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Vol. 2

No. 41302 lSth 5t", Nt{; Sr¡{teWaehington, D.C. 20036

203USA

OCTOBER

r982

CONTENTS

FragmenÈs...... ...."1Notes of A Perlpatetic Correspondent

David Banta. ..,..2Eealth Technology AssessmenÈ 1n

Denmark: Current InLtlativee' Per Buch Andreasen.. ....,....4

InËernatlonal Ramificatlons of U.S.llealth Informatlon PollcyGloria Ruby.

Mediclne Flyiog High (A SatLre)Stanley J. Reiser.

At the Movies: Technologlcal Thenesin Ehe Flfur f'E.T.'T.L. Nally ...................9

Update on the Offlce of TechnologyAssessuenÈKerry Brltten Kenp. .........12

New, Low Cost Microcomputer Programfor Clinical DeciElon AnalysisTom Grundoer, et al..........."...13

Development of Portable RapidDlagnoet,ic Mlcrobiology Systensl{. R. Sanborn. . .. .. .. .14

Trlp to Federal Republlc of GernanyJane E. Slsk.. ........16

Report on the "New" OETAJack Laugenbn¡nner. .........19

Book Revle¡v:CosË Effectlveness Analysls luHealth Care.. ... 19

TSA ContesË Announcement! ! .....21Other Sources of Infornatlon. ........22Addftions to the TSA Network..... ....25Index to Vofu¡mes 1 and 2. ......27

FRAGMENTS

First,.,please BoÈe that 1t 1s no¡¡ renewaltime for the uajorlty of the networkmembers. If you are one of tho6e members, agreen renewal form should have been tncLudedln Ehls uallfng. Please check the lnforna-tlon on the 1abel attached to ÈhaË foru,make any changes, and return it w"iËh yourpayment to us. And thanks for a very suc-ceseful year! I{e have also added a eectfonfor you to glve glft nenberships. Think ofthat favorfte nl.ece, son, or daughter 1ngrad school, or Èhat hard rcorkfng colleagueyou would like to rersard! True, solicfËlngglft nenbershlpe 1s a blatant narketlngtechnlque, but w'tth hollday seasons conlngup for DoBt of our reäders and wlth thebeneffts that eccrue to all of us ln thenetwork frou lte grolrth, ¡ve declded to do ltaltjrlray.

The second f.uportant note 1s that fheSorcerer's Apprentice address has char@ã-once nore. Our friend and colleague, Sa1leyRelmolds Shannon, whose office ¡¡e used foruail forwardfng, has uoved and cao no longeroffer the Bervlce to us. I{e would l1ke tothank Salley publfcly (she helped also byglving ue a rldlculously low rent to get uson our feet during Èhis flrst year) a4dgrant her a complluenËary rnemberehip ln thenetwork.

The uer¡ address for neËwork actfvltles andfor the newsletter ls ltIE SORCERERTS APPREN-TICE; 1302 18th Street, N.I.ü. ; SulÈe 203;Waehlngcon, D.C. 20036.("Fragments" contlnues on p.22)

NOTES CF

A PERIPATEÎIC CORRESPONDENT

During August and Septenber, I conbined avacation in Europe r¡ith several activltiesrelated to nedical Ëechnology. This columnwill describe ¡vhat I learned and r¡trat I did.

0n August 19, I visited the tlorld HeatthOrganizatlon Regional OffÍce ln Copenhagen.I learned that Dr. tJ1I Wahba, the vlgorousChief of Development of Comprehensive llealthSystens, ls retfrlng. Dr. llahba has been incharge of technology assessuent acEÍvities.I spent ti¡ne ¡¡Ith Dr. llahba díscussing medl-caf technology and also had another chanceto talk wlth Dr. Krlsten SÈaehr Johansen,who fs developing the WIIO Progræ forMedical Technology AssessnenL. The rnalnactlvitÍes will be in developing the networkmentioned 1n the last Sorcererts Appren-tice. Dr. SÈaehr Johansen also hopes toE6 Ctre lead in developing an lnfornaËÍondata base for ¡qedical technology assessmentstudies; (Dr.'Stehr Johansen as also inTampere, Flnland for the neetfng to be des-cribed later tn this artlc1e, and some ofour conversation occurred there.)

I also saw Per Buch Andreasen (a partiei-pant aÈ Bellagio) during rny stay fnCopenhaggn. Per and I conpared fiotes ondeveloments ln nedÍcal t,echnology assessment1n our two countries. Per told me that atthe tine I sas there Ëhe Danish Parliauentwas debating the establishroent of an agencyËo assesô. nedical technology. (Per dld areport to the Danish ParlÍanent on thatsubject about three years ago, following avlsft to OTA. )

On AugusË 2I, I EeÈ Dr. Johannes Vang inhis country house in SouË.hern Srveden. Dr.Vang is a srrrgeon trho is one of the most

2

David Banta

sophisticated physiclans in issues concern-ing assessnent. that I knor¡. He told meabout his new posltlon as head of a surgÍcaIservice 1n KuwaiÈ for Èwo years. Dr. Vanghopes to staft assessment activiEies inKursait, and also hopes to organize aconference 1n Kuwalt durlng hls stay.

Duríng the week of Septenber 6-10, I gavea number of lecÈures concerning ne<licalEechnology assessment. These were mainlyinterestlng ln.that t.hey showed Èhe great

.lnterest in the subject 1n Sweden. Dr.Bernard Bloon and Dr. Duncan Neuhauser hadalso arrived in S¡seden for the conferencescheduled for the next week. On Septernber7, Dr. Bloon and I gave a joint lecture acthe University of Stockholm. 0n Septernber9, Dr. Bloom and I traveled to Karstad Èoglve a lecture aÈ the Universfty. And onSepÈeuber 10, Dr. Bloom, Dr. Neuhauser, andI lectured at th¿e Untverstty of Llnköping.

In Linkäping, we also had extensívediscussions abouE a proposal to establish anew program in Linköping. The proposal,prepared by Dr. Robert F. Rushmerr êDAmerican from Seattle, was Eitled, "A Centerfor Assessmenr of llealth Technologies andServlces, Program Potential ln OstergoË1and,Subnitted to a Commfttee of the Count.yCouncíl, Orvar Stehn, Chairnan." Theproposal was for a center comblnlng pol1cy-oriented analysls and syntheses coricerningtechnology wlth orLginal research such asclinlcal trials. All of us felt that theproposal was basically sound. One key Íssuenot yet resolved Ís wheÈher such a cehterwould functÍon prirnarlly t.o serve the CountyCouncil or would have a ¡nore naÈlonalrole. (County Councfls ln Sweden have amajor role in paying for and organlzlnghealth services in each county.)

On Septeraber L2, we trevelled frouStockholn to the island of Uto in theSÈockholn archipelago- , The A¡nerlcan grouphad been joined by Dr. Stanley Relser. TheresÈ. of that r"7eek was taken up with a.conference .on mediaal technology assessmentorgan:'-zed by Egon .Jonsson of SPRI. Besidesthe Auericans, parÈj.cipants were all Swedes,

.and included a cross-sectlon of interests,lncluding central goverr¡ment, countycouncils, academi-cs, analysÈs, and pract.ic-ing physicians. The participants were eerycarefully chosen and v¡ere quite sophlsËi-cated 1n the issues under discussion. Theforroat was excj.tlng. Each úornÍng, one ofthe ,.\nerlcans started the dlscusslon ¡v-ith apaper. Reiser discussed history; Bloon

discussed methods; Neuhauser discussedclinical decÍslon analysls; and BanEa dis-cussed pollcy. Thls was then followed bygeneral dlscusslon, ably orchestraËed by Dr.Tore Schersten. It v¡as a particular pleas-ure to meet Goran LiedsÈron, a subscriber toThe Sorcerqr's 4ppry4qigg-, from the NationalBoard of ltealth and Welfare. The flnaIsesslons. of the conference concerned thepossibtllty of developlng a natlonal Progréul¡on nedfcal Ëechnology assessmenÈ 1n Sweden.There seemed to be strong consensus Lhatsuch a progr¿m ls necessary. Ttre OTA modelof dotng assessuents was examined by che.conferees in sone depth and necessarymodiflcatlons for the Swedish context weredf.scussed. I came away convlnced thaÈSr¡eden will develop a Program.

An aslde -- Ëhe tsland of Utä Is south-west of Stockholn and 1s the last island inthat dlrection in the Stockholu archlpelago,which contains at least 20,000 lslands. ItÍs a beautfful spot, raÈher remote buÈ rslEhall- the amenÍEi.es. A perfecE place for acooference, or for just relaxing.

Ac Èhe close of the conference, theAmericans and Egon Jonsson traveled toFinland for another conference. On October20 we were ln Eelslnki, where we vislged theFlnnLsh ltospiËal Board. lùe learned aboutinteresclng studies.Èhe Board carries outfor its coûstituent hospiEals. I'Ie thentraveled oû Èo Tampere, sfte of the confer-eûce on September 2L-22.

The Tanpere conference, "As'sessûent ofMedical Technology -- l{ethodologlcalAspects," iùas sponsored by the FlnnishMedlcal Board, the Medical Research Councilof Flnland, and the NaEfonal Board ofIiealt.h. Septenber 2l was nade up oflectures by che Americans on the same

subjecÈs ai ttt the Utä'conference, adiscusslon by Egon Jonsson of the raÈionalefor medlcal technology assessnenË andactlvltles ln swèden, a presenÈatlon by Dr.SEaehr Johansen on the WllO program, andstatemencs by Finnish offfclals. Ûpeoingremarks rvere made by Kari Puro of the Mlnls-try of ltealth and Soclal Affairs and byProfessor Rlsto Santti, Chalrroan of theMedical Research Councll. Both sËronglysupporEed the need for a naËlonal efforç inFinland. Ttre final sesslon of the dayconsisted of staÈeúenEs from Ëhe fLoor,r¡hlctr generally also supported Èhe need.The nexE day was an lnformal senlnar on Ë.he

need and possible structure for such aprograrl. I also felt afcer this experiencethat Finland r¡ill develop a program, buEprobably noE. so rapidly as Sweden.

Particular people r¡ho will probably belnstrumental 1n Finland besfdes those named

are Dr. ttarry Frey, Chairman of Èhe Deparü-ment of Neurology in the Unfverslty ofTampere, who organlzed and ably chaired theconference; Dr. Jaari Kankaapää, who hasmade a career commi tm.enË to nedlcaltechnology assessmenE and who was helpful inrnany i.rays (presently wth the Departnent ofPubllc l{ealth, UnlversiËy of laupere, Ðr.Kankaapää w1ll do his doctoral thesis onso¡De aspect of nedical technology); and Dr.Tuula Paarnula, Department of Radlology,UniverslËy of Tampere. AnoËher lnÈerestingperson thac I met is Dr. Elina l{erominki, whohas done work on drugs and is now studyingobstetrlc and perinatal Eechnology inFlnland. Dr. Ilenminki cold me that elec-tronic fetal rnonitorlng is generally doneroutinely in Finland, as 1s epislotoroy (twoof oy particul-ar interescs). Dr. He¡oninkiwill probably come Eo Ëhe UnlÈed Staces fora year or two to learn more about Ëhisdeveloplng ffeld.

.

I then reÈurned Èo l.Iashington. Ironic-ally, a visit fron a party from Llnköpinghad been organfzed for Septenber 27-28, so Isaw Egon Jonsson, Tore SchersËen, and Èhreerepresentatives fron Llnköplng 1n Washlngtonbeglnning September 26. I had meÈ OrvarSËehn, I{osplÈal ¡Director, and N11s-ilolgerAreskog, Dean of the Medlcal School, lnLinkoping. They were aecompa.nied by StureAlexandersson, from Ëhe Linkoplng CounEyCouncll. The group r¡as also joíned byProfessor Bjärn Soedby fron the DepartrnenEof.Social Medicine in Uppsala, who þappenedto bê vislting 0TA at the sane Ëime. ¡

i.le spent one day presentÍng OTAI s work andone day dfscusslng medlcal teehnologyassessnenL in general . Ðr. Seymour Perry,forner Dlrector of the National CenEer forHealth Care lechnology, chalred the secondday. The represeritatives fron Lfnkäplngtold ne that they are quite commlcted tohaving a program 1n nedical technologyassessûenE. The Swedish elections ofSeptenber. 19 seeu to have r¡ade it even úoreltke1y. The ner¡ Social Deoocratic govern-menÈ is apparently connltted to developlngsuch a progr¿¡¡tr for the country as a whole.

J

In an lnteresting lrony: Dr. RichardCrout, new Dlrector of the NatlonalInsEiEutes of Health Consensus DevelopmenEProgran participated ln the SepEember 28

rûeeÈÍng at 0TA and told rne that he isbeginning Eo plan a consensus developnentneetiog on long-Èern care. t{e said Èhat her¿ould be planning jointly wlth a Sr¡edishgroup for a meetLng there, but that he,hadnoc. yet rnet the Swedes. As it turned:out,t.hree of the vlsieors to 014 - ToreSchersten, Bjärn Srnedby, and Egon Jonsson -are Lhe prlnctples froru S¡veden planníng thatðonference !

The world of medlcal technology assessnentls snall, .buÈ lE seens to be growlng!

In 1980, I delivered on request. a reporton health technology assessment to theDanish Folkecing (Parlianent). This reportrecomnoended legislative and adnLnístrativeactions ín the field of health Èechnologyassessnent. Þloreover, stinulation ofresearch ln health technology transfer andassessnent v¡as consldered a conditio sl-nequa non for a cost-containDent strategy inthe hosplcal sector.

Thls year, the ltinlstry of InÈerior hasreceived an appropriaÈ1on from the DanfshParlianent for health technology assessment.The nembershlp of the CPS-RP w'ill ln thefuture lnclude represenËatives froo theDanish Hospital Institute and Ehe DanlshMedlcal Research Councll. It is stated Èhatguidelloes concerning assessnent of nedicaltechnologies ûust rei-y extensively oninternaËional sËudles and experiments, buÈthe CPS-RP also sha1l be allot¡ed co ínitiatecontrolled trials.

The notivation for a nore systematiceffort in the field of assessment of nedicaltechnology aE the central level ls largelyeconomic. There is "an increaslng gapbetween the potential posslbllities oftreatmÊnt etc. as a consequence of thetechnological developnent ln the medicalsclences and the exlsting restricÈedeconomic resources." Central funding ofcapltal and operating costs is graduallybelng phased out. By 1984, only renaldialysls and transplantatlon actlvicies !ri1lbe supported by earnarked staEe funds.

The counÈy activitles, includin1expenditures on hospÍtals, are financed inparÈ by "block grancs" fron lhe state oû thebasis of objective indlces (size and popula-tion, etc.) and in part by local Eaxation.The need for planning guidelines and advfcefrom central bodies has fncreased withoutcompromLsing the fundanenEal idea that Ehecounty has che econooic responsibility forthe running of the hospital servlce.

I{.edica1 Equiprnent. Decip"lons aboutpurchase of medical equipmenE orÍglnate fronthe head of the clinlcal or laboratory

: departuents. In many hospltalso "equipment"comittees exist to seÈ priorlties. lfore-over, marly countÍes have equipnent comûit-tees that play an advlsory role for chehoepltal conuÍtcee of the county. Thecounty counclls are dlrectly elected andlevy taxes for thelr activities. ThehospiÈal comittees consequenÈly conç1st ofpolitlcians elected 1n local elections everyfour years. Fixed budgeEs are allocated

CURRENT INITIATIVES OF

I{EALIH,TECHNOLOGY ASSESSMENT -- -' IN DENMARK ¿:,- - :.

-' å '\-¡: / -i* -*ì .-'-- -/...--:*n/

lo L977, the Conmíttee on Pl4nnlng ofServices and Referral of PaÈlents (CPS-RP)

was escablished ln Denrnark, w-ith Partlci-paÈion of the countÍes, university hospÍ-Eals, the NaEional Board of llealth, and theI'finistry of Interlor and Educatlon. CPS-RP

has an advlsory role and trles to coordinatethe national and regional activitles and thereferral of paElenÈs fron Ëhe countles torhe unlversity centres. Thls activlty'lnvolves

PayüenEs from one couûty Ëo anotherfor the. servlces rendered. SubcommiEËeesare formed to work out ProPosals for gulde-lines'for speclalized service's, for example,oncology cenEres or cardiac surgery.

