Eddama Oya, Coast Joanna
National Perinatal Epidemiology Unit, University of Oxford, Old Road, Headington, Oxford OX3 7LF, United Kingdom.
Health Policy. 2009 Mar;89(3):261-70. doi: 10.1016/j.healthpol.2008.06.004. Epub 2008 Jul 25.
To explore decision-making and the use of economic evaluation at the local health care decision-making level in England (UK).
Data collection was over a 16-month period (January 2003 to April 2004). Data collection comprised 29 in-depth interviews with a range of decision makers, 13 observations of decision-making meetings, and analysis of documents produced at meetings. A constant comparative approach was used to identify broad themes and sub-themes arising from the data. Data were analysed using Microsoft Word.
National Institute for Health and Clinical Excellence (NICE) guidance provides the main way in which economic evaluation is used at a local level in the UK, although following NICE guidance is often regarded as detrimental to pursuing local priorities. Other than through NICE, economic evaluation is not considered at the local level; we found no evidence for use at the meeting group (by individuals). Although decision makers appear to understand notions of scarcity, with some also referring to value for money, the process of decision-making departs from these principles in practice. Disinvestment decisions are not made nor are decisions weighted against pre-defined criteria. Options appraisal is conducted, but it does not embody the principles of economic evaluation, since options are not considered in terms of their costs and benefits and opportunity cost is not accounted for. There appear to be two reasons why economic evaluation is not used at the local level: (1) the nature of management decisions concerned with the employment of extra staff and new equipment, rather than the choice of medicines or specific interventions usually assessed in published economic evaluation; (2) lack of awareness of the economic evaluation approach to decision-making. These two factors point to a lack of freedom in decision-making at the local level and a lack of understanding of how priority setting can be achieved in practice.
A more detailed and rigorous approach to prioritisation at the local level is required. Whilst, PCTs have been given greater responsibility for priority setting, they lack the necessary power and understanding of the ways in which long term solutions to problems in health care can be achieved. Economics can be a valuable asset to priority setting and has already filtered into the jargon used by decision makers. Whilst most concepts are understood, the leap to adopting these concepts into the practice of decision-making needs to be made.
探讨英国英格兰地方医疗保健决策层面的决策制定以及经济评估的使用情况。
数据收集历时16个月（2003年1月至2004年4月）。数据收集包括对一系列决策者进行的29次深度访谈、对决策会议的13次观察以及对会议产生文件的分析。采用持续比较法来确定数据中出现的宽泛主题和子主题。数据使用Microsoft Word进行分析。
英国国家卫生与临床优化研究所（NICE）的指南是英国地方层面使用经济评估的主要方式，尽管遵循NICE指南通常被认为不利于追求地方优先事项。除了通过NICE，地方层面不考虑经济评估；我们未发现会议小组（个人）使用经济评估的证据。尽管决策者似乎理解稀缺概念，一些人还提及性价比，但决策过程在实践中背离了这些原则。未做出撤资决策，也未根据预先定义的标准对决策进行权衡。进行了选项评估，但它并未体现经济评估的原则，因为未从成本、效益和机会成本的角度考虑选项。地方层面未使用经济评估似乎有两个原因：（1）管理决策的性质涉及额外人员的雇佣和新设备的采购，而非通常在已发表的经济评估中评估的药品或特定干预措施的选择；（2）对经济评估决策方法缺乏认识。这两个因素表明地方层面决策缺乏自由度，且对如何在实践中确定优先事项缺乏理解。
地方层面需要一种更详细、更严谨的优先排序方法。虽然初级保健信托基金（PCTs）在确定优先事项方面承担了更大责任，但它们缺乏必要的权力，也不理解实现医疗保健问题长期解决方案的方式。经济学对于确定优先事项可能是一项宝贵资产，并且已经融入决策者使用的行话中。虽然大多数概念已被理解，但需要将这些概念应用到决策实践中。
