Objectives: The objective of this study was to collect all systematic reviews on invasive strategies for acute coronary syndromes (ACS) and reanalyze the data in these reviews to reach combined estimates, as well as to make predictions on the effectiveness and risk of harm so as to facilitate relevant decision making in health care.

Methods: The data sources used were the following electronic databases, searched from 1994 to September 2004: Cochrane Database of Systematic Reviews; Cochrane Central Register of Controlled Trials; DARE, HTA, EED (NHS CRD); MEDLINE(R) In-Process, Other Non-Indexed Citations, MEDLINE(R), and PubMed (2000 to 2004). References to the identified systematic reviews were checked. An ancillary search to identify recent randomized controlled trials (RCTs) covering the period from January 2003 to January 2006 was done in MEDLINE(R). We included systematic reviews of RCTs on patients with ACS. In unstable angina and non–ST-elevation myocardial infarction (UA/NSTEMI), eligible reviews had to compare early routine invasive strategy with early selective invasive strategy. In ST-elevation myocardial infarction (STEMI), a comparison between primary percutaneous coronary intervention (PCI) and thrombolytic therapy was required. The methodological quality of the reviews was assessed, and a standardized data extraction form was used. Results for the main outcomes of the RCTs in the reviews were reanalyzed. An additional search of those RCTs not included in the meta-analyses was performed for UA/NSTEMI and short-term morality data on STEMI. Bayesian models were constructed to estimate the uncertainty about a possible treatment effect and to make predictions and probability statements. Main results are based on these analyses. Mortality was considered as the primary outcome measure.

Results: One systematic review on invasive strategies was identified for UA/NSTEMI and nine on invasive strategies for STEMI. Five reviews of the latter that were published after the year 2000 were included for the final analysis. The median quality score was 10.5 (range, 7–13; n = 6) on a scale from 0 to 18 points. An updated literature search identified one further RCT on UA/NSTEMI. Regarding NSTEMI and mortality, the average risk difference favoring an early invasive treatment strategy compared with early conservative strategy was .6 percent (95 percent credible interval [CrI], −2.1 to 1.0). Predicted risk (relative risk/risk difference scales) of doing harm was 26.7/26.6 percent. Regarding STEMI and mortality, the absolute risk reduction in favor of primary PCI over thrombolysis was 4.1 percent (95 percent CrI, −7.1 to −1.1) when PCI was compared with streptokinase and 1.2 percent (95 percent CrI, −2.7 to .2) when compared with fibrin-specific thrombolytics. Predicted risk of harm was 8.9/5.3 percent and 8.0/13.3 percent, respectively.

Conclusions: There seems to be at present no solid evidence for survival benefit on early invasive strategy for UA/NSTEMI as a broad diagnostic group, and the risk of doing harm should be considered. Also, the evidence for PCI to decrease early mortality after STEMI is scanty. Estimations of predicted harm may further aid decisions on whether to implement the new treatment over the old one. It may also give an additional dimension for interpreting the results of any meta-analysis.

Once-daily antibiotics (ODAs) represent a technological change in hospital processes that can lead to substantial savings of scarce resources. In a three-hospital prospective study, five antibiotics were administered to 58 patients suffering from infections classified by major body system. Savings ranged from 10.9% to 38%, depending on hospital organization, method of delivery, and daily dose. Per-unit price proved a poor indicator of hospital cost, as variable delivery costs for labor and materials ranged from 11.6% to 39.5% of total costs.

Oral radiology still seems to be expanding depending upon increasing availability of dental care. It is widely used more or less routinely, although investigations on efficacy, cost-benefit, and cost-effectiveness are sparse. Such studies should be encouraged and decision-making courses included in dental curricula. Decision-making aids and clinical algorithms should be developed to increase efficiency of oral radiology and to help in the abandonment of its routine use.

Objective: The rise in the number of implantations of cardiac pacemakers is of some concern to decision makers in the health sector. We assessed the intrinsic and relative clinical efficacy of cardiac pacemakers in current clinical indications to find out whether scientific or clinical arguments might justify differences in market prices.

