Buxton Martin J
Health Economics Research Group, Brunel University, Uxbridge, Middlesex, UK.
Pharmacoeconomics. 2006;24(11):1133-42. doi: 10.2165/00019053-200624110-00009.
This article reviews the development of economic evaluation of health technologies in the UK and its impact on decision making. After a long period of limited impact from studies mainly carried out as academic exercises, the advent of the National Institute for Health and Clinical Excellence (NICE) in 1999 provided a transparent decision-making context where economic evaluation plays a central role. This article reviews some of the key characteristics about the way NICE works, for example, the way NICE has defined the form of analysis that it requires, reflecting its objective of maximising health gain (QALYs) from the predetermined and limited UK NHS budget. Two broad areas of widespread concern are noted. The first relates to the cost-effectiveness thresholds that NICE uses and the basis for them. The second is the patchy implementation of NICE guidance and the possible reasons for this. But even within the UK, NICE is the exception in making extensive and explicit use of economic evaluation and this article goes on to suggest that if there is to be a more widespread and consistent use of economic evaluation at both central and local levels, then health economists and others need to address three issues. The first is to be clear about what is the correct conceptual basis for determining the cost-effectiveness threshold and then to ensure that NICE has the empirical evidence to set it appropriately. The second is to recognise that even using the limited view of costs adopted by NICE, economic evaluations imply temporal and cross-service budgetary flexibility that the NHS locally does not in practice enjoy. The third issue is that with academic pressures for ever-increasing sophistication of 'state of the art' economic evaluation analysis, the NHS has more and more precise understanding of the cost effectiveness of just a few new technologies and little or no analysis of most. This limits the value of the former by reducing further the scope for appropriately disinvesting from cost-ineffective technologies to meet the additional costs of investing in cost-effective new ones. Whilst NICE stands out as an example of a context where high-quality economic evaluation plays a major role in decision making, the process is far from perfect and certainly is not representative of the use made of economic evaluation by the NHS as a whole. Health economists need to engage with the public and the health service to better understand their perspectives, rather than focusing on academic concerns relating to details of theory and analytical method.
本文回顾了英国卫生技术经济评估的发展及其对决策的影响。在主要作为学术活动进行的研究长期影响有限之后，1999年国家卫生与临床优化研究所（NICE）的出现提供了一个透明的决策背景，经济评估在其中发挥核心作用。本文回顾了NICE工作方式的一些关键特征，例如，NICE定义其所需分析形式的方式，这反映了其从预先确定且有限的英国国民医疗服务体系（NHS）预算中最大化健康收益（质量调整生命年，QALYs）的目标。文中指出了两个广泛关注的领域。第一个涉及NICE使用的成本效益阈值及其依据。第二个是NICE指南的参差不齐的实施情况及其可能原因。但即使在英国国内，NICE也是广泛且明确使用经济评估的例外情况，本文进而指出，如果要在中央和地方层面更广泛且一致地使用经济评估，那么卫生经济学家及其他人员需要解决三个问题。第一个是要明确确定成本效益阈值的正确概念基础是什么，然后确保NICE有适当设定该阈值的实证证据。第二个是要认识到，即使采用NICE所采用的有限成本观点，经济评估也意味着时间和跨服务预算的灵活性，而NHS在地方层面实际上并不具备这种灵活性。第三个问题是，在学术压力下，“最先进的”经济评估分析日益复杂，NHS对仅少数新技术的成本效益有越来越精确的了解，而对大多数技术几乎没有或根本没有分析。这通过进一步减少从成本效益不佳的技术撤资以满足投资于成本效益高的新技术的额外成本的空间，限制了前者的价值。虽然NICE是高质量经济评估在决策中发挥主要作用的一个背景范例，但这个过程远非完美，当然也不能代表NHS整体对经济评估的使用情况。卫生经济学家需要与公众和卫生服务部门互动，以更好地了解他们的观点，而不是专注于与理论和分析方法细节相关的学术问题。
