journal oj lnternal Medicine 1991 : 230: 1-3 ADONIS 09 5468209 100 1 103

Editorial Do we know what we are doing?

It is a truism to state that the developments in medical sciences since World War I1 have been phenomenal, The advances in our knowledge of basal mechanisms in both healthy and diseased individuals have greatly increased our ability to diagnose and treat diseases, and have led to a marked optimism regarding the prevention of many chronic illnesses. The increased longevity in all countries, not only in the developed but also in the developing world, is one consequence of the application of this increase in knowledge to the social and health services in most countries.

The medical profession has been keen to apply the results of advances in biological sciences to patient care as soon as possible. More often than not, this has been done before the new method of diagnosis or treatment has been thoroughly evaluated with re- gard to its safety, sensitivity, specificity and long- term results. Only when the new method has been based on a new drug, i.e. a new chemical entity, has a thorough evaluation been necessary before it could be recommended for general use. By contrast, all new surgical procedures and most diagnostic methods have been introduced and widely distributed long before any attempt has been made to evaluate their long-term .effects. In some cases it has been found that procedures thought to improve patient care are in fact ineffective or even detrimental.

Partly due to such experiences, and partly because of the rapid increase in the costs of health care, in particular the application of newer, more sophis- ticated and much more expensive methods, there has been increased interest in assessment of the procedures used in the health services, using ap- proaches similar to those adopted for the evaluation of new medicines. In general, this has been referred to as medical technology assessment, where medical technology refers to all ‘techniques, drugs, equip- ment, and procedures used by health-care pro- fessionals in delivering medical care to individuals, and the systems within which such care is delivered’. This definition, originally constructed by the Office of Technology Assessment (OTA) of the US Congress [1], has been endorsed by the US Institute of Medicine

[2] and by different official bodies in several European countries.

Once the problem of assessing technologies was recognized it became obvious that most of the procedures used in the health services had never been critically evaluated. This is true both for many long-standing routines and for more novel methods of diagnosis and treatment, as well as most measures aimed at the prevention or postponement of disease, such as cancer and cardiovascular disease. In order to improve this situation, many governments have been interested in organizing assessments of medical technologies, leading to initiatives of different kinds. In the USA several official or semi-official organ- izations have promoted various methods of evalu- ating new or old medical technologies. In 1987 the Swedish government created a new agency for this purpose, the Swedish Council for Technology As- sessment in Health Care (SBU), which reports directly to the Secretary for Health and Social Services. This agency is governed by a board representing all the organizations responsible for the provision of medical services or medical research. This has enabled efficient, ongoing, and face-to-face communication between the new agency and all those individuals working in, or with problems related to, the health services.

The Swedish Council for Technology Assessment in Health Care employs a central office with a small but highly qualified and motivated staff under the leadership of a professor in health economics asso- ciated with the medical faculty of the Karolinska Institute. Most of the actual work is done by project teams, with members selected from those actively involved in the health services from all over the country. The project teams have usually been selec- ted with the aid of the various specialty organizations which form part of the Swedish Medical Society. All projects are defined and the final reports are critically scrutinized by an expert group appointed by SBU, as well as by the SBU board, the majority of whom are medically qualified. This approach has guaranteed the production of reports of the highest quality. It has also provided the basis for their being well received

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2 LARS WERKO

by the medical profession and others working in the health services.

One of the first aims of the new agency was to try to list the procedures in most urgent need of critical evaluation. A questionnaire was sent to about 400 leaders in the health services, including physicians and administrators. The response was overwhelming, more completed questionnaires being received than were originally distributed. Almost 2000 different methods or procedures, both old and new, already applied and expected to be introduced, were thought to be in need of scientific assessment. This indicates that everybody working with patients would like to know much more about the value of present routine procedures than it is possible to deduce from the literature.

