USE OF HEALTH OUTCOMES INFORMATION IN
HEALTH POLICY AND HEALTH SYSTEMS
Report of a workshop jointly organized by the:
International
Society of
Technology Assessment
in Health Care
and the project:
Celle, Germany
January 1998
©
Department of Epidemiology, Social Medicine and Health System Research
Hannover Medical School
Carl-Neuberg-Str. 1, 30625 Hannover
Germany
Homepage
Hannover, 1998
The
International Society of Technology Assessment in Health Care (ISTAHC) is one
of the world's leading scientific and educational societies in the area of
health technology assessment. It was established in 1985 as a nonprofit
organization to encourage research, education, cooperation and the exchange of
information on the clinical, economic and social implications of health
technologies. The Society is an international forum for those concerned with
evaluation of health technology. It endeavors to stimulate scientifically based
assessment activity in government and the private sector and thereby foster the
optimal and appropriate use of health technologies.
Technology
assessment is gaining considerable importance in health care: remarkable
technological advances continue to bring more varied and sophisticated
equipment and pharmaceutical products onto the market. At the same time,
budgetary and fiscal constraints are obliging health care professionals,
planners and decision-makers to offer the best quality of care, while managing
costs. In order to make decisions, they must rely on the best available
information about the impact of these technologies on health care.
ISTAHC
promotes technology assessment throughout the world, including developing
countries. ISTAHC uses an interdisciplinary approach, to ensure that health
care providers and decision-makers in government, health care organizations and
industry, integrate assessment into their decisions in order to improve the
quality of health care and control costs. ISTAHC is committed to the timely and
effective dissemination of information as a key component of the assessment
process.
The
European Commission (Directorate
General V) funded project "The Present and Future of Health Technology
Assessment and its Impact on the Future of Health Systems in the European
Community" (in short HTA Europe) aims to explore the situation with HTA in
Europe. This projects builds on the previous EUR-ASSESS project but focuses on health
policy instead on methods.
The
objectives of HTA Europe are as follows:
1.
Contribute to the effectiveness and cost-effectiveness of health systems in the
European Community through improved HTA
2.
Strengthen the coordination of health technology assessment in the European
Community
3.
Contribute to the development of methods of information transfer between EU
member states
4. Furnish
recommendations to the European Commission concerning how to strenghten and aid
coordination of HTA activities in the European Community
The
working agenda of the project comprises commissioning of papers to document the
current state of affairs in each Member State and in Switzerland as well as
four workshops on important present and future issues. This booklet reports on
the fourth workshop of this project. Others were on emerging technologies,
future health systems and on the development of a framework proposal for
international assessments.
Contents
Acknowledgements
Preface
Methods
for using health outcomes information in health systems and decision-making
A
framework for outcomes measurement: definitions and dimensions
Which
outcomes for whom and what: appropriate outcomes in clinical care and
preventive medicine
A
step-by-step guide to health outcomes
Discussion
Parallel
discussion groups I
Do
health outcomes matter in policy-making?
Principles
of measuring the impact of Health Technology Assessment - the experience of the
Quebec Health Technology Assessment Council
Health
policy - how to incorporate health outcomes? - Forces in the making of health
care policy decisions
Parallel
discussion groups II
Conclusions
Participants
The
workshop was made possible with the financial support of:
German
Federal Ministry of Health
The HTA
Europe Project
MSD
Munich, Germany
Siemens
Erlangen, Germany
We would
also like to thank Kalina Soja and Peter Karre for their help organizing the
workshop.
This
report was prepared by Dr. Matthias
Perleth, MD, Department of Epidemiology and Social Medicine, Hannover
Medical School, Germany.
The aim
of the workshop was to explore the use of health outcomes information and its
impact in health policy-making and in practice. The workshop was divided into
two parts. In the first part, important aspects of outcomes research and
measurement were discussed. Furthermore, methods of the use of outcomes
information in health systems and decision making with regard to HTA were
summarized. The second part examined the impact of health outcomes information
on decision making in health policy. Each part ended with a parallel discussion
session and presentation of the results in the plenum.
Morning Session
Methods
for using health outcomes information in health systems and decision-making
A framework for
outcomes measurement: definitions and dimensions
Clifford
Goodman introduced a framework for outcomes measurement. This focused on outcomes
research in contrast to outcomes management, which aims to improve the
performance of health care.
Main
factors that have contributed to interest in outcomes research are: (1)
significant unexplained variation in clinical practice, (2) inadequate
scientific evidence to support many health interventions, and (3) better means
to evaluate effectiveness.
