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 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.

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.

Technological aspects and early clinical experiences are arousing great enthusiasm over magnetic resonance imaging (MRI). However, influences such as regulation, reimbursement, and increasing competition also are playing important roles in determining the diffusion of this new technology. Of these considerations, competition among providers seems the most important. Competition related to MRI is manifested as direct competition over MRI services, using MRI to improve a provider's strategic position and competition among specialties. In making decisions concerning MRI acquisition and operation, providers are drawing upon their experiences with computed tomography (CT) to help them determine when would be the best time for acquisition, how to decide whether acquisition is appropriate, and how best to acquire, operate, and market the technology.

Our assessment of influences affecting MRI acquisition, described in Part I of this paper, also elicited interesting parallels between the acquisition, operation, and marketing of this new technology and experiences with x-ray computed tomography (CT). We noted that acquirers' personal experiences with CT and how individuals perceived the occurrences surrounding the diffusion of CT in general strongly determined their approach to MRI. Specifically, we found that potential and actual acquirers of MRI had learned three categories of lessons from experiences with CT: (a) “Optimal” timing for acquiring MRI; (b) how acquisition decisions are made; and (c) how to best acquire, operate, and market MRI.

This paper assesses the impact of mechanisms for financing intensive home health care services in the United States on their utilization. As lengths of stay have decreased in response to prospective payment methods for hospitals, demand has increased for intensive and complex services provided to patients in the home. Third-party payers, however, are willing to satisfy only some of this potential demand that their reimbursement policies have generated. It is the policies of payers rather than the safety and effectiveness of devices and procedures that are the major constraints on the expansion of intensive home health care. We describe the effects of these policies on who receives intensive home health care services, who provides them, what services are provided, how their quality is monitored, and what they cost.

We analyzed the cost-effectiveness of nonemergent treatment for esophageal varices commonly used in Japan (endoscopic injection sclerotherapy, nonshunting direct interruption procedure, and selective shunt). We assessed the cost per survivor from the perspective of the Japanese government and other payors. Epidemiologic and economic data from published Japanese literature and from Japanese hospital-cost information were applied in decision analysis. While sclerotherapy is the most cost-effective treatment, the popular surgical procedures save the most lives, thus raising difficult ethical issues regarding trade-offs of cost and quality.