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Developing the instrument and process for abstracting data
To systematically review Cost-effectiveness analyses (CEAs), we first developed a tool for abstracting relevant information from individual studies in a standardized way. Through a literature search and consultation with experts, we located several existing abstraction tools (28,39) and quality-rating criteria (4,40,41). We drew on the strengths of each of these instruments to develop a novel abstraction tool that met the needs and objectives of the USPSTF. The tool is largely adapted from the CEA abstraction instruments developed by the Task Force on Community Preventive Services (39) and the Harvard Center for Risk Analysis (29).
The USPSTF CEA abstraction instrument, which we are currently piloting, was designed to (1) ensure that the CEAs being reviewed are applicable to the question posed, (2) assess the studies' methodological rigor, (3) ascertain that their models contain the appropriate components of effectiveness, (4) examine the degree to which they use the best available evidence of effectiveness, (5) evaluate the validity and impact of their assumptions, and (6) assess the type and quality of cost information used. Our criteria for rating methodological quality are based on recommendations of the Panel on Cost-Effectiveness in Health and Medicine (4). Sample quality rating items are listed in Table 2. Because simple counts of criteria fulfilled do not differentiate studies of varying quality with great precision, these criteria will not be used to generate quality scores but rather as a guide in categorizing study quality as high, fair, or poor.
Table 2. Sample quality rating items for cost-effectiveness analyses
- Are the interventions and populations compared appropriate?
- Is the study conducted from the societal perspective?
- Is the time horizon clinically appropriate and relevant to the study question?
- Are all important drivers of effectiveness included?
- Are key harms included?
- Is the best available evidence used to estimate effectiveness?
- Are long-term outcomes used?
- Do effect measures capture preferences or utilities?
- Are all appropriate downstream medical costs included?
- Are charges converted to costs appropriately?
- Are the best available data used to estimate costs?
- Are incremental cost-effectiveness ratios presented?
- Are appropriate sensitivity analyses performed?
Our reviews will focus mainly on high-quality studies. When few or no high-quality studies exist for a given question, we will also consider studies rated fair. Poor-quality studies will not be considered. Our objective is to present the best evidence currently available while appropriately identifying study limitations, because policymakers are sometimes required to make decisions without having perfect information.
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Process for reviewing studies
The process for systematically reviewing CEAs is similar to that for reviewing studies of effectiveness (Table 3). As with any systematic review, before reviewing the evidence, one must define the question at hand. USPSTF "topic teams" (38) reviewing the evidence for the effectiveness of preventive services within specific clinical topics (e.g., screening for hypertension) are asked to identify relevant questions related to the cost-effectiveness of services within each topic (Table 1).
Table 3. U.S. Preventive Services Task Force process for conducting a systematic review of cost-effectiveness analyses
- Define the question to be addressed.
- Comprehensively search relevant literature databases.
- Screen abstracts for inclusion.
- Review reference lists and call experts to identify studies not captured by the literature search.
- Abstract relevant studies.
- Compare the impact of varying assumptions and resolve differential results across studies through consensus.
- Synthesize and present results in evidence tables.
Once the question is identified, a comprehensive search for appropriate CEAs is conducted. Searches may be limited by year (e.g., after 1990), based on when relevant technologies came into use. Abstracts identified by the search are screened for inclusion using three items: (1) Does the study address the identified question? (2) Is the study an original CEA? (3) Does the study report results using an appropriate outcome metric (e.g., LYS, QALY, or cases of illness averted)? If no CEAs exist for a specific question, we consider reviewing other types of economic analyses, such as CBAs.
Studies meeting inclusion criteria are abstracted by at least two reviewers. To determine whether the best available evidence was used in each study, whether included assumptions are reasonable, and whether each study appropriately addresses the question at hand, the CEA review team for each question includes a member of the topic team reviewing the effectiveness evidence for that topic (38). The data used in the CEA are compared with the evidence derived from the systematic review of effectiveness conducted by the topic team, which serves as the "gold standard" for whether the best available evidence was used.
