J. Underused Technologies and HTA

When used properly, HTA can result in the reduction or elimination of the use of technologies that are not safe and effective, or whose costs are too high relative to their benefits. Less attention is given to the ability of HTA to identify technologies that are underused and to determine why they are underused (Asch 2000; McNeil 2001). Underuse is prevalent in preventive, acute, and chronic care; applies to care for children, youth, and adults; and contributes to tens of thousands of deaths and billions of dollars of losses to the economy and unnecessary health care costs (GAO 2002; Mangione-Smith 2007; McGlynn 2003). According to one estimate, replacing more costly, non-superior health care with proven cost-effective care would save approximately one-fourth of US health care spending (Fuchs 2011).

Underuse of some proven therapies affects large proportions of at-risk populations. For example, there is high-quality evidence that smoking cessation interventions, including nicotine replacement therapy, the antidepressant bupropion, and counseling, are safe, effective, and cost effective (Anderson 2002; Foulds 2002; Stead 2008; Woolacott 2002). However, in Europe, North America, and elsewhere, these interventions are used far less than is indicated. Two further examples in the US are management of hypertension and childhood vaccinations, as follows.

Based on data from the US National Health and Nutrition Examination Survey (NHANES) 2003-2010, the Centers for Disease Control and Prevention (CDC) estimates that the prevalence of hypertension among US adults was 30.4%, or about 66.9 million people. (Hypertension was defined as an average systolic blood pressure ≥140 mmHg or an average diastolic blood pressure ≥90 mmHg, or currently using blood pressure-lowering medication.) Among those with hypertension, 53.5% did not have their hypertension controlled. Among these people, 39.4% were not aware of their hypertension, 15.8% were aware of their hypertension but were not receiving medication for it, and 44.8% were aware of their hypertension and were being treated with medication (CDC 2012). Hypertension accounted for an estimated $131 billion in direct US health care costs in 2010, including its contribution to costs of complications associated with other cardiovascular conditions (Heidenreich 2011).

Vaccination rates in the US remain highly variable by vaccine type and age group, although these rates have generally increased in recent years. For example, according to 2012 National Immunization Survey data of the CDC, vaccination rates (with minimum appropriate number of doses) for children 19-35 months old were at or near the US objective of 90% for poliovirus (92.8%); measles, mumps, and rubella (90.8%); varicella (90.2%), and hepatitis B (89.7%). Rates were lower for other vaccines, including diphtheria, tetanus and pertussis (82.5%); pneumococcal conjugate vaccine (81.9%); Haemophilus influenzae b (80.9%); and hepatitis B birth dose (71.6%). Rates were low for hepatitis A (53.0%, vs. target of 85%), and rotavirus (68.6%, vs. target of 80%). Rates of vaccination coverage were generally lower for children living below poverty level, including 6.0% to 9.5% lower for several of these vaccination types (CDC, National, state, and local area vaccination coverage among children, 2013).

Underuse of particular technologies is attributed to various reasons. For smoking cessation, these reasons include: lack of insurance coverage, concerns about short-term costs without regard to cost-effectiveness in the short-term (e.g., for pregnant women and infants) or the long-term; lack of smoker awareness of effective interventions; insufficient demand by patients, physicians, and the tobacco-control community; and the influence of the tobacco industry on policymaking (Schauffler 2001). Available evidence suggests, for example, that greater insurance coverage of smoking cessation interventions increases the likelihood that smokers will stop smoking (Reda 2012).

Rates of underuse can be highly variable in a country or region. In the instance of pediatric vaccinations in the US, underuse is affected by such factors as differences in socioeconomic status, payment mechanisms, and shortages of certain vaccines (CDC, National, state, and local area vaccination coverage among children, 2013; CDC, National and state vaccination coverage among adolescents, 2013; Hinman 2006). In developing countries, the major cause of vaccine shortages is lack of resources to purchase them (Hinman 2006).

