Epistemological issues of technology assessment

The most important function of a technology assessment is to reduce the level of ignorance about the costs and benefits of technological changes. The distinction between technique and technology serves to focus on technology assessment as an analytical process for the study of the relations of technology, society, and public policies. Some of the epistemological issues that threaten the claim to legitimacy of this process are traced to competing theories of social and political changes. It is suggested that phronesis rather than value-free rational analysis is an appropriate model for technology assessment. The proper role of technological forecasting and public participation, two problematic activities, is discussed. It is concluded that technology assessment makes an important contribution to the political process in providing information from a broad perspective.     

Modes of biotechnology assessment in the USA,Japan and Denmark

Since the 1970s technology assessment by public bodies has become generally accepted as necessary. Modes of technology assessment differ from country to country, in terms of degree of institutionalization, acceptance by policy makers and level of public involvement, and these in turn depend on the goals, methods and organizational framework of the particular technology assessment. The varying social and political roles of technology assessment arise out of national political traditions and differing cultural views of technology. This article compares modes of biotechnology assessment in the USA, Japan and Denmark, focusing on the role of public discussion in the policy-making process. By analysing these three different contexts, the article seeks to uncover ways in which the cultural conditioning of technology policy takes place.     

A formal discussion of the Sarewitz-Nelson rules

In this paper, we formally discuss the Sarewitz-Nelson rules for technological fixes (SN-rules). In their original form, the SN-rules were formulated from an implicit theoretical framework such that they define a broad technology assessment heuristic. This formulation has advantages and disadvantages. In this work, we propose that it is possible to make advances in the interpretation and use of the SN-rules, if we formally consider them as a procedure for technology screening, integrated within a wider process of technology choice and policy-making. This conception helps us to assess the nature and applicability of the SN-rules in different contexts, and allows us to position them as a contribution to the economic theory of technology policy.     

A theory of classification and evolution of technologies within a Generalised Darwinism

This paper here proposes a theory of classification and evolution of technology based on taxonomic characteristic of interaction between technologies that is an under-studied field of research in economics of technical change and management of technology. The proposed classification of technologies, in a broad analogy with evolutionary ecology of parasites, within a theoretical framework of Generalised Darwinism, is: (1) parasitic technologies, (2) commensal technologies, (3) mutualistic technologies, (4) symbiotic technologies. This theory here suggests the property of mutual benefaction from interaction between different technologies and the theorem of not independence of any technology to explain and predict characteristics and evolutionary pathways of technologies over time. Overall, then, this study may be useful for bringing a new perspective in economics of innovation to categorise and analyse the interaction between technologies that can be a ground work for development of more sophisticated concepts to explain and predict the evolution of technology and generalise aspects of technological change in human society.     

Social assessment of technology and some of its international aspects

Search for some means of social management of technology has become a major concern for science and technology policy in recent years. Social Assessment of Technology (SAT) is considered as a potentially important instrument of this new orientation of policy. The concept of social assessment of technology leads to a reappraisal of the role of science and technology in a contemporary society, both with regard to policy, and to final objectives. It is a new approach to a better informed decision-making. Though it is of interest to all segments of the policy-making process, one would expect that social assessment of technology should be closely linked to technology policy. However, from the institutional point of view, technology has no place of its own. The term “technology” was only recently added to that of science in the relevant national government agencies. This is a purely formal link. To arrive at an operational outline of technology policy, a much deeper understanding of technology and the innovative process in general is still necessary.The lack of an appropriate institutional “niche” makes it particularly difficult to envisage technology assessment studies at an international level. The work accomplished by OECD is of interest, since it is the first experience of its kind. Theoretical and factual investigations had led to the publication of a comprehensive analysis, Society and the Assessment of Technology, and a report on Methodological Guidelines for Social Assessment of Technology. This was followed by an attempt to test the social assessment approach in applying it to real problems of interested member countries. International cooperation in the field of social assessment of technology is hampered by a number of major difficulties such as changing objectives of national policy, secrecy, race for a competitive advantage, insufficient diffusion and understanding of the concept itself, and the unwillingness or inability of decision-makers to consider middle- and long-term policies.     

