Health services research and health policy

Health services research (HSR) has the potential to influence the decision-making process in a health services system that is acutely aware of its resource limitations. Nonetheless, health services researchers feel, with some truth, that their research has had only a limited effect on health policy. Some reasons for this are described, including the primacy of political, rather than technical, considerations in policy making, the lack of a comprehensive health policy, and the poor quality and irrelevance of much HSR. The role of funding for HSR by the Federal government is described; it is shown that the Federal effort is fragmented, despite the consolidation efforts made in 1968. Increased support for specific targeted, problem-solving health services research is proposed, and some possible methods to achieve this are described.Dr. Banta is a Professional Staff Member with the Office of Technology Assessment, Congress of the United States, Washington, D.C. 20510, and Associate Clinical Professor, Mount Sinai School of Medicine of the City University of New York. Ms. Bauman is a Professional Staff Member, Committee on Labor and Public Welfare, Senate of the United States, Washington, D.C. 20510. The authors would like to thank Carl Taylor of the Office of Technology Assessment, Arthur Viseltear of Yale University, and Richard Seggel of the Institute of Medicine for their helpful comments. Dr. Banta is grateful to the Robert Wood Johnson Foundation for its support of the Robert Wood Johnson Health Policy Fellowship and to the Institute of Medicine, which developed the Fellowship. A version of this paper was presented at the Medical Care Section, American Public Health Association meetings, Chicago, Illinois, November 19, 1975.     

Balancing statistical data and clinician judgments in the diagnosis of patient educational needs

Survey content is necessarily limited by the investigators' foresight and by prior research on their subject of inquiry. Clinical data must supplement statistical data whenever the prior research is insufficient to delineate exactly what problems to expect. The differing perspectives on needs of patients sometimes set up competing demands. This calls for strategies based on a programmatic or population perspective that identifies the commonalities in patient educational needs from the statistical profiles, while at the same time allowing for the development of interventions that provide for as much tailoring of the educational experience based on clinical judgments as possible. By combining the community health education perspective with a clinical perspective, we were able to design interventions that responded to the educational needs of a population of low-income, black hypertensive patients. A needs assessment process that combined these perspectives began with a historical and community assessment of the problem in its most general terms. A second phase focused on the most important behavioral and organizational points for intervention. A third phase required formal assessment of predisposing, enabling, and reinforcing factors that may be determining the priority behaviors of health care organizational problems. Finally, clinical and administrative judgment sharpened and supplemented the educational interventions that were suggested by statistical data from formal surveys. Behavioral science theory was applied usefully in all these phases.At the time this study was conducted, the authors were all with the Health Services Research and Development Center and Division of Health Education, The Johns Hopkins Medical Institutions, Baltimore, Maryland 21205. Dr. Green is now Director of the Office of Health Promotion, DHEW. Dr. Lewis is currently with the Department of Community Health Care Systems, School of Nursing, University of Washington, Seattle. Correspondence and reprint requests should be addressed to Lawrence W. Green, Office of Health Promotion, Office of the Assistant Secretary for Health, U.S. Department of Health, Education, and Welfare, Room 721B, Hubert Humphrey Building, 300 Independence Avenue, S.W., Washington, D.C. 20201.Parts of this paper were presented at the Second Annual Needs Assessment Conference, March 28–31, 1978, in Louisville, Kentucky; the National Conference on High Blood Pressure Control, Los Angeles, April 3, 1978; and Endocrinology Rounds at the Indiana University Diabetes Research and Training Institute, Indianapolis, January 29, 1979. This research was supported by Grant Nos. 1R25 HL 17016-03 and IT32-H10710 from the National Heart, Lung, and Blood Institute. The authors would like to acknowledge the support and consultation of Drs. Carol Johns and R. Patterson Russell of the Johns Hopkins Hospital and of Robert Bertera, Michael Bowler, A. Judith Chwalow, Sigrid Deeds, Marion Field Fass, Brian Flynn, Michael Gross, Donald Morisky, Patricia Mullen, and Sam Shapiro of the Health Services Research and Development Center and the School of Hygiene and Public Health, Johns Hopkins University.     