Box X-2. Some Underused Health Care Technologies (US)

• ACE inhibitors for treatment of heart failure
• ACE inhibitors for prevention of renal deterioration in insulin-dependent diabetics
• Ambulation aids (canes, crutches, walkers)
• Antibiotics for gastrointestinal ulcers
• Beta blockers for survivors of acute myocardial infarction
• Cholesterol-lowering drugs for patients at risk of coronary artery disease
• Childhood vaccinations
• Cochlear implants for severe-to-profound deafness
• Colorectal cancer screening
• Corticosteroid inhalants for treating asthma
• Corticosteroid therapy for fetuses at risk of preterm delivery
• Depression diagnosis and treatment
• Diabetic retinopathy screening
• Hemoglobin A1c testing every 6 months in diabetic patients
• Hepatitis B virus vaccination of infants
• HIV testing and treatment with antiretroviral therapy
• Hypertension management
• Implantable cardioverter-defibrillators for survivors of cardiac arrest
• Incontinence diagnosis and treatment
• Influenza immunization
• Inhaled corticosteroids in adults with asthma
• Intraocular pressure screening for glaucoma
• Mammography (especially women age 50+)
• Oral rehydration therapy for dehydrated children
• Organ transplantation
• Pain management
• Pap smears
• Pneumococcal vaccine for high-risk patients
• Prenatal care
• Smoking cessation interventions
• Thrombolytic therapy for acute myocardial infarction
• Thrombolytic therapy for ischemic stroke

Box X-2 shows examples of health technologies for which good evidence exists of safety, effectiveness, and cost-effectiveness, but that are used significantly less than is indicated, even where they are affordable. Although this list applies primarily to the US, many of these technologies are underused elsewhere in North America, Western Europe, and other wealthy countries.

The reasons that worthy technologies are underused are diverse, and include the following.

• Lack of awareness on the part of patients, physicians, and others
• Inadequate or ineffective information dissemination
• Limited coverage policies (e.g., for preventive services)
• Limited access to primary care
• Poor socioeconomic status
• Fee-for-service payment systems that reward use of high-paying services without regard for cost-effectiveness
• Concerns about short-term cost without regard for cost savings and cost-effectiveness in the short- and long-terms
• Inappropriate or unsubstantiated concerns about improper use (e.g., pain therapy)
• Inconvenience and misperceptions on the part of clinicians, patients, or the public (e.g., false information suggesting that vaccines increase the risk of other disorders)
• Clinical inertia, i.e., unwillingness to change practice habits
• Insufficient supply (e.g., organs for transplantation)
• Health technology companies’ marketing efforts to emphasize brand name products rather than less-expensive technologies that are at least as effective and safe
• Disproportionate concerns about adverse effects (e.g., warfarin to reduce risk of stroke)
• Concerns about adherence to therapies by some patient subgroups
• Fear of stigma (e.g., treatment of mental health disorders)
• Professional conflicts and “turf battles” on the part of physician specialists, provider institutions, industry, and others

Merely generating better evidence is not enough to meet the decision-making needs of consumers, patients, health care providers, and purchasers. To maximize its impact on the quality and value of health care, these parties must cite and use evidence when making clinical and policy decisions. Disseminating evidence into clinical practice must be accompanied by ongoing evaluation and feedback to decision makers, the key characteristic of a true learning health care system. However, this is not happening consistently. In a review of adherence to 439 indicators of health care quality for 30 acute and chronic conditions as well as preventive care, McGlynn and colleagues concluded that American adults received only 55% of recommended care (McGlynn 2003). The same study found that children and youth received only 46.5% of recommended care (Mangione-Smith et al., 2007).

These gaps between evidence and execution underscore the need to identify more effective tools to help patients, providers, and policy makers to use the available evidence. Those in HTA must consider how implementation of HTA findings and recommendations, including the extent to which technologies may be underused, overused, or inappropriately used, may be affected by such factors as those listed above. Data suggesting underuse of health technologies known to be safe, effective, and cost-effective may be used to develop priorities for HTA and evidence questions. Explicit attention to underuse of proven technologies conveys that HTA is concerned with optimal use of proven health technologies, not just reducing use of inappropriate ones or the mistaken view that it seeks to diminish innovation or diffusion of health technology.