Lessard Chantale
Department of Health Administration, Public Health Sector, University of Montreal, C.P. 6128, succursale Centre-Ville Montreal, Que., Canada H3C 3J7.
Soc Sci Med. 2007 Apr;64(8):1754-65. doi: 10.1016/j.socscimed.2006.12.006. Epub 2007 Jan 26.
Economic evaluations are analytic techniques to assess the relative costs and consequences of health care programmes and technologies. Their role is to provide rigorous data to inform the health care decision-making process. Economic evaluation may oversimplify complex health care decisions. These analyses often ignore important health consequences, contextual elements, relationships or other relevant modifying factors, which might not be appropriate in a multi-objective, multi-stakeholder issue. One solution would be to develop a new paradigm based on the issues of perspective and context. Complexity theory may provide a useful conceptual framework for economic evaluation in health care. Complexity thinking develops an awareness of issues including uncertainty, contextual issues, multiple perspectives, broader societal involvement, and transdisciplinarity. This points the economic evaluation field towards an accountability and epistemology based on pluralism and uncertainty, requiring new forms of lay-expert engagement and roles of lay knowledge into decision-making processes. This highlights the issue of reflexivity in economic evaluation in health care. A reflexive approach would allow economic evaluators to analyze how objective structures and subjective elements influence their practices. In return, this would point increase the integrity and reliability of economic evaluations. Reflexivity provides opportunities for critically thinking about the organization and activities of the intellectual field, and perhaps the potential of moving in new, creative directions. This paper argues for economic evaluators to have a less positivist attitude towards what is useful knowledge, and to use more imagination about the data and methodologies they use.
经济评估是评估医疗保健项目和技术的相对成本及后果的分析技术。其作用是提供严谨的数据，为医疗保健决策过程提供信息。经济评估可能会过度简化复杂的医疗保健决策。这些分析往往忽略重要的健康后果、背景因素、关系或其他相关的调节因素，而在多目标、多利益相关方的问题中，这些因素可能并不合适。一种解决方案是基于视角和背景问题开发一种新的范式。复杂性理论可能为医疗保健中的经济评估提供一个有用的概念框架。复杂性思维培养对包括不确定性、背景问题、多种视角、更广泛的社会参与和跨学科性等问题的认识。这使经济评估领域朝着基于多元主义和不确定性的问责制和认识论发展，要求外行与专家参与的新形式以及外行知识在决策过程中的作用。这凸显了医疗保健经济评估中的反思性问题。一种反思性方法将使经济评估者能够分析客观结构和主观因素如何影响他们的实践。反过来，这将提高经济评估的完整性和可靠性。反思性为批判性思考知识领域的组织和活动提供了机会，或许还有朝着新的、创造性方向发展的潜力。本文主张经济评估者对什么是有用知识持较少的实证主义态度，并对他们使用的数据和方法运用更多想象力。