Tffi.asen is with the Faculty' of Medlclne, Gentofte HosPltal, the'UnLverslEy of Copenhagen, Niel's AndersensVej, DK 2900 llelleruP, Denrnark.

4

each year for equiproent. In recent yearscost-concainraenc efforts hâve resulËed in aninsufficÍent. rener¿al of nedical equipment.As reductlons ln staff are politlcallyunaccepEable because of the high-level ofunemploymenc, cost-saving efforts haveconcenÈrated on reductions 1n Èhe purchaseof equlproent and drugs, in addf.tion co adecrease in hosplËal construction.

ltre lndividual countfes are lncreaslnglyinÈeresEed 1n cosÈ-effectlveness studies,aad one county has recently earnarked noneyin È.he hospiËa1 budget for this purpose-.

Danlsh Eospital Institute. Ihe DanishtlospiEal InsÈ1tute, Jointly financed by the.scac.e and the counEies, has been developlngthe so-called rnedical care prograromes. A

nedical care prograome is aû action pro-'grâurme for examinaElon, diagnosis, treatmentand follow up relaËed Èo a disease orsytlPtolt.

A nedlcal care progra¡nme tnay.contaÍn thefollowlng element.s:

o a survey of causes, incidence,character, and socfal consequences ofthe disease,o possfbiLiËies for Ehe use ofprophylactlc oeasures,o dlagnosËic and therapeuticmeasure6,o coopllcations and means of conÈrol,and

type and organlzation of care.

The nedfcal care programmes can be aproiess where ne¡¡ medlcal procedures may besubjected to a systematfc and conËlnuousexaãination, evaluatlon, and ?evleqt.CurrenE nedical care prograûdes ln Dennarkinclude patients with hlp fracÈure andarterial hypertenslon.

Health lechnology Assessment and TheDanish Medlcal Research Councll. ;-Iladition-ally, healÈh servíces research and iesearchon health Èechnology transfer and assessmenEhave had a low priorlty in biornedicalsclence. Ttre Danish Medical Research Coun-cil has recently shor¿n great inÈerest 1nthese areas of research.

In I981, a coomlËlee was established e¡'lthrepresentaE,ives frorn the research conrounilyand the various instituÈlons engaged 1nhealth servlces research and health Eechnol-ogy assessûent. The nain purPose of thlsnerv coamittee ls to stimulaËe research andÈo act as a natlonal focal pofnÈ for the

international cooperaEíon in Ehe fields ofhealth servlces research and nedical tech-nology assessuent activities.2

INTERNÀTIONAI RAI.ÍIFICATIONS OF

U.S. DOMESTIC POLICIES TOWARD

THE NATIONAL LIBRARY OF MEDICINE

by Glorla Ruby 3

The significance of information Èo soci.eÈy1s becomlng lncreaslngly apparenË e¡it.hadvances l-n cechnology. Most natíoûs todayreallze thaE they must be able to obtaln andefflcÍently process informatlon vlËal tonational lLfe, Infornation needed for theassessmenL of nedical Èechnol-ogies 1s vitalÈo natlonal l1fe. The transfer of such1nfornat.lon, both to researchers who requlreit in Èhe conduct of cheir investigaÈlonsand to oedical and other health care practi-tloners, 1s essential for the health ofpeople worldç¡ide.

Infor¡oatlon for Medical TechnologyRstr"dical Ee"hnology assessment can often befound in prinary publlcacions -- such asjournals and books, governnent reports,technical publfcacions, and PaÈents. Inreceût years, Ehere lias been a dramatic rlseln the rate of publishing in the area ofnedlcal technology assessment. I,¡lth access

The author is vlce-chafr¡oan of thiscommlt tee.Offlce of Technology Assessment, U.S. Con-gress, I.Iashington, D.C. 20510. Vlev¡s ex-pressed are'noÈ necessarily those of 0TA.

q

.to che prinary llEeraÈure often confusingand difficulÈ, secondary publicatÍons, whichfacilitace access to Lhe prlnary llEerature,are beconi ng an increasingly inportanÈeleoent ln the infornaulon transfer cycle.Secondary publlcations, such as catalogs,indexes, bibllographles, and abstracts' canalso provide readers with superficlal lnfor-nation about subject BaËËer. (A bibliog-raphy on X-ray tornography, for example, canallo¡r a reader to approxlnaEe the sÈate ofche art sirnply by scanning Èhe tltles of theartLcles and books 11sted.)

It should also be noted Ehat the sophlstl-cated appllcatlon of computer technology toÍnfornation products and servlces hascreated and spurred the development of a newoethod of lnfor¡¡atlon organlzation andtransfer ;- conputerlzed bibliographlc databases. The lnformaÈion J-n many blbllo-graphic daÈa bases can be obtalned "online."I,Iith onltne access, a person aÈ a coroputerterninal can carry on a dialogue w'ith thecompucer, direcËÍng Ehe colDPuter to locateand retrieve informat.lon and then Ëo provldethls infornaÈion either at the t.ernl-nal orln a prinÈed forn Eo the requester.

Infor¡natlon concernlng nedical Lechnologyassessnent ls often soughL and can frequenÈ-1y be found Ín cooput.erized bibliographfcinforaation systems.: Although nedical tech-nology assessment 1s noË a neatly c1¡cr¡m-scribed disclpline and ofLen requíres lnfor-^tlon from several subject areas (e.9.,

law, finance, ecoáomlcs, blonedicÍne,sociology), a commort need in most assess-ûencs is for lnformation fron the field ofbionediclne.

Þ

Infornatlon concerning blonedlclne can befouad in many differenÈ data bases. World-wide, over 90 computerized data bas¡s coo-taln infor¡natlon on medlcine alone.Although Èhere ís some dupllcation of Ëheconteûts of blonedtrcal coropuEerízed daÈabases, for che most part it ls relatively

.ninor; ln general, the daea bases t,end toconpleoent, one another. Each conputerÍzeddata base ls unique 1n nahy aspects, includ-lng contents, arrangeû¡ent, and lndexingphilosophy. To obtain couprehensive infor-

4 wÍ11i.r", If., Lannon, L., OtDonnell, R.,and Barth, S. ComPuter-Readable DataBases: A Direceory and Data Soùrceb

socieffi'rInfornatlon Scl.ence , L979).

mation for a uedical technology assessnent,therefore, an investigaÈor usually needs t.oconsult more than a single biornedical database as well as data bases in disclplÍnessuch as law and nedicine.

The Natlonal Library of lfêdiciner; Although both government and private sector' organizatlons ln Èhe Unlted States creaEe'and dÍstrlbute access to blonedical and

oEher health-related daË.a bases that can beused for rnedical technology asaessoents, theNatlonal Library of Medlclne (NLM), throughlts conpuÈerLzed bibllographlc reÈrievalsystem known as. I'ÍEDLARS (Medical Lf teraLureAnalysis and Retrleval System), lspreemlnent.

the orlginal and major data base of NIJ.frssystem is known as MEDLINE. The source ofdaËa for MEDLINE is the daËa Èape used forthe printlng of che publfcatfon InlexMedLcus. Ttris publicat.lon, begun in 1879 bythe Llbrary of the Office of the U.S. AnnytsSurgeon General (the forerunner of che NL,M),was Ehe ftrst printed lndex to Ëhe rsorld'sbiooedlcal llteiaËure. Worldwlde, IndexMedÍcus has served as the means of ãðõõs tollñããIcaf inforuation for more than 100years.

The NII{fs responsibility Ëo serve as areposÍEory of blonedical literature in EheUnlted SËates necessitates thaE the NLM

actlvely acquire and preserve informaË1onfron around the r¡orld. Indeed, fully two-thirds of the journals lndexed for' IndexMedicus are published abroad- fnr'r"l-*tt"ttMEDLARS became operational, nany counÈrieswere interested in obtaining access to Èhesystem. The NLM accomnodated these coun-Ëries by establishing bilateral quid pro quoarrangements w"iÈh then. In exchange forJ-easing Ëhe NLMIs daËa base tapes orobtainlng orillne access Lo E.he NII'Its daEabases through its cooputers, particfpating

'corihtries provide (or pay comnercia:ilr firnsln Èhe Untted SeaÈes to perforn) lnddxfngand other servlces for che NLM-

Current]-y, 13 countries and one interna-:tlonal argarLLzation (the Pan American ltealthOrganlzaË1on) have quld pro quo airangementswlÈh the NLll. Each country wlth a bllateralagreeuent selects a single MEDLARS center aslts national blonedlcal lnformationresource. The foreign ceoter musÈ meet NLM-esÈabllshed technical requireruent.s forpersonnel, equlpment, and fiscal resourcesand musË serve a u6er comnunlty sufficlentlylarge for the supporË of extenslve computer-lzed services. Though no oonles are trans-

,...ferred beËween the NLM and the forefgn cen-ters, the lndexing and other services thecenEers provlde are valued by the NLM at$600,000. Operational declslons (e.g.,decisloos concernlng ¡¡ho accesses theMEDLARS data bases and onlfne accesscharges) are the responsibillty of theforelgn cenËer.

Nl,l"tf s Creatlon of MEDLINE. In partbecause of the quld pro quo arrangements,internatlonal consideraLlons arise in thecurrent domestlc pollcy issues confrontlngÈhe NLM. Otre do¡oestic issue r.¡'ith interna-tlonal significance ls Ehe NI¿Yrs role ln Ehecreatlon of ehe daÈa base MEDLINE. Gtvenlts extenslve collectlon of blouedlcalnaeerlals, fts leglslatlve nandate "to aidthe díssemlnatlon and exchange of scientiflcand other fnformatlon lurportant to Èhe prog-ress of nediclne and Ehe publlc health"(Publfc Law 84-941), the social benefits,and low cosÈ to the NLM of erectlng MEDLINE,t,he NLI'Í appears to be Justifled in thlsactivl ty.

Whether a private fir¡¡ ç¡ould be lnterest.ed1n producing MEDLINE if the NLM r¡ere tocease doing so is a ûatter of speculaËíon.Although Ehere are other health-related databases t,haE conLafn fnformation of potenÈialuse 1n rnedlcal technology assessmenËs, theinfor¡nation in these data bases complementsrather than dupltcates the infornaËlon foundin Ì-fEDLINE.

InternaËlonally, lhe nedical and scientif-ic comrnunltles depend heavlly on IndexMedlcus and MEDLINE and, with few excep-ÏñiÇltrongly support their contlnuance.Indeed, the medlcal journal Lancec hasrequested Ehat "...medical research ¡¡orkersin Britaln and elsewhere -- and lndeed alllnterested tn health -- join 1n support Èo

maintaln Ehe Index Medicus and its adrnirableservices as cE{a:ffire NLM relles uponthe lnÈernat,lonal health connunity, and itslnEeractlon; w'lch Ëhf s cornmunity hae been ofgreat value tn developing and nafntalnlngthe quallty of MEDLINE.

' NLM! s Provislon of Onllne Access col'ßfffi'tfonal overtones 1s the NLM' s pro-vislon of onllne access to MEDLINE and otherMEDLARS dat,a baSes. The argunents for oragalnst the Nl,t'frs providing this servlce arenoE coapelllng, because there are commerclal

5.Lancec, edltorlal, Apr. 24, Ig82, p. 945.

firms in the United SEates that leaseI'fEDLINE data base tapes and oÈher MEDLARShealth-related data tapes and rnake themaccessible onllne in Lhe United SEates andoÈher countrles. A major argumenË, in favorof the NLM's conÈlnulng Èo provide thisservice Ls Ehat onllne access charges ruightbecome much hlgher 1f one of the providers\tere noE the NLM. If charges were higherÈhan Èhey are today, sone users ln both theUnited SËates and ot,her countrles would beunable to nalntaln t.helr current level ofuse. One could argue thaÈ forelgn centersthat were adversely affected by the NL¿YisnoÈ provlding onllne access Eo MEDLINEcould, as sone foreign cenEers do now, leasethe MEDLINE daEa base Eapes and nount themon their or¿n computers. I{owever, someforefgn cent,ers might not have the E.echnicalcapablllty to do this and would have Èo

adjust Ëo Èhe posslbflfEy of fncreasedsearchlng charges. Furthermore, the NLMnould lose the indexing servlces that thecenters now provide under quid pro quoarrangements.

NIì.{r s Pricing Pollcies. A third issuer,¡ith international signlficance ls thenaÈure of the NLM's pricing strucÈure foronll-ne access to MEDLINE. Thls lssue, inpart, is the result of an interesE 1n theU.S. GovernmenË,rs recovering Ehg "fulleosts" of the MEDLARS service ln onlineaccess charges. Ilowever, there ls no agree-nent withln or outslde of Èhe GovernmenÈabout the deflnition of'full costs. Thereare varlous irotlons of the cost categorlesto be lncluded ln a fu1l cost calculatlon.There is a sirnilar lack of agreement êbouEthe allocation of costs. The recent sugges-Ëion to include the "costs of creaLlon" (noEprecisely deflned elt,her) in Èhe calculatÍonof fu1l cost has coopllcated maÈt.ersfurther. If che full cost of accesslngMEDLINE includes Èhe cosls of online accessand tape eosts on1y, the.lf{LrY is approachingfu1l cosÈ rec.overy at presênt through itscr¡rrent online access charges.6 However, ifful.l cost is deflned Èo lnclude the cosÈs ofcreaÈ1ng Ëhe IÍEDLINE data base as well, theonline access charges t¡ou1d i.ncrease sub-stantially, and Ehe new charges nlght beprohibitive Èo sone foreign and some domes-

tic users.

q'"".t.t ^"""""tlng

Office, U.S. Congress,Nat.lonal Llbrary of Mediclne's MedlcalLiterature ar,d þtri"ual_9Jst"r, HRD-82-

a/

CosE of creatioo is a concept that is alsoat Ehe core of another current prlcing issue=- differentlal leasing fees for Ehe MEDLINE

daea base tape. Currently, the leasing feefor the TYEDLINE tape. is the same for U.S.conmercial inforrnac.ion services and forforeign centers. llor¡ever' there 1s some

lnteresË in differentlal pricing, underr¡hlch U.S. conmerclal inforroation serviceswould lease the data base tape aE Èhe cosEsof reproduction and forelgn centers wouldlease Eherl at these costs plus the costs ofcreaÈ1on.

On Èhe surface, differentlal prlclng seems

atÈractive. If MEDLINE and the otherMEDLARS data bases are considered a naEfoûalinvestEenÈ, soBe would argue that, the bene-fLEs from Èhat Ínvestúen! should go Èo Ehe

cltizens of the Unlted SEates, i.e., Ehey

need noÈ necessarlly be shared with foreign'natlonals.

Eowever, this view does not adequatelyconsider the PoEentlally serious l-nterna-tional raulflcati.ons of differentlalpricing. Countrles abroad night viewdifferential pricfng as aû antagonistlc acton the part of the UniÈed SÈates. Thesecountrles night reconslder their quid pro

' quo arraûgemenÈs qrith the NI¿Y and cease Èo

provide iadexing services, thereby interruP-cÍog the flow of needed nedical inforrnaËlonfron abroad. Furthernore, Lt might bedifficult to enforce a dlfferential pricingpolicy. Forelgn users often find a U.S.èource of infornatlon when príce barriersexisE. Unauthorlzed copies of data basetapes are also feasible.

Concludlng Thoughts. The interlockíngnacure of donestlc policy issues and inËer-natlonal concerns as typified by ÌfEDLARS ischaracÈeristic of mosE U.S. infornation pol-icy and suggests that dotnestic and inEerna-Èional lnfornation issues¡ including healthinfornaclon lssues, night be usefullyaddressed in a coordlnated fashlon. The

' effect of new and ernerging technologles on

lnfonnaÈlon transfer needs Èo be recognized.It appears that "\te are rapldly approachlng2lst. century Eechnologies l¡ith 19th centuryinstiEuÈtonal rne¡hanisms governlnglnplen€nt at lon . '

t-/ Bro*rr, G. 8., "Inforoaelon and Societyr A

Congressional Vlew,"' remarks before theAmerican Soclety for Infonnation Sclence,October 27, L981.

