Habtamu B.

Introduction Although previous investigations have shown that economic evaluation studies of health-care interinterventions are of limited use, decision makers generally recognize that economic considerations must be taken into account when making decisions about health-care resource allocation [1,2]. The recent move to include cost-effectiveness findings in reviews commissioned by national regulatory bodies such as the newly formed National Institute for Clinical Excellence (NICE) in the United Kingdom not only acknowledges the importance of economic evaluations at the national policy level but also raises the question of how economic evaluations are to be integrated into healthcare decision making, both at the local level and within the formulation of guidelines. Despite this increasing awareness of the need for economic evaluations, it is also generally accepted that the quality of published studies is variable. Moreover, researchers adopt a wide range of methodological approaches that may not be familiar to those making decisions about competing health technologies. The interpretation of economic studies may also be limited by the reader's knowledge of what constitutes good research in health economics, and as such, the relative strengths and weaknesses of particular studies may not be immediately obvious. Several surveys concerning the use of economic evaluation by decision makers in the UK National Health Service (NHS) have been conducted. Drummond et al. [3] surveyed almost 800 individuals (283 prescribing advisers, 400 directors of pharmacy, 101 directors of public health) in the United Kingdom by mail questionnaire. The following areas were considered: 1) the decision makers' knowledge of economics; 2) the importance of efficiency as a decision-making criterion; 3) sources of information on costs and outcomes used by decision makers; 4) barriers to the use of economic evaluation; and 5) actual application of the results of economic evaluations. The authors concluded that the use of economic evaluation at the local level was not extensive. The main obstacles to the use of study results related either to the inflexibility of budgets, which limited the movement of resources from secondary to primary care, or the inability to free resources to adopt new therapies. In addition there were concerns about the studies themselves, such as the large number of assumptions and the credibility of industry-funded studies. In another survey by Duthie et al. [4], 17 pairs of UK NHS decision makers (a mixture of managers and clinicians) were interviewed about the usefulness of economic studies and presented with a variety of health-economics outcomes statements in order to determine the relevance and appeal of diverse health economic measures to different decision makers. The principal finding of this study was that a high proportion of statements conveying traditional health-economics outcomes, including incremental cost-effectiveness ratios, qualityadjusted life years (QALYs) and willingness to pay, were either not understood or were considered irrelevant by those surveyed. A third survey by Crump et al. [5] involved 12 medical decision makers from the Leicestershire Health Authority in the United Kingdom (fourmedical directors of hospitals and eight local general practitioners) who were interviewed individually and also participated in a focus group discussion. The interviewees were first asked what information they would require to make decisions regarding the use of a hypothetical new drug for obesity, and were then asked more general questions about their use of economic information, the relevance of economic considerations to particular types of decisions, and barriers and incentives to the use of economic evidence. This was part of the European Network on Methodology and Application of Economic Evaluation Techniques (EUROMET) project [6], which investigated the impact of health-economic studies on decision making in nine European countries and surveyed 1022 decision makers by postal questionnaire, semi-structured interviews, or through focus groups. The results of this study [5] largely confirmed the findings of the earlier work by Drummond et al. [3]. However, when asked which factors might encourage decision makers to make more use of economic evaluations, the interviewees placed particular emphasis on the appraisal of studies by a trusted source, the need for more flexibility in health-care budgets and more detailed explanations of the practical relevance of study results. Whereas surveys of the kind carried out in the United Kingdom and other European countries have well-known limitations, these findings are comparable with the results of similar studies carried out in the United States. Several surveys have been conducted to explore how managed care organizations and hospitals establish formulary policies and the relevance of cost-effectiveness analyses to this process [7–9]. Despite increasing awareness and use of economic evaluations, costeffectiveness information was found to be of secondary concern. US decision makers were also found to lack expertise in health economics and tended to prefer timely information targeted at the decisions they had to make. Whereas some of the concerns of decision makers, such as those about rigidities in healthcare budgets, could only be met by changes in the management and organization of healthcare systems, others could be alleviated by changes in the ways economic evaluation studies are accessed and presented. In particular, it would be possible to provide busy decision makers with critical reviews of published studies in a readily accessible form. Several databases of economic evaluations now exist. For example, the Collège des Economistes deDo Decision Makers Find Economic Evaluations Useful? 73 la Santé (CODECS) Database, the NHS Economic Evaluation Database (NHS EED), and the office and the Office of Health Economics Health Economic Evaluation Database (HEED) contain structured abstracts of published studies. In principle, these should help overcome some of the barriers to the use of economic evaluations identified by decision makers and can assist in assessing the usefulness and limitations of economic evaluations within the decision-making process at the local level. As a vehicle for this research we chose the NHS EED [10] because in addition to being familiar with this particular database, we deemed it the most suitable for the task given that one of its stated aims is to be a decision-making tool for the NHS. To this end, and in contrast to certain other databases, it provides critical assessments of published studies and comments on their usefulness to the NHS.