalConsultant and will be Acting Program Managerfrom March to October, 1993. He is a practicingphysician and holds a Ph.D. in medical anthro­pology from McGill University. His thesis topicon Electronic Fetal Monitoring is an examinationof the motivation for its use by different stake­holders.Karen Cardiffis a Researcher with BCOHTA.Her major research interests have focused ontechnology assessments, decision makingprocesses related to the acquisition of newtechnologies, evaluation of utilization manage­ment programs and quality assurance activities.Karen holds an undergraduate degree in Nursing(University of British Columbia) and Science(University of Alberta) and a Master's degree inCommunity Health and Epidemiology from theUniversity of Toronto. Karen has been withBCOHTA since 1991.Kathryn Friesen is the Program Manager forBCOHTA. She coordinates all activities of theprovincial office including requests from healthorganizations for technology assessments andtechnology information; liaison with the SteeringCommittee which supports BCOHTA; andcollaboration with local, provincial, national andinternational agencies on technology issues. Pastresearch interests, prior to management appoint­ment in 1990, included technology assessmentand decision models, national medical resourcespolicy, health human resources and healthadministration. Current research interests are inthe areas of technology assessment and policydevelopment, alternative research modalities andthe translation of research outcomes into clinicalpractice.Carolyn Green is a Researcher with BCOHTA.She is project manager for technology assess­ment reports, coordinating and conductingtechnology assessment research design, datacollection, critical appraisal process and reportproduction. Carolyn holds an M.Sc. in HealthServices Planning and Administration from theUniversityof British Columbia and has abackground in Rehabilitation and InternationalHealth. Her current research interests are in theareas of clinical research and synthesis method­ology including meta-analysis.David Hadornis a Senior Medical Consultantwith BCOHTA. His primary research interestsare concerned with the definition of health careneeds and the development of outcome-basedclinical practice guidelines. His backgroundincludes serving as senior research associate atthe University of Colorado and a postdoctoralfellow in health services research at the RANDCorporation in the United States. David alsoserved as a consultant to the Oregon HealthServices Commission.Nicole LeMire is a Researcher with BCOHTAand has been with the Office since January 1991.She holds an M.Sc. in Economic Science fromthe University of Montreal. Her research inter­ests include technology assessments, theeconomics of health care and health servicepolicy and labor economics. Current researchactivities focus on the economic evaluation ofhealth care technology. Nicole is project manag­er on specific technology projects and provideseconomic expertise on others. In addition to herresearch activities, she also assumes primaryresponsibility for the Office budgeting andfinancial reporting.Michelle Rhone is a Researcher withBCOHTA. She is currently the project managerfor the provincial directory/database of healthtechnology research projects and the BCOHTAstrategic planning process. Her research activi­ties involve conducting literature searches, datacollection and assisting in the assessmentprocess of ongoing projects. Her past researchinterests have involved evaluating healthoutcomes of paediatric transplant patients inEngland and environmental ergonomics.Michelle holds an Bachelors degree in sciencewhich she obtained from Simon FraserUniversity.Tracy Woodland is the Program Assistant toBCOHTA. She acts as the initial contact forenquiries related to office activities. Her back­ground in human resources and softwareapplications provides support to operations roleas liaison between the Centre for Health Servicesand Policy Research, the University of BritishColumbia and the BCOHTA.Mary Doug Wrightis Librarian for BCOHTA.She has a B.Sc. in Genetics from University ofAlberta and an M.L.S. from the University ofBritish Columbia. She has extensive experiencein health science research in academic andspecial library settings.19The B.C. Office of Health Technology Assessment gratefullyacknowledges the generous financial support of the followingorganizations for the 8th AnnuallSTAHC Meeting:B.C. Children's HospitalB.C. Ministry of Healtha.c. Health AssociationB.C. Health Research FoundationCIBA-Geigy Canada Ltd.Greater Vancouver Regional Hospital DistrictNational Health Research Development ProgramNovopharma Ltd.Sandoz