PARODY PARODY PARODY PAROÐY PARODY

å¿.a,s

. ^Ø9qø!-

50ø

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Inagine yourself glidlng on a wlde-bodi-edalrlíner effortlessly through the strato-sphere lov¡ards your business engagement inChicago, whíle skilled hands and complicatedmachines v¡ork srviftly on you, repairing theleg so long a disconfo.rt, treatlng the lungsvictlnized by chain-srooking. No tioe islost ctrecklng into earth-bound hospitals,wasting precious hours or days. Itts busi-ness as usual for you. l4edical and aero-nautic Èechnology have been creativelycor¡bfned to produce Aerornedielne!

You will recall that by the end of che1980ts hospitals and Èhe aírllires r¡erefacing grave crises. Rapidly rising costsand publlc dlscontenÈ with each wroughE,

tremors, in boardrooms across Èhe nation,that threatened .Èo enlarge into Eajorquakes. Survlval of both insticutioûs was

in question.Who had heard of Fred Breyer untfl his. now

famous e{ltorial 1n the @';Scalpel and Throttle-St@Necesslty," appéared in April 1990. It con-tained an anatrysls and proposal as far-reachlng as lE was profound. The excesscapacity of aj-rlines could be used to ËreacpaEients and fly t,hen Eo lnportanE engage-ments at Ehe saoe címe. I{alf-filled space

8 Dr. R"i"er is w'ith the University ofTexas Health ScÍences CenÈer, llouston,Texas.

7 /.

aÈ eirport rotels could become centers foradnissÍon Èo the alrplane-hospital, andserre also as coovalescent centers. Alrlínecerninals Èhemaelves, by then overstzed lnrespect to use, could house docE.orstoffices. The ternlnals could even havediagnosclc and therapeuËfcally progrnmmedcomputers for Ëhose en ror¡te who neededfollowup evaluatlon and care. No need, fors¡emple, Èo worry about nlssing the weeklypsychlatric session. Soundproof booths vt'IthcoE.puters hooked Ínto therapeutlc prograúswould keep you 1n tlp-Ëop analytic shapefrom Hong Koug to Rlo.

The coopetftive splrit of the alrllneindusEry hasr naÊurally, lowered the costsof he¡1 Èh care dellvered Ëhe Aeronedlclneway. Inescapable and unforgettable commer-cials appear frequently on television.--lncluding the famous "fly ne" uessages ofTSA ("Îrans-Souatic Airllnes") :

"IIi, Ir¡¡ tlendy -- fly wlth roe on ourrs'ide-bodied straÈocruisers fromWashiogton to StockhoLn -- you'11arrlve relaxed, and wlth any I of 18painful or failing body parts speedllyremoved and replaced ¡¡ith one of ourtrouble-free uniEs."

Aeronedicl.ne has altered the organizatlonof health servlces drastlcally. ConblningEhe oedlcal w'lsdon of speclallzatlon andcoumerclal wfsdon of product ldentiflcaÈ1on'sooe afrlines and alrports have begun tofocus on certaln aspects of health care.lSA , for exanple, and lËs connectlng najorairports 1n llouston, San Françisco andSeattle are the lray lo go if you need a bodypart replaced.

And therers "B1g Apple Air" and affillatedNew York Clty alrports for psychlatricattentlon. No airline ln che world tops"01de Engllsh A1r" and lLs cooperacingLondon airporEs for general nedicine Prac-ticed the "tradltlonal" way.

Such speclallzation has caught oû, and isspreadlng. Itls eye care in Boston, via"PatrloLic Air;" fertllfty work-uPs inNorfolk on "Southern Cqnfort À1r;" plastlcsurgery 1n Los Angeles through "Up-LiftAir;" and lherefs no gettlng round lt.

In consolaÈlon, the prfce of an airllneËiekeÈ buys you much more t.han before. And

Just think, nor{ Èrlps Eo far-ar¡ay citleé andlands are r¡lthln reach of anyone having ablg patn -- they can be charged to BlueCross.

AT THE IIOVIES:TECITNOLOGICAI. TTTEI,ÍES IN

TIIE FILM 8.1.o

"...In our endeavors to undersËandreality we are somewhat like a manErylng to undersÈand the nechanism of aclosed \.ratch. I{e sees the face and thenovlng hands, even hears iÈ ticklng,but he has no way of opening the case.If he Ís ingenious he may form someplcËure of the mechanism which could beresponsible for all the things heobserves, but he ¡¡ray never be qult.esure his plcture ls the only one r¡hichcould explaln hls observatlons. I{e wÍlInever be able to corûpare his picturew-ith Ehe real mechanlsm and he cannoteven lmaglne the possibtlity of themeaníng of such a comparison."

- Albert EinsteinThe Evolutlon o*f Physlcs

In Septenber, I attended a natlonal ueet-ing of chenlsts. They gather blannually toconduct business and exchange sclentificinforoatlon and fnslghts derived frorn thelrr¡ork. At a dlnner for members of a scfenceeducatlon commÍttee, a conversatlon aroseabout the Steven SpÍelberg feature filn E.T.

Those who had seen the roovie were quitetaken with tt, wlth'one reservaËion. Manywere concerned that Splelberg, llke many ofhls colleagues produclng sclence flct,lonf1lns,, portrayed the world of science andtechnology as an evll one. fhese scienceeducators,¡sensed rhaL his E¡essage is Ëhat :i.

adulÈs, ratlonallty, and scfence and r:

Èechnology are ho11olr, devold of hurnanity,and thereln a nenace Èo all that, ls wholeand vltal.

The novle opens with the quiet, easyseËtÍng down of a pod-shaped spaceshlp. Theshape fs an appropriate one, for lhe lnsideof the shlp ls a greenhouse of exotic life.PasÈoral music f1lls the background as the

-.à-o' Ms. Nally ts wlth the Anerlcan ChemlcalSocÍety, and appears to be fast beconi.ngthe ner¡sleEterrs resLdent "science, tech-nology and societyr critic.

I

space creatures venture ouË of their shipand begin Eo explore Earth in all itswonder.

The scene ls an 1dYllic one -- theseplaat-loving, l1fe-lovlng sPace creatureswanderlng about ari earthly paradlse. The

only vlslble aspecÈ of these creatures :

initially seen by the vlewer is thelrhearts. Thelr hearts glow, llluoJ'naË1ngthelr enÈÍre chests, allowÍng the world to6ee they are creatures of heart -- aû idealv¡hich is not alien Eo the best of hu¡¡anasplraÈ1on.

As ln contemporary PasÈoral settlngs, anabnrpt disnrptlon lnvades Èhe envtronnenÈ'narring thJ.s peaceful natural sceue. Ilumansarrive w'ith car llghts bJ-aring and englneÈracing. Ihfs disruPtion ls of the classlcal"rnachlne 1n the garden" genre, where sclenceand technology are seen as lnvaslve andiahospltable. In hot pursuit, the huuansfrantically chase the creatures. The pod-shaped spaceshtp escaPes Earth, leavingbehind one of the space creatures to facethe hr¡mans, who are lnEenE on capturÍ.ng aspeclmen.

A fugielve orr Earth, Lhe "al1en" leftbehlad allows a boy, Elliot, Èo befriendtt. Elllot and his sibllngs take thecreature under their care and chrlsten lt"8.T." for "extra-Eerre6tr1a1." Inltiallythe chtldrenrs purpose Ís to keep E.T. asthey night a stray Pet' hiding iÈ from theadults who would dlsapprove of such anaqufsiElon. EvenEually, as the chlldrenreaLJ-ze that E.T" 1s an equal at Ehe veryleast, thef.r Purpose ls transformed.Throughout thã remainder of thð movle, thechildren scherne to help E.T. return home tothe world from whlch he came and belongs.

The chenlcal educators held that the"oachlne Ln the garden" inage T,ùas the najorforce shaplng Ëhe movie. They poinÈed Èo

three other occurrences 1n the filn as proofof their claim:

1) the calculaEed tr.acking of E.T. by thehumans,

2) the blology classroqo scene whereElllot realLzes that he musÈ save thisllvlng belng 8.T., and

3) the capture of and the attemPt t,orevlve a dylng E.T. bY the humans.

Ehe tracklng and survelllance of the"alien" at Elllotrs home adds to thevler¡erts lnpresslon that sclence and

Èechnology are lnhuuane. The sclence andtechnology, which for centuries haveprovlded humans l,rlEh a feellng of powerEhrough nanipulaËÍon of nature' are Present

tn Èhls movie -- but thelr preseûce 1s noElauded. Scfence and technology are 1np11-cated 1n the poller struggle that afns toreduce E.T. to a sinple creature ¡¡hoseprivacy can be lnvaded and whose life shouldbe moaiËored and controlled by thoee rsho sowtl1 lt. Sclence and technology provlde thehr¡mans rrlth a capacLty to pursue 8.T. , .tobecoue hunters and that makes E.T. thehunted.

Moveover, the humansr relfance on hlghlysophistl.cated cameras and lLstenlng dêvicesfor Ëheir iúvesElgatlon and remote means ofobtalnlng lnfornatlon contrast rrlth 8.1.'sand the chlldrents ¡oeEhod of knowing. Theletter se@ to be av¡are of happenlngs aroundthem through tacit knowledge, a sort, oflntuition.

The blology class ls where Elliot con-scLously objecËs to conplylng wlth theexf.sting systen of authorlty, legltimatedknowledge, and ways of learning. Elllotrsdeffance of this system -- as represented byscience -- grov¡s as the biology t.eacher"cal.nly" and "objectlvely" describes theproper procedures for asphyxlaEing a frog,the specimen slated for dissectfon. Ratherthan leading Elliot to perceive the frog asan object of study, Ëhe teacherfs descrÍp-tlon leads Elliott to make analogles thatcause him to relate to Èhe frog as a belngqrhose lJfe he has not the rlght to take.Rather than dlsplaying "objectivlty," Elliot,turns ln$rard, focuslng on his feellngs in asearch for a neanlngful understandlng ofreality.

From Ehls scene, the noviegoer nay beglnÊo belleve, as Elllot does, Lhat the sclen-tlfic proEocols of separating and analyzingwholes (such as the process of dissectlon)are not the only way of learnÍ.ng. Elllotrsrebelllon raises a number of questions: Is

,. taking a llfe, ln the name of scfence, anapproprlate meaûs to undersÈandfng life? Dounderstandlng and learnlng occur onlythrough seelng, hearfng, t,asË1n9, touchlng?Is scfence ratlonal? Is it the champíiJn .ofreason? Does scLentiflc objectivity serveas the ratlooale dlsguising a cold act ofexploitatloa -- the shaplng of sltuatlons,and controlllng of llfe to suit anotherrsw111 and fulflll another's need? Doesscientlflc authorlty exlst only throughpeoplers reluctance Èo questlon it?

The chlldrs biology classroou reappearstransformed ln the grown-upts versÍon when anear-death E.T. 1s capÈured and a ¡nedicalËean attempts Èo keep hln al1ve. 'These are,perhaps, the mosL devastaEfng of events, andLhereÍn Ehe úost pointed in critlclzíng

scleûce and technology. Differenc ways ofuslng Eechoology, of know'lug, of life-glvlngaqd life-taklng are coûËrasted in thsesceûes.

The stress of the hunt and:of adaptlng.toas allen environmenE leaves'E.,T. helpless,clearly vulnerable to hls pursueìrs. It fsat thls polnt that the humans are able toovertake E.T. In a dræatlc uarch theyclose-Ln, enveloplog the house with plasticboth outsideÇand 1n, pr.mplng ln a1r, bring-iog 1n the latest of emergency nedicalequipment. Ttre hunaus dressed ln Bpacesul.tsand the houee enclosed 1o a technologLeal,artiflcial environment strike the viewerresenslblllÈles as beÍng more alleo than thecreaÈure frm another rsorld.

Covered f.n surgical costunes, monltorlngÈheir patlent/speclmen through a maze of-sophlsticated" devÍces and procedures,sg¡semlng orders at each other, franticallyÈrflng Eo coûtrol l1fe, the uedical person-nel disregard Elllotrs pleas that lt 1sthey, Èhrough thelr technology and acÈions,nho are ktlling E.T. Thls affalr roakesnedlcJ.ne - Èhe scfence dedicated to heallngand the presewatlon of ltfe -- appearlnhumane, lrratlonal, lncapable.

Euuans nay be koowledgable 1n terms ofcreatLng aud uslng nedlcal..teehnology, yetthey fall regrettably short, of, undersÈandínglLfe fn all. lts for¡oq. Their efforts,¡, thelrscfence and. technology, would, have' serived,life far rnore. had they used:, lt to ¿tsslstE.T. fo returnlng hone. Such actlon: wouldhave dlsplayed a respect for lLfe, koowledgeof the lnpllcatlons of ecologlcal richness,'and, perhaps, woutrd have ledl"to a greaterunderstauding of an extra-terrestrial world.

I agree !¡-tEh the cheulcal educaEors thatthe rnoviegoer 1s apt Èo leave E"T. lrlÈhpeJoratlve iropressions, for a critfcalco¡nmentary of sclence and technology-,doesexlet ln the filn. Eowever, there wêrepositlve elements that energed. Alongsldethe uegatlve lmages, Splelberg providesfavorable ones that present dlfferent aP- 'proaches to llfe, different value orien-ËaElons leadlng to alternative definltlonsof scLence and technology, rationallty, and¡¡bat 1t means to be gro!ùn-up. TheseaLternaÈÍvea are the pedagoglc vebicfe Èhatallows Ëhe vleser to t,ranscend her/hinself.

E.T. 1s a sclence flctfon filn w'lth gdiffience, for tt challenges, like quanÈumphyelcs, thaË wtrlch Ís accepted. And in eodotng lt allows the vÍewer Ëo thlnk otherthoughte, forn other'attftudes, drean of'oÈher possfblllties.

The fifun does not endorse antl-science norantf-lncellectual crlticfsms. It does,however, questlon sclence and raÈlonaltty asthey are non expressed and sho¡ss that thereare other wa)rs to.perf orm legltiuate,., :

science-, and that there are other aEpects toraElonally. $clence and lntelllgentthlnlclng as practlced by E.T. and Elliot, donoÈ deny tacit knowledge and feellngs.' Norare they compelled Èo control, dl.seect, andobjectlfy. Thelr science lnvolves eapplngall of oners senaes. Thelr learnlng ls noËbased on a destnrctlve lnvaslon or a dualls-t,fc observation that. alteuates. Thelrs lsan enpaËhy Ëhat retalns wholeness, and al-lows for differences ¡ctthout fear or Ëhreat.

The flIn is not, a reaction against a1Itechno-logy so much as 1t fs a comment on ì

appropriate techoology and the appropriat,euse and developoent of technology.

The technology chat holds our attentlon lsE.T. I s comuurifcatLons systerl, constructed.fron such household Ltems as an umbrella,coffee caû, batL,ery, coat hanger, and sawblade. The bfcyclee that f1y, powered by abeln¡irs own energy, are more phenomenal Ëhanspaceshlps. Identifying llfe signs througtr,taclt knowledge seenos more relfable Èhan thernost sop-hlstfcaÈed of rnedical- lffe-nonltor-,lng systerne; And the heallng energfes froua belngts. flnger are more awesome and.powerful than drugs aad hlgh t.echuologlee;

Most science flctlon filns portray,an,alleged advanced socieÈy involved ln theclassfc struggfe of, good and evfl. Theirmessage is that technology has grown fasterand larger, but llttle of substance haschanged, whereas &T. presents hope of newfutures by pronpting vlewers to rethlnk t.hemeaulng of such chings ae the hfghÈechnology lmperaË1ve, reality, allens, and-relationshfps. E.1. allows movlegoers toreoake vlslous. If only for one rnomentr. f.t.a1lows a re-r¡ndersLêûdÍng of such thlngs.as:miraclee, which nay ha-re more to do withllfe ln all Its forns Ëhan !ü'tth lnterplane-Èary travel; or a science and EechnoLàgy..v¡hich may be more valuable when they are"accessible; or learnlng whlch nlght be mr.e,-,roeanlngful wtren it focuses on the whole ofthlngs; or a healing power ishlch may begenerated fron wlthin a lffe force.

