Ergebnisse von TA-Projekten - neue TA-Projekte

by Koos van der Bruggen

Introduction

Medical Technology Assessment (MTA) has received a lot of political attention in the Netherlands the last few years. In February, 1994, the Dutch Parliament held a hearing concerning the state of MTA in the Netherlands. Later that same year a new coalition-government was established. In its first declaration of policy the cabinet stated that there should be a law on Medical Technology Assessment. Of course these political activities led to much discussion and debate in the Dutch MTA-community. The Rathenau Institute played a part in this discussion by carrying out a project in which the organization of MTA in the Netherlands was evaluated, and by presenting its conclusions to parliament just before a debate on MTA was held.
In this article I will give a short overview of the main lines of the political discussion, the contribution of the Rathenau Institute and the results so far of this process.

Profile of the Rathenau Institute

The Rathenau Institute has the task of supporting societal and political opinion-forming on questions surrounding science and technology. The Institute has developed various methods to perform its task, varying from organizing discussions and public debates to instigating scientific research.

The Rathenau Institute is independent and targets the conclusions of its projects to the Dutch parliament. Once every two years the Second Chamber of parliament discusses the Rathenau Institute's work programme, in which the most important themes for the coming period are presented.

Organization of medical technology assessment in the Netherlands

During the hearing of Dutch Parliament in February, 1994, many achievements were highlighted, but one problem was mentioned by many groups testifying: Dutch activities in health care technology assessment are fragmented and sometimes duplicatory and leave many important issues untouched as well. Furthermore, the lack of a coordinated effort in this field hampers international cooperation.

The Rathenau Institute asked the research organization TNO-PG [Netherlands Organisation for Applied Scientific Research, Department of Prevention and Health] to prepare a report on health care technology assessment in the Netherlands, focusing on the last 10 years. TNO was asked to describe past developments in the field, the present situation, and possibilities for the future. The aim of the report was to contribute to a discussion of the organization of medical technology assessment in the Netherlands.

Definition of medical technology assessment

Broadly conceived, medical technology assessment can be defined as a structured analysis of a health care technology, a set of related technologies, or a technology-related issue that is performed for the purpose of providing input to a policy decision. Dimensions evaluated in MTA include not only benefits and risks (efficacy, effectiveness and safety) and financial costs, but also technical aspects and social, ethical, legal, and cultural issues concerning the use of technology.

The main arguments and conclusions of the TNO-report on the organization of MTA in the Netherlands are as follows:

The Netherlands has been one of the world leaders in developing technology assessment information. The last decade has seen rapid development of institutions for health care technology assessment. Many researchers have been trained, and are in training. Resources are available to support assessments. Results of MTA are of high quality and are increasingly visible nationally and internationally.

The Netherlands has also been a leader in policy development. Policies have been aimed mainly at controlling health care costs and at rationalizing the introduction and use of high technology services. A number of policy-related organizations is involved in different aspects of medical technology assessment. Several government agencies depend on technology assessment in making decisions. However, many organizations involved work largely autonomously and without much attention to the activities of others. Work is sometimes duplicated but also many important subjects are not investigated.

Policy-oriented organizations have begun to coordinate their efforts, but there is no ongoing forum involving policy-makers, clinicians, researchers, insurers, and the public. The outcome is that the results of MTA have not had the impact that they could have had. So MTA seems to have had little impact on clinical (micro level) or administrative (meso level) decisions.

It has become apparent that information from technology assessments is not having the desired effect on health care practice. In other words, merely disseminating information often does not lead to change of behavior. This has led to an increasing emphasis on implementation to improve clinicians' compliance with MTA recommendations.

A conclusion is that, despite many accomplishments, much remains to be done. Some examples: many thousands of "small-ticket" technologies remain unassessed in most cases. It is becoming clear that many health care technologies are used for medical indications where benefit is unlikely or has not been demonstrated. MTA in the Netherlands has focused largely on hospital technology, often capital-intensive technology, while neglecting other needs, such as extra-mural technology and technology for disabled people. Social, legal, and ethical analyses are uncommon.

The six main problem areas that can be addressed are as follows:

Problem 1.
The institutions for health care technology assessment have developed separately and without coordination. The result is ineffective attention to national needs for information. The government has taken little leadership in this field.

Problem 2.
Priority-setting is not carried out effectively. One problem is that models for priority-setting have not been worked out and implemented.

Problem 3.
The methods of technology assessment are many and varied. Methods should be matched to the problem being addressed. In addition, methodological developments are needed in many areas to assure valid results. International cooperation is necessary in methodological development to assure that the results of work can be fully shared.

Problem 4.
Although synthesis methods have been rather well-developed internationally, synthesis is not a method in widespread use. Correct interpretation of the medical literature and of recently completed studies requires the background of a full and accurate synthesis. Synthesis activities need to be developed and supported.

Problem 5.
The results of technology assessment have not been effectively disseminated. The lack of effective dissemination has been associated with continued patterns of poor quality care and cost-ineffective care. Increasingly, the literature uses the term "implementation" to indicate a more active process than dissemination of information. More attention for implementation of MTA results is needed.

Problem 6.
An analysis of the processes of technology diffusion and the effects of different policies on diffusion is urgently needed.