Outcomes
research is problem-oriented rather than technology-driven, its focus lies within
the care delivered in common, "everyday" settings. Thus, outcomes
research emphasizes effectiveness (the health benefit of an intervention used
in everyday settings) rather than efficacy (the health benefit of an
intervention used in more ideal treatment settings). Multidisciplinary outcomes
research teams analyze a wide range of patient outcomes and nonexperimental
data as well as the relationship between practice variations and patient
outcomes. They also take into account the patients' role in clinical decision
making. Outcomes research evaluates the impact of health care on the health
outcomes of patients and populations.
The
findings of outcomes research can inform health management and policies in
different ways, including, among others, clinical practice guidelines, payment
policies, and disease management.
The main
categories of outcome measures are: (1) clinical, (2) quality of life, (3)
patient satisfaction, and (4) economic. Of course, a health outcome is a stream
(progression or series) of health states over time for an individual. A
person's health state at a given time may be measured in multiple domains, each
of which can be combined into a single score for that health state. In turn,
these discrete health states must be combined over time to represent health
outcomes.
Clinical
outcomes are increasingly valued by strength of evidence.
Randomized controlled trials are generally stronger than
epidemiological/observational studies, which are stronger than case series,
etc. Health care policy makers increasingly use evidence hierarchies to grade
the strength of the available evidence on particular health care interventions.
Although outcomes research has encouraged the use of large administrative data
sets, researchers should be cognizant of the weaknesses of these sources and
ways to improve their usefulness. In addition to primary data gathering
methods, methods that combine or synthesize data are used in outcomes studies.
These include meta-analysis, decision analysis, simulation or modeling, group
judgment or "consensus development", non-quantitative literature
reviews, and editorials.
Outcomes
research has contributed to the value of health-related quality of life
(or QoL) measures. Interest in QoL derives mainly from the fact that
physicians deal more often with QoL-related outcomes than with life-threatening
situations or even death. QoL outcomes capture such dimensions as physical and
social function, cognitive function, anxiety or distress, pain, sleep and rest,
energy, and general health perception. QoL measures can be disease specific or
address general health, measure one dimension or multiple dimensions, and be
expressed with a single score or multiple scores. Examples of widely used
general measures are the Sickness Impact Profile, Short Form (SF)-36,
Nottingham Health Profile, Quality of Well-Being Scale, and EuroQol Descriptive
Index.
Patient
satisfaction with care covers aspects such as access to health
care providers, convenience, financial coverage, quality of care (e. g. quality
of interaction with physicians and other health professionals), and overall
satisfaction.
Outcomes
studies increasingly involve economic evaluations. Main types of cost
studies include: (1) cost of illness, (2) cost-minimization analysis, (3)
cost-effectiveness analysis, (4) cost-utility analysis, and (5) cost-benefit
analysis. Costs measured in such studies may include: direct costs, indirect
costs (usually productivity losses due to illness or death), and intangible
cost (such as pain and suffering). Given the increasing use of cost studies,
various national and international groups are producing guidelines for proper
conduct of such studies. These guidelines address such matters as perspective
of costs and health outcomes, direct and indirect costs, time horizon, marginal
vs. average costs, discounting, and sensitivity analysis.
Which outcomes for whom
and what: appropriate outcomes in clinical care and preventive medicine
The
appropriate choice of outcomes was discussed by Albert Jovell using
several case studies. In general, the selection of convenient health
outcomes might be influenced by several factors, such as the purpose of the
assessment, the nature of the research, the type of study design, the
measurement tool, and the level of understanding and values of decision makers.
The appropriateness
of outcome measures depends on their suitability and psychometric properties.
However, the most valid outcomes, such as death, may not be the most
appropriate and one must rely on more meaningful measures which may reflect the
effect of the health care intervention.
The assessment
method is also important in deciding which outcomes need to be assessed. A
randomized controlled trial might not be feasible to assess long-term mortality
in the assessment of the effect of a treatment in a chronic disease.
Observational studies might be flawed by the lack of an adequate control group
or by an unbalanced distribution of prognostic factors between comparative
groups.
The purpose
of the evaluation might determine the number and type of outcomes that need to
be measured. This was illustrated using an assessment of prenatal screening for
Down syndrome. A broad approach was chosen that included data from
meta-analyses of diagnostic studies and from the context of care in which the
screening takes place, including economic and epidemiological data. However, it
was also shown that contradictory results might arise depending on what
outcomes are used to measure the effects of interventions. In the case of
thrombolytic therapy for the treatment of acute stroke, mortality as an outcome
may lead to recommendations quite different from those derived from studies
with disability as the outcome.
