Section of Hospital Medicine, Department of Medicine, The University of Chicago, Chicago, IL 60637, USA.
J Eval Clin Pract. 2011 Aug;17(4):606-14. doi: 10.1111/j.1365-2753.2010.01557.x. Epub 2010 Oct 4.
In budget-constrained health systems, decision makers need to consider both the costs and effects of introducing and actively implementing clinical guidance. We aim to demonstrate how, as an alternative to conventional methods, a total net benefit approach to economic evaluation can be used to inform decision making about guidelines and specific implementation strategies, like education or financial incentives.
Aside from providing more detail on the decision framework, we describe how to collect and analyse the relevant data for calculating the total net benefit of guideline use and the value of implementation. We illustrate the process of decision analysis for a stylized example on improving diabetes care in the UK. For the analysis, economic evidence on intensified glycemic control and that on audit and feedback to promote control is combined with information on diabetes practice.
Our illustration demonstrates that the total net benefit of guideline use and the value of implementation can vary substantially, depending on the clinical intervention chosen, the health system being studied and the specific implementation strategies. This also holds for the threshold value for cost-effectiveness, the duration of guideline usage or validity, the size of the patient population served, and the trends and ceiling rates in the implementation of clinical guidance.
In comparison with conventional methods for health economic evaluation, a total net benefit approach allows for the explicit consideration of the current (or future) use of guidelines or guideline recommendations, the cost of implementation and the scope of clinical practice. Decisions made on the basis of the total net benefit of all plausible combinations of clinical guidance and implementation strategies provide optimal patient care and an efficient use of resources.
在资源有限的卫生系统中，决策者需要考虑引入和积极实施临床指南的成本和效果。我们旨在展示如何使用总净收益方法进行经济评估，作为传统方法的替代方法，为指南和具体实施策略（如教育或经济激励）的决策提供信息。
除了提供关于决策框架的更多细节外，我们还描述了如何收集和分析相关数据，以计算指南使用的总净收益和实施的价值。我们以英国改善糖尿病治疗为例说明了决策分析的过程。对于分析，将强化血糖控制的经济证据与促进控制的审计和反馈的经济证据与糖尿病实践信息相结合。
我们的说明表明，指南使用的总净收益和实施的价值会根据所选的临床干预、所研究的卫生系统以及具体的实施策略而有很大差异。这也适用于成本效益的阈值、指南使用的持续时间或有效性、服务的患者人群规模以及临床指南实施的趋势和上限率。
与健康经济评估的传统方法相比，总净收益方法允许明确考虑当前（或未来）使用指南或指南建议、实施成本以及临床实践的范围。基于所有可能的临床指导和实施策略的总净收益做出的决策可提供最佳的患者护理和资源的有效利用。
