We analyze what is known and unknown about the contribution of the pharmacist as patient educator, physician consultant, and agent to affect patient outcomes in ambulatory settings. The need for pharmacist services is discussed, as are the theoretical underpinnings and quality of the scientific evidence to support their efficacy. The analysis is conducted in the context of a shift in pharmacists' roles from product to patient orientation as well as recent U.S. legislation mandating enhanced pharmacists' roles via drug utilization review for all Medicaid patients. We conclude with a research and action agenda, calling for stronger research designs in evaluating pharmacists' interventions. The shifting paradigm in the pharmacy profession, coupled with the implementation of the Omnibus Budget Reconciliation Act of 1990, provide unique opportunities for rigorous evaluations of pharmacists as agents of change for rational drug therapy.

The total cost of the Swedish handicap system is estimated at US $ 10.7 billion for 1989. The cost is distributed across different authorities with separate legal and financial responsibility. The concept of technology must be extended to include consideration of both the resources spent and benefits gained in the public sector and the magnitude and distribution of transfer payments from social insurance to fulfill its function in handicap policy decision making.

In a cross-sectional, retrospective study of 604 cases, variations among three Norwegian hospitals in use of perioperative parenteral nutrition (TPN) after gastrointestinal surgery was determined. Postoperative TPN rates were 25%, 34% (p =.05) and 56% (p <.0001). respectively. However, a substantial part of the variation was explained by differences in patient characteristics.

The use of randomized control trials to assess the usefulness of therapeutic drugs over the last half century has brought significant benefits to patient care. The full potential benefits, however, have been only partially fulfilled because available data are frequently poorly used. Meta-analysis has emerged as an important tool for combining clinical evidence. Several examples are presented that compared the results of cumulative meta-analysis of randomized control trials with clinical expert recommendations. These comparisons demonstrated that clinical expert recommendations are often not synchronized with accumulating evidence, and this lack of recognition often resulted in delays in the acceptance of effective drugs and the slow abandonment of possibly harmful therapeutic practices. The problems of inappropriate therapeutic drug use will only intensify as new drugs are introduced and new uses for established drugs are proposed. The rational use of therapeutic drugs can be achieved only through the routine use of meta-analysis on high-quality clinical data. Some suggestions are made to improve the quality of the original research and the ways of assembling meta-analyses and disseminating their results.

Socioeconomic evaluation is an issue dealt with in the European Commission's research program TIDE. The principles of cost-utility analysis have been examined for usability in the assessment of rehabilitative technologies. A case study, the choice of a type of wheelchair, is described to demonstrate how estimates of utility can be derived and how cost-utility ratios can be used to guide decision making.

Over the last few years, the pharmaceutical industry has financed an increasing number of health economic evaluations. The purpose of this article is to describe how and why the pharmaceutical industry is applying health economic evaluations. Seven different fields of application are identified, and the varying reasons for use are discussed.

There is growing demand for translations of health status questionnaires for use in multinational drug therapy studies and for population comparisons of health statistics. The International Quality of Life Assessment (IQOLA) Project is conducting a three-stage research program to determine the feasibility of translating the SF-36 Health Survey, widely used in English-speaking countries, into other languages. In stage 1, the conceptual equivalence and acceptability of translated questionnaires are evaluated and improved using qualitative and quantitative methods. In stage 2, assumptions underlying the construction and scoring of questionnaire scales are tested empirically. In stage 3, the equivalence of the interpretation of questionnaire scores across countries is tested using methods that closely approximate their intended use, and empirical results are compared. Data analyses from Sweden and the United Kingdom, as well as other research cited, support the feasibility of cross-cultural health measurement using the SF-36.

We consider the nature of technology assessment and then briefly summarize technology assessment activities in five countries: Canada, France, the Netherlands, the United Kingdom, and the United States. Drawing from these examples, we then identify determinants of the emergence and impact of technology assessment.

This paper reports the results of a study of the association between volume of activity and patient outcome in 26 intensive care units in the United Kingdom. Hospital fatality rates showed a statistically significant (p =.016) negative association with volume. However, mean APACHE II scores, as a measure of the severity of case mix, were also negatively associated with volume (p =.021). Thus, one explanation of the lower death rates at higher volumes is that larger units admit less severely ill patients. For patients admitted immediately after surgery, the correlation between severity standardized mortality ratios and volume (while not significant, p <.1) suggests there may be a volume-output effect unexplained by severity.

Eighty-one published papers on the performance of prostheses in total hip replacement were appraised. Sound methodology was demonstrated in 1 of 8 randomized controlled trials and 4 of 17 nonrandomized comparative studies. Of 56 case series without controls, 32 met the appraisal criteria, but these are intrinsically less useful. The published literature does not provide solid evidence for the superiority of cement-free or hybrid prostheses over modern cemented types.

Five “big ticket” medical technologies (BTTs) in 1990 were compared in the 24 OECD countries in relation to population, the number of physicians, gross domestic product (GDP), and health care expenditures (HCE). Wide variations were observed between and within countries for all measures. Regression analysis revealed that HCE explains part of the variation in the distribution of computed tomography scanners (excluding Japan), magnetic resonance imaging units, and radiation therapy units (R2 between 0.40 and 0.69), but not extracorporeal shock wave lithotripters. To a lesser extent, GDP was also found to correlate with the distribution of these technologies, but no correlation was found with number of physicians. Other factors affecting the diffusion of these technologies are proposed for study.

Acquiring expensive, new medical technology requires an evaluation of the efficacy and effectiveness, safety, profitability, feasibility, and risk of a project in the context of the hospital's social responsibility and institutional strategy. A case study of the decision to bring biliary lithotripsy to Strong Memorial Hospital illustrates how these criteria offer managers a coherent approach to difficult and consequential decisions about acquiring medical technology.

The purpose of this study was to examine differences in the way Britain and the United States invest in and deploy a new medical technology. We used structured interviews to obtain information on the technical sophistication and approximate replacement value of all hospital-based obstetrical ultrasound machines in every maternity hospital in Washington state and Wales. The supply of hospital-based ultrasound machines—approximately two machines per 1,000 births—was similar in both countries. Wales had fewer advanced ultrasound machines than Washington state, and they were based exclusively in high-volume district general hospitals; there were no obstetric ultrasound machines in the private sector. In Washington state, the majority of advanced machines were in small and medium-sized hospitals, and many private offices had ultrasound machines. The approximate replacement value of hospital-based machines was three times as high per birth in Washington state as in Wales. In the case of obstetrical ultrasound, centralization of facilities, a relatively small private sector, and global budgeting lead to lower expenditures per patient within the National Health Service without compromising access to care.

In a survey of 196 Norwegian radiologists and 37 breast imaging centers, physicians' preferences were found to be likely to influence the use of mammography. In their decision making, the radiologists appear to be influenced by income motives and by perceptions of the risk of misdiagnosing breast cancer. Despite opinions favorable to mammographic screening, most radiologists would prefer a CT scanner or a magnetic resonance imaging unit to a mammographic unit if the x-ray department were in a position to acquire capital equipment.

While laparoscopic cholecystectomy is now widely used, diffusion of other laparoscopic surgical methods has been more modest. Uptake of most laparoscopic methods has been influenced by considerations of effectiveness compared with open surgery, competing minimally invasive therapies, and the inconvenience and cost of technical change.