Use of Cost-Effectiveness Data in Priority Setting Decisions: Experiences from the National Guidelines for Heart Diseases in Sweden

Document Type: Original Article

Authors

1 Division of Health Care Analysis, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden

2 Department of Cardiology and Department of Medicine and Health Sciences, Linköping University, Linköping, Sweden

Abstract

Background
The inclusion of cost-effectiveness data, as a basis for priority setting rankings, is a distinguishing feature in the formulation of the Swedish national guidelines. Guidelines are generated with the direct intent to influence health policy and support decisions about the efficient allocation of scarce healthcare resources. Certain medical conditions may be given higher priority rankings i.e. given more resources than others, depending on how serious the medical condition is. This study investigated how a decision-making group, the Priority Setting Group (PSG), used cost-effectiveness data in ranking priority setting decisions in the national guidelines for heart diseases.
 

Methods
A qualitative case study methodology was used to explore the use of such data in ranking priority setting healthcare decisions. The study addressed availability of cost-effectiveness data, evidence understanding, interpretation difficulties, and the reliance on evidence. We were also interested in the explicit use of data in ranking decisions, especially in situations where economic arguments impacted the reasoning behind the decisions.
 
Results
This study showed that cost-effectiveness data was an important and integrated part of the decision-making process. Involvement of a health economist and reliance on the data facilitated the use of cost-effectiveness data. Economic arguments were used both as a fine-tuning instrument and a counterweight for dichotomization. Cost-effectiveness data were used when the overall evidence base was weak and the decision-makers had trouble making decisions due to lack of clinical evidence and in times of uncertainty. Cost-effectiveness data were also used for decisions on the introduction of new expensive medical technologies.
 

Conclusion
Cost-effectiveness data matters in decision-making processes and the results of this study could be applicable to other jurisdictions where health economics is implemented in decision-making. This study contributes to knowledge on how cost-effectiveness data is used in actual decision-making, to ensure that the decisions are offered on equal terms and that patients receive medical care according their needs in order achieve maximum benefit.

Highlights

Commentaries Published on this Paper

  • Lonely at the Top and Stuck in the Middle? The Ongoing Challenge of Using Cost-Effectiveness Information in Priority Setting; Comment on “Use of Cost-Effectiveness Data in Priority Setting Decisions: Experiences from the National Guidelines for Heart Diseases in Sweden”          

            Abstract | PDF

  • The Use (or rather the non-Use) of Cost-Effectiveness Data in Priority Setting Decisions – Are We Underestimating the Barriers to Using Health Economics in Real World Priority Setting Decisions?; Comment on “Use of Cost-Effectiveness Data in Priority Setting Decisions: Experiences from the National Guidelines for Heart Diseases in Sweden”

            Abstract | PDF

  • Incorporating Cost-Effectiveness Data in a Fair Process for Priority Setting Efforts; Comment on “Use of Cost-Effectiveness Data in Priority Setting Decisions: Experiences from the National Guidelines for Heart Diseases in Sweden”

            Abstract | PDF

 

Authors' Response to the Commentaries

  • Including Both Costs and Effects – The Challenge of Using Cost-Effectiveness Data in National-Level Policy-Making: A Response to Recent Commentaries

            Abstract | PDF

Keywords

Main Subjects


 

1. Grip L, Lindahl B, Levin LA, Karvinge C, Eklund K, Wallentin L. From European to national guidelines on heart disease. Scand Cardiovasc J 2011; 45: 3-13.  doi: 10.3109/14017431.2010.536566

2. Eddama O, Coast J. Use of economic evaluation in local health care decision-making in England: a qualitative investigation. Health Policy 2009; 89: 261-70.  doi: 10.1016/j.healthpol.2008.06.004

3. Williams I, Bryan S. Understanding the limited impact of economic evaluation in health care resource allocation: a conceptual framework. Health Policy 2007; 80: 135-43.  doi: 10.1016/j.healthpol.2006.03.006

4. Drummond M, Cooke J, Walley T. Economic evaluation under managed competition: evidence from the U.K. Soc Sci Med 1997; 45: 583-95. 