The valuing
of outcomes may depend on different levels of decision-making in health care.
Physicians pursuing the benefit of the individual patient might prefer to treat
acute myocardial infarction with primary angioplasty rather than thrombolytics,
based on hospital mortality results. On the contrary, policy-makers pursuing
the benefit of the community might choose to pay for thrombolytic therapy based
on budgetary constraints and lack of long-term outcome data of treated
patients. An individual having suffered an ischeamic stroke might have
different thoughts in considering therapeutic options depending on whether
emphasis is on valuing quality of life or on expected survival rates.
'Informing
decision making in health care' can be taken as a general answer regarding the addressees
of outcomes. However, conflicting values and a broad spectrum of possible
outcomes call for a more rational approach to decision-making in health care.
As an example, prostate cancer screening is a source of conflicting
recommendations from world-known professional societies in favor or against
screening. Moreover, once cancer is detected there is no evidence as to which
is the best therapeutic alternative among the wide range of options.
As a conclusion,
appropriateness of outcomes might change depending on who makes or judges the
assessment and for what purpose it is made. A multidisciplinary approach
assessing multiple outcomes might be more advisable than a narrower approach
focused on a single outcome, method, or setting of care.
A step-by-step guide to health
outcomes
Andrew
Long approached the question of 'what interventions, underlying conditions,
service mixes and professional practices produce best outcomes from a range of
stakeholder perspectives?' by introducing a step-by-step guide to health
outcomes.
A number
of approaches to exploring outcomes within routine practice were
demonstrated in the context of stroke care. The first approach (the outcomes
grid) provides a framework of key questions to guide the measuring and
monitoring of outcomes within research and routine practice. A set of 'W' questions
are applied in order to choose appropriate outcomes. These focus on
stakeholders, desired outcomes, timing and disease stage of measurement,
reasons for data collection and use, available and feasible instruments and
setting of measurement. User and/or carer specified outcomes should be
preferred over professional interpretations of desired outcomes. The result of
the outcomes grid should be a set of outcomes which is in contrast to the often
observed practice that outcomes serve as a starting point.
The second
approach, a step by step guide, widens attention to address outcomes
measurement within the context of a systematic review of the effectiveness of a
particular intervention or care process. Having chosen a topic area for
evaluation, one starting point is to clarify the desired outcomes of key
stakeholders, as in the first approach. Alternatively, one can begin by
identifying and systematically reviewing research evidence on effectiveness,
noting outcome criteria, measures used and time scales of measurement for
subsequent further review for their adequacy.
The third
approach builds on the distinction between the use of outcomes information at
an individual and population level. A simple, if rational, outcomes
information model is generated outlining the possible role, need and use of
outcomes information. If there is sound evidence on what works and with whom,
at the level of individual care the practitioner and health care user need to
ensure that this treatment is provided. However, recognizing that much of the
available evidence is on efficacy, it is important to monitor how the treatment
is going in daily practice. If evidence is less secure, the establishment of
clear goals (desired outcomes) is required, and steps must be taken to monitor
their achievement. A similar argument applies at the population level with the
addition of the need for information on key case mix variables and review of
any adverse outcomes.
Some
aspects deserve consideration if the measurement, monitoring and use of outcomes
are to yield success. Firstly, at a very basic level, it is essential that the
health care practitioner recognizes the value of the task and the need for good
data collection. Secondly, there is the critical issue of attribution: is this
'outcome' really an outcome of the particular process? Here, there is the
critical role of the research base. Thirdly, many of the available measuring
instruments are too lengthy for use in routine practice and, most importantly,
have unknown (or assumed) responsiveness to change. Fourthly, the
organizational culture is itself more attuned to process evaluation.
The
general discussion was centered around methodological and practical
aspects of the use of outcomes information. It was stated that a tendency towards
use of QoL measures instead of or in addition to clinical outcomes can
be observed, especially in the elderly. One problem, however, remains the
resistance of clinicians towards QoL measures.
Also a
matter of discussion was the concept of effectiveness. There is a
tendency towards mislabeling randomized controlled trials (RCT's) as
'effectiveness studies'. This may lead to confusion. An important development
is the inclusion of costs as outcomes in effectiveness studies. It was
concluded that there exist a spectrum of studies ranging from mere efficacy and
safety investigations to context sensitive effectiveness studies incorporating
a broad array of outcomes. Thus, there seems to be no clear cut distinction
between 'efficacy' and 'effectiveness'.
