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Suggested Citation:"FRONT MATTER." Institute of Medicine. 1992. Setting Priorities for Health Technologies Assessment: A Model Process. Washington, DC: The National Academies Press. doi: 10.17226/2011.
×

SETTING PRIORITIES FOR HEALTH TECHNOLOGY ASSESSMENT

A MODEL PROCESS

Molla S. Donaldson and Harold C. Sox, Jr., Editors

Committee on Priorities for Assessment and Reassessment of Health Care Technologies

Institute of Medicine

NATIONAL ACADEMY PRESS
Washington, D.C. 1992

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1992. Setting Priorities for Health Technologies Assessment: A Model Process. Washington, DC: The National Academies Press. doi: 10.17226/2011.
×

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for this report were chosen for their special competences and with regard for appropriate balance.

This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.

The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy’s 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education.

Support for this project was provided by the Agency for Health Care Policy and Research and the National Research Council.

Library of Congress Catalog Card No. 92-80702

International Standard Book Number 0-309-04696-3

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The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1992. Setting Priorities for Health Technologies Assessment: A Model Process. Washington, DC: The National Academies Press. doi: 10.17226/2011.
×

COMMITTEE ON PRIORITIES FOR ASSESSMENT AND REASSESSMENT OF HEALTH CARE TECHNOLOGIES

HAROLD C. SOX, JR. (Chair), Professor and Chair, Department of Medicine,

Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire

ROBERT A. BERENSON, Medical Director,

National Capital Preferred Provider Organization and Practitioner in Internal Medicine, Washington, D.C.

PETER BOUXSEIN, Deputy Executive Vice President,

American College of Physicians, Philadelphia, Pennsylvania

GLENNA M. CROOKS, Executive Director,

Merck and Company, Rahway, New Jersey

B. KRISTINE JOHNSON, Vice President and General Manager,

Tachyarrhythmia Division, Medtronic, Inc., Minneapolis, Minnesota

BRYAN R. LUCE, Director,

Battelle Medical Technology Assessment and Policy (MEDTAP) Research Center, Washington, D.C.

CHARLES E. PHELPS,* Professor and Chair, Department of Community and Preventive Medicine, and Professor, Political Science and Economics,

University of Rochester, Rochester, New York

RUTH B. PURTILO, Professor of Clinical Ethics, Center for Health

Policy and Ethics, Creighton University, Omaha, Nebraska

MICHAEL F. ROIZEN, Professor and Chair, Department of Anesthesia and Critical Care, and Professor, Department of Internal Medicine,

University of Chicago, Chicago, Illinois

CARY S. SENNETT, Medical Director and Director,

Clinical Quality Management, AEtna Life and Casualty, Hartford, Connecticut

GEORGE F. SHELDON, Professor and Chair,

Department of Surgery, University of North Carolina at Chapel Hill

CATHY SULZBERGER,

Chevy Chase, Maryland

GAlL L. WARDEN,* President and Chief Executive Officer,

Henry Ford Health System, Detroit, Michigan

STUDY STAFF

Division of Health Care Services

KARL D. YORDY, Director

KATHLEEN N. LOHR, Deputy Director

MOLLA S. DONALDSON, Study Director

THERESA H. NALLY, Senior Secretary

*  

 Member, Institute of Medicine

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1992. Setting Priorities for Health Technologies Assessment: A Model Process. Washington, DC: The National Academies Press. doi: 10.17226/2011.
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Suggested Citation:"FRONT MATTER." Institute of Medicine. 1992. Setting Priorities for Health Technologies Assessment: A Model Process. Washington, DC: The National Academies Press. doi: 10.17226/2011.
×

Acknowledgments

As in any effort of this kind, thanks are due to many people who assisted the committee. Several made presentations at its meetings and reflected on its work. They included Richard Goldbloom of the Canadian Task Force on the Periodic Examination; Thomas Holohan, director of the Office of Technology Assessment at the Agency for Health Care Policy and Research (AHCPR); J. Sanford Schwartz at the Leonard Davis Institute of Health Economics, University of Pennsylvania; and Steven Thacker of the Centers for Disease Control.