5. Drummond M, Weatherly H. Implementing the findings of health technology assessments. If the CAT got out of the bag, can the TAIL wag the dog? Int J Technol Assess Health Care 2000; 16: 1-12. 

6. Ernoft S. The use of health economic evaluations in pharmaceutical priority setting. The case of Sweden [Dissertation]. Lund Business Press, Lund Institute of Economic Research: Lund University; 2010.

7. Priority setting in health care (1996/97:60), Ministry of Health and Social Affairs (1997).

8. Carlsson P, Kärvinge C, Broqvist M, Eklund K, Hallin B, Jacobsson C, et al. Nationell modell för öppna vertikala prioriteringar inom svensk hälso- och sjukvård (The National model for open vertical prioritization in Swedish health care). Linköping: National Centre for Priority Setting in Health Care; 2007.

9. Health and Medical Service Act (SFS 1982:763), S. §2, Ministry of Health and Social Affairs (1982).

10. Nationella riktlinjer för hjärtsjukvård 2008. (National guidelines for cardiac care 2008). Bilaga 3 till beslutsstödsdokumentet - Metod. (Annex to decision support documents - Method), 2008.

11. Eckard N, Janzon M, Levin LA. Compilation of cost-effectiveness evidence for different heart conditions and treatment strategies. Scand Cardiovasc J 2011; 45: 72-6.  doi: 10.3109/14017431.2011.557438

12. Nationella riktlinjer för hjärtsjukvård 2008. (National guidelines for cardiac care 2008). Bilaga 2 till beslutsstödsdokumentet - Det hälsoekonomiska faktadokumentet. (Annex to decision support documents - The health economic facts document), 2008.

13. Kvale S, Brinkmann S. Interviews: Learning the craft of qualitative research interviewing. Los Angeles: Sage Publications; 2009.

14. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today 2004; 24: 105-12.  doi: 10.1016/j.nedt.2003.10.001

15. Nationella riktlinjer för hjärtsjukvård 2008. (National guidelines for cardiac care 2008). Tabellbilaga till beslutsstödsdokumentet - tillstånds och åtgärdslista för hjärtsjukdomar. (Table annex to decision support documents - Medical conditions and  interventions for herat diseases), 2008.

16. Nationella riktlinjer för hjärtsjukvård 2008. (National guidelines for cardiac care 2008). Beslutsstöd för prioriteringar.(Decision support for priority-setting), 2008.

17. Singer PA, Martin DK, Giacomini M, Purdy L. Priority setting for new technologies in medicine: qualitative case study. BMJ 2000; 321: 1316-8. 

18. Hasman A, McIntosh E, Hope T. What reasons do those with practical experience use in deciding on priorities for healthcare resources? A qualitative study. J Med Ethics 2008; 34: 658-63.  doi: 10.1136/jme.2007.023366

19. Bryan S, Williams I, McIver S. Seeing the NICE side of cost-effectiveness analysis: a qualitative investigation of the use of CEA in NICE technology appraisals. Health Econ 2007; 16: 179-93.  doi: 10.1002/hec.1133

20. Weiss C. The Many Meanings of Research Utilization. Public Adm Rev 1979; 39: 426-31. 

21. Landwehr C, Böhm K. Delegation and institutional design in health-care rationing. Governance 2011; 4: 665-88. 

22. Landwehr C, Nedlund A-C. Legitimacy Problems in the Allocation of Health Care: Decision-making Procedures in International Comparison. In: Bluhdorn I, editor. In Search of Legitimacy Policy Making in Europe and the Challenge of Complexity: Barbara Budrich Publishers; 2009.

23. Williams I. Institutuions, cost-effectiveness analysis and healthcare rationing: the example of healthcare coverage in the English National Health Service. Policy & Politics 2013; 41: 223-39.