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Early warning of new health care technologies in the United Kingdom.

In this paper we describe the present range of organizations that have a role in the early warning of new and emerging health care technologies in the United Kingdom. We discuss in more detail the processes and prioritization criteria used by the U.K. horizon-scanning project for the NHS Health Technology Assessment Programme, and the principal methods of technology identification for the horizon-scanning project are outlined. The United Kingdom plans to develop an integrated system for the identification of technologies for commercial planning, health service research prioritization, financial planning, and provision of information to policy makers, purchasers, and providers of health care.

Diffusion of Innovation↗

The early experiences of a national system for the identification and assessment of emerging health care technologies in Sweden.

This article presents the experiences from a pilot study and the establishment of a permanent system called SBU Alert. The question of establishing a system for the identification and assessment of emerging technologies in health care in Sweden has been on the agenda since the late 1980s. The demand came primarily from policy makers. The pilot study showed that the awareness of the project in the target group (politicians, leading managers, hospital directors, and senior medical advisors) was high. Almost all of those who replied to an assessment questionnaire were in favor of a continuation of the work. In 1997, the Swedish Council on Technology Assessment in Health Care (SBU) was selected to establish a permanent organization. This work has resulted in the identification of a number of methodological problems and tentative solutions concerning all components in the SBU Alert system. We have found that a system for systematic identification and early assessment of emerging technologies is a new and promising tool in the health technology assessment arsenal. Still, experiences are limited. Methodology and the impact of early judgments on decision making need further evaluation.

Diffusion of Innovation↗

Scanning the horizon for emerging health technologies. Conclusions from a European Workshop.

To share the existing, albeit limited, experience among nations and to explore the feasibility of international collaboration on the identification and early evaluation of health care technologies, an workshop was arranged in September 1997. Twenty-seven policy makers and researchers from twelve countries attended the meeting and concluded that: the policy environment in most European countries is characterized by insufficient data on safety, effectiveness, and cost-effectiveness of health care innovations; that an early warning system is perceived as an essential mechanism for facilitating communication among policy makers, technology experts, and health professionals; and that collaboration on early warning activities might be even more useful than traditional collaboration in health technology assessment.

Diffusion of Innovation↗

Health technology assessment in Italy.

Italy has a national health service (SSN) dating to 1978. Italy's system of government is characterized by a rather high degree of decentralization of power, and the health system is likewise decentralized. Most of the responsibilities for health care have been ceded to the regions. The state retains only limited coordinating and supervisory powers. The state has a financial responsibility for the national health service, but state contributions are limited and expenditures in excess of this made by the region must be financed from other sources. Health reforms of 1992-93 aimed at making the regions more sensitive to the need to control aggregate expenditure and to monitor measures to promote efficiency, quality, and citizen-patient satisfaction. The diffusion of individual health technologies has been relatively uncontrolled in many regions in Italy, although tight central constraints on capital spending have contained diffusion of new technology. Regulation of placement of services is a planning function and is the responsibility of both the Ministry of Health and the regions. Health technology assessment (HTA) activities have been expanding since the early 1990s, but these activities tend to be untargeted, uncoordinated, and without priorities. Nonetheless, the principal actors in the SSN at national, regional, and local levels are becoming more sensitive to the need to apply criteria of clinical and cost-effectiveness and to be more rigorous in deciding what services to guarantee. There are reasons to be guardedly optimistic about the future of HTA in Italy.

Delivery of Health Care↗

Health technology assessment in Luxembourg.

Luxembourg's public health insurance is a compulsory insurance for all employees, self-employed professionals, farmers, and pensioners. It is financed through contributions of the insured people, as well as by state taxes. Providers of health care are mainly private nonprofit institutions and self-employed professionals. All healthcare procedures are defined in fee schedules determined by a common decision of the Ministers of Social Security and Health according to proposals of a board of experts. The relative value of a service is also determined by the corresponding fee schedule. Hospitals are financed by individual budgets negotiated between each hospital and the health insurance. These hospital budgets do not cover services provided in hospitals by medical specialists, who are reimbursed on a fee-for-service basis. A low on hospital planning and organization allows the government to restrict the installation in hospitals of very expensive equipment or of equipment for which there is only a limited need in Luxembourg hospitals. Until recently there has been limited interest in or use of health technology assessment (HTA). However, large hospital investments have provoked some interest in the last few years. The Ministry of Health has asked for some HTA studies when a concrete decision had to be taken. Luxembourg decision makers have become more aware that HTA may help them to become more informed about the short- and long-term consequences of the application of health technology.