The cost-effectiveness of celecoxib vs diclofenac in the treatment of osteoarthritis in the UK; an update to the NICE model using data from the CONDOR trial

Abstract

Objectives:

The National Institute for Health and Clinical Excellence (NICE) health economic model for assessing the cost-effectiveness of celecoxib plus a proton pump inhibitor (PPI) compared to diclofenac plus PPI in the treatment of osteoarthritis has been updated using new adverse event (AE) risks from the CONDOR trial. In light of this new information, this study aimed to evaluate the incremental cost-effectiveness ratio (ICER) of celecoxib plus PPI compared to diclofenac plus PPI.

Methods:

NICE developed a health economic model as part of their 2008 multiple technology assessment of treatments for osteoarthritis. The model was adapted for this study to update the relative risks of adverse events, using data from the CONDOR trial.

Results:

Using the AE data from the CLASS trial alone, celecoxib plus PPI has an ICER of £9538 per QALY when compared to diclofenac plus PPI. When the AE data from CONDOR alone is used, this ICER decreases to £4773 per QALY. Using the pooled data from both trials, celecoxib plus PPI has an ICER of £9377 per QALY compared to diclofenac plus PPI.

Discussion:

The results suggest that when new AE risks are used, celecoxib plus PPI remains a cost-effective treatment for OA when compared to diclofenac plus PPI. However, this analysis is limited by the short time horizon, and additional AEs that have not been considered.     

Tailoring CTA for emerging technologies

Technology assessment (TA) has developed into a method that puts a strong emphasis on facilitating interfaces between supply of science and technology and the demand for useful applications. Recently, we also see that TA becomes an integral part of science and technology programs, for instance in nanotechnology. The basic aim of the latter is to articulate the needs, wishes, and constraints, for example from professional users, already in the emerging stage of technological development. TA methods come in many different forms, although they are often different versions of a limited set of ‘basic approaches’ adapted to specific conditions with the overall aim to improve societal embedding. The thrust of this paper lies in the development and results of a variant of constructive TA (CTA), addressing technological development in an early phase in order to bypass the Collingridge dilemma by developing and testing scenarios including options for the further development of emerging technologies.How to support a broad selection of relevant actors effectively with CTA in such a way that they are enabled to play their role in innovation processes of emerging technologies? This is the main research question taken up in this paper. To take on this challenge we develop, apply, and evaluate an intervention we named the 3-step constructive technology assessment (CTA) approach. We will apply the approach to a nanotechnology related topic, Lab-on-a-chip technology. By assessing the effects and evaluating the proposed approach, we also want to contribute to the development of new methodological insights relevant for the TA community.     

Bridging the gap between technological possibilities and people:: Involving people in the early phases of technology development

Technology provides endless promising possibilities to support people's lives. In reality, it is not a matter of what is possible, but rather a matter of how and when technology will be integrated, accepted and adopted by people. However, conventionally within organizations the areas of technology development and market research are not closely related nor applied in the process of innovation and do not always share the same scope. In that sense there is a gap between the potential of technology and humankind's preferences.This paper discusses the current areas of technology development and market research in a business environment and proposes an integrated approach to bridge the gap between technology and people, in which people, rather than market sizes become central in the development of technology. In addition, it also describes how this approach of people-driven innovation is brought into practice through the development of early experience demonstrators. The core focus of this paper is on the processes and practices regarding innovation within an organization, rather than the adoption of innovation by users or the rate of the adoption of a marketed solution (Rogers, 1995 [E.M. Rogers, Diffusion of Innovations, The Free Press, New York, 1995. [1]]).     