As the committee developed its model, it sought and received valuable additional advice, especially on the feasibility of the model, from Clyde Behney at the Office of Technology Assessment, David Eddy of Duke University, Steven Thacker of the Centers for Disease Control, Seymour Perry of the Program on Technology and Health Care at Georgetown University, Linda Johnson White of the Clinical Assessment and Efficacy Program of the American College of Physicians, and representatives of the American Managed Care Review Association, Blue Cross and Blue Shield Association, Group Health Association, the Health Industry Manufacturers Association, the Health Insurance Association of America, and Prudential Insurance Company of America. Kathleen Buto, director of the Bureau of Policy Development of the Health Care Financing Administration, and Michael Hash, senior staff associate for the Subcommittee on Health and the Environment, House Committee on Energy and Commerce, also provided helpful insight on the federal role in technology assessment.

Several members of the Institute of Medicine staff critiqued the manuscript. Annetine Gelijns reviewed Chapter 2. Everette James, an IOM vis-

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1992. Setting Priorities for Health Technologies Assessment: A Model Process. Washington, DC: The National Academies Press. doi: 10.17226/2011.
×

iting scholar, provided many helpful comments on medical technologies. Richard Rettig provided a wealth of background material and historical knowledge and critiqued Chapter 1. Michael Stoto critiqued an early draft of the quantitative model. Kathleen Lohr not only reviewed the manuscript but helped to solve many quandaries throughout the study—we are particularly appreciative of her efforts. We are also indebted to the staff efforts of Leah Mazade for her skillful editorial review, to Nina Spruill, financial analyst, and to John Devereux and Donna Thompson for their help in preparing the manuscript. Karl Yordy, director of the Division of Health Care Services, provided counsel during the study.

Two other individuals deserve special mention. At Dartmouth-Hitchcock Medical Center, Ray Kulite of MHMH Productions produced a briefing videotape for the committee. Mary Kiernan, executive secretary to Dr. Sox, was unfailingly helpful and gracious.

Finally, financial support for this study was provided by the U.S. Public Health Service, Department of Health and Human Services, and the National Research Council. The committee would like to acknowledge the valuable assistance of Steven Hotta, in AHCPR's Office of Health Technology Assessment, who acted as the study's project officer.

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1992. Setting Priorities for Health Technologies Assessment: A Model Process. Washington, DC: The National Academies Press. doi: 10.17226/2011.
×
Page viii Cite
Suggested Citation:"FRONT MATTER." Institute of Medicine. 1992. Setting Priorities for Health Technologies Assessment: A Model Process. Washington, DC: The National Academies Press. doi: 10.17226/2011.
×
   

Recommendation 9,

 

12

   

Recommendation 10,

 

12

   

Recommendation 11,

 

13

   

Adoption of the IOM's Priority-Setting Process by Other Organizations,

 

13

   

Technology Assessment and Clinical Practice Guidelines,

 

14

   

Potential Problems with the Priority-Setting Process,

 

15

   

Concluding Remarks,

 

15

1

 

TECHNOLOGY ASSESSMENT AND THE NEED FOR PRIORITY SETTING

 

17

   

Evolution of Technology Assessment Toward Outcomes, Effectiveness, and Appropriateness Research,

 

18

   

The Effectiveness Initiative and Establishment of the Agency for Health Care Policy and Research,

 

20

   

The Office of Health Technology Assessment,

 

20

   

Origin of the IOM Study,

 

21

   

Previous Pilot Study of Preliminary Model,

 

21

   

Study Methods,

 

22

   

Definitions,

 

23

   

Medical Technology,

 

23

   

Technology Assessment,

 

23

   

Reassessment,

 

25

   

Report Structure,

 

26

   

Summary,

 

26

   

Appendix: The Agency for Health Care Policy and Research,

 

26

   

Center for Medical Effectiveness Research,

 

27

   

Office of the Forum for Quality and Effectiveness in Health Care,

 

27

   

Office of Science and Data Development,

 

27

   

Center for General Health Services Extramural Research and the Division of Technology and Quality Assessment,

 

28

   

Office of Health Technology Assessment,

 

28

2

 

METHODS FOR PRIORITY SETTING

 

31

   

Priority-Setting Processes Used by Organizations,

 

32

   

Example 1: Health Care Financing Administration,

 

32

   

Example 2: Private Sector Pharmaceutical Industry,

 

33

   