Delivery of Health Care↗

Health technology assessment in Spain.

The Spanish Constitution of 1978 established a healthcare system available to everyone and free at the point of service. The General Health Law of 1986 also established the framework for a National Health System (NHS). The Constitution and the law form the regulatory framework for the devolution of healthcare services to the Autonomous Regions. All the 17 Autonomous Regions have complete power regarding public health and planning. However, responsibilities on healthcare financing, organization, provision, and management have devolved to only seven Autonomous Regions. Financial support for health services comes mostly from taxes. Global budgets are a mechanism used by hospitals to control the acquisition of medium and low health technology. Major capital investments for health technology are controlled by the central government in 10 Autonomous Regions (population coverage of 38%) and by the Regional Health Services in the seven remaining Autonomous Regions. In 1995 a regulation for basing the introduction of new procedures and medical equipment on the assessment of safety, efficacy, and efficiency was issued. Health technology assessment (HTA) has a long history in Spain, beginning with the Advisory Board on High Technology in the government of Catalonia in 1984. This board evolved into the Catalan Agency for HTA (CAHTA) in 1994. The Basque Country established a unit for HTA in 1992 (Osteba) and the Andalusian government created an agency in 1996 (AETSA). A national agency for HTA (AETS) was established in 1994. These different programs coordinate their work and together act as an Advisory Committee of the Interregional Council of the NHS.

Aged↗

A logit model for the effect of telecardiology on acute newborn transfers.

UNLABELLED: The deregionalization of neonatal intensive care in the United States has shifted the site of care for many newborn infants away from academic medical centers where subspecialty support is available. OBJECTIVE: To investigate the effect of immediate echocardiogram interpretation via telemedicine on rates of neonatal transfer to academic medical centers. METHODS: A logit model was developed to predict the probability of transfer from two regional level 3 neonatal intensive care units to academic medical centers. One of these units implemented a telecardiology program and the other acted as a comparison institution with on-site cardiology expertise. The telecardiology intervention began 18 months into the 36-month study period. SUBJECTS: Infants (n = 2,142) admitted to neonatal intensive care at either of the two institutions during calendar years 1994 through 1996. RESULTS: A statistically significant reduction in the rate of transfer to academic medical centers was observed. Telecardiology was associated with a 58% reduction of such transfers (p = .001, 95% CI = 30%, 75%). No such reduction was noted at the comparison institution. It is estimated that approximately 30 transfers were eliminated during the study period, resulting in the elimination of approximately $150,000 in hospital charges. In addition, the infants that were transferred after the adoption of telemedicine were more often transferred to their telemedicine partner institution (p < .02).

Academic Medical Centers↗

Biocommodity Engineering.

The application of biotechnology to the production of commodity products (fuels, chemicals, and materials) offering benefits in terms of sustainable resource supply and environmental quality is an emergent area of intellectual endeavor and industrial practice with great promise. Such "biocommodity engineering" is distinct from biotechnology motivated by health care at multiple levels, including economic driving forces, the importance of feedstocks and cost-motivated process engineering, and the scale of application. Plant biomass represents both the dominant foreseeable source of feedstocks for biotechnological processes as well as the only foreseeable sustainable source of organic fuels, chemicals, and materials. A variety of forms of biomass, notably many cellulosic feedstocks, are potentially available at a large scale and are cost-competitive with low-cost petroleum whether considered on a mass or energy basis, and in terms of price defined on a purchase or net basis for both current and projected mature technology, and on a transfer basis for mature technology. Thus the central, and we believe surmountable, impediment to more widespread application of biocommodity engineering is the general absence of low-cost processing technology. Technological and research challenges associated with converting plant biomass into commodity products are considered relative to overcoming the recalcitrance of cellulosic biomass (converting cellulosic biomass into reactive intermediates) and product diversification (converting reactive intermediates into useful products). Advances are needed in pretreatment technology to make cellulosic materials accessible to enzymatic hydrolysis, with increased attention to the fundamental chemistry operative in pretreatment processes likely to accelerate progress. Important biotechnological challenges related to the utilization of cellulosic biomass include developing cellulase enzymes and microorganisms to produce them, fermentation of xylose and other nonglucose sugars, and "consolidated bioprocessing" in which cellulase production, cellulose hydrolysis, and fermentation of soluble carbohydrates to desired products occur in a single process step. With respect to product diversification, a distinction is made between replacement of a fossil resource-derived chemical with a biomass-derived chemical of identical composition and substitution of a biomass-derived chemical with equivalent functional characteristics but distinct composition. The substitution strategy involves larger transition issues but is seen as more promising in the long term. Metabolic engineering pursuant to the production of biocommodity products requires host organisms with properties such as the ability to use low-cost substrates, high product yield, competitive fitness, and robustness in industrial environments. In many cases, it is likely to be more successful to engineer a desired pathway into an organism having useful industrial properties rather than trying to engineer such often multi-gene properties into host organisms that do not have them naturally. Identification of host organisms with useful industrial properties and development of genetic systems for these organisms is a research challenge distinctive to biocommodity engineering. Chemical catalysis and separations technologies have important roles to play in downstream processing of biocommodity products and involve a distinctive set of challenges relative to petrochemical processing. At its current nascent state of development, the definition and advancement of the biocommodity field can benefit from integration at multiple levels. These include technical issues associated with integrating unit operations with each other, integrating production of individual products into a multi-product biorefinery, and integrating biorefineries into the broader resource, economic, and environmental systems in which they function. We anticipate that coproduction of multiple products, for example, production of fuels, chemicals, power, and/or feed, is likely to be essential for economic viability. Lifecycle analysis is necessary to verify the sustainability and environmental quality benefits of a particular biocommodity product or process. We see biocommodity engineering as a legitimate focus for graduate study, which is responsive to an established personnel demand in an industry that is expected to grow in the future. Graduate study in biocommodity engineering is supported by a distinctive blend of intellectual elements, including biotechnology, process engineering, and resource and environmental systems.

