Recent health reports, including the 1993 World Development Report, have emphasized the importance of integrating the needs of the population into technology assessment. This paper reviews previous approaches to technology assessment and identifies the missing link between technology and its impact on the physical, emotional, and social needs of the community, namely needs-based technology assessment. It stresses the key role played by issues of equity and community values in making technology decisions. A number of models for needs-based technology assessment are described.

Investment in health can offer additional benefits to development independent of economic improvement. Many technologies have been useful in improving the health of the people in the past. However, rapid and often unpredictable change has contributed to the inequity, inefficiency, and rising cost of health care. This paper outlines why a needs-based approach to assessing any new technology in the health sector is essential. To respond to changing needs, capacities within the health care system, several of which are described here, must be strengthened. Needs-based technology planning and implementation is affordable and feasible and is crucial in order that both health as a basic human right and good health at low cost can be attained.

Countries worldwide spend huge sums on health—about $1,700 billion a year, or roughly 8% of global income. But the World Development Report 1993: Investing in Health shows that these monies could be spent much more wisely, in the process doing a great deal to help the world's 1 billion poor. Essential national public health and clinical packages are proposed based on assessment of the burden of disease (measured in disability adjusted life years) and the cost-effectiveness of interventions. Governments can play a central role in improving the health of their citizens: they can foster an environment that enables households to improve health and they can also improve their own spending on health, targeting it to support universal access to essential national public health and clinical packages based on the above methods. This is a good example of the concept of needs-based technology assessment, combining the disciplines of epidemiology, economics, and policy formulation. When applied, it should lead to improved effectiveness, efficiency, and equity.

This article describes the experience at the Greater Victoria Hospital Society of assessing the appropriateness of introducing laparoscopic cholecystectomy (lap chole) within the framework of an established technology assessment process. Lap chole promised to deliver cost savings; however, these could only be realized by capitalizing on the reduced length of stay by removing the surgical beds from service. A cautionary note is raised as to whether the increased use of lap chole in the population is appropriate.

Essential national health research (ENHR) ensures that health research will be undertaken in priority areas defined by the people and will be used in decision making. Needs-based technology assessment (NBTA) is anchored on the ENHR philosophy. Two case studies are presented, one illustrating a successful application of NBTA and the other a failed approach. Reasons for the difference in success are examined.

The three-stage World Health Organization-International League of Associations for Rheumatology Community Oriented Programme for Control of Rheumatic Disease (WHO-ILAR COPCORD) is described. Stage I results from Indonesia and Brazil are presented. This is a needs-based approach that offers efficiency in large-scale survey research that aims to estimate the prevalence of rheumatic diseases. It saves human resources, time, and cost in the collection of epidemiologic data. Awaited with interest are the results of the next two stages of COPCORD, which involve the development of educational programs on rheumatic disease and the evaluation of their impact on the burden of illness.

This paper outlines the need for and development of a practical set of tools to improve needs-based health management and technology assessment. International reports have documented the lack of adequate information for the managerial process in primary health care. The components of the Primary Health Care Management Advancement Program (PHC MAP) Series, designed for both manual and computer applications, are described. The series has been widely pretested and is currently being implemented by many government health services and nongovernmental organizations worldwide. Information is included indicating how the PHC MAP materials may be obtained.

While international variations in intervention rates are well recognized, little is known about their implications for patient selection. This paper describes an exploratory study in which the probability of undergoing an elective intervention (surgery for benign prostatic hyperplasia) in an area in the United Kingdom was compared with an area in the United States. It found that the area with high intervention rates was associated with higher levels of surgery in men with low levels of need who are unlikely to gain much benefit.

The extent of variation in the use of breast-conserving surgery was analyzed using the 1990 and 1991 hospital discharge data of Lombardia, Italy. The proportion of patients undergoing breast-conserving surgery for unilateral breast cancer was estimated for each of the 10 geographic areas (9 provinces plus metropolitan Milano) in which the region is divided. Overall, the rate of use was 41% of 3,225 patients in 1990, and 45% of 3,736 patients in 1991. In both study years, patient age was strongly correlated with the likelihood of undergoing conservative surgery, with younger women more frequently treated with this approach. In each province, patients treated at centers located in the main city had a greater probability (OR, 1.54; 95% Cl, 1.37–1.69) of having conservative surgery. This procedure was also more often used in private hospitals (OR, 1.59; 95% Cl, 1.20–2.08) where care is paid at the point of consumption by patients, directly or through their private insurance. The observed variation in the use of the conservative procedure across the 10 regional areas was greater than that expected by chance alone (p <.0001), with rates ranging from 29% to 60%. This pattern persisted even after adjusting for the relevant patient and hospital characteristics. Despite the relatively large body of scientific evidence, it appears that the surgical management of breast cancer is more dependent on physicians' attitudes in each geographic area than on individual patients' characteristics.

In a cross-sectional, retrospective study of 604 cases, variations among three Norwegian hospitals in use of perioperative parenteral nutrition (TPN) after gastrointestinal surgery was determined. Postoperative TPN rates were 25%, 34% (p =.05) and 56% (p <.0001). respectively. However, a substantial part of the variation was explained by differences in patient characteristics.

Over the last few years, the pharmaceutical industry has financed an increasing number of health economic evaluations. The purpose of this article is to describe how and why the pharmaceutical industry is applying health economic evaluations. Seven different fields of application are identified, and the varying reasons for use are discussed.

This paper reports the results of a study of the association between volume of activity and patient outcome in 26 intensive care units in the United Kingdom. Hospital fatality rates showed a statistically significant (p =.016) negative association with volume. However, mean APACHE II scores, as a measure of the severity of case mix, were also negatively associated with volume (p =.021). Thus, one explanation of the lower death rates at higher volumes is that larger units admit less severely ill patients. For patients admitted immediately after surgery, the correlation between severity standardized mortality ratios and volume (while not significant, p <.1) suggests there may be a volume-output effect unexplained by severity.

Eighty-one published papers on the performance of prostheses in total hip replacement were appraised. Sound methodology was demonstrated in 1 of 8 randomized controlled trials and 4 of 17 nonrandomized comparative studies. Of 56 case series without controls, 32 met the appraisal criteria, but these are intrinsically less useful. The published literature does not provide solid evidence for the superiority of cement-free or hybrid prostheses over modern cemented types.

While laparoscopic cholecystectomy is now widely used, diffusion of other laparoscopic surgical methods has been more modest. Uptake of most laparoscopic methods has been influenced by considerations of effectiveness compared with open surgery, competing minimally invasive therapies, and the inconvenience and cost of technical change.

The possibility of restoring fertility among some infertile couples through assisted reproductive technology has led to questions about the terms under which such treatments should be made available. Although there is now evidence on their effectiveness, there is considerable variation in the availability of these treatments under the U.K. National Health Service.