Institutional Aspects of Medical Technology Assessment
- Presenter:
Mon June 5, 2006 9:30-10:45 Room Alumni Lounge
Economic evaluation is being prescribed for improving allocation of health care resources, for marketing technologies, and as an academic endeavor unto itself. The institutional arrangements for the delivery of health care technologies are often assumed to be exogenous to the technological assessment. However, for MTA to be a valuable tool, the institutional aspects of the assessment have to be made explicit. The first aspect to be considered is the nature of the patient-practitioner transaction. The decision on the use of a technology may be bound by institutional rules, a specific practice environment, or be relatively open to clinical imperative. The decision may have a directly measurable pecuniary impact, generate a charge, or may be made in a framework of a priori allocation of health care resources. Agency issues need to be addressed. Secondly, the decision framework may be “ex-post” or “ex-ante”; ‘ex-ante’-undertaken prior to the implementation to estimate net outcome in relation to costs or “ex-post’ subsequent to knowing a program’s net outcome effects. The ex-ante analysis may be based principally on an experimental design where as the ‘ex-post’ may be based principally on retrospective data. Ex-post data may be based on multiple experiments introducing the ambiguity of common comparator trials. Ex-ante evaluations are required for technologies that will be difficult or impossible to control after they are diffused. Third, the values used in economic evaluation may be determined by the institutional rules used to allocate resources in an area, and may be determined by a precedent of using cost-effectiveness in such allocations, leading to the impossibility of finding a set of preferred programs. Non-transparency or ambiguity about these institutional aspects will limit the usefulness of the subsequent evaluation. Non-transparency or institutional ambiguity allows for the publication of essentially useless studies and to the ability of vested interests to use economic evaluation for non-substantive purposes, such the marketing of a technology. Critical appraisals from treatments for dementia, chemotherapy, and diabetes are used to illustrate the importance of the specification of these institutional aspects.