11:i1 -'rìi:.^!rt' ltr:Eîâì-ejÌr'-;:îr

UPDATE ON ACTIVITIES OF

TIIE OFFICE OF TECIINOLOGY ASSESSMENT

Kerry Britten Keropl0

In recent nonths, OTA has beeir publlshingreports at a rather ast,ounding pace. Forthose of our readers l¡ho àre lnteres'ted,herets whatts been going on since our lastupdate 6 nonths ago-

o A major report, Technology.andEandicapped People. was published ln May-Ttrõ responée to this report, which discussesÈhe app::opriate application of technologlesto dimlnishlng the llnltatlons and extendingÈhe capabfllties of dlsabled and handlcappedpersotrs, has been Sgatlfylng'

On Septenber 29, joint hearings were heldon the report by the House Conmittee onSclence and Technology and the SenateÇo¡nnl¡¡sg on Labor and Human Resources. Thehearlngs r¡ere well aÈtended. in part becauseÈhey were planned as Part of a two-dayconference on the report, sponsored by theAmerican AssocÍatlon for the Mvancemerit ofSclence. the Office of Technology Assess-rneût, the Presídent's Conoittee on Enploy-oent of the Handicapped and the Rehabili-tation Englneerlng CenÈer of the Universityof Vlrginia-

Testlmony !¡as presented not only by 0TArsDirector Dr- John H- Glbbons, who was

accmpanied by the project director (and rtow

Health Program Manager) Clyde Behney, buE bynuBerous other individuals in the rehabilt-tation field. A hlghlight ltas the fact thatthe hearings lrere the first evef Eo includetestinony glven through the use of anartiflcial speech synchesizer-

OTAts report ldentlfied po1lcy options forCongress in five key areas: 1) consumerinvólvenent, 2) Production and narketing oftechoologles' 3) evaluaËion of current and '";

energlng technologles, 4) flnancfal barriersto technology acquislÈÍon or use' and 5)personnel avallabllity. Each of these areasr¿as addressed by a separace panel ofw-itnes ses .

A1so. Technology and tlandlcaPped PeoPlehas been chosen by che NaÈional LlbraryServlce for Ehe Bllnd and PhyslcallyIlandicapped of the Llbrary of Congress to beput fnto a cassette version ("ta1ting book")

qtt*"t*t t*.or, Itealth and LifeSciences Diviston, OTA; and AssociateEditor of The Sorcererrs APprentice.

for distribution to qualified blind andphysically handlcapped people throughouÈ theUnited States. A sunmary will be nadeavallable in paper bra11le-

o In conjunction w.ith the l{andicappedstudy, OiA has also,published a backgroundPaper on mandatorypassive resErainÈs inauLomoblles. This case study. whlchexamines lssues 1u the debate on whetherpassfve restrainE systens should be requlredln all new autonobtles sold in the UnltedsÈates, 1s lûtended to lllustrate apreventfve approach Èo the problero ofdisabilltles. It r¡as prepared for OTA byKen l,,Iarner of uhe University of Mlchigan.

o Another rnajor report, Strategles forMedf. ca1 Te chno I ogy es s e s smlniliãã-pi6Ils heaTEã-TirsÈ @ imnãdiatelyrushed to Sweden for use at the SPRI confer-

. ence on nedical cechnology assessmenÈ. (AreporE on the conference appears in DavidBantats "Notes of a PerÍpatetic Correspon-dent".) The "SËraËegies" report expands onOTA's prevÍous rsork in the area of rnedicaltechnology assessüent, including Assessingt.he Efflcacy and Safety of Medical Technolo-s&e (1978)

""d lþ=l*$igg!.9-" of Cost-Effectiven."s 4l"1ysi" of Medic"l T

assessuãntsysÈeÉ in the United States w-lth respect tol.dentifylng nedical technologles forassessmenË; developfng and synthesizinglnfon¡atlon about sueh technologiesr health,economlc, and soclal effects; and dlssen-lnaÈing this infornatlqn to health caredecision¡nakers -

The project dlrector, Bryan Luce, left OTAat the end of I98l to head the Office ofResearch and Demonstrations of Èhe HealthCare Flnancing AdnlnÍstratfon. Jack Langen-brunner Iand Kerry Kemp -- Ed note] broughtÈhe projecc through its final sÈages.

c Also publlshed fn Septenber was MEDLARS

and ltealth Infornation Poiicy, a tecããTãÏ-. memorandum on the computerized blblÍographlc

u. retrieval syst.en of the U-S. NatlonalLibrary of Medicine- In an article ln thfsfssue of The Sorcererts Apprentíce. theproject dTiõcto@ her vlewsregardlng some internatlonal aspecÈs of thelssues addressed ln Èhat studY.

o Flnally. the last tvro case st,udles ofBackground Paper ll2 of 0TArs assessment ThehopllcaËlons of Cost-Effectiveness AnalysG

ttrããã-two caãeitndfes, one on cardlacradionucllde lnaging (prepared by BllISt,ason and Eric ForÈess) and the oËher onthe artificial heart (by Deborah Lubeck and

T

John Bunker), illustrate the application ofcost-effecÈlveness analysls Ëo specificuedical technologÍes. Also released wasBackground Paper #5, on Èhe economlcevaluation of four counon dfagnostic X-rayprocedures (prepared for OTA by Judy llagnerand MarÈha Krleger) -

Soon to be publfshed is Medfcal Technologyunder Proposals To rncreas@Health Care. This report analyzes theCpIGãmns for the use of nedfcal technol-ogy of proposals Èo pronoEe conpetitlon 1nthe fiuancing and delivery of care. Theproject dfrector ls Jane Sisk-

Also Èo be released shortly is volune IIof the Strategies report, PosEnarkeÈingSurvel,l.lance of frescription Urugs. ftÍsr e porfü ã sc iTu Js@ Adntni s-ÈraÈionrs drug regulatory actlviEies,presenÈs Èhe rationale for a postmarketíngsurvel.llance progran, assesses postnarketingsurveillance approaches, and offers po11cyopËions for Congress. Larry l.flike ts theproject dfrector.

The OTA l{ealth Progran 1s currenÈIy hardat work on yet another najor projecÈ, thÍsote oo "medical technology and the cosEs ofthe l{edlcare progråm. " The project direcEoris Anne Kesselnan Burns. Cindy l(1ng (arecenÈ addftlon to the staff), Glorla Ruby,Larry MÍlke and Judy üagner (these last Eqro

half tfne) round out the project staff.Another naJor project just under way Ís asÈudy of Federal polletes aûd the nedlcaldevLces lndustry. That project is headed byJane Sisk. It fs staffed by Judlth Larrabee(a new enployee), Jack Langenbrunner. andthe "other half" of the tine öf Larry andJudy-

Projects continuing lnclude one on healthand safeÈ.y conËrols in the workplace (MikeGough, ¡.¡-ith Hellen Gelband and Karl Krone-busch), review of the.VA agent orange sÈudyprotocol (also lfike, and Hellen), an evalu-aclon of the Envlronmental Protection'Agency's premanufacture notices (Mike, yetagalu, this t1¡ne t¡lth Scedna.n Stevens),several other case studies from the handi-capped people reporÈ. and a brief study ofthe lnpact of controlled cllnlcal trÍals ouhealth policy and nedlcal practlce (IlellenGelband). Everybody 1n the Health Programof 0TA can be reached on phone number202/226-2090. Ttre address ls 0TA, U.S-Congress , frlashíngton, Ð. C. 20510.

And, the Blological Appllcations Progranof 0TA 1s looking aE technologles andpollcles relaÈing Ëo aging- The projectdlrector 1s David McCallun (226-2070).

-

lf-l 0lNEI.I, LoW CoST I'ÍICRoCOìIPUTER PROGRAI,Í

FOR CLINICAL DECISION ANALYSIS

lon Grundner, Benjaml-n Littenberg,Duncan Neuhauser,

and Kathleen Snyth-St.aruch

We ¡v'ish to lnform the readershlp of theavailabiliËy of a low-cost, couputerlzeddeclsfon analysls prograxû appropriaEe for anApple I.I* computer. The program lncludesEwo decisfon analyses: What to do abouEsore Ehroats (treat with peniclllJ-n, testfor pharyngltis, and if positlve-ËreaÈ or donothfng), and the cholce of electivelnguínal hernlorrhaphy versus truss for anon-emergency ingulnal hernla patlent.

The program allows the user to vary nûanyof the assumptlons 1n these decision roodelsand see what fmpact these changes have onthe deci-slon. Even the sinplest clinlcaldeclslon analyses become burdensome v¡hen onewaûts to recalculate chem repeaÈedly fordifferent patfent characteristlcs anddif ferent assumptions.

The prograú rÍas inltlally developed forteachlng nedlcal studenÈs at Case tr{esternReserve Unlverslty and is expected Eo be thefirsË of a series of such nicrocomputerPrograltrs.

Ifedícal technology assessment nus& lncludethe éllnica1 decislon rules relevant "to tcsuse. Thusr,we feel Ehat such models areworthy of. attenElon.

l.

This cornputer program is very "userfríendly," in that all necessary instruc-tlons are wlthln t.he progran and all theuser needs Eo know is hov¡ to lnsert the dlskand Ëurn on the Apple II* compuEer. If youwould 1lke to obtaln a copy of chls dlskplus a userrs gulde, please send $10 to:

Blonatrfx2401 Queenston RoadCleveland, Ohio 44LI8

îr"' äåi.0, "ììå

T3

In Europe r¡riÈe to:

Dr. Egon JonssonEriksbergsgaËan, 36

It4 30 StockholtoSt¡eden

Readers fanlliar with Elcrocomputersoftware prlces w111 know thaÈ thls ls a

remarkably low prlce. trt ls our hope Ëhatthls prograo rv'111 be wÍde1y considered, and\re encourage others to develop simÍlarPrograms.

DEVELOPMENT OF PORTABLE RAPID

DIAGNoSTTC MTCROBIoLOGY SYSTEIIS I 1

FOR SUPPORT OF PRIMARY I{EALTH CARE^^

.. ! I.¡. R. Sarrbor., 12

Infectious diseases cause extensive human

suffering and pose najor obstacles to boEh

econoulc and soclal grov¡Èh in developingcouotrles. It has been observed thar peoplebecome Poorer because Ehey are slck, and

then they become sicker because they arepoorer (i). Thls vlclous cycle must be

broken for economic developúent to occur'Advancement of lndustrlalized countrles hasbeen posltively correlated with luprovedcontrol of endemic and epidernic infectlousdiseases (2).

?

: Control of pedlatric infectlous dlseasesís especlally inportant. Children representa vital resource for developlng areas;healthy children become sËrong workers for

Reprinted wltb Dr. Sanbornrs pennlssionfrom Èhe Indian Journal of Pediatrics '"ãil¿é,

t tngwiE,h Ehe author regardlng the probleus ofdeveloping and delivering approprlatehealLh technology 1n developing coun-trfes. Dr. Sanborn ls seeklng advlce and

as,slstance ln getting technologles shouldas the ones descrlbed in Ehe artlcle Ëo

Èhose r¿ho need Èhem, Partícularly rerûoteareas ln develpoÍng countries. Anybody*tttt ",tgg"sttons,

õr who wlshes nore 1n-forrnation, should wrlte directly to hlm.

Dr. Sanboiù ls the Managing Dlrector ofÞortable Rapld Diagnosls Technology, P.0.Box 667, Solana Beach, Californla 92075'

1I

L2

economic and social advancement, whlle sick,debilltated children become future llabili-ties for their society. Control of infec-tlous diseases of chlldren should receiveprfnary aLtention.

In the collectlve opinlon of the delegatestp the Alna-Ata Conference 1n 1978,çponsored by the l{orld Health Orgá.nization

, (tütto) and Èhe Unlred NaÈlons Chíldrensr Fund(UNICEF), the key Ëo achievlng acceprablelevels of health ln developing nat,lons llesin prfmary health care dellvery:

"Governments have a responqibllity for ËhehealÈh of their people r+hlch can be ful-filled only by the provlsion of adequatehealth and soclal neasures. A nain socialt,arget of governruents, lnternational organl-zatlons and the whole world conrounity ln thecoming decades should be the atËainment, byall peoples of the ç¡or1d by the year 2000 ofa level of healËh ËhaÈ er'111 pernit them tolead a socially and econonically produetlvellfe. Prlnary heal¿h care is the key toatËaining t.his target as part of developmentin the splrlE of social justice." (3)

A prerequfsite for adequat,e lnfectiousdlsease conËrol and prevention is rellablediagnostie capability. IÈ is necessary Èohave preclse etlologic and epidero:lolog1clnformatlon regarding the infectiousdlseases exiscing ln each geographic area.Frequently, individuals Ín troplcal regionshave concoúiLant diseases, uakfng dlffer-entJ.al diagnosis difflcult, evet for.mostexperlenced nedlcal practÍtloners (2). Someacute diseases ( typhold fever and Eubercu-losls) often mlnic other infecE,ions. Infec-tions such as cerebrospinal nenJ.ngitis (CSM)and pneumonia requlre preclse etiologlcinformaËion for selection of effectivetherapy. A varlety of etiologic agents arecommon 1n African CSM outbieaks (4), andappropriaÈe antibacterlal therapy for oneeLloLoglc agent ls not necessarlly adqquate

1.for anoEher.

These examples lllusÈrate the need forlabqratories.. Eowever, ln mony developingcountrles, 807a ot the people live in ruralareas where difflcult logistics, communlca-t,1ons, and Ëransportation situatlons exlsÈ.Nevertheless, exËenslon of diagnostlc labor-atory servlces to these people in thelr ownenvironment must be acconpllshed to ralsethe general level of health.

Rapid, on-slte diagnostlc capablllttes areespecially valuable in roany childrenrsdiseases t¡trÍch are Particularly severe andfu}ninant. Early, correcE. therapy selectedon Ehe basis of preclse mlcroblologlcal data

Eay be the crucial factor for good prognosisand nay also prevent handicapping sequelaechac llnlt the individualrs functional placein society. Thus, effective di.agnostlcsicrobiology systems, Ehat can deflne theetfologles of lnfectlous diseases where theyare found, a:re necessary for developingareas.

Concept Developuênt. fhyslcally brlngingnedlcal science Eo the people in developingcountries ls dlfflcult. It is prinarlly aIoglstlc problero. Sfuopllfied and portablesystems are requfred. These systeús shouldbe approprlate for field Þrork t.o controlepidemics in renote rural areas and alsoapproplate for routine use 1n sroall hospi-Eals and cllnics.

The developmeût of a pracLlcal approachfor sÈreamlinlng rnicrobiological laboratorydÍagnostics for the prlnary health carelevel requlred reassessing or even discard-ing certaln conventlonal concepEs. Forexanple, culEure lsolation and laboriousbloche¡n1cal identification of isolates wereoeEhods clearly Eoo complex and expensive tobe used 1n rural settings. On the otherhand, certain conventional meÈhods such asnfcroscopy dld fulfill requirements forrapid, slnple diagnostic methods. thus,accepEance of some traditÍonal techniquesand equlpment, modfflcation of oEhers, andappllcatÍon of new technology r¿ere allûecesary to reach thls goal.

Diagnostic microscopy has remalned afirst-llne technique for rapld diagnosls.The approach 1s stralghtforward, and adecision based on direct observatlon usuallycan be nade immediately. The introductionof new, rapidly actÍng stainé and inproveddifferentlal stains has enhanced the effec-Eiveness of mJcroscopy as a diagnosLic tool,and oinlaturlzation of microscopes has lm-proved portability.

Perhaps Èhe nost slgnificanc recent.advances 1n dlagnosClc olcroblology havebeen made ln sero-diagnosElc syscems..Inproved technlques have been developed todeEect and measure antibody, and rnoreLrnportanEly, Ilany sero-diagnosÈic roethodsare beÍng eveloped to detecÈ and identifyantlgens of lnfecting m{ s¡oe¡ganisms incllnical specimens. E:<anples of suchuethods lnclude enzyne-linked-lrumunosorbentassay (ELISA), radio-lmrnunoassay (RIA),fluorescenË antlbody (FA), elecErophoretlenethods, and lnert partlcle aggregation(IPA) Eests. 9fht1e al1 chese Eechniqueshave provided excellent new diagnostictools, not all are sulted to apid diagnoslsl-n the fleld or in smaller health

facilitles. The conplex, expensiveequipmenÈ and special reagents rquired forRIA, ELISA, and FA roake them irapractical foruse ln Eost developing areas. I{owever,counEerinmunoelectrophoresis (CIE), andcertain IPA tests -- coaggulation (CoAG),hemagglutination (ItA), and latexagglutinauion (LA) -- offer operatlonalsi.npliclty, rapid results, and economy.Therefore, these appear to be suitable forfleld-operable rapld dlagnostic Eests.