Methods: We retrieved papers on cardiac pacing (January 1993–April 1998) from five databases (MEDLINE, HealthSTAR, EMBASE, Cochrane Library, and PASCAL). The citations in these papers were used to seek further articles. We selected the articles that met the criteria of evidence-based medicine (EBM) (randomized and nonrandomized controlled trials) and classified them according to clinical indication and type of evaluation (either of the intrinsic efficacy of a pacemaker versus a control or of the relative efficacy of different pacing modes).

Results: A total of 542 references were retrieved, but under 10% met our EBM criteria. Very few were comparative studies versus controls; most were recent and tended to use endpoints other than survival. Clinical efficacy was not proven on the basis of EBM criteria, even in common indications (e.g., sick sinus syndrome). Studies comparing different pacing modes were rarely randomized and did not provide consistent evidence for the superiority of any pacing mode in a given indication.

Conclusions: Knowledge of the natural history of the diseases for which cardiac pacing is indicated is scarce. There is an approximately 20-year gap between technological progress and clinical evaluation that cannot be easily bridged because of methodologic difficulties and ethical issues. Current guidelines on pacemaker use either rely on expert opinion or highlight present inadequacies and make recommendations for future work. Available clinical efficacy data do not justify the wide differences in the price of cardiac pacemakers.

For some observers, the artificial heart represents the latest, and perhaps the most flagrant example of the health system's tendency to favor the rapid introduction of expensive but ineffective technologies over efforts to prevent disease and to improve access to care (5;6;19;44;45). Even if it can be perfected, they argue, its opportunity cost in terms of other foregone health benefits would be exorbitant. The ultimate failing of the health care system, it would seem, is its failure to establish mechanisms to select among alternative uses of resources. If such mechanisms had existed, some critics believe that the quest for an artificial heart never would have begun and certainly its premature clinical uses could have been prevented (6;45).

Objectives: Some experts have promoted preparticipative cardiovascular screening programs for young athletes and have claimed that such programs were cost-effective without performing a critical analysis of studies supporting this statement. In this systematic review, a critical assessment of economic evaluations on these programs is performed to determine if they really provide value for money.

Methods: A systematic review of economic evaluations was performed on December 24, 2014. Web sites of health technology assessment agencies, the Cochrane database of systematic review, the National Health Service Economic Evaluation Database of the Cochrane Library, EMBASE, Medline, Psychinfo, and EconLit were searched to retrieve (reviews of) economic evaluations. No language or time restrictions were imposed and predefined selection criteria were used. Selected studies were critically assessed applying a structured data extraction sheet.

Results: Five relevant economic evaluations were critically assessed. Results of these studies were mixed. However, those in favor of screening made (methodological) incorrect choices, of which the most important one was not taking into account a no-screening alternative as comparator. Compared with no screening, other strategies (history and physical examination or history and physical examination plus electrocardiogram) were not considered cost-effective.

Conclusions: Results of primary economic evaluations should not be blindly copied without critical assessment. Economic evaluations in this field lack the support of robust evidence. Negative consequences of screening (false positive findings, overtreatment) should also be taken into account and may cause more harm than good. A mass screening of young athletes for cardiovascular diseases does not provide value for money and should be discouraged.

Beginning in the 1960s, the maternity patients' movement in the United States was joined by lay, medical, and political critics who protested the escalating cost, poor and inequitable distribution, and overspecialization of medical care. During the 1970s some goals of the maternity patients' movement were met, including fathers' attendance at birth, care in low intervention birth centers, and keeping the newborn baby with the parents immediately after delivery. At the same time, however, perinatal care became ever more based on new technology, tests, and procedures, some of which were promoted by doctor-developers in continuing education courses and in expert witness testimony at malpractice trials. Primary obstetric units closed while urban and suburban centers advertised new services to people who could pay. In the 1990s the maternity patients' advocates have most of the same complaints as in 1970, as well as many new ones.

