We challenge assumptions that have guided much research and policy aimed at understanding and reducing medical practice variation. Paramount is the focus on doctors as the cause of variation to the neglect of other possible influences. Some research literature suggests that patients, families, and the community context of practice may also influence treatment decisions. Failure to question present assumptions, despite weak evidence in support of them, may account for inability to explain persistent practice variation, develop appropriate implementable guidelines, or anticipate the effect on treatment decisions of greater patient involvement. In this paper, we discuss the weak response to the NIH Consensus Conference on early stage breast cancer because it may have reflected these problems. We urge a more complex and more empirical approach in explaining treatment choice and guidelines sensitive to the potential for value differences.

Objectives: The assessment of electronic fetal monitoring (EFM) carried out by the authors in the late 1970s provides an early case of a systematic review of evidence in health technology assessment. This paper identifies lessons pertinent for the present day in this field.

Methods: We reviewed our own files for the description of our assessment and reactions to it. We also reviewed recent literature to evaluate our observations in relation to recent evidence.

Results: Our findings of insufficient evidence of efficacy and concerns about safety have been confirmed by subsequent research. Still, despite findings and recommendations of prominent professional and governmental bodies, EFM continues in widespread use in the United States and Europe and is spreading into developing countries around the world. Aggressive attacks on our assessment as well as our skills and integrity have been mirrored in recent years by criticism of other researchers in health technology assessment.

Conclusions: The case of EFM points to the limitations of assessment without other actions to assure the implementation of results. Health technologies that are accepted by the majority of clinicians in a particular field may require extraordinary efforts to assure appropriate use of technology assessments.

Objectives: This paper explores the use of evidence, focusing on economic evidence in particular, in the development of local health policies through an in-depth study of Health Improvement Programmes (HImPs) in England.

Methods: A questionnaire was sent to the person responsible for coordinating the development of the HImP in each of the 102 English health authorities. In addition, semi-structured interviews were conducted with 10 HImP leaders, and a random sample of 26 HImP documents was reviewed using a standard pro forma.

Results: Of the 102 mail questionnaires sent out, 68 (67%) were returned. It was found that those developing HImPs had multiple objectives, only some of which (e.g., efficiency in healthcare provision) would necessarily require evidence. Where evidence was used, this was a mixture of internal (experiential) and external (empirical) evidence, with the balance (66%) being in favor of the latter. Government reports and guidance from the National Institute for Clinical Excellence (NICE), were the main sources of external evidence, rather than published papers. Key barriers to the use of economic evidence were lack of time and availability and the difficulties in synthesizing information at the local level.

Conclusions: Based on responses to our survey, the main ways of increasing the use of evidence in the development of local health policies in England are to produce more evidence-based national guidance and to produce accessible summaries of the available literature for local decision makers.

The Bayesian approach to statistics has been growing rapidly in popularity as an alternative to the frequentist approach in the appraisal of heathcare technologies in clinical trials. Bayesian methods have significant advantages over classical frequentist statistical methods and the presentation of evidence to decision makers. A fundamental feature of a Bayesian analysis is the use of prior information as well as the clinical trial data in the final analysis. However, the incorporation of prior information remains a controversial subject that provides a potential barrier to the acceptance of practical uses of Bayesian methods. The pur pose of this paper is to stimulate a debate on the use of prior information in evidence submitted to decision makers. We discuss the advantages of incorporating genuine prior information in cost-effectivene ss analyses of clinical trial data and explore mechanisms to safeguard scientific rigor in the use of such prior information.

Objective: The objective of this study was to examine the economics of administering calcium and vitamin D3 to post-menopausal women in Sweden. We focus primarily on the cost-effectiveness of treating older women for whom clear evidence of efficacy is available. We supplement this information, however, with estimates of the cost-effectiveness of treating certain high-risk groups of younger women, while acknowledging the greater uncertainty involved.

Methods: We developed a Markov model for analyzing the occurrence and timing of hip fractures, based almost entirely on peer-reviewed data from Sweden. In a 3-year randomized clinical trial, the combination of calcium and vitamin D3 was shown to reduce the risk of hip fractures by 27%. Costs for treating hip fractures were based on 1,080 women who were hospitalized in Stockholm.

Results: Treatment of 70-year-old women was cost saving at efficacy as low as two-thirds that seen in the clinical trials, and upwards. Even at modest rates of efficacy, treatment of the high-risk 50- and 60-year-old cohorts was generally cost-effective and in some cases even cost saving. Particularly cost-effective was treatment of women with identified osteoporosis or a maternal family history of hip fracture.

