ASSESSMENT OF TECHNOLOGIES
RESULTS
The structure proposed for technical reports on obsolete health technologies is shown below.
Figure 5. Proposed structure for obsolete health technology assessment reports.
INFORMATION ON OBSOLETE HEALTH TECHNOLOGY
This section will include general information referring to the obsolete health technology, including the technology's name, synonyms and type by reference to the use to which it is put in patients (diagnostic, therapeutic, rehabilitative, etc.). An indication will also be included as to when it was first introduced into the health-care system. In this respect, there may be technologies on which this information is unavailable, and in such cases the date will be indicated on which knowledge of its first being used in clinical practice was received.
Lastly, in this section, a detailed account will be given of the indication or indications for which the technology's obsolescence is proposed. There may be a given technology that is useful for one indication but is possibly obsolete for others. It is therefore extremely important to specify in detail precisely what is being proposed as an obsolete technology, bearing in mind here that most technologies usually tend to have more than one indication. Supplementing this information, there will be an indication as to where information on the technology can be obtained. This data source may consist of web pages of commercial firms, scientific societies and institutions, or even scientific papers, whether published recently or at some time in the past, which give a detailed description of the characteristics of the technology said to be obsolete.
In some cases, technologies are proposed as being obsolete generically, without specifying any indication, and are therefore deemed obsolete for all indications. This may be the case of imaging tests which emit radiation and for which alternatives are found that possibly emit far less radiation. In such cases, the technology will be proposed as obsolete per se, without specifying the indications or indicating the subgroups of patients to which it could be applied.
If the technology has been prioritised vis-ā-vis other obsolete technologies, this should also be indicated in this section.
CONTEXTUALISATION OF TECHNOLOGY
Under this section, indication should be given as to whether the condition or disease to which the technology is applicable is highly prevalent or incident. Furthermore, the report should specify whether the condition generates an elevated disease burden and whether the technology is applied to healthy (e.g., screening tests) or diseased individuals. The ideal would be to obtain such information in a contextualised manner from the setting to which the technology's obsolescence pertains (local, regional or national), and always, where possible, from registries or data sources that afford maximum reliability and are population-based.
It is also necessary to indicate the technology's frequency of use. The condition to which it is applicable may be very frequent in the study area but the technology may not be applied or hardly used, or the inverse may be true, i.e., a case where the condition is relatively rare and yet the technology is applied in almost all cases, though this second situation is somewhat unforeseeable. To this end, it will be necessary to estimate the number of patients on whom the obsolete technology is being used. In many cases, such estimates will be very difficult to obtain but, by way of a data source, information can be found in the procurement departments of health centres or services, commercial firms, or the clinicians themselves who form part of the specialisation connected with the obsolete technology. The last-mentioned would not only furnish relatively reliable information, but could also provide information on any technologies that might have replaced the obsolete technology, as well as any possible repercussion on their routine clinical practice if the obsolete technology is withdrawn.
The section dealing with diffusion and implementation of obsolete technology will indicate whether the technology is being performed in many centres, whether the centres in which it is used are primary or specialised care centres, and, whether these are specialised, whether they are first-, second- or third-level. Indication will also be given as to whether there is evidence of the technology being used in settings other than national or regional.
Lastly, the section on the setting and infrastructure of the technology should indicate the needs in terms of the equipment, space and human resources required for the obsolete technology's use, something that will also indirectly indicate the possible impact of its withdrawal.
CONSIDERATION OF TECHONOLGY OBSOLETE
This section is the most important part of the report, and included in it will be the available scientific evidence supporting the obsolescence of the assessed technology.
The reason for the assessed technology being obsolete must be clearly explained firstly, stating whether the underlying cause is a loss of effectiveness, a loss of safety, or perhaps excessive organisational costs or aspects relating to its alternatives. Combinations of all three aspects can also be considered. A clear indication must also be given of what the existing alternative technologies are and in which respects these supersede the potentially obsolete technology. These alternatives must have given ample proof of their efficacy/safety/diagnostic capacity and be incorporated into the service portfolio.
There must be a specific section addressing efficacy/effectiveness. This section will list any published studies (original research, systematic reviews or any reliable data source) that may have analysed the efficacy/effectiveness of the alternative technologies vis-ā-vis that of the obsolete technology. The results of this section should focus, in particular, on the most robust outcome variables, if any, (mortality, morbidity and quality of life, or sensitivity, specificity and predictive values in the case of diagnostic tests) because, if such outcomes favour the alternative technology, this will reinforce the evidence attesting to the technology's obsolescence. Studies having the highest methodological quality should be highlighted, and the information is to be reported as succinctly as possible. It is in this section that the treatment standards for the indications of the potentially obsolete technology being considered are to be specified in accordance with clinical practice guidelines, HTA reports or high quality systematic reviews, if any.
The following section is to address the safety of the obsolete technology versus the safety of alternative technologies. As in the preceding section, this section should be brief and should focus on the general results of studies and, in particular, on easily measurable and objective variables.
The costs and organisation results section will provide information detailing which organisational or cost-related aspects are reported by the literature as placing the obsolete technology at a disadvantage vis-ā-vis the alternative technology. Information received from commercial firms or furnished by clinicians can be included in this section. In these cases, care must be taken with regard to any possible existing conflicts of interest, and the source of all data obtained must be clearly shown.
There will be a final section headed, "Other aspects to be considered", which can be covered for any technology requiring this. Here, other relevant aspects of the assessed technology can be commented upon, i.e., ethical, legal or social aspects that might be of importance for some obsolete technologies.
LEVEL OF SCIENTIFIC EVIDENCE
This section will summarise the quality of the evidence available for classifying or not classifying the technology as obsolete. A number of already published scales can be used. The use of the scale of the Scottish Intercollegiate Guidelines Network (SIGN) (33) or that of the Oxford Centre for Evidence-Based Medicine Levels of Evidence (34) is recommended..
CONCLUSION AND RECOMMENDATIONS
The Conclusions section will succinctly sum up the conclusions of each of the preceding sections. The conclusions may themselves be accompanied by recommendations and proposals about the obsolete technology.
DATABASE SOURCES AND BIBLIOGRAPHY
The databases consulted and the search strategies used for making the report will appear in this last section. This section must record the rules governing systematic reviews, which, in essence, require that the method applied be reproducible. The systematic review is the methodology that should follow all assessments of potentially obsolete technologies.