Portable KiE Evolution. A portable labor-at@ved only follow-tngthe development of a philosophy of rapid di-agnosElc tests. Both have been based onexperience thaË has indlcated which approachnay be appropriat,e. Te¡o protoÈype klts havebeen developed and evolved Èhrough actualfield experiences.

The basic klÈ 1s a completely portable,self-supportlng diagnosclc laborat.ory con-ÈaÍning three dlagnostic systems. . . .TheEhree dlagnostic systens ln the prinaiy kltsare n{croscopy, CIE, and IPA. These aresupplemented by linited selectfve culÈurecapability for use in certain situatj.ons.CIE, COAG, and LA tests, used for bothantlgen and antibody deEection, may beemployed for rapíd diagnostic methods andfor serologlc surveys.

AppliSqtlS¡tC. A v¡:i.de varieËy of rapidaf"g"o""" "t. possible !flith the threesysterns in the prloary kit. Diagnostlcmicroscopy appllcatlons are fauilíar; bloodand stool examina!Íon for parasltes, Gram-stained súears fron lesions and exudates,and darkfÍeLd examinations. The CIE testsystem has been used to diagnose a varietyof diseases caused by bacterla, fungl, para-sites, and virses....Ihe apparatus has beenníniaturlzed and has been used Eo detectboth ancigens and antibodies in pat,ientsr,¡-1 ch CSM durlng vaccfne field trials irrEgypt aàd E.he Sudan (7,8)....

:,

IC0AC tests utilize] scablllzed protein A-containlng' sËaphylococcus aureus cells ascarrier partlcles for speclflcanËísera....The COAG The COAG Ëest, makesposslble a 5 mlnute bed-side diagnosls ofsuch diseases as CSM and cholera, by testingthe prfunary specinen directly (10)....TheCOAG cest offers greaÈ pronlse for expandedappllcation.

The snall COAG kit has been used success-fully by nedical attendanÈs j.n west Afrlcanrural clÍnics to perforro...diagnoses of CSMcases. The fleld result.s were compared w-ithsEandard bacÈerlologlc t,echÍques at the base

'!5

laboratory. The correlation of results from30 CSF speclmens obtained 1n one villale was

97 percent and v¡as 80 percent w1Èh 20 CSF

specimens from another village.Protocypes of tr¡o porEable rapld diagnosis

kit.s have been developed and tested. One lsa basic kit cont.aining a variety of testsysÈeûs; the other is a sinple CoAG testklt. It has been denonstrated that preclseetlologlc dlagnoses of acute infectious dls-eases can be made 1n rual areae of develop-lng countrles using these k1ts. Therapeuticand prevenEive measures for most lnfectlousdlseases are conmon uedical knowledge. I{henspeclflc dÍagnoses can be nade where thepatlenË 1s located then approplate acËioncan be undertaken iørnedlately. These Port-able, rapld diagnostic kits rePresent"approprlaÈe cechnology" Ehat can provÍdes.tgnlflcant suPPort to prlmary health caredelivery fn develoPing areas.

References

I 'Bloon, B.R. , "Ethical lssues in interna-tional health: I{ea1th research and devel-oping natlons." I{astlngs Cent. Rep. 6:9,197 6.

Z Buck, 4.4., "Infectlon and lllness in thecoumuûlty: the diagnostic challenge oftropical diseases as seen by an epidem-is." Amer. J. TroP. Med. liyg. 28zL7|,Lg7 g .-

3 t{orld llealth OrganizaÈlon (ed.), A,l-ma-AEa '' L978. Prlnary llealth Care. I'Iorld Health

Organlzation, Geneva, P.2.4 Waddy, B.B., "African epidenic cerebro-. splnal rneningitis." J. lrop. Med. Hyg.

602L79, 1957.

7 Wahden, M.H. , et al., "A controlled fteldtrial of serogroup A meningococcal Poly-saccharlde vaccine." 8u11. WHO 48:667'

' Lg73. :

I Erwa, 8.H., et.a1., "A seÌogrouP A menln-.gocoecal polysaccharide vacclne: Studiesln che Sudan Eo combat cerebrospinal men-lngttis caused by Neisseria menlngitidisgroup 4. " 8u11. IrrHO 49 :301 ' 1973.

10 Thlrunoorthl, M.C. ' Dajanl, 4.S.,"Conparlson of staphYlococcalcoagglutination, latex agglut.ination, and

counLerlmmunoelectrophoresls fo rbact,erlal anLlgen detection." J. Clín.Mlcrobiol. 9228, 1979.

REPORT OF A TRIP TO THE

FEDERA]. REPUBLIC OF GERMANY

Jane E. Sisk, Ph.D. 13

I traveled to Harnburg at the lnvlEatlon ofthe llorld Congress on l{edical Physics and

Bionedical Engineering. One of the presl-dents of the Congress, Prof . Dr. I.IalterBleifeld, organiied a sesslon on "Problerns

in Leglslation" in dlfferen't countrles. Igave an overvlew of U.S. Federal activitesielated to nedical devlces ' \rl,th Particularemphasis on the Food and Drug Aduinistratlonand on Medicare. The PaPer 1s availablefron the llealth Program of 014 and w111 bepubtished l-n the December lssue of thejournal M"dicql P¡ogr."" Tht"ngh T .

At the same session Dr; Gerfried Fischeroan attorney fron a West C'erman Unlversity'dÍscussed clvil 1lab1lÍty l-n West German

law. He said Ehat Ge.rnany noet has no legis-1atlon that regulates lhe narketlng of oedi-ca1 devlces, but that the government hasprepared a draft statute Ehat r¡ould takeeffect ln 1984. The draft calls for designli-censing, which aPpears eomparable topreoarkeLing apProval, and requires thatinstltutions ensure that medical equipnentis operated only by competent people.14 Inmatters of liabllity, he found nuch slnllar-lty wlth U..S. law. Ihere ls a tendency tohold manuf,acturers, rather than physiciansor hospltals, striclly llable, and for

13 D.. Sfsk (fornerly Jane Sisk Willens) isProject Director/SenÍor Analyst in theIlealth Program of OTÀ. She ls currenËlydlrectlng an OTA study on Federal Poli-cies and the Medical Devlces Industry.

l4 This lat,ter provlsion, restricÈing use tocoupetent people, dlffers froo U.S. law,although the use of sophlstlcated devlcesby untrained people has been raised as an

- lssue ln the U.S.

neglleace to be the lnportant lssue regard-lng the use of a devlce.

lbe most fnterestlng ldea to cme out ofthe sesslon lras a nultinatlonal neÈwork forreportlng problems that ari.se ¡s-lth rnedlcaldevices. An engfneer from the KarollnskaInsËl.tute fn Stockholm described a projectthat 1s analyzing reports of accldents andlncldents wlth rnedlcal devlces ln hospitalsaud taking followup actlon.

Ee advocated that a sr¡ltinatlonal systen ,

be eet up to share lnformaÈ1ou about productdefects. Ttre ldea was supported by severalpeople fron the audfence, eepecially thosefroo countrles such ae Canada a¡d Swedeathat rely on luported nedlcal devlces.

Several sessions of the Congråes provfdeduseful background lnforostlon for the OTAnedlcal devicee study. For example, ouesessÍon reviewed recent developmeuts 1uloagfng. The speakers descrlbed seväraldffferent devlces, suqh as nuclear nagnetfcresonauce; ultraeound. conputed touography(CI)' scanu.lngn and dlgltal subtractloa

. angiography (DSA), aud rhey also discussedthe advautages and disadvauËages of eachdevice for particular medÍcal condltlons.

Conveyed at these seeslons of theCongress, of course, wa6 the fast pace aEwhlch these roodalltles are evolvfng- Inadditlon, speakers fro¡o all the countrÍesexpressed concern about risf.ng nedlcalexpeadÍcures. Many of the sclentlets, whileacknowledging the problem of rlsing costa,strongly pointed out the benefits thaÈ werebelng achleved n'ith sophlsticated ¡oedlcaltechnologf.es. , In cont,rast to the content ofsluflar meetings 1n t,he Unlted Statee. Ëhepreseûtatfons and discussion aË Ehe l{orldpongress on Medfcal Physlcs and BlonedlcalEngineering alluded to ne¡rl1cal devices fordisabled people as part of mâlnstreammedical care-

I{est Geruany is the only country fronwhich the Unlted States lnports nore medicaldevlces than lt exports, and it has aneepeclally st.rong, poeftlon 1n radfologicalequipmenE. I was lnterest,ed ln the procesaof research and deweloprnent ln Gernany andln gover ental policles ÈhaË affect flrnsthat mann¡facture medfcal devlces or f-adustryln general.

Through Ëhe l{eet Gernan Embasey and theMfnlstry of Reeearch and Technology, I net,wlth several represeutaÈ1ves of conpanlesthat nanufacture uedical devices.

Accordfng to t.he these represeûËatlves,Ph1l{ps and Sfemens together accormE for

about Ewo-thlrds of ehe world markeÈ forradlological equlpnent. Thefr explanatlon- for the strong Geruau position ln

electronedlcal devlces ls the reputaË1on ofGe¡rnan companfes that has Ueen butlt up overlhe years, especlally slnce the early1960's -

As an example, the representatives I spokewlth polated to phototÍ.nI.ng equlpnent Ehatthe UnÍted Stares developeã during Horld HarII, but dfd l1ttIe rrlth subsequenlly.Gernan companles began narketiug that andother fûnovatlve equlpnent (inagelntensiflers and three=phase generators)during the early 1960fs. Slenens vrlth' Ëhree-phase getrerators and phflips wlÈhfuoage fntenslfÍers r¡ere in the forefrout oftechnologlcal developnents after. World lfarII, and they gafned a repuÈation forproducfng equlpnoent that ¡¡as reliable.

Ihe represeutatLves also thought thatGer¡nan companies have beea nore flexlblethan U.S. coupanl.ee about adapting thelrequlpuent !o userst Êeeds

The najor Gernan compatry that nanr¡facËuresmedfcal devlces is Siemens. Sfemensrnedlcal product lfne cons:ists ma1n1y of

. dlagnostfc equiprnenÈ, such as X-rayco¡nputed tonography, and nuclear nägnetlcreaoaance (NMR) equipnent. Sienens also

, manufactures paÈient moultors, pacemakers,<fental eqr.lipuent, and hearlug aids. Thej conpany ts also lnvolved tn Ine artlffclal

; pancreaa (at Erlangeo) and manufactureslloear acceleraÈors at l{alnut Creek,Callfornia

About Ewo-thlrds of Sleueneri groas salescoue fræ, diago.ostlc equipneut. Overal-l ,Ehe coopauy puts abouË

-chä saue percentage

of gross sales lnto research and developuentas lnto research and development ln medicalenglneerlng.

Sfemens does not cond,uct baeic research(research Èhat 1s goal free), but relÍes ongovernment fundlng and universityresearch. The compaoy does engage in someþaelc developnent, r¡trich precedeÀ productdevelopment, and the na¡'orfty of,1is nedlcalengineerlng producte are less than flve.years old.

In the sgeciffc area of er(port policy. cherepresentatlvee I spoke to sald that duringEhe laËe 1950ts, there l¡as a prograu wherebyconpanies could cooperate with one another(presr.rnably wlthout vlolatlng aûtl-trustlaw) ln matters relaËed to eiports todeveloping countrles. philips and SlenensaË thaË Èfme cooperaËed on hospltal equlp-noent ln less developed countrlås. The

l7

represeutatives I talked Èo were not. aetareof any such eodeavors now- As far asresÈrictlons on lnported equlpnent, theypotnted out that vlolatlons could be ËakenÈo the Gernan Econonic MÍnistry or to theCourt of the European Ecooo¡n1c Connrmlty(EEc).

The representatlves al-so descrlbed aprogran uuder çhlch Èhe Gernan governmentand a coúpany èach fund 50 percent of the :

research and develoPment of a product- Any )

patent that resulËs is owued by thegovernment, and the comPaûy must 11cen8e iÈfron Èhe government,. Ph1l1ps does notpartlclpate very much ln thls progran.

there Ís a consensus that, there ls Uttleventure capltal and fe¡¡ srnall fims ln thenedlcal devfces field ln Gernany. It ¡rasalso polnted out that a couPany needs am{xture of establlshed and new products.

Standard settlng for uedlcal equlpnent hashad a long htstory ln Germany. For about 60years, Ëhere have been lndustrlal norms, aodfor about 50 years, there have been nornsfor radlological equiPnent. Theorgaulzation that oversees the standardsettlng i-s the Deutsche Instftut fur Normr-md(DIN. pronounced "dean"). DIN ¡¡as founded' by the companles- DINrs funding comes fromÈhe conLributions of member companfes(accordfug Ëo conPany slze), from thegovernment, and frou t,he sal-e of publlshedstandards

The body that sets the standards consistsof manufacturers and users that are selectedby the corapanles:and representatfves of che

. federal governaent, and the German natlonalbureau of standards. Standards regardlûgsafety and perforroance are seÈ by cotrsensua '1.e-, everyone'on a cm-tttee Euat agree-Once set, Ëhe süandards are revlewed everyflve years

In the radlologfcal area, for example,there are about elght dçpartments, fncludingdepartrents of lnaglng (of whlch quality 1sa subcom'lttee), r:adlologfca1 safety, tmitsof neasuremeot, andi nuclear nagnetlcresoûatrce (NMR).

The Gernan trade àssociatfon conparable tothe U.S. Nat,lonal Electrical ManufacturersAssoclation ls l/EI. Plcker and oEher U. S.

companles are members. There ls a sensethat VEI ls a partner of Èhe goverrment.Soue of the Europeau rePresetËatfves I spokeËo had the lnpresslon that U. S. autl-trustlaw was strlcter. than the Gernan-

One cornpany representative had ahfstorfcal perspective abouË recent

l8

developments ln lnaging devlces. Ee saldEhe prlnclples applled in dlgftalsubtracË,1on anglography (DSA) ¡¡ere flrstdeveloped ln 1903 ln astrouomy and wereapplfeå to radlology durlng the 1930's. Hq

thlnks DSA 1s "overrated," because 1t 1sprone to "motlon artifacts" (because t¡volmages are needed); the very thin layers ofarteries pose a problem and lead toconfusfng fnages; and the lmage quallty' acrltlcal facÈor in radfology. ls less Ehanthe quallty rrlth f1ln t,echnlquee- Thfsrepresentatlve does belleve, hor¡ever, thatDSA 1s good for sone PurPoses, such as,checkfng to see lf a bypass graft fs stlllpatent and perhaps for carotld arËerlee.

Slnllar historical developments la sclencepreceded the develoPuent of NMR- Theorfgtnal mathematÍcaI theory lvas developedtn 1917 and the rnethodology establlshed by1945. After the developneot of úT, appllca-t,lons of thls nathenatlcal theory were alsomade to NMR, and papere were publfsheddurlng the 1970's.

One representative thoughE that the bestrnedlcal progress 1n radlology ls now beÍngnade 1n Sweden and the Untted States. Henoted that ln the Unlted SEaEes, al-l largehospit,als have research departmenLs and thatall radlologists engage ln some research,---iñconErast to Europe. In the area ofradiology, he pointed out, baslc nedlcal t

needs are r¡e1l deflned -- contrast I

resolutÍon, spatial resolutlon, safety, audspeed. Advauces come through developnents1o the state of technologY, such asconputers, that cau be applled to theseneeds

In addltlon to meeÈing wlth people at ÈheIùor1d Congress, I vfsited the Drager Co. lnLubeck and talked to people involved ln thedeveloproent of electronlc instrunenÈs.Dragerrs product 11ne revolvee aroundresplraÈ1on equlpment, orlginally deepseadiving equlpment. The coupany now manufac-Eures such products as incubators for prema-

";Lure bables, anestheslology equfpBent,devlces to monilor alr quallty 1u::theworkplace, and respirators for fireflghters-It export8 to the Uníted Stat,es and ha9 aplant l-n PhÍladelph1a, PennsylvanLa.