Developing technology assessment methodology: Some insights and experiences

The authors suggest that policy-oriented assessments of newly emerging technologies could benefit from explicit attention to methodological concerns. Although some of the early literature attempted to develop distinct methodology for performing technology assessment, the authors do not believe that a singular approach is possible. In spite of having some common elements or aspects, assessments vary widely depending upon their specific subject matter, the normative factors included in them, and the policy work to which they pertain. Thus, the methodology appropriate for any particular assessment must be derived from experimental knowledge and “savvy” as well as the more formal and replicable techniques. In closing, the authors urge persons involved in technology assessment to share their project experiences; such a practice will facilitate the creation of a larger pool of competence and help others to cope with the difficulties that have befallen previous technology assessment studies.¹     

Cost and time savings from a rapid access model of care using transient elastography to screen and triage patients with chronic Hepatitis C infection

Background:

Treatment uptake amongst patients with chronic Hepatitis C virus (HCV) in Australia is relatively low. New approaches to assessment have the potential to reduce public waiting lists, improve access to treatment, and to reduce healthcare costs.

Aim:

To describe the costs to the public hospital system and waiting time associated with a novel integrated rapid access to assessment and treatment (RAAT) model of care that utilizes Transient Elastography (TE) as a specialist outpatient-based approach for a streamlined assessment of patients with chronic HCV, compared to conventional outpatient management with liver biopsy (LB).

Methods:

Time from first medical review to treatment plan and costs associated with detection of fibrosis were recorded for patients receiving RAAT during a 3-month period, and for a similar historical cohort managed conventionally with LB. Costs related to medical and multidisciplinary team reviews and the TE/LB test itself were included.

Results:

Patients receiving RAAT had lower costs (n?=?27, median AU$2716) and shorter time to treatment (median?=?194 days) than for conventional management (n?=?13, median $5005, 420 days; p?Conclusions:

Based on real world audit data, this evaluation suggests TE, used as part of a new RAAT model of care, is cost saving to the health system in the short-term and reduces waiting times. The analysis reported here was intended to assess the costs related to detection of fibrosis, and is limited by the small sample size and potential selection bias. Future research should undertake a full economic evaluation at a whole of service level, to consider a more comprehensive and longer-term assessment of the costs and benefits associated with HCV management.     

EVEREST II high risk study based UK cost-effectiveness analysis of MitraClip® in patients with severe mitral regurgitation ineligible for conventional repair/replacement surgery

Abstract

Objectives:

To evaluate the cost-effectiveness of MitraClip, an interventional procedure for patients with chronic severe mitral regurgitation.

Methods:

A decision analytic model with a lifetime horizon was developed to assess the cost-effectiveness of MitraClip vs conventional medical management in patients with severe mitral regurgitation, ineligible for surgery. The analysis was performed from a UK NHS perspective and the estimates for mortality, adverse events, and cross-sectional NYHA class were obtained from the EVEREST II High Risk Study (HRS). Utility decrements were obtained from a heath technology assessment on Cardiac Resynchronization Therapy, while unit costs were obtained from national databases. The concept model was clinically validated. Costs (2011 £UK) and benefits were discounted at an annual rate of 3.5%.

Results:

Compared to medical management, over 2- and 10-year periods MitraClip had incremental Quality Adjusted Life Year (QALY) gains of 0.48 and 2.04, respectively. The Incremental Cost-Effectiveness Ratios for MitraClip at 2 and 10 years are £52,947 and £14,800 per QALY gained. Overall, the model was most sensitive to the choice of time horizon, the discount rate applied to benefits, the starting age of cohort, the utility decrement associated with NYHA II, and cost of the MitraClip procedure. The model was insensitive to changes in all other parameters. MitraClip was also found to be cost-effective, regardless of the modelling approach, and insensitive to the key assumptions of the procedure cost.

Study limitations:

The primary limitation of the analysis is the reliance on aggregate data from a modestly sized non-randomized study with a short-term follow-up period. Aligned to this was the need to extrapolate survival well beyond the study period in order to generate meaningful results. The impact of both of these limitations was explored via extensive sensitivity analyses.

Conclusion:

Compared to medical management, MitraClip is a cost-effective interventional procedure at conventional threshold values.     

