BOOKS OF RtfiDIfGS - PAHO/WHO

iKlarman
- 371 -
in the use of services or an improvernent in health. There seems to be Little point to using
multiphasic screening if this is the case.
A second answer is that of Garfield(lll), which I have criticized at length. He
provides no persuasive reason for choosing this instrumentality to control the use of
physician services.
A third answer is possible: that automated multiphasic screening is an integral part of a
package of comprehensive health services to which everybody has a right. Usually a
service is aspired to by the poor because the middle and upper classes are already getting
it. This is not yet the case regarding automated multiphasic screening.
Clearly, a reasonable answer can only be provided through an evaluation of automated
health screening for its worthwhileness. The report by the Advisory Committee(115)
states, "There are elements of AMHTS that defy cost-effectiveness analysis, but which
depend primarily on medical, social, and scientific objectives." If I understand the
statement, I disagree with it. It may be, however, that I do not understand it. What are
the medical, or social, or scientific objectives that defy measurement?
Following the formulation of data requirements given in the preceding section, 1
propose that data be compiled to evaluate automated multiphasic screening as follows:
the volume of disease detected that was not previously known;-what could be and in fact
was done about all this disease; what the outcomes in terms of health status and
subsequent utilization of services were; and at how much cost, inclusive of diagnosis and
treatment, the outcomes were attained (116, 117). It must be added that, as indicated by
a recent paper(ll8) which compares study and control groups for such measures of
outcome as work and health services utilization, CoUen's group is steadily compiling more
and more of the requisite data. Still lacking is information on costs that correspond to the
specified benefits.
Barriers to Systematic Analysis
To bring some focus to a discussion of the necessary steps ahead, I have prepared a list
of barriers to the systematic and rational analysis of expenditures for health systems
technology. At the same time 1 shall assess the prospects for lowering or overcoming each
barrier.
1. When the costs of operation mount beyond all projections, the tendency is to argue
that the computer or automated laboratory, as the case may be, is not merely providing
services but is performing a research function. Yet doing things we know little about does
not define research. Certain features of research, such as formulation of hypotheses,
design of study, and capability for statistical analysis of data, are not necessarily available
wherever services are rendered. Although some replication of research is desirable, it
should be intentional and need not be universal (119). It follows that sources of research
funds should exercise discrimination in allocating them. If the absorption of so-called
research costs by patients is precluded, this tendency to encourage pseudoresearch will be
minimizae
2. A tendency exists to expand the range of functions said to be performed by new
equipment. Surely, data on payroll could assist management in controlling cost by
department; data on billings could provide a proxy for cost data by diagnosis. The first of
these applications can be evaluated according to a strict criterion: is potential cost control