The field for those interested in assessment of medical technologies is thus vast. To gain as much new knowledge as possible and to avoid unnecessary duplication of work it is necessary to encourage and maintain close international co-operation. This will constitute an important part of the work of the few agencies so far established. It will be facilitated by the International Society for Technology Assessment in Health Care (I STAHC) [ 3 ] , the Society’s annual meetings and periodic conferences, and its quarterly publication, The International Journal of Technology Assessment in‘Heulth Care. It is also possible that the World Health Organization may contribute to in- creased international co-operation in this new field.

To date, SBU has published about ten major reports. The first major project was the evaluation of preoperative routine investigations. A questionnaire sent to departments of surgery, orthopaedic surgery and anaesthesiology revealed that a fairly large number of routine chest X-rays, electrocardiograms and laboratory examinations were still performed prior to elective surgery, although recent reports in the literature have demonstrated that such pro- cedures are of little or no consequence as pre- operative investigations. The report summarized the literature, reviewed present routines in Swedish hospitals, evaluated experience gained both in Sweden and abroad, and recommended that such routine investigations should be abandoned in patients less than 50 years of age. The report stated that such procedures are appropriate only for specific indications determined from the thorough medical history that should be obtained from each patient before surgery. If these recommendations are fol- lowed, the possible monetary savings would be of the

order of 100-200 million Swedish kronor per year (17-35 million dollars). A follow-up of this report has demonstrated that the use of such routine examinations has decreased. However, more time and a considerable educational effort will be needed for the recommendations of this report to make the proper impact on all hospitals in the country. In some counties, educational programmes have been devised in order to communicate the recom- mendations to appropriate personnel.

Other completed projects whose reports include specific recommendations from the SBU board are ‘ Gastroscopy in the diagnosis of upper abdominal pain ’, ‘Surgical treatment of peripheral arterial disease’, ‘Bone marrow transplantation ’ [6], and ‘Shock wave treatment of renal and gall-stones’. Currently being prepared for publication are reports on ‘ Surgery for epilepsy ’ and ‘Back pain ’.

SBU has also organized conferences on suitable topics. The first of these was on the general problem of assessment of medical technologies, and the second was on the social problems of back pain, to which considerable social and medical resources are devoted today [ 51. In both these conferences the introduction was delivered by the Swedish Secretary for Finance, thereby emphasizing the importance attached to this activity by the government. The next conference will address, in relation to traffic accidents, the organ- ization and delivery of health care, with special emphasis being placed on early rehabilitation. The agency has also arranged seminars on special topics related to technological assessment. A week-long seminar on critical analysis of present knowledge is on the agenda for later this year.

The reports are published in Swedish, as their target is the health care establishment in Sweden. A summary of the reports, including the recom- mendation from the board, has been prepared in English for the purpose of international communi- cation.

Since the SBU started its work, considerable related activity has been undertaken in many countries, both in Europe and in the Americas [7]. One of the most important future tasks is to create an inter- national network for the exchange of information between the various individuals and many organiz- ations that are working within the broad field of technology assessment in health care. ISTAHC and the World Health Organization are well-recognized bodies that will have an important role in this context. It is also necessary that those interested in

EDITORIAL 3

this new field actively promote international com- munication of their work. Medical research recog- nizes no national boundaries: this is particularly true for technology assessment in health care.

L A R S WERKO, MD Chairman. Swedish Council for Technology Assessment

in Health Care Box 16158

S-10324 Stockholm Sweden

References 1 Office of Technology Assessment. Strategies jor Medical Tech-

nobgy Assessment. Washington, DC: US Government Printing

2 Institute of Medicine. Assessing Medical Technologies. Washing- ton, DC: National Academy Press, 1985.

3 International Society for Technology Assessment in Health Care. New York: Cambridge University Press.

4 International ]ournal of Technology Assessment in Health Care, Johnsson E. Reiser S. eds. New York: Cambridge University Press.

Office. 1982 ; 1-1 20. -

5 Conference on Back Pain. SBU. 1990. Stockholm, Sweden. 6 Summary of Reports, SBU. 1988-1990. Stockholm, Sweden. 7 Task Force on the Use and Provision of Medical Services.

Proposal to establish the Ontario Council on Health Tech- nology Assessment. December 1989, Ontario, Canada.