One particular aspect of the issue of rising costs is the introduction of new and expensive technologies or pharmaceuticals which can be used in such a way that there is no improvement in outcome. A technology can be expensive either because of the cost of the initial equipment which can now be very large or because skilled staff are needed to use it. It is not enough to know that a technology is safe or that it does what it purports to do and does it with accuracy. The vital question is whether it improves outcome and on which patients. An effective new technology or drug can so easily replace an older and much less expensive technology for routine use when, for many conditions, the outcome using the old technology or drug may be just as good as with the new. And it is by no means uncommon for the old technology or drug to continue to be used as well as the new which is proved to give better results. To establish the appropriate and efficient use of a new technology or drug is by no means easy. Considerable resources are needed for this type of research and it cannot be done quickly.

Technology assessment and Pharmacoeconomics include the evaluation of technical performance, clinical efficacy, safety, economic efficiency, organizational impact, social consequences, and ethical implications (FINNEBERG et al., 1979; GLASSER, 1988; FUCHS, 1990). In all cases, economic evaluation («comparative analysis of alternative courses of action in terms of both their costs and consequences») must play a key role (DRUMMOND, 1987).

The most frequent tasks undertaken by organisations involved in technology assessment are (STOCKING, 1988):

- monitoring emerging or existing technologies and setting priorities for evaluation;
- ensuring that appropriate research is undertaken;
- systematically reviewing and disseminating information.

The process of selecting technologies or drugs for assessment must be designed carefully. In most countries in Europe this is largely an informal process with no systematic procedures involved. An exception is the United Kingdom where a Standing Group on Health Technology exists under the aegis of the NHS Research and Development Programme (NHS MANAGEMENT EXECUTIVE, 1993).

A survey of technology assessment activities in the EU Member States reveals the following general themes (ABEL-SMITH et al., 1995):

- Technology assessment research activities are concentrated in half of the Member States. Application of the evidence produced in different contexts is not straightforward, and circulation of information is very limited at present.

- Most technology assessment activities, and almost all primary research programmes, are undertaken by academic or independent institutions. However, most economic evaluation studies in the field of pharmaceuticals are undertaken by the industry. The evidence they produce, however, is seldom made available to decision-makers in a timely and effective fashion.

- Technology assessment activities are extremely dispersed within the most active Member States. Many bodies operate with limited staff and funding, pursuing similar objectives. Few, if any, efforts have been made to co-ordinate research and provide incentives for the concentration of resources on specific projects. There seem to be no systematic and structured procedures to assist it. In many organizations involved in technology assessment in the United States, priorities are set by special committees on the grounds of explicitly stated criteria such as:

- the impact on aggregate cost of health care (cost-saving or cost-inducing);
- significant variability in medical practices;
- the prevalence of treatable conditions;
- the potential impact on patient outcome (benefit and risk);
- social and ethical concerns;
- the availability of a reliable base of knowledge.
- the probability that the assessment will produce conclusions that can potentially change the use of the technology.

Second, there needs to be more harmonisation of evaluative techniques and their orientation toward a common goal. Crucial issues currently on the agenda include:

- improving the evaluation of health outcomes by means of more reliable measures of health state utilities;

- understanding the relation between outputs and outcomes, which is critical in diagnostic and preventive interventions;

- accounting for the distribution of costs and benefits of technology or a new pharmaceutical product over time (discounting);

- making assessment models more dynamic and flexible for improving transferability and validity in situations characterized by complexity and uncertainty.

- deciding what costs to bring into account and how to measure benefit or utility so as to make studies comparable.

While a manufacturer can prove effectiveness in terms of outcome on some use, the problem remains that the practice of using it more widely often develops. Thus there is a need for further research to establish whether there are further applications which lead to improvements in outcome. Moreover, the standardisation of the procedures for accepting new technologies or pharmaceuticals between countries would assist the manufacturers of useful new technologies and secure their more rapid introduction. On the other hand, the detrimental side effects of treatment can be more easily detected when monitoring a larger population.

A further problem is the lack of evaluation of existing pharmaceutical products. Little is known about the extent to which many of them improve outcome and this is a gap which also needs to be filled. Customary use can so easily be guided more by convenience than proven evidence of effectiveness.