To read the newspapers, the whole practice of medicine suddenly has been transformed from the learned profession it used to be into a high technology, beset on all sides by scientific hubris. And complaints about this perceived change are heard everywhere. There is too much science, it is claimed. Doctors are unable to deal at first hand with their patients, it is said, because of the sheer mass of machinery required for medical care. There is, it is asserted, such a high technology needed for health care that no society can cope with the cost. If it continues, medicine will be done in by its own scientific success.

This paper compares information synthesis to literature review and meta-analysis as tools for the researcher trying to summarize published information and identify information gaps on emerging technologies. Because information synthesis is narrowly focused and addresses the question of what is not known, as well as what is known, it is a good precursor to a full-scale technology assessment. An example of information synthesis is given, comparing cost-effectiveness of extracorporeal shock wave lithotripsy to two other treatments for kidney stones.

This article describes the use of research synthesis procedures (e.g., meta-analysis) in evaluating medical technologies. The synthesis process involves retrieval, extraction, and analysis of pertinent information from a set of research studies. There are several advantages of research synthesis: determining overall effectiveness, explaining seemingly contradictory findings, providing a standard measure of effect, and increasing statistical power. In addition, such syntheses provide timely results that can assist various policy decisions such as initiating clinical trials at NIH, reimbursement at HCFA, and answering NIH consensus conference questions. The authors' synthesis of the research literature on coronary artery bypass graft surgery (CABGS) illustrates how this method can address the various elements of a technology assessment such as safety, efficacy, and cost-effectiveness. The paper concludes by noting how research synthesis can be particularly advantageous in assessing technologies that are rapidly evolving (e.g., lytic agents for acute myocardial infarction).

This paper analyzes medical technology decision making in the United States and England in terms of the appropriateness of different decision-making models to the organization and delivery of medical care, and to the rationing of technology among and within hospitals. It examines the effect on the American hospital of prospective payment programs from the perspective of organizational structure and decision making. The strategies of central control and specification which characterize these programs are contrasted with decision-making procedures in the English National Health Service, which have emphasized decentralization, delegation, and consensus. The analysis suggests that decentralized models of decision making are more supportive of essential elements of medical care including doctor-patient trust and professional responsibility and are more able to achieve rationing decisions which are compatible with professional and consumer preferences.

It was in 1967 that the first patient went from Tunbridge Wells to the Brompton Hospital for pacemaker implantation. The recipient was a typically robust female octogenarian and while the eminent cardiologist was engaged in his task, she tapped him on the shoulder. “Young man” she said, “how many of these operations have you done?” He replied, somewhat modestly, “About 300,” expecting her to compliment him on his expertise. Instead, she said “Well, if you've done that many you should know to keep your patient's feet warm. Cover them up!” This anecdote aptly illustrates the contention implied in my title that a new and somewhat disruptive dimension in the form of technology has entered the field of medicine, a view which has attracted considerable support from various quarters (14; 16).

Today, computers are used in several important and fast-growing medical imaging modalities, such as digital subtraction angiography, positron emission tomography, magnetic resonance imaging, nuclear medicine, and diagnostic ultrasound. The ultimate test for the computer in medical imaging will be its ability to replace traditional film-based radiography as the mechanism for displaying, communicating, and storing imaging information. This transition will require radiologists and other imagers to accept information in digital form. The speed of that acceptance depends on the economic incentives of the health care system. These are changing as a result of cost containment, which is moving away from fee-for-service toward bundled payment. The increase in capitated health plans will encourage the development of digital radiography systems that realistically trade-off the perceived quality needs of radiologists with the costs of producing and operating such systems.

High technology developments in diagnostic imaging raise a number of issues that are disturbing. New developments do not always favor greater diagnostic efficacy since fads, marketing promotion, and entrepreneurs can distort medical goals. New advances disseminate rapidly in affluent societies before formal benefit evaluations are completed. We suggest that digitization of radiography must be critically assessed, and simplicity of equipment design should be promoted. Though medical and economic factors can provide guidelines for policy making, the ultimate priority decisions are political in nature.