The evolution of clinical technologies presents potential adopters with considerations in planning for clinical program development that include the stage and the rate of a technology's evolution. This paper presents a conceptual framework for these considerations and applies the framework to orthopedic technologies. Eight orthopedic surgeons were asked to assess 14 orthopedic technologies and position each of them along a spectrum of research, clinical, and adopted technologies. The distribution of responses for each technology–year combination is presented, and estimates of central tendency, dispersion, and variances provide measures of the change in the distribution of responses over time for each technology and the change in the degree of rater consensus over time for each technology. While orthopedic trauma was chosen to illustrate the technology spectrum model, the model and assessment methodology is applicable to other medical specialties as well. Adoption of this framework in a hospital setting should enable more systematic and effective clinical program development.

Scientific reports should be orderly, clear, and unambiguous. Clarity is even more important for health technology assessments (HTAs), which aim at supplying reliable and up-to-date evidence on the effectiveness, safety, and cost of healthcare interventions. Increasingly assessments also provide information about the effects of technologies on organization of care, as well as relevant legal, social, and ethical considerations.

Objectives: The translation of research findings into policy and practice is crucially dependent on the applicability of such findings in a given decision-making context. We explored in a case study whether a generic consultation guide to assess the applicability of a health technology could be rapidly deployed and deliver useful insights.

Methods: A consultation guide based on the context and implementation for complex interventions (CICI) framework was developed and piloted to assess the applicability of reinforced home-based palliative care in three European countries. Individual consultations in England and Germany and a panel discussion in Poland were completed.

Results: Various barriers may hinder successful implementation of reinforced home-based palliative care in the three countries. Whilst the experts across all countries emphasized the lack of funding along with organization and structure as major barriers, information varied by country for many of the other identified barriers and facilitators. Participants in the pilot study provided positive feedback in terms of understanding the topic and purpose of the consultation, and both individual and panel consultations could be easily implemented.

Conclusions: In this case study, the consultation guide presented a pragmatic, ready-to-use tool to assess the applicability of a health technology. As shown here, it can be used in a generic manner without discrete empirical information on the technology in question or, ideally, makes use of specific information collected as part of a HTA. Further studies are needed to validate this guide and apply it to other types of health technologies and more diverse decision-making contexts.

Healthcare decision makers are increasingly demanding that health technology assessment (HTA) is patient focused, and considers data about patients' perspectives on and experiences with health technologies in their everyday lives. Related data are typically generated through qualitative research, and in HTA the typical approach is to synthesize primary qualitative research through the conduct of qualitative evidence synthesis (QES). Abbreviated HTA timelines often do not allow for the full 6–12 months it may take to complete a QES, which has prompted the Canadian Agency for Drugs and Technologies in Health (CADTH) to explore the concept of “rapid qualitative evidence synthesis” (rQES). In this paper, we describe our experiences conducting three rQES at CADTH, and reflect on challenges faced, successes, and lessons learned. Given limited methodological guidance to guide this work, our aim is to provide insight for researchers who may contemplate rQES. We suggest several lessons, including strategies to iteratively develop research questions and search for eligible studies, use search of filters and limits, and use of a single reviewer experienced in qualitative research throughout the review process. We acknowledge that there is room for debate, though believe rQES is a laudable goal and that it is possible to produce a quality, relevant, and useful product, even under restricted timelines. That said, it is vital to recognize what is lost in the name of rapidity. We intend our paper to advance the necessary debate about when rQES may be appropriate, and not, and enable productive discussions around methodological development.

The objective of this article is to describe and analyze the decision-making process and its consequences for medical technology transfer in China. Data were obtained in 1987 from 35 elite teaching hospitals affiliated with 13 medical universities, directly supervised by the Ministry of Health in the People's Republic of China. This article focuses on three kinds of diagnostic equipment: computerized tomographs, ultrasonic diagnostic units, and high-power x-ray diagnostic apparatuses. Decision-making on the transfer of medical technology in China is decentralized. Most hospitals rely on foreign medical sales representatives and medical exhibits, and their decisions on the acquisition of equipment rely more on the services available than on the price of the product. Chinese hospitals also encounter serious infrastructure problems when buying medical equipment. A number of alternatives are suggested for improving the efficiency of medical technology transfer in China.