Guía metodológica para la evaluación de la eficacia y la seguridad de nuevos fármacos: implementación de las recomendaciones de EUnetHTA

The European network for Health Technology Assessment (EUnetHTA) is the network of public health technology assessment (HTA) agencies and entities from across the EU. In this context, the HTA Core Model^®, has been developed. The Andalusian Agency for Health Technology Assessment (AETSA) is a member of the Spanish HTA Network and EUnetHTA collaboration In addition, AETSA participates in the new EUnetHTA Joint Action 3 (JA, 2016–2019). Furthermore, AETSA works on pharmaceutical assessments. Part of this work involves drafting therapeutic positioning reports (TPRs) on drugs that have recently been granted marketing authorisation, which is overseen by the Spanish Agency of Medicines and Medical Devices (AEMPS). AETSA contributes by drafting “Evidence synthesis reports: pharmaceuticals” in which a rapid comparative efficacy and safety assessment is performed for drugs for which a TPR will be created. To create this type of report, AETSA follows its own methodological guideline based on EUnetHTA guidelines and the HTA Core Model^®. In this paper, the methodology that AETSA has developed to create the guideline for “Evidence synthesis reports: pharmaceuticals” is described. The structure of the report itself is also presented.     

Improving the Contribution of Regulatory Assessment Reports to Health Technology Assessments—A Collaboration between the European Medicines Agency and the European network for Health Technology Assessment

In response to a recommendation from the Pharmaceutical Forum, the European Medicines Agency and the European network for Health Technology Assessment initiated a collaboration with the aim to improve the contribution regulatory assessment reports can make to the assessment of relative effectiveness of medicinal products by health technology assessment bodies. This collaboration on improving European Public Assessment Reports (EPARs) started in February 2010 and was performed over 2 years. As a result, the templates for preparing EPARs were revised to better address the needs of heath technology organizations. The better understanding of information needs was a key outcome of the collaboration. To ascertain whether these template changes led to the inclusion of relevant information, a review of a small set of EPARs for recently approved medicinal products was carried out in parallel by both the European network for Health Technology Assessment and the European Medicines Agency. This report provides an account of this project on improving EPARs, which is part of the ongoing dialogue between regulators and health technology assessment bodies on a European level to support policymaker decisions in the future.     

A tale of three cities--where RHIOS meet the NHIN

Regional health information exchanges in California, Indiana, and Massachusetts have been collaborating on a prototype for a nationwide health information network, first under the auspices of the Markle Foundation's Connecting for Health program and now under contract to the Department of Health and Human Services' Office of the National Coordinator for Health Information Technology. Since mid-2004, this collaboration has evolved from a collection of regional efforts to a standards-driven cooperative and now to one of four prototype national networks fostered by federal efforts. This development reflects a maturing market for interoperability and integration in healthcare information technology, starting with RHIOs, and suggests one response to the industry's need for the type of plug-and-play information exchange available in other industries. The authors share their experiences and their views of how RHIOs and a Nationwide Health Information Network will further develop to make interoperable electronic health records a reality in coming years. The content of this article is solely the responsibility of the authors and does not necessarily represent the official view of the Office of the National Coordinator for Health Information Technology.     

Analysis of the National Institutes of Health Medicare coverage assessment

The National Institutes of Health (NIH) is periodically asked to conduct assessments of new medical technologies to assist in coverage decisions made at the Office of Health Technology Assessment (OHTA) for the Health Care Financing Administration coverage policy. Analysis of NIH assessments indicates that even though most NIH assessments rely only on expert opinion, OHTA agreed with NIH recommendations in over 90%.     

Challenges,choices, and Canada

The Canadian Coordinating Office for Health Technology Assessment (CCOHTA) was established by the Federal, Provincial, and Territorial Ministers of Health in 1989 for a 3-year trial period. In 1993 CCOHTA was made a permanent organization and in 1999 the Deputy Ministers of Health renewed CCOHTA's mandate and increased its funding. CCOHTA's role is to coordinate health technology assessment (HTA) priorities across jurisdictions, foster and undertake assessment activity, and function as a clearinghouse for technology assessment results while increasing healthcare system stakeholder awareness of HTA findings. The coordinated and collaborated approach adopted by CCOHTA minimizes duplication with other national and provincial organizations and contributes to the ability of the Canadian healthcare system to continue to deliver high-quality health care to its constituents.     