Referring
to the fact that the consideration of outcomes is a relatively recent
development in health services research, the challenge of "bridging the
gap between internal validity (such as provided by RCT's) and external
validity (does it work in real life)" remains an issue. Thus, a link
between outcomes research and health technology assessment can be established
by ensuring the use of all relevant and available outcomes from different
sources, and with regard to policy-making.
Current
problems in health outcomes measurement
After
these presentations, two parallel discussion groups were set up (led by
Clifford Goodman and Andrew Long). The results were presented in the plenum.
One of the groups discussed perspectives of the use of outcomes information
in Germany. While analyzing the German "market" for possible
users of outcomes information, a significant potential for development became
apparent. To date, only a small community of researchers is asking for outcomes
information, however, a growing interest, especially in the hospital sector and
by sickness funds in an increasingly competitive health care system can be
observed. It was agreed that sickness funds and ambulatory care and hospital
physicians are among the most important potential groups for using outcomes. A
number of important steps to develop an outcomes culture in Germany were
formulated. These include measures to raise awareness, particularly among
sickness funds, who also should have an interest in financing research;
redesign and integration of administrative databases and registries to serve
the information needs of outcomes research and monitoring; training of
researchers and clinicians; setting incentives for providers to assess and use
outcomes; and linking quality of care and outcomes to financing.
The second
discussion group focused on methodological issues. Firstly, largely
unresolved problems were identified, such as the question of how to value
outcomes and changes in health status, how to assess future implications of
emerging technologies, how to integrate cultural differences and how to close
the gap between efficacy and effectiveness. Possible helpful steps might be the
narrowing of the range of measures used for each condition, acceptance of the multidimensionality
of outcomes and translation of research results into interpretable results for
all persons concerned.
Afternoon Session
Do health
outcomes matter in policy-making?
The second
part of the workshop examined the impact of health outcomes information on
decision-making in health policy.
Principles
and practice of measuring the impact of outcomes information were
discussed by Renaldo Battista. If health technology assessment
information aims at ensuring efficacy and safety of health technologies,
effectiveness, efficient use of resources etc. then HTA itself must be
submitted to a proper evaluation in order to justify the resources that it
needs.
Two
challenges were depicted that are crucial to HTA organizations if they are to
have an impact on policy-making, management and clinical practice. These are
capacity building within the organization and establishing and maintaining
linkages with the recipients of HTA information.
Different
types of impact that need to be examined in assessing the effectiveness of
health technology assessment organizations can be identified. These can be
categorized at the macro, meso or micro level. The future will see the
development of methods of impact measurement at the patient level.
There are
several steps involved in measuring the impact of HTA information. The first
steps are to determine the intended impact and the recipients of the
information. The impact of the information can be traced by analyzing both the
influence on the distribution and utilization of health technologies and on
policy-making. The latter was discussed in more detail using the case of
Quebec. Using a case-study approach, so-called critical incidents at
different levels of decision-making were identified. These included general
statements of ministerial policy, planning guidelines of health services
organizations, practice norms of professional organizations, ministry and
hospital rules, and ministry decisions. According to this analysis, all but
three of twenty-one reports released in 1995 influenced policy and also caused
savings.
Health policy - how to incorporate health
outcomes? - Forces in the making of health care policy decisions
The clinical
perspective of the impact of outcomes information was provided by Andreas
Laupacis. Many practice changes in the last ten years have been based on
level one evidence, i. e. evidence derived from RCT's or systematic reviews.
However, organizational problems (such as waiting times or too early
discharges) in the treatment of patients often remained unchanged despite
existing evidence. The use of outcomes information in clinical decision-making
became more important, in particular for chronic diseases, such as diabetes,
coronary heart disease, and postmenopausal disorders. Other forces
influencing health care policy decisions, such as the government (e. g.
coronary angioplasty), local committees (e. g. refusal of admission and early
discharge), costs (e. g. arthroplasty), lobbying (e. g. 'statins'), and
advocacy groups, public and media (e. g. hip replacement therapy) were
discussed. In general, economic issues seem to be more important than QoL
outcomes, while "traditional" clinical outcomes are still dominating
in determining practice.