Example 3: Health Care Provider Organizations,

 

35

   

Example 4: Institute of Medicine/Council on Health Care Technology Pilot Study,

 

36

   

Example 5: Food and Drug Administration,

 

37

   

Quantitative Models for Setting Priorities,

 

38

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1992. Setting Priorities for Health Technologies Assessment: A Model Process. Washington, DC: The National Academies Press. doi: 10.17226/2011.
×
   

Example 6: Technology Assessment Priority-Setting System,

 

38

   

Example 7: The Phelps-Parente Model,

 

38

   

Setting Priorities for Spending on Health Services,

 

39

   

Example 8: Oregon Basic Health Services Act,

 

39

   

Discussion,

 

41

   

Reactive and Implicit Processes,

 

41

   

Analytic Models,

 

43

   

Need for a Comprehensive, Proactive Process for Priority Setting,

 

44

   

Summary,

 

44

   

Appendix: Medicare Coverage Decision Making,

 

45

3

 

GUIDING PRINCIPLES

 

50

   

Building a Model Process for Setting Priorities,

 

50

   

Process Building for OHTA,

 

51

   

The Process Must Reflect the Mission of OHTA,

 

51

   

The Product of the Process Should Be Consistent with the Needs of Users,

 

53

   

The Process Must Be Efficient,

 

54

   

The Process Must Be Sensitive to the Environment in Which OHTA Operates,

 

55

   

Summary,

 

56

4

 

RECOMMENDATIONS FOR A PRIORITY-SETTING PROCESS

 

57

   

Preview of the Quantitative Model,

 

59

   

Elements of the Proposed Priority-Setting Process,

 

60

   

Step 1. Selecting and Weighting Criteria Used to Establish Priorities,

 

60

   

Step 2. Identifying Candidate Conditions and Technologies,

 

61

   

Step 3. Winnowing the List of Candidate Conditions and Technologies,

 

62

   

Step 4. Data Gathering,

 

62

   

Step 5. Creating Criterion Scores,

 

62

   

Step 6. Computing Priority Scores,

 

63

   

Step 7. Review by AHCPR National Advisory Council,

 

64

   

Details of the Proposed Priority-Setting Process,

 

64

   

Step 1. Selecting and Weighting the Criteria Used to Establish Priority Scores,

 

64

   

Step 2. Identifying Candidate Conditions and Technologies,

 

66

   

Step 3. Winnowing the List of Candidate Conditions and Technologies,

 

66

   

Step 4. Data Gathering,

 

68

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1992. Setting Priorities for Health Technologies Assessment: A Model Process. Washington, DC: The National Academies Press. doi: 10.17226/2011.
×
   

Step 5. Creating Criterion Scores,

 

69

   

Step 6. Computing Priority Scores,

 

83

   

Step 7. Review by AHCPR National Advisory Council,

 

87

   

Reassessment,

 

88

   

Role of Reassessment in the Complete Assessment Program,

 

88

   

Methods of Identifying Candidates for Reassessment,

 

90

   

Final Steps After Establishing Priority for Reassessment,

 

94

   

Summary,

 

94

   

Appendix 4.1: Winnowing Processes,

 

95

   

Intensity Rankings by Nominating Persons and Organizations,

 

95

   

Preliminary Ranking Processes,

 

97

   

Panel-Based Preliminary Weighting,

 

98

   

Comment,

 

99

   

Appendix 4.2: Methodologic Issues,

 

100

   

Properties of Logarithms,

 

101

   

Application to the IOM Model,

 

102

5

 

IMPLEMENTATION ISSUES

 

103

   

The Priority-Setting Cycle,

 

103

   

Setting Criterion Weights,

 

104

   

Resources Needed to Implement the Process,

 

105

   

Technology Assessment Program Staff Requirements,

 

105

   

Priority-Setting Panel,

 

106

   

Implementation Considerations for OHTA and Other Organizations,

 

108

   

Validity and Reliability,

 

108

   

Criteria,

 

109

   

Availability of Data to Generate Criterion Scores,

 

110

   

Publicly Available Products,

 

110

   

When the Scientific Evidence Is Insufficient for Assessment,

 

111

   

Interim Statements,

 

112

   

Modeling,

 

112

   

Summary,

 

113

6

 