The death knells of mature technologies

The oscillatory behavior in the mature phase of some technologies' diffusion-related S curves are investigated, specifically with regard to the influences that other technologies can have on the oscillations. The notion of mortality indicators is raised, that is, whether such behavior is a signal that the mature technology is under attack from an emerging technology. The case of structural panels in the wood products industry is considered as an example, and an updated forecast of the substitution of oriented strand board for plywood is made. It is concluded that factors such as macroeconomic business cycles are primarily responsible for the oscillations in plywood's S-curve, although it is argued that an emerging technology can also contribute to perturbations in a mature technology's S-curve. Two possible alternative explanations for the oscillatory behavior are also discussed, a previously proposed chaos formulation, and a mathematical model based on modified Lotka-Volterra equations. This model shows that the oscillatory behavior in mature technologies' S-curves can also result from symbiotic interaction between two technologies under certain circumstances.     

Hicks's Valuation of Social income: an appraisal *

This paper attempts to reconstruct and assess the intellectual itinerary of Hicks on the valuation of social income. His 1958 and 1981 papers on that topic have been wholly ignored in the economic literature. In both of them differentmeasures of real income are provided. These show to what extenteach one of them can be relied upon. Our assessment argues that it is impossible to measure social income independentlyof the reasons for which that measure is required and that any valuation cannot ultimatelybe made independently of political and ethical considerations.     

The generalized distance measures of technology

This paper presents a discriminant analytic framework for the measurement and assessment of technology. It circumvents entirely the problems associated with the other approaches to measurement of technology presented in the literature on technological forecasting and economic theory of quality change. The proposed framework is also capable of providing a whole new variety of systematic approaches to technology assessment. It has been pointed out that the present approach may be regarded as complementary to the dimensional analytical approach presented earlier by the author. In comparison of the two, the notion of process discriminant as distinguished from feature discriminant is advanced. A partial application of the framework to the illustrative case of piston-type aircraft technology is presented. The results of the study provide further support to the hypothesis that the majority of technological change occurs at the level of emperical rather than fundamental knowledge.     

Evolving provider payment models and patient access to innovative medical technology

Objective:

To investigate the evolving use and expected impact of pay-for-performance (P4P) and risk-based provider reimbursement on patient access to innovative medical technology.

Methods:

Structured interviews with leading private payers representing over 110 million commercially-insured lives exploring current and planned use of P4P provider payment models, evidence requirements for technology assessment and new technology coverage, and the evolving relationship between the two topics.

Results:

Respondents reported rapid increases in the use of P4P and risk-sharing programs, with roughly half of commercial lives affected 3 years ago, just under two-thirds today, and an expected three-quarters in 3 years. All reported well-established systems for evaluating new technology coverage. Five of nine reported becoming more selective in the past 3 years in approving new technologies; four anticipated that in the next 3 years there will be a higher evidence requirement for new technology access. Similarly, four expected it will become more difficult for clinically appropriate but costly technologies to gain coverage. All reported planning to rely more on these types of provider payment incentives to control costs, but didn’t see them as a substitute for payer technology reviews and coverage limitations; they each have a role to play.

Limitations:

Interviews limited to nine leading payers with models in place; self-reported data.

Conclusion:

Likely implications include a more uncertain payment environment for providers, and indirectly for innovative medical technology and future investment, greater reliance on quality and financial metrics, and increased evidence requirements for favorable coverage and utilization decisions. Increasing provider financial risk may challenge the traditional technology adoption paradigm, where payers assumed a ‘gatekeeping’ role and providers a countervailing patient advocacy role with regard to access to new technology. Increased provider financial risk may result in an additional hurdle to the adoption of new technology, rather than substitution of provider- for payer-based gatekeeping.     

The value and consequences of using public health technology assessments for private payer decision-making in Canada: one size does not fit all

Background: Both public and private insurers provide drug coverage in Canada. All payers are under pressure to contain costs. It has recently been proposed that private plans leverage the public health technology assessment (HTA) evaluation process in their decision-making.

Objectives: The objectives of the current study were to examine use of public health technology assessments (HTAs) for private payer decision-making in the literature, to gather the perspectives of experts from both public and private insurers on this practice, and to summarize which value parameters of public evaluations can be used for private payer decision-making.

Methods: A targeted literature review was conducted to identify publications on the use of public HTA or cost-effectiveness data for private payer decision-making on pharmaceutical reimbursement. Concurrently, a roundtable meeting was organized with invited panelists, including private payer representatives and health economic consultants (total n?=?9). The findings from both were synthesized and expressed in qualitative terms using the PICO framework.