我国卫生技术现存问题分析

利用卫生统计年鉴数据,通过比较分析我国卫生技术的现状,找出我国卫生技术评估存在的问题。建立权威性的卫生技术评估机构,发挥药物经济性评估在卫生技术中的意义,从而合理配置卫生技术资源,解决当前问题,有利于更好的开展卫生技术的改革与发展。     

Inaugural address of the 162nd president of the American Medical Association

On June 26, 2007, Ronald M. Davis, MD, was inaugurated as the 162nd president of the American Medical Association at an ornate ceremony in the Grand Ballroom of the Hilton Chicago Hotel. He is the first AMA president to be board-certified in preventive medicine. After Dr. Davis completed the Epidemic Intelligence Service program and the preventive medicine residency program at the U.S. Centers for Disease Control and Prevention, he served as director of CDC's Office on Smoking and Health and then as medical director of the Michigan Department of Public Health. Since 1995, he has served as director of the Center for Health Promotion and Disease Prevention at the Henry Ford Health System in Detroit. By tradition, the presidents of state medical societies and the leaders of a few other medical organizations sit on the dais during the AMA president's inaugural speech. Reflecting Dr. Davis's interest in strengthening the partnership between clinical medicine and public health, he invited leaders of seven preventive medicine and public health organizations to join him on the dais during his address: the Aerospace Medical Association, the American Association of Public Health Physicians, the American College of Occupational and Environmental Medicine, the American College of Preventive Medicine, the American Public Health Association, the Association of State and Territorial Health Officials, and the National Association of County and City Health Officials. Dr. Davis's inaugural address appears below, except for a portion at the beginning in which he gave tribute to many family members, friends, and colleagues for their support through the years. This portion of his speech can be found on the Journal's website at www.ajpm-online.net.     

Achieving smoke-free hospitals. Tips for administrators

Almost thirty years have passed since the surgeon general of the United States released the first report on the effects of smoking (U.S. Department of Health, Education, and Welfare 1964). Over the ensuing years, further reports have expanded our knowledge of the widespread physiological effects of tobacco smoke and those at greatest risk (U.S. Department of Health, Education, and Welfare 1979; U.S. DHHS 1987, 1991, 1992; American Medical Association 1989). Subsequently, there has been a dramatic decrease in the number of smokers; more than thirty-six million Americans have quit smoking since the surgeon general's report (U.S. DHHS 1987, 7). Supporting this trend are the surgeon general's national health objectives for the year 2000 to achieve smoke-free work environments (Koop 1985). All of these trends contribute to current efforts to make hospitals smoke-free environments.     

What are the relative merits of the sources used to identify potential research priorities for the NHS HTA programme?

The NHS Health Technology Assessment (HTA) Programme runs an annual process of identifying suggestions for health technology assessment. The objective of this paper is to describe and evaluate the relative importance of the different sources used by the program in 1998 to identify potential priorities. There were four different sources: a) a widespread consultation of healthcare commissioners, providers and consumers; b) research recommendations from systematic reviews; c) reconsidering previous research priorities which had not been taken forward for funding; and d) horizon scanning. Collectively, the four sources generated just over 1,100 HTA suggestions. By far the largest source of suggestions and priorities was the widespread consultation. However, the success rate of this source, in terms of being commissioned, was low. Research recommendations from systematic reviews provided the second largest source of priorities and the best success rate of all sources. Value was found from different sources for different healthcare areas.     

The impact of early career specialization on licensing requirements and related educational implications

Purpose: It was hypothesized that physicians who pursue early career specialization in their first year of graduate medical education after medical school are likely to experience a decline in their scores on the medical licensing examination. Method: A longitudinal prospective design was used in which 1,927 physicians who graduated from Jefferson Medical College between 1980 and 1991 were studied. Type of first-year graduate training program was the independent variable, and performance on a medical licensing examination (Part III examination of the National Board of Medical Examiners [NBME]) was the dependent variable. Scores on Parts I and II of the NBME taken in medical school, medical school class rank, and gender were the control variables. Results: Findings showed significant differences on Part III scores among physicians in 12 different graduate programs despite statistical adjustments for baseline differences. Physicians in family medicine and emergency medicine programs obtained the highest adjusted Part III scores, followed by physicians in internal medicine and transitional programs. The next group consisted of physicians in pediatrics, obstetrics-gynecology, anesthesiology, and general surgery programs. The group with the lowest Part III scores included physicians in pathology, radiology, and psychiatry. Implications: These findings suggest that students who meet only the minimal standards in medical school should be advised to pursue a broad training program in the first year of graduate medical education to strengthen their general clinical competence as a means to increase their chances of passing licensing examinations.Dr. Gonnella is Dean, senior vice president, professor of medicine, and director of the Center for Research in Medical Education and Health Care. Dr. Hojat is director, Jefferson Longitudinal Study of Medical Students and Graduates at the Center, and is research associate professor, Department of Psychiatry and Human Behavior (DPHB); Dr. Erdmann is associate dean for administration and registrar, and professor, Department of Medicine; Mr. Veloski is director of the medical education division of the Center, and instructor, DPHB, all at Jefferson Medical College, Thomas Jefferson University. Correspondence and requests for reprints should be addressed to Dr. Gonnella, Office of the Dean, Jefferson Medical College, 1025 Walnut Street, Philadelphia, PA 19107.     

