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Effective Health Care Program

Assessing the Impact of Economic Evidence on Policymakers in Health Care — A Systematic Review

Research Report

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Structured Abstract

Background

Many health care experts are demanding greater use of economic evidence in the assessment of new and existing health technologies.

Objectives

To assess whether and how economic evidence has an impact on health care decisionmaking in the United States and in other countries and to identify antecedents or obstacles for use in health policy.

Data Sources

Searches of MEDLINE, EconLit, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase®, and ISI Web of ScienceSM from 1991 until January 2012.

Methods

The review included original studies that applied a quantitative or qualitative method for evaluating use of economic evidence in any country. We excluded articles that were opinion- or experienced-based without newly generated data. Paired reviewers independently determined whether articles met eligibility criteria and then extracted data from eligible studies. Reviewers also assessed the quality of each study and graded the strength of the body of evidence using an adaptation of the grading of recommendations assessment development and evaluation (GRADE) recommendations, indicating study limitations, quality, strength of findings, and the type of data available.

Results

Of 19,127 titles initially screened, 43 studies were included, with all but five published since 2000. The most frequently studied countries were the United Kingdom (15), and Australia, Canada, and the United States (5 each). Most studies (27 studies) considered national-level policy and examined the key health actors involved. Important decisionmaking topics were reimbursement and health package decisions, and priority setting in program development.

Thirty studies found evidence that use of economic evidence had a “substantial” impact on health care policymaking, 27 of which emphasized at least one other criterion, such as equity considerations, usually ill-defined (14 studies), clinical effectiveness, budget impact, ethical reasons, and advocacy arguments. The 30 studies confirmed the acceptance of economic evidence as having an impact on either general policy or specific decisions, such as reimbursement decisions. In 11 of the studies, the use of economic evidence had only a “limited” impact on health policy decisions. In two studies, economic evidence had no impact on health policymaking.

A few factors played a key role in the use of economic evidence: (1) quality and transparency of the studies that provided the economic evidence was a promoting factor (7 studies) in the case of a good study and a strong obstacle in the case of a poorly presented study (18 studies); (2) transparency and quality of the decisionmaking process was important in the acceptance or rejection of the decision (10 studies for acceptance, 13 studies for rejection); and (3) clarity of the economic information and the way it was communicated were promoting factors (7 studies), while lack of clarity was an obstacle in accepting evidence (17 studies).

Of the 37 observational studies of policy impact, 11 (30%) received a favorable rating on more than three of the 8 items on the study quality checklist. Five of the studies had a comparison group and provided intermediate quality evidence that economic evidence is useful in general health policymaking.

Conclusions

The body of evidence on the use of economic evidence in policy is small and patchy. It shows that the utility of economic evidence, alone or in combination with systematic reviews, is influenced by technical issues, such as transparency and clarity, as well as by the transparency of the decisionmaking process.