Political discussion on MTA

As already said, the project of the Rathenau Institute was carried out in a period when there was great interest for MTA in Dutch politics, especially after the new coalition-government stated in its first declaration of policy that there should be a law on Medical Technology Assessment. The new Minister of Health Care, mrs. Borst is a great expert on matters of MTA. She was vice-president of the Dutch Health Council, the most important advisory body on health care policy for the government. Furthermore she had taken part in national and international organizations and activities regarding MTA. Mrs. Borst asked her department to investigate if legislation on MTA really was necessary. The actvities of the department were conducted in the same time as the project of Rathenau Institute. Because of that it is understandable that information was exchanged between the department and the researchers of TNO. This was illustrated by the policy letter "Policy letter MTA and efficiency of care", which was published by the Minister of Health Care in November 1995. In this letter she presented her proposals regarding MTA.

The letter illustrates the fact that the Minister attaches great importance to the efficiency of money spent on health care. The Minister considers Medical Technology Assessment (MTA) an instrument able to contribute to improved efficiency in health care. Her proposals about the use of MTA in promoting more efficiency in health care were on main points in line with the most important conclusions of the Rathenau-report:

1. Coordination and prioritization of MTA-research

2. Stimulation of synthesis and dissemination of MTA-knowledge

3. Stimulation of implementing MTA-knowledge.

The Minister proposed a number of concrete measures to implement her proposals, e.g the organization of a "national efficiency research programme". But she came to the conclusion that a special law on MTA was not necessary, if existing regulations and institutions wouls be used more effectively.

Report to the parliament of the Rathenau Institute

Because of its advisory function for the Dutch parliament, the Rathenau Institute has written a Report to the parliament. In this Report some conclusions of the TNO-study were translated into recommendations. Furthermore the Report was a reaction of the Institute to the "Policy letter MTA and efficiency of care".

This report was formally presented to the parliament one day before a debate on the Policy letter. Some important issues in the Report to parliament are:

The concept of efficiency

The concept of efficiency has not yet, or not yet sufficiently, been made operational in policy practice. The test criteria resulting from these definitions generally limit themselves to one sector of health care. MTA can contribute to operationalising the concept of efficiency. This contribution lies at the level of specific deliberations regarding individual technologies, and between technologies in a certain area. With regard to the quest for efficiency in the area of health care as a whole, the contribution of MTA is however much less clear.

In the opinion of the Rathenau Institute, a "national efficiency research programme" as considered by the Minister should specifically set down what the operational definition of the concept of efficiency within a certain programme of research should be. The added value of such a programme in relation to existing programmes should also be set down.

Broadening MTA

According to the Rathenau Institute, broadening MTA should involve as many aspects, parties and actors as possible.

Aspects

MTA should not be limited to technical and/or economic aspects. The social, ethical and legal aspects are given low (financial) priority. These can, however, be of great importance to increasing efficiency in health care and should be given higher priority.

Parties and actors

The Minister attaches importance to the fact that in the development of future protocols and guidelines (on the basis of MTA) not only suppliers of technology should be involved, but also health care insurers and those seeking help. This procedure can lead to so-called tripartite guidelines. The Rathenau Institute considers jointly drafted protocols an important means to intensify the interaction between the important parties of the health care sector.

Following the plea to broaden MTA, the Rathenau Institute makes the following recommendations:

Take into account the differences in perspective of those involved, for instance, health care insurers or patient organisations, during the prioritisation process.

Examine the question why so little use is made of the possibility of doing research into the ethical, legal and social aspects of the use of medical technology.

Prevent one-sided orientation of MTA activities through the creation of cooperative arrangements, for instance, with the departments of Economic Affairs and Social Affairs and Employment.

Involve more factors in MTA (for instance social-economic, cultural or environmental questions) by requesting an explicit explanation of the manner in which they can be involved in the research at the proposal stage.

Discussion in Parliament

Seldom a Minister will have had such an easy job in parliament as Mrs. Borst when she defended her policy letter. Members of all political parties (also of the opposition) supported her proposals and agreed that a law on MTA was not necessary. Several speakers referred to suggestions that were made in the publications of the Rathenau Institute, e.g. by pleading for broadening the scope of MTA research.

Ongoing process

After the debate the Ministry has started to implement the proposals in the policy letter.

The result of this whole process so far is that attention for the possibilities of MTA has been more widespread in Dutch society, especially in the health care sector. More clinicians know the possibilities of MTA and this enhances the chances for implementation of MTA-results. The measures that are prepared now by the government are intended to stimulate this process further. But it is not only government that takes action. The Dutch 'MTA-community' has started its own "Association for Technology Assessment in Health Care" which has now about 200 (individual and institutional) members.

As Rathenau Institute we are satisfied that our publications have proven to be useful tools in this process towards an improvement of the organization and implementation of Medical Technology Assessment in the Netherlands.

References

H.D. Banta, W.J. Oortwijn, W.T. van Beekum, The Organization of Health Care Technology Assessment in the Netherlands. Rathenau Institute, The Hague 1995. [in English]

E. Borst-Eilers (Minister of Health Care), Beleidsbrief Medische Technology Assessment en doelmatigheid van zorg. The Hague, 28 November 1995. (Policy letter Medical Technology Assessment and efficiency of health care). [in Dutch]

Koos van der Bruggen, Chris Tils, Doelmatigheid van zorg. Hoe kan MTA eraan bijdragen? Rapportage aan het Parlement. Rathenau Institute, The Hague 1996. (Efficiency of health care. How can MTA contribute?) [in Dutch; English summary of 3 pages included]

Koos van der Bruggen
Rathenau Institute
P.O. Box 85525, NL-2508 CE The Hague
Tel.: +31 70 3421542
E-mail: K.vanderBruggen∂rathenau.nl
Internet: http://www.rathenau.nl