                             THE CHROMIUM CAGE

                          By ELLEN van WAGENINGEN
                                Windsor Star

     WINDSOR, Ont. - Every year, Canadians spend billions of dollars on
     unproven medical equipment, procedures and drugs.

     Health experts say no single factor is more responsible for driving
     up health care costs.

     Estimates suggest as much as 70 to 80 per cent of medical
     technology has never been fully evaluated - in some cases for
     safety and benefit, in others for cost.

     There's no government review of 95 per cent of the 20,000 new
     medical devices that hit the market in Canada every year. In 1990,
     sales of these items, everything from tongue depressors to CAT
     scans, reached $2 billion.

     Spending on prescription and non-prescription drugs soared from
     $6.5 billion in 1988 to $8.4 billion in 1990, 14 per cent of all
     health care expenditures. But some new drugs on the market are
     turning out to be no better than old ones, just more expensive.

     It seems the faster technology evolves, the harder it is to keep
     up.
        See <22health> for discussion of medical discoveries

     A current example is magnetic resonance imaging, or MRI, which uses
     a powerful magnetic field to produce a photo of a cross-section of
     the body. MRI scanners cost about $3 million to buy and another
     $1.5 million a year to operate. A growing number of hospitals are
     lobbying to acquire them.

     But scanners of this sort have been evolving so quickly that by the
     time any evaluation can be made of whether the benefits outweigh
     the costs, a new version may be ready for market.

     Aggressive marketing by drug and equipment manufacturers only
     encourages the growth of runaway technology, as do the high
     expectations of patients and attempts by doctors to satisfy them.

     It all adds up to a tremendously expensive problem that Canada is
     only barely beginning to police.

     ``There is no one thing that drives costs in the health care system
     more, with less attention paid to it in analytical terms, than the
     area of health technology,'' says Graham Scott, head of an Ontario
     task force on medical services.

     Examples of how new technology can run up costs are numerous.

     In the late 1980s, most Ontario hospitals started using new X-ray
     enhancing liquids. Given intravenously, these ``contrast mediums''
     make a patient's blood vessels show up clearly on an X-ray.

     Doctors were impressed by how much more comfortable the new
     contrast mediums left patients. The older, thicker mediums often
     caused nausea, vomiting and pain.

     However, even today there is no evidence the new mediums are safer
     than the ones they replaced.

     They are also 10 times more expensive. It cost Toronto General
     Hospital, which has an annual budget of $250 million, $2 million to
     switch to the new contrast mediums.

     Facing a financial crunch, Ontario hospitals must now decide
     whether to sacrifice the comfort of X-ray patients or cut other
     hospital services.

     Without more independent research, tough decisions such as these
     are only going to get tougher, say a growing number of health care
     providers, academics, public interest groups and government
     officials.

     The questions to be addressed are quite simple: What's working and
     what isn't, what's cost-effective, what's wasteful and, last but
     not least, what's safe?

     Consider the case of extracorporeal shock wave lithotripters, which
     use shock waves to smash kidney stones.

     Introduced as an alternative to surgery, the machines were already
     in wide use in North America by 1985 when questions were raised
     about whether they might cause kidney damage.

     Lithotripters should not have been approved until those questions
     were answered, says Dr. John Dossetor of the University of Alberta
     who, with two colleagues, discussed the issue in a recent edition
     of the Canadian Medical Association Journal.

     ``The point we were hinting at with lithotripsy is that, although
     it may get rid of today's stones, it may be causing high blood
     pressure 10 years from now.''

     Official monitoring of drugs and equipment has until recently been
     the exclusive jurisdiction of the federal health protection branch.
     But with 180,000 drugs and 490,000 medical devices now on the
     market, experts say the work being done by the branch isn't enough.

     Although drugs are subject to premarket trials that are considered
     to provide good results about safety, studies do not address the
     issue of whether a new drug may be mainly a more expensive version
     of an old one.

     Testing of equipment is more haphazard. The branch's bureau of
     radiation and medical devices simply requires notification within
     15 days of new items being offered for sale, studying only those
     products intended to be implanted into the body for more than 30
     days.

     Three years ago, Quebec established the first provincially funded
     health technology assessment council in Canada.

     Despite a limited budget of $800,000 a year, council president Dr.
     Maurice McGregor sees his work as essential. There's no question
     governments, hospitals and doctors need independent experts to help
     them assess today's technology, he says.
     
     ``I believe this is one of the few mechanisms that can somewhat
     combat advertising.''

     British Columbia has also opened a provincially funded technology
     assessment office, Nova Scotia is not far behind and one is being
     recommended in Ontario.

     Another first step came last fall when the new Canadian Co-
     ordinating Office for Health Technology Assessment quietly opened
     its doors in Ottawa.

     The national office has a modest annual budget of $500,000, split
     between the federal government and the provinces. Its success will
     be evaluated at the end of 1993.

     But critics say the office doesn't have the necessary financial
     support or clout and executive director Dev Menon has no illusions
     about what he and his staff of five can do.

     The council reports to the federal and provincial governments and
     has no control over the fate of its recommendations, Menon says.

     As well, there's no money for original research. Menon and his
     staff will rely on research that's been done elsewhere.

     Even with more technology assessment offices in place, the task
     they face will be tough.

     TPA, a controversial new drug that dissolves clots, demonstrates
     how the answers about technology are seldom black and white.

     Tissue plasminogen activator was approved for use on heart attack
     patients in Canada in 1987. Used 30 per cent of the time by
     Canadian doctors and 75 per cent of the time in the U.S., it costs
     $3,000 per patient, 10 times as much as streptokinase, an older
     drug used for the same purpose.

     Aggressively marketed by Genentech, its U.S.-based developer, TPA
     was supposed to be faster, more effective and safer than
     streptokinase.

     Four years after its introduction, TPA has received more scrutiny
     than many other drugs or devices - yet debate continues about
     whether it is really as good as its supporters say.

     A 1988 study by the Ontario Medical Association found no evidence
     that TPA is better than streptokinase, although TPA is less likely
     to produce side-effects.

     Two recent international trials reached a similar conclusion but
     Genentech disputed the way the TPA was administered in those tests
     and is sponsoring a new international trial.

     ``I would have hoped we'd been able to resolve this issue by now,''
     says Dr. Paul Armstrong, a Toronto cardiologist who is co-
     ordinating the Canadian part of the study.