The STARPAHC collection: part of an archive of the history of telemedicine

An early telemedicine project involving NASA, the Papago Tribe (now the Tohono O'odham Indian Nation), the Lockheed Missile and Space Company, the Indian Health Service and the Department of Health, Education and Welfare explored the possibilities of using technology to provide improved health care to a remote population in southern Arizona. The project, called STARPAHC (Space Technology Applied to Rural Papago Advanced Health Care), took place in the 1970s and demonstrated the feasibility of a consortium of public and private partners working together to provide medical care to remote populations via telecommunication. In 2001 the Arizona Health Sciences Library acquired important archival materials documenting the STARPAHC project and in collaboration with the Arizona Telemedicine Program established the Arizona Archive of Telemedicine. The material is likely to interest those studying early attempts to use technology to deliver health care at a distance, as well as those studying the sociological ramifications of technical and scientific projects among indigenous populations.     

Health technology assessment in the United Kingdom

The National Health Service (NHS) provides universal health coverage for all British citizens. Most services are free of charge, although modest copayments are sometimes applied. About 11% of the population also has private insurance. General practitioners, generally the first point of contact for accessing the system, are independent contractors who serve as gatekeepers for specialist and hospital services and enjoy substantial clinical autonomy. Hospitals are public and are regionalized, but the 1990 reforms made them self-governing trusts that contract with local purchasers (health authorities and general practitioner fundholders). Reforms beginning in 1990 moved the NHS away from a centralized administrative structure to more pluralistic arrangements in which competition, as well as management, influences how services develop. Health technology and health technology assessment (HTA) have gained increasing attention in the NHS during this period, as part of a wider NHS Research and Development (R&D) Strategy. The strategy promotes a knowledge-based health service with a strong research infrastructure and the capacity to critically review its own needs. HTA is the largest and most developed of the programs within the strategy. It has a formal system for setting assessment priorities involving widespread consultation within the NHS, and a National Co-ordinating Centre for Health Technology Assessment. The strategy supports related centers such as the U.K. Cochrane Centre and the NHS Centre for Reviews and Dissemination. A hallmark of the HTA program is strong public participation. The United Kingdom has made a major commitment to HTA and to seeking effective means of reviewing and disseminating evidence.     

The Swedish Council on Technology Assessment in Health Care.

During its first year of operation (1988) the Swedish Council on Technology Assessment in Health Care focused on nine areas. Additional activities will be added as need requires and resources permit. Also, preparations for 1989 projects have begun. The nine areas include: identification of technologies needing assessment, including international comparisons; review and synthesis of the value of preoperative routines; review and synthesis of the value of gastroscopy for diagnosing stomach pain; assessment of different treatment methods for back pain; assessment of the value of vascular surgery for vascular spasms in the legs; organization of a strategy conference concerning medical technology assessment in Sweden; creation of a strategy that addresses an international review of medical technology, future technologies in health care, waiting lists for medical care--the importance of medical technology, resource utilization and organizational and educational aspects of introducing new technology in health care, and costs and medical technology; translation of foreign assessment studies, with comments; national and international cooperation. SCTA has discussed the need for assessing specific technology such as bone marrow transplantation and surgical treatment of epilepsy. SCTA's Scientific Advisory Committee has additionally considered the following subjects for future projects: medical, social, and economic consequences of alternative technologies screening for prostate, colorectal, breast, and cervical cancer; costs, indications, and medical benefit of surgery for varicose vains; and modern urology technologies, particularly those related to prostate care.     