Conclusion: Simulation results suggest a role for lifetime treatment of older women with calcium and vitamin D3 in Sweden. While there is more uncertainty underlying the treatment of younger women, our simulation results suggest that treatment may also be cost saving or at least cost-effective for many cohorts of high-risk 50- and particularly 60-year-old women, in particular those with osteoporosis or a maternal family history of hip fracture.

Objective: To identify training programs and educational resources in health technology assessment (HTA) in Europe.

Methods: A postal survey among potential informants in European countries and Israel, expanding on surveys among ISTAHC and INAHTA members. Informants were identified either using HTA networks or by means of Internet sources.

Results: The combined results of the three surveys show that in the European Union (EU), including Norway and Switzerland, 13 of 17 countries (76%) provide either university level courses or continuing education HTA courses. In the candidate EU countries, 4 of 10 countries (40%) provide HTA courses. In the remainder of countries, only Israel provides HTA courses. Ten different types of courses were identified, mainly applying traditional teaching methods. A substantial number of the courses were first organized in recent years. Many countries in central and eastern Europe expressed the wish to become more involved in HTA.

Conclusion: There is a rapid increase in the number and diversity of courses in HTA in Europe. In particular, countries in the EU are well represented. Education and training in HTA is scarce in EU candidate membership countries, and virtually absent in the remainder of countries. In general, HTA as a field is in the process of becoming established and institutionalized both in individual countries and internationally. To stimulate this development in the area of education and training, both bilateral cooperation and an EU-wide coordinated effort are recommended.

Objectives: To describe the number of trials and participants in a typical systematic review from The Cochrane Database of Systematic Reviews.

Methods: The number of trials in 1,000 Cochrane systematic reviews in issue 1, 2001 of The Cochrane Database of Systematic Reviews was counted for three categories of trial: included trials, ongoing trials, and trials awaiting assessment for inclusion. (The term trial is used in this paper, although a small number of Cochrane reviews include studies that are not trials.) The total number of participants in included trials was extracted from a sample of reviews.

Results: A total of 9,778 trials were included in the Cochrane reviews. There were a further 356 ongoing trials and 1,138 trials awaiting assessment for inclusion. A typical review contained six included trials. Forty percent of the reviews listed ongoing trials and/or trials awaiting assessment for inclusion. Based on a sample of 258 reviews, the median number of participants per review was 945 (interquartile range, 313 to 2,511) per review and 118 (interquartile range, 60 to 241) per trial.

Conclusion: This report is a descriptive study of the number of trials and participants in a typical Cochrane review from The Cochrane Library, issue 1, 2001.

Objective: A recurring question is whether evidence from systematic reviews has any impact on medical practice. We have studied this question in relation to some conclusions in seven reports, where relatively simple means to monitor trends could be used.

Results: As recommended, in the report preoperative routines the number of preoperative examinations diminished at six hospitals, during around 3,000 operations studied, a savings of SEK 130 million. After the report on moderately elevated blood pressure sales of the preferred drugs, diuretics and beta-blockers, stopped falling while calcium blockers and ACE inhibitors stopped rising. As concluded in the report, general prostate cancer screening has not been introduced, but tests as a sign of opportunistic screening have increased. Bone density measurements were not recommended for screening, and sales of equipment have declined after the report. The use of neuroleptics as unspecific calming therapy for old persons was discouraged due to the serious side effects. The frequency of patients given this medication diminished from 34% to 28% at nursing homes after 1 year. For smoking cessation, the use of nicotine substitution medications has increased, which is in line with suggestions presented in the report. For stomach pain proton pump inhibitors given for functional dyspepsia have diminished in a region of the country after special efforts to disseminate the message.

Conclusions: It appears to be possible to monitor changes in practice corresponding to selected conclusions in systematic reviews. After rather extensive disseminating efforts, some results look encouraging.

Somewhat over 1 million people in Sweden suffer from asthma or chronic obstructive pulmonary disease (COPD). These two diseases greatly reduce the quality of life, and together they account for approximately 2,300 deaths annually in Sweden.

The 30th annual meeting of the International Society for the Study of the Lumbar Spine will be held in Vancouver, Canada, May 13–17, 2003. If you are interested in attending the meeting as a nonmember, you must have a paper on the program or be invited by a member. Please contact the Secretary, Dr. Scott Boden, at Sunnybrook and Women's Health Science Center, Room MG 323, 2075 Bayview Avenue, Toronto M4N 3M5, Canada.