I also rnet wlth a rePreseBtatlve fron EheFraunhofer InstfÈut fur SysËemtechnlk lnI(arlsruhe. Thls lnstlÈute 18 one of ãbout28 whose fuuctlon 1s Èo facflltate Èhe

corûmercializatlon of inuovatlons that havebeen developed. The job of the wouan Ispoke Èo 1s to perforu thls frmctfoo ln theoedlcal area and. speclflcallyr to ttry to help sna11 and mediursized \

firns Ëo commercialize products. She de-scrlbed some of her efforts to Batchresearch work and companies. llovever, thisseens to be fairly smallrscale effort, sinceshe 1s the only person involved ln medicalarea. She s¡as extremely helpful, andoffered to send a great deal of naterialabout Gernan legfslacleh, policy, andfundfng.

REPORT ON THE 'NEW"

OFFICE OF HEALTH TECHNOLOGY

ASSESSMENT

Jack Langenbrunner

Since the late 1960ts, the Medfcere pro-gran of the llealth Care Flnancing Admlnis-tration has relied on the Publlc HealthService (PHS) for nedlcal and sclenËificadvice needed Eo deternine the safety andcllnlcal effectiveness of nedfcal Èechnolo-gies for coverage and reimbursement pur-poses. The procesé of assessoent and reso-lutloo of Medicare issues evolved over timeand was fornalized and sÈrengthened by thethen new NaElonal Center for llealth Care

. Technology (NCHCT) tn 1979.

In 1981, however, NCHCT.fundlng wasdiscontlnued, a vlctin of budgeË cuÈbacks.under Ehe neru Reagan AdminlstraEion. ThePHS Medicare issue assessment process vtas

' nevertheless naintal-ned and t¡ansferred tothe Office of che AssisËant Secretary forIlealth (OASH¡ vrithin the PHS. Ilowever, an

. excessive backlog of coverage lssues devel-oped over Ehe last year due to a pauclEy ofstaff and budget.

The. respo4se, as. a resulË;, has been Ëo... ...,.,.

,recently creat,e a nelt Offlce of llealeh.Technology AssessuenË (OI{TA), located withinÈhe Natlonal Center for Health ServlcesResearch, Offlce of che Asslstant'Secretaryfor llealth; Department of llealth and l{umánServices. The purpose of 0I1TA, withlncreased sÈ,aff and budgetary support, w111be Ëo eoriËlnue and expand Èhe PHS coverageassessnent process. OI1TA has also set goalsfor Ehe nexÈ two fiscal years of i )s¡¡sngthening the PHS/HCFA pollcy role inidentifytug prlorlties and appropriatehealth care technologies for assessment, 2)fncreaslng participatlon of PHS agencl.es Ínthe lû1Èiation and development of assess-

'ment, 3) exploring and proroot,lng prlvate

sector partlcipatlon in technology assess-úenË, 4) explorlng the greater use of theDIIHS Technology Coordinaring Conmlttee andlmprovements in technology assessment lnPHS.

Questlons about OlllA can be directed toMr. Dennis Cotter, Deputy Dlrector, at30L/ 4'43-4990. Malllng address:

Room 174555600 Ftshers LaneRockvllle, Maryland 20857

BOOK REVIEWI5

Cost-Benefit and Cost-Effectiveness Analysisln llealth Care by Kenneth E. Warner andBrya" R- Luc% Health Ad.nlnlstraÈ1on Press,Ann Arbor, Mich. , L982, 318 pp.

Revtewed by Marvin If. Krlsteln, Ph.D.16

This 1s an lmportant book, which 1s builton the authorst work on the OffÍce ofTechnology Assessmentts 1980-81 volumes onThe Lnpllcatfons of Cost-EffectivenessAnalysls of l4edical Technology. It lsimportan! for health care professÍona1s andpoltcy makers seeking a useful lnÈroductlonto CBA/CEA and for teachers of healtheconomics seeklng a supplementary Eextbook.For practltioners of health care evaluaÈ1on,its appendices are a convenient natershedreference source. The book contains 1ts ownbest review, 1n an excellent foreward byProfessor Vlctor R. Fuchs.

,.-.,.,Ihe,.',b-pqlc is well organized and clear; i(rtrles to separate the foresE fro¡n the Erees.¡It v¡orks hard to be falr Èo differenE phllo-sophlcal änd speciallsËsr vier¡s on CBA/CEA,provfdes excelienÈ summarles of good andless good work, and is a well balancedlntroducÈ1on Eo the subject in its manyfasclnatlng facets. There are six chapters,

îÉ---t' Jack Langenbrunner fs Book Revlew Editorfor The Sorcererts Apprentice.Departúent of Econonlcs, StãEe Univer-slty of New York, SEony Brook; Consul-tanE t.o the Natlonal lleart, Lung , andBlood Instftute, Bethesda, Maryland, andto the Amerlcan Health Foundation, NYC.

l6

l9

four appendLces, and an lnportant bibliog-raphy of 35 Pages.

Chapter One provides a suümary of theeconomics EhaË 1s essentlal as background tounderstanding the growlng interest inCBA/CEA tn health care -- i.e., the grow-ing

concern with the risíngrcosEs of nedÍcalcare, the dlagnoses, anâlyses, and prognosesby econcmlsts and the pressures on thehealth care profession to respond toaËteopÈs to deal wfth these lssues. ChapEer

lwo piovldes aû lntroductLon to CBA/CEA'clarlfying the difference between them. A

brtef history shows Lhat only since the rníd-1970's have medlcal journals published an

increasing number of CBA/CEA. Chapter Threeis the longesc and is the "how to" chapteron Èhe methodology on CBA/GEA. IE isdirected to producing an appreclative,aware, and properly crltlcal consuuer ofsuch analyses, raEher than a PracEitioner ofCBÀ/CEA. It covers many najor lssues wel1,ineluding maÈters of equity, sensitivltyanalysis, rnarginal analysls, and concludesr.¡-ith the fssue of from s¡hose poinÈ of viewhas the CBA/CEA been perforrned. ThLs lsrelated to the vltal lssue of tryfng to make

analyses more relevant to decislonuakers.

Chapter Four revler{s a great deal of theaclual CBA/CEÀ 1lt.erature. It points outthe trend Lo CEA vs. CBA (perhaps because 1t1s philosophlcally nore coufortble andeasier to do); rlore concern wlth dlagnoslsand treatmenE lssues; more work by and w1thphysiclans, although nuch of cancer treat-nent a.rd dlabetes remain the least popularsubject areas. This chaPter should ¡nake

absorbfng readlng on lnany level,s ofinteresE. Particularly striklûg are thedÍscussions on: lmplementaÈion barriers,quality of analysls, the "moving target"problens in C.nput data, quallty-of-lifeadjusted years, sensitlvity analyses(partlcularly in aiding ProEocol deslgn),the dorninance of positive ffn-díngs (perhapsshifttng now under the pressures of costconsciousness), aqd uhe lack of a broadervl.ew on non-roedlcal alernatives in' analysesdealing with health care Eopics (bestcounEer examPle: fluoridatlon).

Chapt.er Flve discusses the poEentlalusefulness of CBA/CEA and E.he Past hlstoryof use in pollcy naking. Of course, CBA/CEA

has had llttle direcË use by governruentaland non-govern¡oent,al agencies. Ihe authorsfeel chat Ëhe near future ls not very proÍn-islng even lhough Ínterest ln CBA/CEA isrlsiog. They euphasize technlcal probleus(1.e. the pauity of high quallty analysesand data problems) and pollcy makersl

incentives. This theme is repeated ÍnChapter Six, which 1s che sunnary chapcerand which concludes-\,rith a research agendadÍscusslon that ls very suggestive andinsightful: Could a major payor decide toreimburse for a safe and nedlcally effectivebut not' cosE-effective (as eoupared to aconpe*iÈive procedure) treatuent or device?Are the mosE, serÍous uneconornical proceduresalso not only lnefflclent (not cosÈ-effectlve), but not effectÍve fn a rnedicalrlsk-benefit sense (as I have Èended toargue ln some papers)? And are these rela-Elvely concentrated, and of more seriouscost to soclety, in the non-glamorous, non-hlgtr technology areas, which CBA/CEA haspald relatlvely 11t.tle acEentiori to? Do weneed nore resources devoted t,o i-mprovlng thequallty of CBA/CEA Eechniques or will ttreiuproveoent of input daEa frorn úore cost-consciou s ep ld emlo 1o g y and c 11 ni-ea1--¡-esearc-eÞprovide a bigger payoff? Is a concentrationon CBA/CEA basically an lneffectual approachco deallng lrith the healt,h cost inflâtlonproblen and is lt diverting resources fronaEtacking underlylng st.ructural problens?The authors believe thaÈ a rnore modestperceptLon of the potential of CBA/CEA forcontributing to pol1cy naking in E,he healthcare area ls desirable. They see a possibleroarglnal contrlbution of CBA/CEA to lmprovedresource allocatlon and c'osÈ contafnment 1nnedlcal care, wlËh the maln contributlon inralslng the generaLLzeð, level of cost-consclousness of decislon nakers

I share Prof. Fuchsr vler¡s when he saysÈhaÈ he recommends this book wi.th enEhus-lasm, but cautions Ehe reader not to be:

overly influenced by che authorst force-ful dell-neaËion of the weaknesses arrdlfmltations of CBA/CEA.... IThe] interest.in and use of CBA/CEA stem from a growingreallzatlon that vre li.ve in a ç¡orld ofscarce r.esources and that the fundanentaleconomli ìproblen of society is to allo- ' ::

caEe these resources ln a way that w111

. best satisfy human wants. . . . tcl l-ven thewide range of poËentlal cholces ln cheuse of health-care facllltles, personnel,and Eechnologies, decision-makers clearlyneed a beÈter undersEandlng of the conse-quences of the alternatives. T'hat ls pre-clsely rùat CBA/CEA is designed to do,[G]1ven the r¡ill and the neehanfsms (EolnplemenÈ rhat w111) ,... CBA/CEA offersthe nost rational, humane basis for ef-f ectlve, ef ficient allocatlon. . .I,Ihen.constraints on health care are lnposedr¡lthouÈ rega¡d to costs and benefits, thenationrs health suffers more than 1snecessary.

2g

I also share Prof. Fuchsr enphasis thatone nusÈ be clear on the public pollcyorienÈaÈion of CBA/CEA in nedícal care,separated fron CBA/CEA for better protocoldesfgn. the lndividual physician ln hisdaily work needs to appreciate nhy certalnconstralots have been tmposed, based onCBA./CEA, but one of the lasË thlnga rüe eranÈis for tulm to view hfs patient as a case inCBA/CEA. I have expanded on Ëhese lastpoints 1q a chapter in the forthcomfngVo1ume W of Advances 1n llealth Economlcsand Health se

Æ'INOUNCING THE FIRST ANNUAI

SORCERNRI S APPRENTICETECITNOLOGY ASSESSMEMITRA.FFIC SIGN CONTEST!

The pollcy and health care vocabularlesare f111ed w-lth references Ëo guidellnes,uarkers, standards, "clear syqbolsr" and Ehel1ke. So...we thought we should nake theprocess more expliclt and encourage thedevelopment of "language non-speclf1c syn-bols that nighc ease the pollcy makerts orthe practiElonerrs journey.

Thus, we hereby announce that entrles arenow belng accepÈed for the First AnnualSorcererts Apprentlce 1A Trafflc Sign.Coûtest. Send.us your ideas or drawlngs oftrafflc signs for policy guldance, thepracÈ1ce of health care, Ëhe assessment ofmedical technology, or any related subject.They need noE be 1n photo ready forn. I{ewlll re-draw them lf you like.

Several s¡amples are provlded below of thetype of thlng we are talklng abouÈ. TheGrand Prtze Winner w111 have hls/her/thedrentry reproduced ln a future lssue of thene¡¡sleËÈer and be gfven a free one-yearrsnenbershlp G-ttre network. Runners-up willhave thelr entrfes prlnted, and perhapsreceive an offlcial Sorcererts Apprentfce

--.,

matchbook, already a sought after collec-torrs iEem! Everyone 1s etrigible; you neednot be a member to enÈer, so pass the r¡ordaround! Contest entries must be received byJanuary 10, 1983. The declsions of t.hejudges w111 be final, and, undoubtedly,totally, arbiÈrary.

Danger: Sllppery Conceprs Ahead

No Cost-EffectlvenessAnalyses Allowed!

Economlst Crossing

l.{arnlng: Inacceqsible Bulldtng

Staff of The Sorcererr s Apprentlce andmembers of ¿heir fanlly are eligible t,opartlclpate. This contest Ís void where¡nisunderstood.

2l

OTI{ER SOT]RCES OF IMORMATIONlT

Ttre International HosPltal Federatlon Ísan independent, non-Politlcal organlzatloneupported.by nembers 1n approxlnately 70countrles. Its goals are to Ímproveplanning and managrnent of hospftals andhealth servlces. It lssues a quarterlyjournal, Wôrld ttospitals, organlzes.lnternatlonal conferences, arranges studyÈours of facllitles and servf'ces ln varlouscountries, and provldes various otherservices, includlng infonoatlon referral.Call. (London) 01-267 5I76i or r¡rite to:. The DirecÈor-C'eneral

InternaÈlonal Eospital Federati-on126 Albert StreeÈLondon Nf.ll 7NX, England

Or, call the WashÍngton' D.C. Offtceat (202) 638-1100; or wrlte:444 North capltol SÈreet, N.W.

SuiEe 500I{astrington, D.C. 2000i Û.S.4.

' Ttre newly forrned Assoclation for HealthServices Research is a national membershipo@d to represent the healthservlces research commtrnlty. It ls an advo-cacy organlzatlon, designed Ëo Pronote andstrengthen health services research ar'td, asthey put it, "tell our story." The AIISR

issues a quaEterly newsletter, 4lg,¡þ'çhtch is available free with membershlp orby subscripÈion otherwise. For lnfornaËlon,phone (202) 625-2624, ot r¡rite the AHSR at:

2233 Wisconsin Avenue, U.ñ.Suite 525f.lashington, D.C. 20007

17 fh.t. 1s no Recent Publicatlons columnthtg lssue. To an extent, 0ther Sourcesw'111 cover publlcations thls Èine. But,as lte have often mentloned' we depend onyou to send us coples or citatfons ofrelevant llterature. Slnce thls has noE

worked out, tte are novt looklng for some-one to Put together a "Recent Publlca-tlons" colunn each lssue. As w'lth therest. of us, Ëhere ls no conpensaÈloa(except for a free membership, and ofcourse the oPPortunlty Ëo be lfsEed asstaff , l¡'ith one of those wonderfullytnflated cltles!). Call or wrlte ifyou are lnterested.

The National Conmlttee tor Clinlcal Labor-atory Standards continues to develop andlssue a series of guidellnês, based on avoluntary consensus Process, for clfnicallaboratorles. For example, .proposed guide-llnes for the quanELtative measurement offetal hernoglobln have just been issued.flhether you have responslbillties directlyrelated to the 1ab, or vdlether your analysisor research requlres thaË you be lnformedabout the latest technlcal sÈandards, YoûDay want Èo conslder becoulng a member ofthe NCCTS or gettLng added to thelr nailingltst. They also publish Ëhe newsletterUpdate, which has been descrfbed ln anearller lssue. For further lnfornation,contact:

Joan Logue, NCCLS

77L E. LancasÈer AvenueVlllanova, Pennsylvania 19085 U.S.A.

Leonard Saxe of the Boston UniversltyDepartment of Psychology and Daniel KoreÈzof the Congressional Budget Office (CBO)

have edlted a book ori the use of evaluationresearch by the U.S. Congress, partlcularlythat conducted by its four suPPort agencies(oTA, the CBO, the Congesslonal ResearchServlce, and the General Accounting Office).Unfortunately, as we "went to Press" on thÍslssue, we couldntt place our hands on any ofour copÍes. If you are Ínterested, however,wrlte to Len; his address is on your NetworkRoster.