CanadaSt. Paul's HospitalUpjohn Company of CanadaVancouver General HospitalMore informationFor-more information about the B.C. Office of Health Technology Assessment,please contact us at:B.C. Office of Health Technology AssessmentCentre for Health Services and Policy ResearchS-184 - Koerner Pavilion2211 Wesbrook MallVancouver, B.C. Canada V6T 2BS20Tel: (604) 822-7049 Fax: (604) ~22-797SYEAR ONE AND TWO COMMITTEESMembers of the Ministry ofHealth Advisory CommitteeReni Chong-KitDirector, Department of LaboratoryMedicine, Surrey Memorial Hospital,Surrey, B.C.Donelle ClarkeClinical Nurse Specialist, Special Care" Nursery, B.C. Children's Hospital.Vancouver, B.C.George Eisler. Dean, School of Health Sciences, B.C.Institute of Technology, Burnaby, B.C.Ken FairburnDirector, Team 3, Hospital Programs,B.C. Ministry of Health, Victoria, B.C.Arminee KazanjianAssociate Director, Centre for HealthServices and Policy Research,University of British Columbia,Vancouver, B.C.David KlassenDirector, British Columbia CancerAgency, Vancouver, B.C.TimPadmoreDirector, Policy and Planning Branch,B.C. Ministry of Advanced Education,Training and Technology, Victoria, .B.C.A.C. Pink~rtonCollege of Physicians and Surgeons ofB.C., Vancouver, B.C.Deborah SheraDirector, Program Monitoring and'Education,Medical Services Plan,B.C. Ministry of Health, Victoria, B.C.Tom VincentActing Executive Director, HealthEconomics and Planning, PolicyPlanning and Legislation, B.C.Ministry of Health, Victoria, B.C.Richard WhitneyExecutive Director, B.C. HealthResearch Foundation, Burnaby, B.C.BCOHTA TechnologyResearch GroupJoan AndersonProfessor, School of NursingThe University of British ColumbiaPeter Borono-wskiMedical Director, Society of GeneralPractitioners of British Columbia,Dawson Creek, B.C.Gerhard Brauer.School of Health Information ScienceUniversity of VictoriaMax CairnsDirector of ProgramsScience Council of B.C.Reni Chong-KitDirector. Department of LaboratoryMedicineSurrey Memorial HospitalPeter DanielsonAssociate ProfessorCentre for Applied EthicsThe Universityof British ColumbiaJames V. DunneInternal Medicine, RheumatologyPrince George Regional HospitalSidney B. EfferProfessor, Department of Obstetricsand GynecologyThe University of British ColumbiaGeorge EislerDean, School of Health SciencesBritish Columbia Institute ofTechnologyJ. FrohlickAssociate Director, Department ofPathology & Laboratory MedicineUniversity HospitalDerek GellmanConsultant in MedicallHospitaiAdministrationGloria GutmanDirector, Gerontology CentreSimon Fraser UniversityDavid HardwickAssociate Dean, Faculty of MedicineThe University of British ColumbiaMartin HollenbergDean, Faculty of MedicineThe University of British ColumbiaDavid JohnsonManager, Health Research &DevelopmentTechnology CentreBritish Columbia Institute ofTechnologyCharles LaszloDirector, Clinical EngineeringProgramThe Universityof British ColumbiaBrian LentleDepartment of RadiologyVancouver General HospitalRon MacPhersonVice-President,MedicineFraser-Burrard Hospital SocietyG.B. John ManciniHead, Department of MedicineUniversity HospitalDavid MathesonVice-President,MedicineB.C. Children's HospitalRobertMcArthurVice-President,MedicineGreater Victoria Hospital SocietyMichael McDonaldDirector, Centre for Applied EthicsThe Universityof British ColumbiaLionel McleodPresident and C.E.O.UniversityHospitals, UBC Site andShaughnessySiteAxel MeisenDean of Applied ScienceFaculty of Applied ScienceThe University of British ColumbiaDavid ScheifeleDirector, Vaccine Evaluation CentreB.C. Children's HospitalNicholas Sladen-Dew.Greater Vancouver Mental HealthSocietyMichael SmithDirector. Biotechnology ResearchCentreThe University of British ColumbiaL.D. SullivanDepartment of Surgery, Faculty ofMedicineVancouver General HospitalTom WardVice-President, MedicineSt. Paul's HospitalDick WhitneyExecutive DirectorB.C. Health Research FoundationMarilyn WillmanDirector. School of NursingThe University of British ColumbiaEarIWmklerAssociate Professor, Philosophy .The University of British ColumbiaCharles WrightVice-President,MedicalAdministrationVanco~ver General HospitalSteering CommitteeGeoffrey M. AndersonAssociate Director, Centre for HealthServices and Policy ResearchThe University of British Columbia'Vancouver, B.C.Arminee KazanjianAssociate Director, Centre for HealthServices and Policy ResearchThe University of British ColumbiaVancouver, B.C.Lionel E. McLeodPresident and CEoO.University Hospitals, U.B.C. Site andShaughnessy SiteVancouver, B.C.SamShepsHead. Department of Health Care andEpidemiologyThe Universityof British ColumbiaVancouver, B.C.


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