Understanding the limited impact of economic evaluation in health care resource allocation: A conceptual framework
Introduction
The techniques of economic evaluation in health care have developed considerably over recent years [1], [2] and are designed to inform the efficient management of scarce health care resources. However, research into local policy decision-making in the UK has reported moderate or low levels of use of economic evaluation information [3], [4], and similar findings are reported in a number of European health care systems [5], [6]. In a US context, use of formal cost-effectiveness analysis (CEA) in technology coverage decisions is, if anything, even more rare [7], [8], [9]. This low level of use occurs despite evidence suggesting that decision makers appreciate the potential value of cost-effectiveness information to the policy process [4], [5], [10]. The concern to maximise the impact of economic evaluation in health care is reminiscent of research utilisation debates rehearsed in the various policy studies disciplines. In this paper we draw on selected themes and frameworks from this literature in order to explore issues and map out an agenda relating to the uptake and use of CEA in health policy decisions. Crucial issues such as the absence of goal-consensus and the interactive nature of the policy environment are discussed, as are the implications of these for our understanding of both what the barriers to use of CEA are and how these might be overcome. The paper is structured first to consider a rational problem-solving model of research utilisation, and then moves on to consider the interactive model. Finally, we discuss the potential for indirect research utilisation and how the community of analysts – in this case health economists – might more actively pursue such an approach.
Section snippets
The problem-solving model
The principles underpinning evidence-based medicine have recently been discussed in the context of health care management and policy making [11], [12], and the aspiration towards evidence-based policy decision-making evokes a conception of research utilisation defined by Weiss as the ‘problem-solving model’ [13]. In this model, empirical and analytical research evidence is applied directly to a policy problem and, whether ‘off the shelf’ or directly commissioned, research supplies the
The interactive model and positive economics
Given the likelihood that policy-makers seek information not just from researchers but from a variety of sources, it appears that Weiss's ‘interactive model’ of research utilisation carries greater descriptive power than the problem-solving model [13]. The interactive model illustrates how decisions are based on negotiated compromise and the balancing of competing interests, rather than solely on the available evidence base. Decisions taken will reflect consultation, experience, political
Accessibility and acceptability barriers
Within a rational problem-solving paradigm, policy makers are encouraged to select the policy option recommended by the normative research findings, and instances where research is not utilised are generally understood to result from limitations in the accessibility of research evidence. Here we use the term accessibility to refer to the availability of relevant research in a timely manner, the clarity of its presentation and the extent to which it can be understood by the policy makers.
Discussion
Normative and positive approaches to health economic analyses correlate, to some extent, with the binary of rational and interactive models of research utilisation. The requirement for agreement of purpose and objectives between researcher and decision maker is a defining premise of both normative economic evaluation and direct conceptions of problem-solving research utilisation. Positive approaches to evaluation, on the other hand, may be seen as more helpful to decision makers involved in
Conclusions
In this paper, we have explored some of the reasons for the moderate impact on health policy of economic evaluation research. We have divided reported barriers into two broad categories: those relating to the accessibility and those relating to the acceptability of economic evaluations. Much of the health economics literature to date has concentrated on barriers of accessibility of economic evaluation results. This suggests a view that improvement in the process by which evaluations are
Acknowledgements
The project on which this paper is based was funded by the UK Department of Health Research Methodology Programme (Project Number: 99/57/08). We would like to thank the following who have helped in developing the ideas presented in this paper: Shirley McIver, James Raftery, Andrew Stevens. We would also like to thank David Epstein for comments on an earlier draft of the paper.
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