Gutzwiller, Felix

Koplan, Jeffrey P.

RERO DOC Digital Library

Special SectionASSESSMENTOF PREVENTIVETECHNOLOGIESGuest EditorsJeffrey P. KoplanCenters for Disease ControlFelix F. GutzwillerUniversity of Zurichuse, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0266462300005638Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 30 May 2017 at 14:44:08, subject to the Cambridge Core terms ofInternational Journal of Technology Assessment in Health Care, 7:3 (1991), 253-255.Copyright © 1991 Cambridge University Press. Printed in the U.S.A.INTRODUCTION TOPREVENTIVE TECHNOLOGIESJeffrey P. KoplanCenters for Disease ControlFelix F. GutzwillerUniversity of ZurichMedical technologies usually are associated with diagnostic or therapeutic devices orprocedures. The association tends toward the "high-tech" side of the developmentalspectrum and emphasizes the recent transfer of experimental techniques to the bed-side. Preventive health care technologies are usually not considered to be in the main-stream of technology assessment. This may in part be because, despite the academicacceptance of the U.S. Office of Technology Assessment's definition of health caretechnology as the "drugs, devices, and medical and surgical procedures used in med-ical care, and the organizational and supportive systems within which such care isprovided," the more general use of technology tends to connote a mechanical or elec-trical piece of equipment. Another factor that may emphasize the assessment of diag-nostic and curative technologies over preventive ones is the linkage of technology as-sessment with reimbursement for medical expenses, health care cost containment, andquality control. These issues are central to clinical technologies but remain tangentialto most preventive technologies.This state of affairs can be illustrated by a cursory review of subjects in the issuesof the last 3 years of this journal. Of over 90 articles, 2 could be considered as dealingwith a preventive technology. We seek to fill in some of this gap with this issue, inwhich we focus exclusively on preventive technologies. We hope to demonstrate forthe reader that (a) these are vitally important aspects of our efforts to improve health;(b) these preventive technologies not only merit assessment, they require it; and (c)the methodologies for, and issues of, technology assessment have several key differ-ences for preventive versus clinical subjects.The range of preventive technologies is broad and can be classified along a con-tinuum of degree of "preventability." At one end is our ability to actually prevent anadverse health event from occurring (primary prevention). If we cannot prevent ill-ness, we then aim at its early detection (secondary prevention), with the understandingthat detection at a pathological process's earliest stages is more likely to lead to cureor reversal of the process. Finally, when we either do not have the tools for early detec-tion or such detection does not alter the course of illness, we can take steps to preventthe complications of disease (tertiary prevention).When carried to an extreme, such as the use of heroic measures in an intensivecare unit to "prevent" death, the use of "prevention" is disingenuous. The preventivemedicine purist is most comfortable with primary prevention activities, but will em-use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0266462300005638Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 30 May 2017 at 14:44:08, subject to the Cambridge Core terms ofKoplan and Gutzwillerbrace some secondary prevention activities (such as screening) if the outcomes seemsubstantial. One factor that seems to make technologies of tertiary prevention moreacceptable is if they permit an individual to avoid an increased degree of disability.For example, we do not have the knowledge or tools for preventing juvenile-onset(insulin-dependent) diabetes. Likewise, we have no data that prove that early detectionand management affects this disease's outcomes. But we do know that proper manage-ment by both patient and health care provider, while a patient is still fully or mostlyfunctional, will avert or appreciably delay sequelae such as lower extremity amputa-tion and visual impairment.The articles comprising this issue present assessments of a variety of preventivetechnologies. For the category of primary prevention, which may be thought of assynonymous with health promotion, we have chosen to look at two broad-based ap-proaches. The first, school health education, deals with a multiplicity of risk factorsfor many diseases and hazards. Provided to young people during the crucial periodof their physical and intellectual growth, this prevention technology, potentially oneof the most powerful, conveys knowledge of bodily functions and of their relationshipto healthy and unhealthy behaviors. During this period, a young person's health canbe profoundly influenced by decisions involving such lifestyle-forming behaviors aseating habits; physical activity; and use of tobacco, alcohol, and other addictive sub-stances. The knowledge provided through school health education, along with tech-niques designed to encourage positive health attitudes and behaviors, has been shownto be effective in a number of studies using different curricula. Dwyer et al. reviewthe progress and effectiveness of school health education programs.Another broad primary prevention approach involves community interventions.For over two decades around the world, many of these community-based efforts havefocused on cardiovascular disease and the several risk factors for coronary heart dis-ease that have been documented. Vartiainen et al. review population-based programsdesigned to alter blood cholesterol and lipoproteins.The annual U.S. Public Health Service Surgeon General's Report on Smoking pro-vides a useful background document for assessment of smoking prevention and con-trol strategies, and there is a growing literature on behavioral, epidemiologic, economic,legal, social, and other aspects of smoking. For this issue, Mackay and Davis assesscommunity approaches to reducing smoking in populations.Immunization is a primary preventive technology that has received considerableassessment. For this issue, Steffen et al. focus on a particular use of immunizationsin the setting of relief and refugee missions. Hatziandreu et al. examine the cost-effectiveness of hepatitis-B vaccination in Greece. This article provides an exampleof a cost assessment of a relatively new vaccine and explores the issue of how diseaseprevalence contributes to technology assessment and, consequently, to decision making.One of the great triumphs of modern preventive medicine, and indeed of medicinein general, has been the dramatic decline in dental caries through the fluoridation ofwater. In this issue, Corbin evaluates fluoridation and other oral disease preventivetechnologies used on a community basis.There are many opportunities for preventive approaches in environmental and oc-cupational health. Actions that can prevent disease and hazards include altering in-dustrial design, enacting laws, using safety equipment, and teaching workers safe prac-tices. The study of motor vehicle collisions, a particular environmental hazard, providesa rich example of the wide assortment of preventive technologies that can contributeto the control of this problem. For this issue, Chorba systematically assesses technolo-2 5 4 INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CAREuse, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0266462300005638Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 30 May 2017 at 14:44:08, subject to the Cambridge Core terms ofIntroduction to preventive technologiesgies developed and designed to prevent motor vehicle collisions or to reduce deathand injury when collisions occur.Early detection of disease using a variety of screening tools is a widespread formof primary and secondary prevention. The screening may be targeted to risk factors(blood tests for cholesterol, community blood pressure measurement for hypertension),to early stages of disease (mammography for breast cancer, Pap smears for cervicaldysplasia and carcinoma in situ), or to congenital abnormalities (amniocentesis forspecific birth defects, school-based screening for scoliosis). In this issue, Rosenbrockconsiders screening for HIV infection and offers a controversial view of this practice.La Vecchia et al. review the effectiveness of screening for various types of cancer.This issue does not attempt to provide an exhaustive review of preventive tech-nology. Many important disease prevention and health promotion technologies arenot reviewed here, such as dietary interventions, exercise programs, prenatal screening,and multiphasic chemistry screening. Those that are presented, however, provide richillustrations of the varieties and importance of preventive technologies and their needfor assessment.INTL. J. OF TECHNOLOGY ASSESSMENT IN HEALTH CARE 2 5 5use, available at https:/www.cambridge.org/core/terms. https://doi.org/10.1017/S0266462300005638Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 30 May 2017 at 14:44:08, subject to the Cambridge Core terms of

Introduction to preventive technologies

Abstract

Similar works

Full text

Available Versions

RERO DOC Digital Library