Results: The targeted review identified 20 studies meeting the inclusion criteria, primarily originating from the US and Canada. The panelists felt that, despite some similarities, there were substantial differences between both systems. The PICO framework highlighted the issues with transferability between the two systems. Most of the value parameters were either not applicable, needed to be added, needed to be adjusted, or their applicability to private payer systems needed to be confirmed.

Conclusion: Some components of public HTA may be relevant for private payers, however there are reservations that still exist on whether the HTA process in Canada, designed for a public system, can address the informational needs of private payers. Private insurers need to use caution in assessing which value parameters from public HTAs can be used and which need to be confirmed, ignored, enhanced, or adjusted. One size HTA does not fit all applications.     

Strategic experimentation and disruptive technological change

This paper studies the diffusion of a new technology that is brought to market while its potential is still uncertain. We consider a dynamic game in which an incumbent and a startup firm improve both a new and a rival old technology while learning about the relative potential of both technologies. The main findings are that (i) risk considerations make incumbents with higher market shares more likely to adopt the new technology and (ii) changes in market power are often preceded by a subpar performance of the new technology. We also show that introducing a better new technology or confronting a worse old technology may hurt the startup firm as its new technology is then adopted earlier by incumbents.     

THE CITATION IMPACT OF FEMINIST ECONOMICS

Abstract

Feminist economics is a transformative project. However, transformation generates resistance. Feminist economics can be deliberately excluded, co-opted through an uncritical application of rational choice theory, or ignored. And feminist economics can be listened to: when the United Nations consults feminist economists; when feminist economists publish in widely read journals; when a student finds inspiration in a Feminist Economics article. All of these are ways feminist economics can, and has, influenced the profession. After ten years of discourse, it is possible to take stock and assess the impact of feminist economics. This article provides a partial assessment through a consideration of citations of the journal Feminist Economics, describing its impact on mainstream economics, heterodox economics, and other disciplines. While the overall project of feminist economics encompasses much more than just one journal, studying the citations for Feminist Economics is a first step toward assessing the influence of the entire corpus.     

Evolutionary economics and economic geography

This article attempts to explore how key notions from Evolutionary Economics, such as selection, path-dependency, chance and increasing returns, may be applied to two key topics in Economic Geography. The first issue is the problem of how to specify the (potential) impact of the spatial environment on new variety in terms of technological change. Evolutionary thinking may be useful to describe and explain: (1) the process of localized `collective' learning in a regional context, (2) the adjustment problems that regions may be confronted with in a world of increasing variation, and (3) the spatial formation of newly emerging industries as an evolutionary process, in which the spatial connotation of increasing returns (that is, agglomeration economies) may result in a spatial lock-in. The second issue is the problem of how new variety may affect the long-term evolution of the spatial system. We distinguish three approaches that, each in a different way, apply evolutionary notions to the nature of spatial evolution. This is strongly related to the issue whether mechanisms of chance and increasing returns, rather than selection and path-dependency, lay at the root of the spatial evolution of new technology.     

Optimism and firm formation

This paper analyses firm formation and innovation in an economy where agents differ with respect to their optimism in the face of ambiguity. Individuals choose between starting a firm or working in one; and also between employing a traditional technology or a new technology about which little is known. In the face of ambiguity, decision-makers are either optimistic or pessimistic. We study the innovation-proof equilibria of the economy: wages clear all labor markets when agents make optimal occupational choices, and no mutually beneficial opportunity for innovation remains unexploited. In equilibrium, optimists are more likely to form firms, but also more likely to be workers in firms using the ambiguous technology. This phenomenon sheds new light on the relationship between firm culture and technology. We find that three types of firms emerge in equilibrium: entrepreneurial firms, where both owners and workers are optimists operating a highly ambiguous technology; traditional firms, where an optimistic owner employs a pessimistic worker and uses a less ambiguous technology; and bureaucratic firms where both owners and workers are pessimists employing a well-known technology. We also suggest how the relative scarcity of the optimists may help to explain the commonly observed S-shaped diffusion profile for successful innovations.