Springer has released The Management ofIlealth Care Techn@,

ttenKemp, wlth foreword by Kerr hlhite. Thecountries are the U.K., Canada, Australla,Japan, France, WesÊ Geroany, Netherlands,Sweden, and the Unit,ed Slates. It 1s avall-able frorn Springer Publlshing Conpany, 200Park Avenue South, New York, N.Y. 10003. Itis 256 pages; $35.95 (hardcover), and $38.80for orders from outside the U'.S.

.:!., 1t

FRAGUENTS (Contlnued fron p. l)

A-trl correspondence, substantive or busl-ness, can be Sent Ëo Ehat address. Articlesor news iteos can alsq be sent to our Offlceof Technology Assessnent'address. And

speaking of correspondence, we are sol1c1t-lng roanuscripts, publfcaÈ1on notlce6' paro-

dies and saÈires, conference reports oraÂoouncernents, and so forth for volume 3.As usi¡al, the first issue of the volune w111be ia January.

A1so, several oembers have told us thaÈtbey keep thelr Íssues of Íhe SorcererrsApprentlce in Èhree-rlng binde4s. Thus, we

r¡ill be naklng the uargln large enough toallow thls more easlly. We have lncluded aniEem on Ëhe renewal forn for you to fndlcacewhether r¡e should punch the copy 1n advancefor you. And, we are checklng on whether t¡ecan have blnders lnprlnted at a reasonableprlce and made available to Benbers. Let us

;know lf you are inÈerested.

Next, Èhe network and newsletter have oút-groern thefr current "organizatlonal" status.I{e also flnd that Èhe activitles we engageia connected to the ne¡vsleEter contlnue togo beyond Èhose of.sirnply putÈlng out aoewsletter. Ihe network functlon has becouea key area. Therefore, r{e are 1n Èhe Proc-ess of checking lnto the settlng up of anoo-proflÈ corporation ln the Dlstrict ofColunbia. This rrlll(rnore accurately reflectEhe status of what Íte are dolng.

These changes will not affect you as amember. Hov¡ever, ln keeplng wIEh the growthof the ûetlrork functlon, rse wlll be jotningin the sponsorshlp cf a sprfng 1983 confer-eûce on lnÈernatlonal health technology(mentfoned ln the previous issue, as a Eestof iuterest fn an lnternatlonal soclety),offerlng an employmeut advertislngi servlce'(free to necrrork members), and, we hope,preparfng an lnternaElonal dlrectory of'healÉh Ëechnology assessmenË resources andacËÍvltÍes. You may be asked to help inthat effort !

In the last issue of The SorcererrsApprentlce, we included an article on theApproprlate l{ealth Resources and Technolo-gies Action Group (ÆIRIAG) " tte have beenlnforned Èhat Katherlne Ell1oEt, onêrof thefounders of the group, has left AERTAG andthaÈ tt ls no longer a collaborating centerof the World llealth Organlzatlon.

It nay not be avallable publtcly just yet,but'the Phase I Final Report of the "Evalua-tlon of Èhe NatÍonal InstiEutes of l{ealthCorisensus Development Process" Is now com-'plete. The conLract for Èhe evaluatlon wasfunded by the NII{ and conducted by theInsticute for Social Research of the Unlver-sity of Mlchlgan. Dr. Paul M. Wortrnan isthe prfnclpal lnvestlgator for theevaluatlon.

The contract was for an evaluation of the"process aspects" of the Consensus Develop-nent progran. Phase I was to develop sug-gestlons for process nodlflcatlons thatnlght improve the program; Phase II wllllnclude experlmental tesEs of the sugges-tions and involve the provisioo of technicalasslstance tö NIE on nethods to evaluate theongolng progress of the progr¿rn.

Ttre Phase I report contalus a detaileddescrlpt,lon of the eleúents of the ConsensusDevelopnent program_, descrfbes the measuresdeveloped to evaluate the eleuents of theprocess, and then provldes an analysls orevaluatfon of ehe qualfty of the processaccordlng to the rneasureúent criterladeveloped. It also provides a plan forlnplenenting Phase II.

The reportrs general find.fng is that Ëheprocess is successful; that is, the processadequately serves lts major objectives.Ilowever, the report also notes Ëhat therersas substantlal variabllity 1n the successof the slx Consensus Development conferencess Eudied.

The study finds uhat Ehe exchange ofinformaËion durlng the conferences is facfl-itated by effective ehairpersons, by a con-genial group, by noderate disagreemenÈsartrong panelists, and by efflcient grouporganlzing procedures. lfore than noderatedisagreenent 1n the group, however, nega-tlvely affects bot.h the process and Èheoutcone of the conference. Thus, iË may beÈhat consensus development, as rnany havesuggested, fs not a terribly effectiveprocess for resolrrlng controverslal lssues.

For further lnfornatfon, we are assumlngLhat you should contact Dr. ülortman, at, ÈheInstitute for Socla1 Research; University ofMtchlgan; Ann Arbor, Mlchlgan 48106.

Jaako Tuomllehto r¿'rltes froro the Unlver-slty of Kuoplo, I'1n1and, concernlng DavldBantats recent Med.ícal Care edltorlal on theNorth Karella pñ¡ect.--Or. Tuouilehto hasJust compleËed a two-year perlod working 1aMan1la, Ttre Ph1ll1plned. IIe has been theco-dlrector of the North Karella project forsone years. Ile enclosed an lnteresÈ.lngmanuscript, "A Cost-Benefit Analysls ofNorth lkrellan Coumunity-Based EypertenslonProgrenme froø, L972 Eo 1977."

Paul Gross of the Instltute of llealthEconomics and Technology AssessmenË lnSydney, Australla, writes to tnforu us thaÈthe new Austallan Co mJ tËee on HealthTechnology Assessment has uet. Ile promlsesto keep readers informed about develop-ments. He also rebukes Davld Banta for

23

statiûg that the Japanese çrere the "firstexample...of active use of the fee systen tocontrol Ëechnology" in the last lssue.David responds that he did overlook theAustralia example of CT scanning, where feesr¡ere redueed ln i978 '...so Èhat profltswill not be so hlgh as to encourage theraptd expanslon of CT Scanning 1n the prl-vate eector." The foregofng sÈatex[enE lsfrou the 1980 Background Paper publlshed byOTA, "lhe Management of Êlealth Care Technol-ogy ln Ten Countrles," ln a paper by SydneySax of the Australian government. Thatreport has Just been publlshed ln improvedforu,ln hard back editlon by SprlngerPubllshtng CooPanY 1n New York.

. In a sinilar veln, l'fr. Yasuo Otanl of theI'tinistry of Eealth and I'Ielfare ln Tokyo¡¡rites (in part) Èo say that the fee for CT

scanoing fn Japan !üas not reduced. Accord-lng to Mlnlstry of Eealth figures, the feewas 12,000 yen fn 1978 and was st1ll 12'000yen fn 1981. David apo_logizes; he was onlypassiog on ¡vhat a presumably knowledgableinfomanÈ uold hfm. The perlls of interna-tiooal commentarY!

Susan Vandale writes from the UnlversityCenter for Educatlonal Technology ln llealth(CEUTES) 1n Mexlco Clty (thls is the Centerheaded by Dr. Jose Laguna Ehat carrled ouE

the fnteresttng survey of technology 1nhospitals.ln Mexico reported in thisnerüSletter). She states ÈhaÈ CEUTES lsorganizlng a series of seulnars on medlcaltechnology and roedical teðhnology assess-nent. The first, ls scheduled for Ehe secondweek. 1o October and is planned to lnvolveDr. Bernard Bloo¡ of the Universlty ofPennsylvanla and Dr. Ìfurray Edðn of the U"S.Natfonal Instltutes of Health. (David Bantahas learned through lndÍrect sources thatthe seninar has been posEponed.) We hope Ëo

publlsh a rePort on Ëhat seminar 1n a fuEurelssue of The Sorcererts Apprentlce.

Dr. KlrsEin SÈaehr Johansen, Reglonalûfflcer for Approprlate lechnology forEealth fn the European Regtonal Off'lce ofthe World Health Organlzatlon 1n bopenhagen,1s sollclting help and advice concerning WHO

actiîlt1ès 1n Eechnology assessment. Dr.Johansen has approached her new task rù1thconslderable energy, and ls aEtemPtfng todeflne an apProPrlate role for Ì{tl0 inprortotlng approprlaÈe technology. She

l¡elcomes euggestions and lnput. IIer address1s:

8 ScherflgsvejDK-z100 CoPenhagenDennark

The nembers of the Pan Amerlcan llealthAssociatlon have elected Dr. Carlyle I'facedoas the new PAIIO Director. Dr. Macedo 1s aBrazilian, and will serve a 4 year tero asDÍrector. According to Dr. Jose Teruel, aparticlpant at the Bellagio conference, Dr.Macedo is very interest,ed in encouraglngnedígal technology assessment acÈivittÊs Ínthe oember counËrles of PAHO.

SEan Relser, ln the last lssue of thisnelrsletter, wrote about a posslble lnt,er-natlonal socleEy of health care technol-ogy. We have heard fron a few peopleregarding such an assocÍatlon and about cheposslbfllty of havlng a cooference nextsprlng ln Washlngton, D.C. Only one personhas lndicated a definite lnËentfon to aÈtendand subnlt a paper, from the U.K. It wouldbe good to get a betÈer sense of lnterest 1nelther a foroal professional assoclatlon ora conference designed Èo exanine assessment-related substant,ive lssues and to test thefeaslblllty and desirabllity of a forcnlng anassoclaÈion later.

The Auerlcan Associatlon for Budgeu &

Progr:m Analysis w-111 hold lts fa1lsyr.posiun on November 19 1n Washlngton, D.C.The theme 1s "Retoollng to Reduce," and thesubject 1s of course planning for anddeallng with reductions ln the Federalbudget. U.S. Senator Pete Domenicl,chairrnan of the Senate Budget Coromittee Ísthe kelnoÈe speaker, and Dr. Alice Rfvl1n,director of the Congressfonal Budget Office,is among the other speakers. For lnfor--matlon, call (703) 94i-4300.' The Assocl-ation of A¡oerlcan Geographers 1ssponsoring Ëhe First Annual InLernaÈlonalSyroposlum on Maps and Graphlcs for theVisually llandicapped, n-fEh the goal ofevaluating recent ernplrieal work and prepar-ing a research agenda for the future. IEtakes ,place March l0-I2, 1983, 1n Hashing-ton, D.C., For lnfornation, contact PatrlclaMcllethy aE'!(202) 234-L450. r

And, as a final note, eze are always opento suggestlons f.pr a nane change for thlscolumn. The only one received so far, how-ever, is 'lShrapnel." Is that a Eessage, ora warnlng, or what?

1. ..

AÐDITIONS TO

TITE SORCERER'S APPRENTICE NETI{ORK

Slnce Ëhe July 1982 Issue

Per Buch AndreasenIlead, Dept- of Gastroenterology

and Cllnical PharnacologyGentofte Hospital Med. afd- FNiels Andersens Vej 652900 llellerup DE¡ü'íARK

Australlan Department of HealthThe LibrarianP-0. Box i00I.iodenACT2606AUSTRATIA

Centre de Recherches pour LtEtude &

L'Observation des Conditlons de VieI42 Rue du Chevaleret75013 Paris FRANCE

CERGASInstÍtuto Economla AzlendaleUniversLta Comm- L. BocconlVia R. Sarfatt.i 2520L36 Milano ITAJ,Y

Doodler ClynerResearch AnalystBiologlcal Applications ProgramOffice of Technology AssessmentU.S- Congress a

lfashington, D.C. 20510

Dennis J. CotterIlealth Science AnalystDHHS/OASH/OHRSTRoon 174555600 Físhers LaneRockville, Maryland 20857

Virginia H. CwallnaAdml-nls trative AssisEantHealth Prograro0fflce of Technology AssessmentU- S. CongressI{ashington, D- C- 20510

Peter E- Dans, M.D., DirectorOfflce of Medical Practice EvaluationJohns Hopklns Hospical600 N. Wolfe SËreeËBaltftuore, Maryland 2I2O5

)

Polly Ehrenhafr5901 llempstead RoadMadison, Wisconsin 5371 I

David FeenyAssociate Professor of EconomicsMcMaster UnlversltyHamilton, Ontarío L8S 4M4CANA-DA

Paul T- Gross, DirectorInstitute of Health Economics and

Technology Assessment50 Bridge Street; Level 14 Al,lp CenrreSydney NSl,i 2000 AUSTRALIA

The LibrarlanOffice of llealth Economics12, WhttehallLondon SI{14 2DY

Health Services Management CentreUnlverslty of Birminghau; Park House40, Edgbaston Park RoadBirninghara, Bl5 zRTENGLAND

:

Health Systens Agency ofNorth Central Connectícut, Inc.

999 Asylurn AvenueHartford, Connectlcut 06105

Ralf Hotchkiss, ph.D.6505 Farallon I,IayOakland, Californla 946LL

Cynthia P. Ki.ngIlealth ProgramOffice of Technology Assessment.U. S. Congressi{ashÍngton, D- C- 205f 0

Arthur F- Kohrman, M-D.DirectorLa Rabida Children's HospitalEast 65th Streer at Lake MichiganChicago, 111Ínoís 60649

?,5

GreËchen S. Kolsrud, Ph.D-ManagerBiologlcal ApplicaÈlons ProgramOfflce of Technology AssessmentU. S. CôngressWashington, D.C. 205f0

Judfch H. LarrabeeHealth ProgramOffice of lechnology AssessmenËU- S. Congressf.lashington, D. C. 20510

Department of EpideniologyR.U- LlnburgP.O. Box 6166200 MD - MaastricheTHE NETHERLANDS

Linkäplng UniversítyLlbrary

5-581 83 LlnkopingSI.TEDEN

Dr. M. L- Mashford Jul-83Reader in Clinical PharnacologyDepE. Med.; Unlv. of MelbourneSt. VÍncentts HospltalVlcÈoría ParadeFftzroy, Vic. 3065; AUSTRAI,IA

David B. McCallun, Ph.D.Biological Applicatlons ProgramOffice of Technology AssessnenÈU. S. CongressIlashington, D.C. 205f0-

Michael D- Mclntyre555 E. l0th Avenue. #110Denver. Colorado 80203

Seyuour Perry, M.D.5203 Benton AvenueBeLhesda, Maryland 208L4

Walter L- Robb, ph.D.Vice presidenÈ and General ManagerMedical SysÈeus OperaËionsGeneral Electrfc; p.O. Box 414Milwaukee, I.Iisconsin 53201

Frederlck C. Robblns, M.D.PresidenÈ, InstiÊute of MedÍcineNati.onal Acadeny of Sclences2101 ConstÍtution Avenue, N.W-I{ashington, D. C.. 2O4Lg

Tore¿ ScherstenProfessor of SurgeryDepartmenÈ of Surgery I,Sahlgrenska sjukhusetUniversÍty of GoteborgS-4i3 45 Goreborg, SIIrEDEN

Sa11ey Reynolds ShannonSuiÈe 203L302 lSth Streer, N.W-I,Iashington, D. C. 20036

P¡me1a J- SinerlyHealth ProgramOffice of Technology AssessmenËU. S. CongressI.IashingÈon, D- C- 20510

St.atens Institutt for FolkehelseGruppe for HelsetJ enesteforsknlngFR StangsgÈ ffl13Oslo 2, NORWAY

Judith L. Wagner, ph.D.Technology Research AssociaËes7816 Glenbrook RoadBethesda, MD 20814

THE SORCERER' S ÀPPRENTI,CE

CUHUT.AIIVE INDEX 10 VOLUMES I AND 2

By SubjecÈ

Nuobers e.fc,er entries refer co Voluoe-Nunber-Page.Publlcaclon daÈes:

VoI.I, No.l !s Jao. l98l; Vol.t, No.2 ls JuIy l98l;VoI.2, No.l ls Jan-. 1982; Vol.2, No.2 is Apr. 1982;Vol.2, No.3 ls Jut.' 1982; VoI.2. No.4 fe Oct. l98L

eppEopriãçe healch technologY 'in develoPtng

countrles............2-3-5, 2-11-14

in European Region of t{HO. .....2-3-3prográri of WHO Eur. RegI. Off..2-l-3lransfer t.o develoPlng counÈrles'

