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.
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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
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-
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.
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.
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