After abstracting studies, reviewers discuss how studies differ in their assumptions, how varying assumptions affect study results, and how different studies may arrive at different conclusions. Finally, key information addressing the initial question and highlighting study quality and the effect of various assumptions are summarized in evidence tables.
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CEAs are valuable tools for incorporating cost considerations into evidence-based clinical decisions. This article has outlined the USPSTF's strategy to incorporate information from CEAs into its process for recommending clinical preventive services. Through these efforts, we hope not only to provide guidance about implementing preventive services, but to identify unmet needs in economic analyses of preventive health care, illuminate some of the trade-offs in alternative approaches to delivering preventive services, and provide substrata for policy discussions and public debate over the role of cost-effectiveness in allocating health care resources.
In the future, ranking of preventive services based on cost-effectiveness may provide busy clinicians and their patients with some scientific basis for deciding how to best spend their limited time providing or carrying out the services that are most likely to have the greatest impact on health. At present, CEAs should be considered an important aid to decision makers striving to achieve the best possible health for a population.
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Supported by contract #290-97-0018 (Task Order #2) to the Oregon Health Sciences University (SS, MH) and contract #290-97-0011 (Task Order #3) to the Research Triangle Institute/University of North Carolina (TJH, MP) from the Agency for Healthcare Research and Quality, and contract # DAMD17-94-J-4212 from the Department of the Army (JSM). The views expressed in this article are those of the authors and do not necessarily reflect those of the Agency for Healthcare Research and Quality or the Department of the Army.
We thank Vilma G. Carande-Kulis, M.S., Ph.D.; Joanna E. Siegel, Sc.D., R.N.; Dennis G. Fryback, Ph.D.; Milton J. Weinstein, Ph.D.; and the members of the third U.S. Preventive Services Task Force, for comments on earlier versions of this manuscript; the Partnership for Prevention Committee on Clinical Preventive Service Priorities and Peter J. Neumann, Sc.D., for sharing their work; and Kathryn Pyle Krages, AMLS, M.A., Susan Wingenfeld, and Gary Miranda, M.A., for administrative support and help with manuscript preparation and editing.
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[a] Saha, Helfand: Evidence-Based Practice Center, Oregon Health Sciences University, Portland, OR.
[b] Helfand: Division of Medical Informatics and Outcomes Research, Oregon Health Sciences University, Portland, OR.
[c] Saha, Helfand: Section of General Internal Medicine, Portland Veterans Affairs Medical Center, Portland, OR.
[d] Hoerger, Pignone: Evidence-based Practice Center, Research Triangle Institute and University of North Carolina, Chapel Hill, NC.
[e] Hoerger: Center for Economics Research, Research Triangle Institute, Research Triangle Park, Chapel Hill, NC.
[f] Pignone: Department of Internal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC.
[g] Teutsch: Merck & Co, Inc, West Point, PA.
[h] Mandelblatt: Departments of Oncology and Medicine, Georgetown University Medical Center, Washington, DC.
*Other members of the Cost Work Group of the third U.S. Preventive Services Task Force include: David Atkins, M.D, M.P.H, Agency for Healthcare Research and Quality, Rockville, MD; Alfred O. Berg, M.D, M.P.H, University of Washington, Seattle, WA; Tracy A. Lieu, M.D, M.P.H, Harvard Community Health Plan, Boston, MA; Cynthia D. Mulrow, M.D, M.Sc, University of Texas Health Science Center, San Antonio, TX; Harold C. Sox, Jr, Dartmouth-Hitchcock Medical Center, Lebanon, NH; and Carolyn Westhoff, M.D, M.Sc, Columbia University, New York, NY.
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Source: Saha S, Hoerger TJ, Pignone MP, Teutsch SM, Helfand M, Mandelblatt JS. The Art and Science of Incorporating cost-effectiveness into Evidence-based Recommendations for Clinical Preventive Services. Am J Prev Med 2001;20(3S):36-43 (http://www.elsevier.com/locate/online).
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