This study compares the cost of antitumor therapy and adverse cardiovascular effects during the first year of treatment with either exogenous estrogens or orchidectomy of patients with prostatic cancer. We found that the higher costs for the orchidectomy patients were partially outweighed by the costs of treating cardiovascular complications in the estrogen-treated patients; the net overcost of orchidectomy is balanced after two and a half years by the ongoing costs of estrogen treatment. The fact that 25% of the patients treated with estrogen suffered cardiovascular complications, but no difference in mortality rates between the two groups was observed, speaks in favor of orchidectomy as the preferred treatment for prostatic carcinoma.

This paper considers economic forces on the organization and use of technology in hospitals from a U.S. perspective. U.S. hospitals are moving from a period of very loose financial constraints to one in which the demand side of the market is likely to exert much greater discipline. Theory and limited evidence suggest some important effects on the adoption and use of technology, leading in general to more emphasis on cost reduction and less emphasis on costly quality improvements. Also discussed are economic influences on the movement of technology out of the hospital and on the development of new technologies. Finally, some peculiarities of very high cost technologies are noted.

Instruction of medical students in the use of technologic procedures in clinical medicine has emerged in recent years on a more or less piecemeal basis. Individual technologies are introduced as the teaching hospital acquires the requisite equipment and personnel; as experience is gained by faculty and attending staff some sense emerges of the indications, contraindications, risks, accuracy, and usefulness of a procedure, which then is transmitted to housestaff and students. Instruction is likely to occur on a case-by-case basis, supplemented occasionally by conferences or formal presentations, generally oriented around major innovations, such as computerized transaxial tomography or magnetic resonance imaging. As relevant clinical literature appears, it is used to reiterate and expand the available information base of trainees, but to a considerably greater extent for housestaff than for students. Ultimately what emerges is a pattern of use, a gestalt, for each technology, reflecting the synthesis of the available information and clinical experience with the procedure in the particular institution. In view of the enormous number and variety of technologies available, the task of the student or house officer in acquiring even basic familiarity with those in common use is formidable. A coherent approach to instruction in the use of technologic procedures is required. Students need, and medical faculties must find, a way to provide intellectual systems for incorporating technologies into the clinical armamentarium in a manner that permits them to be maximally useful.

The paper considers the economic characteristics of technology and suggests a categorization based on the economic nature of particular technologies and their effect on the product health care that may be helpful in considering the economics of technology in hospitals.

It reviews the range of economic forces that might be expected to apply to the use of technology in the hospital setting, and notes some of the evidence to support such hypotheses. In considering the limited evidence from the United Kingdom and elsewhere in Europe, the paper contrasts its focus on socio-political, institutional, and organizational factors, rather than the direct economic factors considered in the United States work.

It suggests that the multiplicity of forces at work make cross-national, empirical, and policy analyses very difficult. Indeed, without more economic appraisal the effect of differences in technology adoption cannot be evaluated.

Diagnostic imaging in small hospitals is discussed. Four key questions are answered: (1) Are diagnostic imaging technologies necessary at this level? (2) Which technologies should be chosen and why? (3) How can they be most rationally and cost effectively used? (4) How can their total impact on health care be assessed? The paper concludes that small hospitals should have diagnostic imaging facilities and that the modalities of choice are diagnostic radiology and ultrasonography. A detailed description is given of the WHO Basic Radiological System and General Purpose Ultrasonographic equipment together with WHO recommendations for the rational use of diagnostic imaging.

The paper presents a French national survey on diagnostic imaging equipment and activity showing that conventional x-ray radiology still dominates and that the rate of diffusion of technological innovations has been very different, being slower than in other industrialized countries for such technologies as CT scanners, nuclear medicine, and magnetic resonance imaging, but on the other hand, very quick for ultrasound and digital angiography.

The variety of regulations for this equipment, although it plays an important role, is not sufficient to explain these differences in the rate of diffusion. The paper shows that other explanatory variables must be taken into account, at least in the French context: the situation of the domestic biomedicai industry, the relations between private and public sectors of health care delivery, and even the “technical” culture and tradition of French radiologists.

Pressures to contain health care costs have challenged physicians to be more discriminating in the use of medical technology. Particularly important is the need to apply diagnostic technology selectively since the costs of diagnostic tests and procedures may account for as much as one quarter of total hospital costs and a smaller but substantial proportion of ambulatory care costs.