Journal Article↗

Real-time monitoring of picomolar concentrations of iron(II) in marine waters using automated flow injection-chemiluminescence instrumentation.

A shipboard-deployable, flow-injection (FI) based instrument for monitoring iron(II) in surface marine waters is described. It incorporates a miniature, low-power photon-counting head for measuring the light emitted from the iron(II)-catalyzed chemiluminescence (CL) luminol reaction. System control, signal acquisition, and data processing are performed in a graphical programming environment. The limit of detection for iron(II) is in the range 8-12 pmol L(-1) (based on 3 s of the blank), and the precision over the range 8-1000 pmol L(-1) varies between 0.9 and 7.6% (n = 4). Results from a day-night deployment during a north-to-south transect of the Atlantic Ocean and a daytime transect in the Sub-Antarctic Front are presented together with ancillary temperature, salinity, and irradiance data. The generic nature of the components used to assemble the instrument make the technology readily transferable to other laboratories and the modular construction makes it easy to adapt the system for use with other CL chemistries.

Automation↗

A signalling theory of excessive technological adoption.

Technology adoption has been identified as one of the main elements behind the growth of health care expenditures. It has been argued that the health insurance arrangements in the US justify, to a certain extent, the technology-driven rise in costs. Moreover, it eases the adoption of less cost-effective procedures and devices. This paper presents an additional argument by which excessive technology investments may occur: providers of care invest in technology as a way to "signal" their intrinsic (and unobservable) quality. Providers face the option of adopting a new technology. The decision of adoption in itself may convey information about his/her quality: for example, patients conjecture that providers who display newer technology are of higher quality. Providers, being aware of this, may invest in technology to reveal themselves as high quality. Thus, technology adoption could result only from the desire to attract patients. The investment is self-defeating in the sense that if all providers invest, no information about quality is transmitted to patients. We evaluate the argument in a context of demand for health care services where patients have initially no information about the quality of different providers. We show that an incentive to invest as a way to signal quality may or may not lead to overinvestment. It is also possible that only some providers invest. They reveal themselves as high quality providers. The analysis suggests that the argument is more important for some services than for others. Overall, an additional argument for overinvestment in technology in some circumstances is provided.

Attitude of Health Personnel↗

Effectiveness of a video-based motivational skills-building HIV risk-reduction intervention for inner-city African American men.

Interventions to reduce HIV risk behavior have shown promise but have demonstrated inconsistent effects with heterosexual men. This article reports a cognitive-behavioral HIV risk reduction intervention designed for heterosexually active African American men. Men (N = 117) recruited from a public clinic were randomly assigned to either (a) a 6-hr video-based small group motivational-skills intervention or (b) a 6-hr video-based contact-matched HIV education comparison group. Results showed men in the motivational-skills intervention reported lower rates of unprotected vaginal intercourse and higher rates of condom use at the 3-month follow-up. However, because of increased condom use in the comparison condition, differences between groups dissipated 6 months following the intervention. These findings are among the first to demonstrate effects from a motivational-skills intervention for reducing HIV risk in men who have sex with women using a model designed to facilitate transferring prevention technology to community settings.

Acquired Immunodeficiency Syndrome↗