PrajecÈ Hope conference on. ..2-3-2

Argentfna,healch serv. research in.....I-1-3

assessoenÈ, see technology assessnent

Australia,confetence on lechnoloSles for rhe

reduc!fon of health cosÈs.'"2-3-3NaËtI Health Technology A,ssessoent

Mv. Panel, creaÈion of ... " '2'1-3

Iglurn, GI scanners 1n. . ... ... .2-2-lO

BIREHE (Regt1 ìfedical Library for theAnericas) ......1-l-3

book review,Clinical Decislon Analisls. "'?-J--LLCost-Benef 1t and Cost-Ef fectfveness

Analysis in HealÈh Care.. ...2'4-19Innovacion fn Health PólfcY and

Service. ......2-2-LsThe Technologtcal Consclence' . 2-3-10 e

Canada,. approach uo health technology''l-2-9

g,tia.ttnu" for speclal svc6... .L-2'7h-ealch 6ysÈe¡û of .... ....1-t-3process of oaklng revisl'ons Èo Èhe

ìlanlcoba fee oahual. ..2-2-3

eliirical trial8 'cervlcal cerclage ln England. .'2-L-7of CT scanning... .. .., .2'?-llln perinacal reeearch. ..2-l-7

. ln the Unlced Kfngdoo. "2-3-4

confe rencee ,Approprface HealÈh Tech. lranefer to-òevàloping

CounÈrleg (Us)...'2-3-2Asaes6¡qenÈ of Blmed. lech. fn Èhe

Health C¿re Fteld: IncernatLonalPerspectlves (Dennark) ......2-L-L7

' A.saeaeænc of l'ledical Technology(Finland) .... "2-4-2

Bellaglo conference (Italy). . .' l-l-3' Bcon. and Hed. EvaI. of Health Care

Îèch. (Sr¡1t2.)...2-l-16 and 2-2-10Frank Ì'1. Norfleet Forur¡ for Èhe

Advanceoånt of gealÈh (Us)..2-I-r8

Intrl. Conf. on Ne$ lechnologl'ee forthe Reductfon of Bealth Coets: thelopact of lfedlclne and GovÈ. Pol-Ícfee (Auecral.)..2-l'17 and 2-3-3

Legal aod Echfcal $,sPecce of gealthõare for chfrdren (us) " ' " '2-1-17

Syup. on AsseasnenÈ of Blooed. lech'1n tt¡e ltealth Care Fteld: IntrlPerspectlve8 . .2-2-I I

t{orld Congress on Hedlcal Physlcsand Blo¡oedlcal Engtneerf ll.9..2'4-16

con6engus develoPoent'fn Sr¡eden. .... '2-3-4

daLa base6, I'GDLA.RS/I{EDLINE- '. ..2-4-5

Denoark,centrel funding of captcal.

and operaEtng coeÈe ln. . - ....2-4-4Cor¡mltEee on Plannlng of Servlces

and Refer¡al of PatlenÈs. ... .2-4-4cosÈ-contatrEent efforts Lr.. .. .2-4-4CT sc¿nners Ln..........!. .....2-2-10Danish. IIospital InscfÈute. . ....2-4-4Danlsh Hed. Regearch Councfl. ..2-4'5purchase of oedlcal equlpaenc..2-4-4rechnology as6easEer¡È 1n. .. . .. .2-4-2

developlng councrfe6'approprLate health technologY

fn.... .2-3-5, 2-4-L4appropriate healch Èech. transfer

to, conference on.Approprfate Health Resources and

lechnológies Accton GrouP. ...?-3-7"cold chaln" sÈor.age of

vacclnes. .. - -..2'3-6dencal servl.ces tn.... ..2-3-6dlarrhoeal dlsease, conÈroI ot.2-3-6dtsablltÈY Prevenclon and -

rehebllltation.-. -. ...... ....2-3-6pedlaErlc lnfeccious diseases'

concrol of.... ....."2-t1-L4prlmary health ðare ln. 2'4-14saÈeIlf Ee cooounlcatlons and health

. and soclal services in.... ...2'2'4utllfzaÈ1on of ¡ned. tech. ln...2-3-6

EnglandheêlÈh econoofcs research la...l-2-2InstituEe of Social and Econo¡alc

Research. ......1-2-.2oedical records llnkage ln-.. - . l-1-3Nacional Perinacal Epiderolology

Unlt.. ..2-I-6nu¡ober of CT scanners in.....'2-2-lO

, l.lorklng ParÈy on Expensive HedlcalTechniques. "'2-l-1f

Europe,approprÍate cech. in the Europe.an

Regloa of ltBO. .2-Y6Coonlsglou of the European

Cmurmltiee. ..2-l-18European Ëealth Pollcy Foruu.... 2-3-4European Hedlcal Regearch Counclle,

cosponaor of fnttl. eyopoeiun onaaaeag. of bfooed. tech. . .. .2'2-ll

Europeaa R.eg I l. Of f . of mO. . .2-2-l theelth plånnfng ln. ... ..2-l-2heal¿h cechnology aaaea6uenÈ netnork

of European Reglon of IJHO....2-3-3nunber of CT scannerg fo......2-2-LOOECD ueerlng . ... . l-l-4reglonallzaclon ln. ... ' .2-l-2soclsl Lnsurance re͡oburse-

r¡eûË: . . .2'l'2cechnology a6ses6ãrenÈ fn. .. . , ..2-l-4

ffln review,8.T... . ..2-4-10

Finland,conference on cechnologY

assessnènE. ....2-4-3healch plannlng in..............1-l-3cechnology assesarlenÈ in..... ..2'4'3

France,Blonedfcal lechnology Board,

creeÈ1on of. .... . .....2-3-4CT scannere fn.... . ....2-2-10Eech. e6sesstrenc in.....1-1-4, 2-3-4

Geraany,CT scanners 1n..... . . ...2-2-10pollcfes tÞward Eedlcal

devlces f{. :.. . .. ....2-4-L7

health econoofcs research,!n England. .....,,.

I. ..r-2-2

heal¿h planning,in Denaerk. .....2-4-4ln Europe. .......2-l-2tn Ffnland. ...... l-t-3

healEh servfces research,ln Argentina .. . t-l-3

Hungary,health expenditures ln. ... .....2-3-3medical Èechnol-ogy in..... .. ...2-3'3

2',1

fnforoatfon and fnforEatlon Èransfer,Iodêx ìledlcua. -...foforaatfoo develoPoent and

dfeeeofnatfon... ¡. .... l-f-3MSDTARS/HEDLTNE. . . . . - . .?-4-5 ' 2-4-12Ì.Éatloaal LlbrarY of Hedlclne

(us).. ..2-4'5'Bedtcal record6 llnkage

fn Englatd. " "1-1-3oallne ãaÈa baeee, accesa to"'2-4-5

Inter-natlonal SocfeÈy on lechnology1D Healch Cåre'plane for. .."2-3-7, 2-11-24

Jagan,."¿fátr technology: regulation, re1'o-

burgeæuÈ' and aaaeasnênt' "'2-y3

LåÈlû AEeticatBIRII{E (Reglonal Llbrary for the

Aærfcae)..

Organizatfon for Econonlc CooperaÈfonáEd lÞveloPltent' Deetlng' " " I-l-4

qualltY assurance'1n the NeÈherlsndg... 'l-l-3

Reglonal ùedlcal LlbrarY for Èhe

ÁDerlcas (BIREITE) ..."1-l-3

rehablLlÈaclon 'df aabll1ty prev. and rehabllltatlon,r:i ln developlag cormtries. . . " ' 2-3-ó 'i.. lnt I I. exchange of

lnforuatlon o.n.... "'l-2-10Robert llood Jolineoa Foundatlon'

g¡aûts for... '2-l-18Unlverefty Center for Internatlonal

Rchabllttatlot¡.... .. . l:2-10

Roster of Sorcererts ApPrentice Net-eorL l{enber8 " " "2-3-15À I

A¡oer. Society of Law and Hedlclne

(u.s.). .......2-l-l'7Approprlace Healch Reeourcee and

' i."ù. Actfon Group (u.K.). "'2-3-7Agen. for tleslth Servtces

ReEearch. . " "2-4-22Cen¡er for EducaÈlonal Technology

for Eealth (Hexico) ' l-2-15Cencér for Èhe Aúa1ys1s of HealEh

Practlcee (U.s.) ""2-l-16Cencer for Eealth Servlces

Research (U.S. ) .. ..'.. l-2-16C@nunltY Prograas for Affordable, BealÈh Care (U.S.) "2-l-19C.ongreeelooal Clearlnghouae on

the Fucure. .,.2-L-16ECRI (u.s.)....¡... ...2-l-16Frank Bor¡e Ageoclates (U.S.)

Rob€rc úod Johnaoo FoundatLon(u.s. ). .2-l-18

Socfety for tledical DeclElonHåkfag (Intrl.) ......2-f-15

Soclety for RteL Aoalysfe..... l-2-¡6Studles of the FuÈure

Progrsû (U.S.). .....1-2"Unlverslty Center for Interuatlonal

Rehabtlttatloa.... ...I'z-LzUolv. of tlanlcoba (Canada). ....2-2-3

Spain, CT ecannerg fn...........2-?-10

sgredeo, l'

flreÈ coneenaua develoPnentæecing 1n EuroPe. ....2-Y4

SPRI evaluatlon of dlffeqentaaaeaaænt oethode. ...2-3-4

techoology aaaeÊaoenÈ 1n.... ...2-3'4

technology assessoenG'Bellagto cooference. ....1-l-3cosÈ-beteflt analYele. .2'¿t-19coet-ef fecclveneee analyets. ..2-4-191n Australls .....2-T3ln Canada..¡à¡¡¡¡¡ ......1-2-óln Deno¡rk. ......2'4-2ln Europe. ..... ...2-3-3in France. .......1-1-4, 2-3;41o Geroany. .....2-4-16ln llungary. .... ..2-3-3ln Japen. .2-3'3ln KuwafÈ. ...,..2-4-L6ln Norway. .... ...2-Y41n S¡¡eden. .......2-3-4-2-4-2ln che llnlted tëngdou. .'.z-Tqln Èhe U.S... .,1-2-4, I'2-12, 2-4-L9lntrl necr¡ork for reporÈ1ng problene

r¡lth uedlcal devlces. .......2-4-i-neÈnþrk ln Eur. Regfon of I'IEO'

úeeÈlng on.... .2-3j¡regl.scry approach Èo therapeutfc

evaluatlon. ...1-2-12synEhe8ls of fnforlÂaÈlon for poucy-

: roåkfng, Prlnclples of........1-2-8see aleo Off,. of. Tech. Àseessuent

ttnlted Klngdoa'cll.nlcel trlsls 1n.... - -2'3-4expeodlturee on eval. of ædical

equlpoeoc 1û.... .,....2-3-4Medical Reeearch Corsrcil. ......2'3-4

lloited StetesrNatlonal CeoÈer for Ueallh Care

lechnology.. ..L-2-4, 2'4-19NaE1o."l Eeart Lung and Blood

: IneEltute PlrcA Reg18try.....l-2-t4í Natloual Ltbrary. of l{edlc1ne...Z-4-5

Offlce of Eealtb leclmologYAase8ar¡ert (DsEs) ....2-4-L9

pollètes tonard aedlcel devlceelû . ... .......2-4-16

technology aaaeasænt fn.... ..2'4-Lg

tlortd Congres8 oo Hedical Physlceaud Blouedlcal Engloeerlo;g..2'4'16

Hofld Beslth Orgaaizatlon'Aloe-Ata coufereuee on PritlarY

i¡edfcal technologY'coata of 1n che U.S. '

EeeÈ1ng ôr¡...¡ """'2-l-18ta Denoeik """'2'4-4lu develoPlng counErie6

.....:. . .2-3-2, 2-3-5, 2-4-L41n Flnland' """2-4-4ln Geroany. ""'2-4-16J.n llungarY. "'"'2-3-3ln l{exlco. """'2-3-2

l{exlco 'CeEÈer of Educatlonal lechnologYfor Healrh. "'l-2-I4

utlllzaclon of new oed{caltechnology fn."" ""z'Yz

Necherlar¡d8,' quallty aasurance Ln'"""''l-t-3

Norfay;Iû881Èuce for tleelth Servlces

Reaearch. " " "2-3-4cechnology åasessnenÈ ln" " ' "2-3-4

offfci of lech. A,s6ee6EenÈ (U's')'cooPeosaÈ10û for vacclne-I rätuced tnJurlee' rePort on"l-I-7cosc-ef fect{veness analYsls of

qedfcal technologY'. : rePort on."'.' """'2'4'12effftacY and safetY of nedlcal

GechDologfes' rePort on"" "2'L-4gastrolûtestlnal endoscoPY'-

"""" eÈudY on. 'l-l-3

lofluenza vacclne cost-ef fectlveness.. analYsta of.... """'l-l-7nedlcai technology under coopetl-

È1ve ProPosale. """2-4-13HEDIARS, rePorÈ on...' '2't1-12N¿tfonal CenÈer for Health Care

. Tächnology, staff PaPer on' "2-I-4pnèuoococcal vacclrie, cosÈ-

effec¡Lveness analysis of" ' ' i-I-5poeÈûarkeci'og eurvefllance of pre-

scrtPÈfon ãr,tg", EePort on:'2-4-13atrategl"e for oedical technology

a{¡sesaÍ¡ent' rePorE on" " "'2'4-Lzsrrãdrst vfslcors ¡o""' """'2-4-3

' technologY and handfcaPPedpeoPle, rePort on"'l-2-18' 2-l+-L2

U.S. vacclne pollcles' rePorE t_r-qoo....

......2-l-15Healch Councll of the

l.¡€Ëherlaûdg. ...2-2'9Health Sen¡fces Df recÈorace

(Caneda). . . .. .. .l-2-7Inscftut.e for Eealch PolfcY

srudles (u.s.) .......2-I-15&LstlÈute for Research on Publfc

'Pol1cy (Canada). ...'2-I-I9Ins¿,1tute of Eealch Ecônæ1cs and

TechnologY Aaaessnent(¡ue¡rdlã) ...2-l-L7

IneÈft,uEe':of Socf al and EcononlcReeearch (England)

.. .. . .1-2-4 , 2-l:16 , 2'2-llLdternactonal ttosPltal

Federaclon. .. .2-4-22læhfgh Uotverslcy Scleuce, Technol-

ogt, "aad Soclety Prograu....2-l-15Hanftobs Health Services

Cmnf eslon (Caaada). "2-2-3l{aternlEy center Aesn. (u.s.).1-2-I8NatLonal AcadeoY of Sciencès

(u.s.) 'l-2-16NaErl. C¡¡ce. for Cllnfcal l'aboracory

Standarde (U.S.)...1-2-15' 2'4-22Project lloPe In6ÈltttÈe for

Hãalch Pollcy (U-s.). ...."'2-1-2Publlc ClÈlzen's HealÈh Research

health care.. .2-4-14Approprlâte Eealth Reeourcee and' techoologieo Actfon GrouP. ...2-3-í

approPrlate technologY 1n tlEo \Èuropean Reglon. ......2-3-3

data baae for ¡oedlcal technologYaaaesaent. ... '2'4-2

European Regloo health technology

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INFORMAÎTON FOR CONTRIBUTORS

Submlssions are encouraged. Send yourmanuscrlpts (2-8 double-spaced pages) onprograns, actlvftLes, research results, oroÈher substanËlve LoPics, book reviews,annolrncements of upcdning conferences,reports of recent conferences, publlcatlons'or studles to 1302 l8Ëh SE., NInl; SulE.e 2O3;l.Iashington, D.C. 20036, or to Clyde Behneyor Davld Banta aÈ the Offlce of TechnologyAssessment; U.S. Congress; I{ashlngton, D.C.205 I 0.

Meubership or subscrfption inqulrles,changes of address, and str-milar correspon-dence should be sent to Èhe lSth St. address

@ 1982 Sttff Little Comounlcatlons

All rnaÈerlal not prevlousJ-y copyrÍghted naybe reprinÈed w'Lthout permlssloo,

but credlt would be swell.

Vo1.2, No.4 October 1982

inr soncrnrR' s A?PRE¡ttTcE