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TA puts quality control into synthesis. It examines all literature, position statements and based on best evidence method synthesises scientific knowledge both for the physician and the health economist.


Professor David Banta was in Singapare in February to conduct a short course on Health Technology Assessment. The editor took the opportunity to interview him on this area of medical science to find out more about the subject. The course was opened by Prof Chee Yam Cheng.
Q. Prof Banta, technology has been viewed as a mixed blessing. Would you comment on this observation? 

A. The perception of a mixed blessing has probably arisen because technology makes us uncomfortable what action to take. The attitude towards technology takes a different turn the moment we look at technology as a tool. We have to be able to decide what technology can be put to good use, what is of no use and what technology is still uncertain. 
     In the real world technology has enormous benefits, costs and also side effects which can be awesome and frightening. As a result, technology may be viewed positively or negatively. It can be seen as a mixed blessing. With appropriate use, the benefits will outweigh the costs.

Q. Thank you. Could you give our readers a thumbnail sketch as to what is technology assessment and its place in the health care delivery system? 

A. TA emerged at the time when policy makers, politicians, medical leaders, heads of professional organisations were concerned with technology as it was used. TA was born in that context. It helps to put a halt to useless technology.
    TA may be misconstrued as anti-technology. For example, it counter-balanced the excessive operations in the 1960s. This is a misconception. TA grew up with a need for information and understanding of technology for policy decision making. It is a multi-disciplinary. TA addresses issues in epidemiology, symptomatology, social aspects and ethical issues in the context of costs and benefits. It has to be multidisciplinary.
    TA is not new but rather it makes use of the information in epidemiology, social science, health economics to put together information for the pragmatic decision maker.
    TA is a synthesis of knowledge. Before TA came, this was done in an ad hoc fashion - in an editorial, a review by an expert or a chapter in a book. Basically TA puts quality control into synthesis. It examines all literature, position statements and based on best evidence method synthesises scientific knowledge both for the physician and the health economist.
    In health care delivery, TA began in US and afterwards spread to Europe by relating itself to formal health policy making, public health regulation, clinical services regulation, regulation of placement of services in specialist hospitals and payment, although that came later. Basing payment on technology is a major issue in TA today.
    All that said, formal policy making is still not adequate to affect practice behaviour. There is a need for a framework for decision formed by the individual physician and the individual patient.
     It has taken 20 years’ development in the field to have a method to put evidence together that will be helpful for clinicians. We now have that information that can be available immediately when needed. It is now possible to track developments in health care delivery. One can be instantly on-line to find out the results of ongoing random controlled trials and get those results even before they are published.
     It would not be possible for this to happen if not for the computer, modern data processing, the Internet, registration of studies, online retrieval and modern information processing. Twenty years ago there was no information on the computer. Now there is quite a lot. Managing information has now become necessary.

Q. Prof Banta, where would health tachnology assessment make its greatest impact?
A. Rationalisation of available service is where TA can make the greatest impact. TA can point out what is totally useless and that can be thrown out and what is useful. The mechanism of control of useless technology can be through payment. With a payment entry barrier, useless technology will be curtailed. 
     In the real world, basically efficacious technology is often used for inappropriate circumstances and on wrong people, wrong setting, and without adequate support. lnformation dissemnisation of the results of TA can influence what doctors do, provide more decision support to administrators, clinic doctors and even department heads.
     There is a concern by doctors that they are not providing what patients want. With the information from TA, one should be confident to say, “I have nothing to offer; it does not work.” Acute backache is a classic example that treatment has little to offer. At most 10% of patients need more than reassurance that the condition will almost always feel better in 2-3 weeks with symptomatic medicine and judicious exercise.
     There is a Iegitimate place for watchful waiting in many of the common problems that the doctor encounters each day. This requires a trust in the physician and a good doctor-patient relationship. The doctor should be able to say, “See me a week from now, when it would be appropriate to look at it again.”
     What has gone wrong is doctors have become too paternalistic and not developing a partnership. The doctor should be prepared for the patient to reject his advice. He gives advice based on information from TA. The patient can always change his mind and come back, provided of course, the situation will not be irreversible in the meantime.

Q. Prof Banta, what is the interest level as   gauged by you by doctors in this region?
A. I have conducted a course in November 1995 in Malaysia and that may give me some idea. In Malaysia, the doctors have a background of several number of years in fostering QA and health services research. They have now throughout the system certain skills and infrastructure that made them ready for adoption of TA. I do not have a knowledge of the background of doctors in Singapore. Nevertheless, I can observe that there was also a strong level of interest and participation by the course participants in Singapore in the short course. 
     For TA to develop there is need for national effort and for several factors to be present – money, Ieadership, and willingness for assessment of issues of national concern e.g., gamma knife technology. 

Q. Prof Banta, how does one become acquainted with TA? 
A. There are several aspects. On methodological techniques, there are several books on measurement of quality, analysis tools and on structured review or meta-analysis. Specialised abstracts on existing technology can be obtained from the HSTAT database on the lnternet. The US Preventive Task Force, NIH and AHCPR also have useful website information on TA.
     The Cochrane Collaboration database is aIso usefuI. For example, the database of studies on obstetric and perinatal care. It is up-to-date and comprehensive. Probably in 10-20 years the Cochrane Collaboration will be able to pull together all RCTs needed for making some sort of synthesis. The database is available for purchase.
     Then there is the International Network of Agencies in Health Technology Assessment (lNAHTA) that one can tap into. They have websites on the Internet.
     There are also some journals in this area, such as “Effective health care” from UK and “Evidence based medicine” published by the BMJ. JAMA too, has enormous amount of evidence based medicine papers. At Ieast one article in each issue is directly related to methodology and high quality RCTs.
     The International Journal of TA is published 4 times a year. Each issue is based on a theme looking at technical issues in different areas such as, TA in dentistry, and primary care. It is peer review based and tells what the world is thinking. Subscription is $95 US. Membership plus journal subscription plus society newsletter for those who join the society. It now has a membership of 1000 from 30 countries.

Q. Prof Banta, what do you see is the future of TA? 
A. TA was viewed as a passing fad in the 1970s and even as recently as 7-8 years ago. With 22 years history of medical experience, building on the RCTs in the UK and cost effective studies. With its development in the US and Europc, one can say TA is now firmly rooted.
     It is now necessary that practice should be guided by information on what is efficacious, cost effective, and what works well. One can see the potential of development in East Asia.

Finally, non directed research and basic research results in one form of knowledge. There is also a need for another type of information on a more immediate basis – the impact on policy and practice guided by ethical principles. This is what technology assessment is all about. 

Prof Banta, thank you very much for sharing the subject of health technology assessment with us.