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In this issue Hoffmann and colleagues [1] presentfurther information about the views of medicaldecision makers in the UK National Health Service(NHS) on the usefulness of published economicevaluations. As the authors state, the study largelyconfirms the results of previous studies by them-selves and others. The Hoffmann study used a focusgroup approach with a convenience sample of decision makers from two cooperative Englishhealth authorities and selected studies from a data-base controlled by the authors’ institutions. Givenits design, the study probably says more about theusefulness of the NHS Economic Evaluation Data-base (EED) than about the more general issuesregarding the use of economics in health-care decisions.

However, a strength of the study is that it directlyrecords the views of the groups of decision makersabout how the information in the NHS EED couldbe made more useful to them. Hoffmann and colleagues are careful to emphasize the respectiveroles of the researchers and subjects in the study andquite naturally have been restrained in their com-ments on the validity of the views expressed. To usthe study raises some fundamental questions thatare not explicitly addressed in the paper, even in therequest for further research.

The general assumption has been that if economic evaluations are being carried out to aidhealth-care decision making and decision makers donot find them useful, then the way the evaluationsare conducted or presented must be changed. Theeconomic approach to evaluation is based on thesynthesis of information to identify the most effi-cient way to achieve predetermined objectives. Inthe health-care field, the principal pieces of infor-mation are health outcomes and the resources usedto achieve them. The objectives are generally tomaximize the health gain within the constraints ofavailable resources and equity concerns. The con-straints can be changed and the method of measur-ing the outcomes can be varied, but the basicapproach remains the same.

If this economic decision framework is not satis-factory for NHS decision makers, then it must beassumed that they have a different and superiormodel of decision making.

Exactly how decisions are made on service plan-ning and resource allocation in the NHS withoutsubstantive economic input is a question that seemseminently suitable for further research. If this as yet undefined approach to decision making can becompared with the economic model and shown tobe superior, then perhaps the current efforts to carryout economic evaluations (and adapt the results tomeet the perceived needs of decision makers) can be reduced. We would also be spared the need totry continually to improve the level of understand-ing of economic evaluation among medical decisionmakers evidenced by Hoffmann and colleagues.

In the absence of a clear understanding of how decisions are actually being made by healthauthorities, economists might be more questioningof the validity of criticisms of their work.

The participants in the focus groups in the Hoffmann study suggested several changes to theformat of the entries in the NHS EED to make iteasier for them to use. For example, they wantedthe commentaries to be more critical and to appearat the start of the abstract. They would preferstudies to be scored for quality. Put another way,this could be interpreted as a desire of the partici-pants to read only a commentary rather than awhole abstract, and preferably to have someone elsetell them how good the study is to save them thetrouble of reading it at all.

There were concerns over the generalizability ofstudies that addressed insufficiently broad questionsor were conducted in other countries. This indicatesa lack of understanding by the participants and alack of economic expertise within their organiza-tions that could help them adapt studies to theirown decision context. It also indicates an unwill-ingness to fund local studies that might be consid-ered more relevant.

Of more concern is the participants’ view that the

Volume 5 • Number 2 • 2002V A L U E I N H E A L T H

Use of Economic Evaluation in Decision Making:What Needsto Change?

John Hutton, BSc, BPhil, Ruth E. Brown, MS

MEDTAP International Inc., London, United Kingdom

© ISPOR 1098-3015/02/$15.00/65 65–66

66 Editorial

clinical effectiveness data used in economic studiesis often of poor quality. This point needs furtherexamination to clarify the circumstances underwhich the economic evaluations were carried out,to see what is meant by clinical effectiveness, andto see whether the problem was that the evaluationmissed good clinical data or that good clinical datawere not available at the time the study was done.In the latter situation, which is not an infrequentoccurrence, the question arises as to what are“good” clinical data. Any data on true clinical effectiveness are in short supply, especially for new technologies. Timeliness and relevance are key datacharacteristics for decision making. Well-collecteddata on tangentially related concepts such as effi-cacy are no substitute for the best available data onthe question to be answered.

So in addressing the problem of the failure ofNHS decision makers to make good use of economic information, what needs to change? Weshould broaden our range of options. Changing theway that NHS decisions are made, changing thepolicy on funding local economic studies and exper-tise, and changing the decision makers for people

with a better grasp of economics might be moreappropriate than distorting economic methods toinform an unclear decision process.

Recent policy developments may resolve some of these issues as the NHS moves toward decen-tralization of budget responsibility to primary caretrusts, while increasing the centralized productionof policy frameworks and clinical guidelines toprovide national templates for service delivery. Provided that these guidelines and frameworks take account of cost-effectiveness as well as clinicalfactors, lack of economic expertise lower down inthe system may be less important. In any case therole of health authorities will be much reduced inthe emerging structures, which may reduce the significance of the results of studies such as that ofHoffmann and colleagues.

References

1 Hoffmann C, Stoykova BA, Nixon J et al. Do healthcare decision-makers find economic evaluationsuseful? The findings of focus group research in UKhealth authorities. Value Health 2001;5:71–9.