Assessment of a technological package using a predictive tool.

Assessment should apply to established as well as to emerging technologies, to procedures as well as to machines, and to packages of tools and for clinical problems. Packages of tools include intensive care units and transplant surgery. Clinical problems requiring a variety of high technology responses include coronary artery disease, renal failure, and cancer in various locations. In practice few technologies prove never to be useful while none are always useful. The aim of assessment is to discover for each technology the sliding scale of value in terms of benefits and burdens for various types of patients and so to define the limits of appropriate use (5). But assessment itself is a costly business that may be regarded as a waste of resources unless it is carried out economically and it subsequently has an influence on the provision and use of that particular technology. No one method of assessment is appropriate in all circumstances. Different problems are posed by the evaluation of drugs, of diagnostic equipment, of surgery, and of technological packages. Yet there are some commentators for whom the only acceptable evidence is a randomized controlled trial (RCT). Like some of those whom they wish to put on trial for promoting technologies that have been inadequately evaluated they are themselves uncritical champions for their own product—the RCT. Randomization gives no guarantee that evaluation will be well designed, well executed, or well analyzed. Moreover, many of the merits ascribed to randomization are no more than the characteristics of competent data collection (which is prospective, with strict protocols and entry criteria, and with assiduous follow-up). What is more validly claimed for randomization is that it tends to balance between treatment groups prognostic factors that are both known and unknown. This makes it likely that comparisons are made between patients whose outcomes were expected to be similar if they had been treated in the same way.