Ways to
make better use of health outcomes information in policy-making
The first parallel
discussion group, led by David Banta started off with a discussion of what
constitutes health policy. Policy-making was divided into formal (such as laws,
regulations) and informal approaches. In both types, decision-making is based
on evidence, on preferences, and on values. If outcomes information will generate
impact it must be linked to evidence-based decision-making. Different
possibilities of bringing outcomes information into the system,
including the mass media and modern technology such as the internet, were
discussed. Dissemination of information should be targeted to key persons and
institutions, including clinicians who usually are the ultimate decision
makers. As a conclusion, ensuring awareness and use of outcomes information at
the levels of policy-making, health care delivery and the public deserves
further research into methods of enhancing acceptance, especially with the aim
of avoiding "bureaucratic" solutions.
Laupacis'
parallel discussion group focused on ways to make better use of health
outcomes information in policy-making for clinical purposes in Germany. At
first, the state of incorporation of health outcomes into clinical
decision-making in Germany was summarized: 1. Health outcomes are
increasingly incorporated into clinical practice guidelines which are in
growing number developed by scientific societies, though awareness of their
existence among German clinicians seems to limited. In addition, guidelines
appear to be instruments for claiming clinical domains of medical specialists
and thus seem to be less orientated towards better health outcomes than towards
the dominance of specialists in the clinical landscape in Germany. 2. There is
a high number of clinical outcomes studies which focus on patient satisfaction,
but there is limited evidence that these results are taken systematically into
account in clinical decision-making. 3. The German Cochrane Centre has recently
been established in Freiburg, yet again, there is limited scope for the
incorporation of evidence-based medicine into clinical decision-making. 4.
There is practically no evidence for the development of clinical pathways in
Germany. The second part argued mainly in favor of improved education towards
the collection of information, interpretation and utilization of medical
outcomes.
The goal
of the health care system is to improve health outcomes. Therefore, health
outcomes information should be a central consideration in both health policy
and health care practice.
Ensuring
awareness and use of outcomes information at the levels of policy-making,
health care delivery, and the public deserves further research into methods of
enhancing acceptance. Effective dissemination can change behavior and avoid
bureaucratic solutions.
HTA and
outcomes information have had a substantial impact on health policy in some
areas. However, impact on the meso and micro (clinical) level seems limited.
Education
and training needs to be oriented towards the collection, interpretation, and
utilization of health outcomes information.
David
Banta, MD MPH
TNO Prevention and Health
Division of Technology in Health Care
Sector Medical Technology Assessment
PO Box 2215
2301 CE Leiden
Netherlands
Renaldo N.
Battista, MD ScD FRCP(C)
McGill University & Quebec Health Technology Assessment Council
201, Boulevard Crématie est, First floor
Montreal H2M 1L2
Quebec
Canada
Dr. med.
Christian Behles, MD
Deutsches Institut für Medizinische Dokumentation und Information (DIMDI)
Weisshausstr. 27
50939 Köln
Germany
Carsten
Berndt
Rhône-Poulenc Rorer
Arzneimittel GmbH
Nattermannallee 1
50829 Köln
Germany
Dr. med.
Eva Bitzer, MD, MPH
Institut für Sozialmedizin, Epidemiologie und Gesundheitssystemforschung (ISEG)
Bissendorfer Str. 9
30625 Hannover
Germany
Dr. Bert
Boer
Ziekenfondsraad
P.O. Box 396
1180 BD Amstelveen
Netherlands
James S.
Breivis, MD
The Permante Medical Group
2200 O'Farrel Street
San Francisco 94115-3394, California
USA
Dr. med.
Reinhard Busse, MD, MPH
Abteilung Epidemiologie, Sozialmedizin
und Gesundheitssystemforschung
Medizinische Hochschule Hannover
Carl-Neuberg-Str. 1
30625 Hannover
Germany
Michael
Drummond, PhD
Center for Health Economics
University of York
Heslington
YO1 5DD
England
Dr. med.
Karin Faisst, MD
Institut für Sozial- und Präventivmedizin, Universtität Zürich
Sumatrastr. 30
8006 Zürich
Swiss
A. Mark
Fendrick, MD
The University of Michigan Medical Center
3116 Taubman Center
Ann Arbor, MI 48109
USA
PD Dr.
phil. Günter Feuerstein
Forschungsschwerpunkt Biotechnik, Gesellschaft und Umwelt (BIOGUM)
Falkenried 94
20251 Hamburg
Germany
Dr. med.