RECOMMENDATIONS AND CONCLUSIONS

 

115

   

Review of the Committee's Rationale and Recommendations,

 

115

   

Recommendations,

 

116

   

Review of Steps and Issues in Implementation,

 

122

   

Steps in a Priority-Setting Process,

 

122

   

Resources for Implementation,

 

123

   

The Priority-Setting Cycle,

 

124

   

Publicly Available Products,

 

124

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1992. Setting Priorities for Health Technologies Assessment: A Model Process. Washington, DC: The National Academies Press. doi: 10.17226/2011.
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Suggested Citation:"FRONT MATTER." Institute of Medicine. 1992. Setting Priorities for Health Technologies Assessment: A Model Process. Washington, DC: The National Academies Press. doi: 10.17226/2011.
×

Preface

The immediate objective of this report is to provide a government agency with a method for deciding which health care technologies it should evaluate. The origin of the task is the 1989 legislation that authorized the creation of the Agency for Health Care Policy and Research. The legislation called upon the new agency to promote health care technology assessment by, among other means, deciding which technologies are the most important to evaluate. The agency asked the Institute of Medicine to study methods for setting priorities and to advise its Office of Health Technology Assessment.

The problem of deciding which health technologies to evaluate is a new problem, and it is urgent. Health technology assessment itself is a new field. It came to fruition during the 1980s, when new health technologies proliferated alongside steadily increasing health care costs. Many experts blamed physicians for indiscriminately using these technologies. The real problem was our failure to do the research that can teach us how to be discriminating. Directing tests and treatments at those who can benefit the most is the unmet challenge. Technology assessment can help to solve this problem by discovering the answer to the question, ''What works in the practice of medicine?'' The answer can often be found by applying rigorous epidemiologic thinking to the published literature. The problem is that there are many clinical problems and technologies to be evaluated, many months of work required to study one problem, and relatively few clinicians with highly developed analytic skills. Therefore, institutions must set priorities.

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1992. Setting Priorities for Health Technologies Assessment: A Model Process. Washington, DC: The National Academies Press. doi: 10.17226/2011.
×

When the Agency for Health Care Policy and Research asked for advice, the Institute of Medicine convened a study group. Our committee's first task was to learn how organizations set priorities. We found that there is little published literature on priority setting in the health field. Unfettered by tradition, we sought a method that would satisfy several criteria that we felt should be important to any public agency. First, the method should provide opportunities for the public to express its values. Second, the method should be explicit, so that people can trace backwards from results to inputs and so satisfy themselves that the process was fair. Third, priority for assessment should reflect the potential benefit to the public from doing an assessment.

Will this report have a broad readership? We certainly hope so. The Institute of Medicine gave us a broad mandate: satisfy the needs of the agency but keep in mind the needs of other organizations that do technology assessment. We therefore tried to develop a generally applicable method for setting priorities. We hope that other organizations will find this priority-setting method to be useful. Some organizations may find the entire method to their liking; others will find some elements of it attractive and will reject others. As authors, we will be quite pleased if we can engage the reader's interest in a problem that we found challenging and important.

Harold C. Sox, Jr., M.D.

Chair, Committee on Priorities for Assessment and Reassessment of Health Care Technologies

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1992. Setting Priorities for Health Technologies Assessment: A Model Process. Washington, DC: The National Academies Press. doi: 10.17226/2011.
×

SETTING PRIORITIES FOR HEALTH TECHNOLOGY ASSESSMENT

A MODEL PROCESS

Suggested Citation:"FRONT MATTER." Institute of Medicine. 1992. Setting Priorities for Health Technologies Assessment: A Model Process. Washington, DC: The National Academies Press. doi: 10.17226/2011.
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The problem of deciding which health care technologies to evaluate is urgent. With new technologies proliferating alongside steadily increasing health care costs, it is critical to discriminate among technologies to direct tests and treatments at those who can benefit the most.

Given the vast number of clinical problems and technologies to be evaluated, the many months of work required to study just one problem, and the relatively few clinicians with highly developed analytic skills, institutions must set priorities for assessment. This book sets forth criteria and a method that can be used by public agencies such as the Office of Health Technology Assessment (in the U.S. Public Health Service) and by any private organization conducting such work to decide which technologies to assess or reassess.

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