Emergency room management of patients with sore throats in a teaching hospital: Influence of non-physician factors

The care of 169 patients with sore throats was evaluated retrospectively to determine if the quality of medical care received in a teaching hospital's emergency room is associated with the degree of control managing physicians have over the medical care process. Diagnostic evaluation (temperature, throat and cervical node examination, and throat culture) was controlled by physicians and was judged adequate in 78% to 98% of the patients. Therapy, defined as appropriate antibiotics prescribed only for patients with positive throat cultures for group A beta-hemolytic streptococcus, was dependent on hospital support services, and the patients, as well, and was judged adequate for 62% of the patients; however, in only one of the 67 patients treated with antibiotics was the culture result known before treatment. The bacteriology laboratory processed the cultures slowly; no administrative mechanism existed to follow up patients. Thus, when medical care involved factors outside physicians' direct control, lower quality care was given.From the Department of Medical Care and Hospitals, the Johns Hopkins University School of Hygiene and Public Health and the Department of Medicine, Baltimore City Hospitals. Address reprint requests to Dr. Fletcher, Department of Medicine, McGill University Clinic, Royal Victoria Hospital, Montreal, Quebec, H3A 1A1, Canada. This work was supported in part by grants from the Carnegie Corporation, the Commonwealth Fund of New York City, and the Robert Wood Johnson Foundation, and by grants 5 H01 HS 00110 and 5 T01 HS 00012 from the National Center for Health Services Research and Development and 5 D04 AH 00076 from the National Institutes of Health, Department of Health, Education and Welfare. Dr. Fletcher was a Carnegie Commonwealth Clinical Scholar.     

荷兰卫生技术评估体系分析及对我国的启示*

目的：介绍荷兰卫生技术评估体系和政策转化现状，为完善我国价值医疗体系、提高卫生改革决策水平提供借鉴。方法：通过查阅国内外相关文献，描述荷兰的卫生技术评估体系，分析其常规应用的转化特点，综合评价其在新冠肺炎疫情中急性护理服务的网络构建特点。结果：荷兰卫生体系被称为“欧洲最佳医疗体系”，卫生技术评估在荷兰卫生系统决策中发挥了重要作用，特别是在降低医疗成本层面。相比荷兰，我国卫生技术评估政策转化成果相对较少。结论：我国需要完善卫生技术评估机构体系，加强研究人员与政策制定者的沟通，提升决策科学性及加快卫生技术评估转化效率。同时，筑牢分级诊疗体系，提升卫生技术评估综合性评价标准，进而推动实践价值医疗，促进我国卫生健康事业发展。     

Elements for assessment of telemedicine applications.

OBJECTIVES: As an initiative of the International Network of Agencies for Health Technology Assessment, an approach to assessment of telemedicine applications was prepared to assist decision makers who are considering introduction and use of this technology. METHODS: Review and commentary drawing on published assessment frameworks and reports of primary evaluations of telemedicine, with particular reference to experience in Finland and Canada. RESULTS: Elements of the approach included development of a business case (considering population and services, personnel and consumers, delivery arrangements, specifications and costs); subsequent evaluation of the telemedicine application; and follow-up (covering the domains of technical assessment, effectiveness, user assessment of the technology, costs of telemedicine, trials, economic evaluation methods, and sensitivity analysis). CONCLUSIONS: Decision makers should link introduction of new and often costly technology to appraisal of its feasibility, followed by evaluation of the application, including longer term consideration of its sustainability and impact on the healthcare system. As the effectiveness and efficiency of telemedicine applications will often be strongly influenced by local issues, results of assessments may not be generalizable.     

Health services in infant day care centers

A study of 13 infant day care centers in Santa Clara County (California) was undertaken to determine the content of the health program, types of health workers participating, utilization of community health resources, admissions policies on children with handicaps and illnesses, and unmet needs in health services. Although there was minimal provision for the health and safety of infants served there were limited services by health workers, irregular utilization of health resources, and neglect of other aspects such as grouth and development of the infants. There is need for more assistance and consultation from community health resources for preventive health services, health education and services for sick children.This study was supported by Grant No. MC-R-060208-03-C from the Maternal and Child Health Service, Office of Clinical Services, U.S. Department of Health, Education and Welfare, Rockville, Maryland.