Bernhard Gibis, MD
Abteilung Epidemiologie, Sozialmedizin
und Gesundheitssystemforschung
Medizinische Hochschule Hannover
Carl-Neuberg-Str. 1
30625 Hannover
Germany
Dr. Helen
Gelband
Health Technology Consulting
321 Lincoln Avenue
Takoma Park, MD 20912
USA
Univ.
Prof. Dr. phil. Hermann Gilly
Ludwig-Boltzmann-Institut für Experimentelle Anästhesie und
intensivmedizinische Forschung
c/o AKH E091, 1080 Wien
Austria
Clifford Goodman,
PhD
Medical Technology, Lewin-VHI
9302 Lee Highway, Suite 500
Fairfax, VA 22031-1214
USA
Alicia
Granados, MD
Catalan Agency for Health Technology Assessment
Department de Sanitat i Seguretat Social
Travessera de les Corts 131-159, Pavelló Ave Maria
08020 Barcelona
Catalonia
Spain
David
Hailey, PhD
Alberta Heritage Foundation for Medical Research
3125 ManuLife Place, 10180-101 Street
Edmonton T5J 3S4
Alberta
Canada
Evi J.
Hatziandreou, MD, MPH, Dr.PH
Astra AB, Astra Hellas S.A.
Health Economics
4 Theotokopoulou & Astroinafton Str.
15125 Athen
Greece
Elina
Hemminki, MD PhD
National Research and Development Centre for Welfare and Health
PO Box 220
00531 Helsinki
Finland
Dr. med.
Elke Jakubowski, MD, MSc. HPPF
Abteilung Epidemiologie, Sozialmedizin
und Gesundheitssystemforschung
Medizinische Hochschule Hannover
Carl-Neuberg-Str. 1
30625 Hannover
Germany
Torben
Jørgensen, Bio-Med Eng BCom
DSI, Danish Institute for Health Services Research and Development
PO Box 2595, Dampfærgevej 22
2100 Copenhagen Ø
Denmark
Albert
Jovell, MD, DrPH, PhD
Catalan Agency for Health Technology Assessment
Department de Sanitat i Seguretat Social
Travessera de les Corts 131-159, Pavelló Ave Maria
08020 Barcelona
Catalonia
Spain
Dr. phil.
Thomas Kohlmann
Institut für Sozialmedizin
Medizinische Universität zu Lübeck
St. Jürgen-Ring 66
23564 Lübeck
Germany
Prof. Dr.
Regine Kollek
Forschungsschwerpunkt Biotechnik, Gesellschaft und Umwelt (BIOGUM)
Falkenried 94
20251 Hamburg
Germany
Dr. Karl
Krobot
MSD GmbH
Lindenplatz 1
85540 Haar
Germany
Andreas
Laupacis, MSc, MD, FRCPC
Clinical Epidemiology Unit, Ottawa Civic Hospital
1053 Carling Ave.
Ottawa K1Y 4E9
Ontario
Canada
Dr. Kalevi
Lauslahti
FinOHTA/STAKES
Siltasaarenkatu 18
P.O. Box 220
00531 Helsinki
Finland
Prof.
Andrew Long
Health Care Practice R&D Unit
University of Salford
Statham Building
Salford M6 6PU
England
Dr. med.
Dagmar Lühmann, MD
Institut für Sozialmedizin
Medizinische Universität zu Lübeck
St. Jürgen-Ring 66
23564 Lübeck
Germany
Dr. Bryan
Luce
MEDTAP International Inc.
Bethesda, MD
USA
Dipl. Ing.
Robert Nemeth
Siemens AG, Medical Engineering
Siemens AG, Med MRP
P.O.Box 32 60
91052 Erlangen
Germany
Dr. med.
Matthias Perleth, MD
Abteilung Epidemiologie, Sozialmedizin
und Gesundheitssystemforschung
Medizinische Hochschule Hannover
Carl-Neuberg-Str. 1
30625 Hannover
Germany
Prof. Dr.
med. Harald Schweim, MD
Deutsches Institut für Medizinische Dokumentation und Information (DIMDI)
Weisshausstr. 27
50939 Köln
Germany
George
Tombs
International Society of Technology Assessment in Health Care (ISTAHC)
380 St. Antoine St. W., Suite 3200
Montreal
Quebec H2Y 3X7
Canada
Dr.
Claudia Wild
Institut für Technikfolgen-Abschätzung
Österreichische Akademie der Wissenschaften
Postgasse 7/4/3
1010 Wien
Austria