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Wang J, Pouwels X, Ramaekers B, Frederix G, van Lieshout C, Hoogenveen R, Li X, de Wit GA, Joore M, Koffijberg H, van Giessen A, Knies S, Feenstra T. A Blueprint for Multi-use Disease Modeling in Health Economics: Results from Two Expert-Panel Consultations. PHARMACOECONOMICS 2024:10.1007/s40273-024-01376-w. [PMID: 38613660 DOI: 10.1007/s40273-024-01376-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND The current use of health economic decision models in HTA is mostly confined to single use cases, which may be inefficient and result in little consistency over different treatment comparisons, and consequently inconsistent health policy decisions, for the same disorder. Multi-use disease models (MUDMs) (other terms: generic models, whole disease models, disease models) may offer a solution. However, much is uncertain about their definition and application. The current research aimed to develop a blueprint for the application of MUDMs. METHODS We elicited expert opinion using a two-round modified Delphi process. The panel consisted of experts and stakeholders in health economic modelling from various professional backgrounds. The first questionnaire concerned definition, terminology, potential applications, issues and recommendations for MUDMs and was based on an exploratory scoping review. In the second round, the panel members were asked to reconsider their input, based on feedback regarding first-round results, and to score issues and recommendations for priority. Finally, adding input from external advisors and policy makers in a structured way, an overview of issues and challenges was developed during two team consensus meetings. RESULTS In total, 54 respondents contributed to the panel results. The term 'multi-use disease models' was proposed and agreed upon, and a definition was provided. The panel prioritized 10 potential applications (with comparing alternative policies and supporting resource allocation decisions as the top 2), while 20 issues (with model transparency and stakeholders' roles as the top 2) were identified as challenges. Opinions on potential features concerning operationalization of multi-use models were given, with 11 of these subsequently receiving high priority scores (regular updates and revalidation after updates were the top 2). CONCLUSIONS MUDMs would improve on current decision support regarding cost-effectiveness information. Given feasibility challenges, this would be most relevant for diseases with multiple treatments, large burden of disease and requiring more complex models. The current overview offers policy makers a starting point to organize the development, use, and maintenance of MUDMs and to support choices concerning which diseases and policy decisions they will be helpful for.
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Affiliation(s)
- Junfeng Wang
- Department of Epidemiology and Health Economics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands
| | - Xavier Pouwels
- Department of Health Technology and Services Research, Faculty of Behavioural, Management, and Social Sciences, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Bram Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, CAPHRI Care and Public Health Research Institute, Maastricht, The Netherlands
| | - Geert Frederix
- Department of Epidemiology and Health Economics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Chris van Lieshout
- Department of Epidemiology and Health Economics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rudolf Hoogenveen
- Department of Statistics, Modelling and Data Science, Center of Research and Data services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Xinyu Li
- University of Groningen, Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, Groningen, The Netherlands
| | - G Ardine de Wit
- Department of Epidemiology and Health Economics, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
- Centre for Public Health, Healthcare and Society, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
- Department of Health Sciences, Faculty of Beta Sciences, Vrije Universiteit Amsterdam & Amsterdam Public Health Institute, Amsterdam, The Netherlands
| | - Manuela Joore
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, CAPHRI Care and Public Health Research Institute, Maastricht, The Netherlands
| | - Hendrik Koffijberg
- Department of Health Technology and Services Research, Faculty of Behavioural, Management, and Social Sciences, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Anoukh van Giessen
- Department of Statistics, Modelling and Data Science, Center of Research and Data services, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
| | - Saskia Knies
- National Health Care Institute, Diemen, The Netherlands
| | - Talitha Feenstra
- University of Groningen, Faculty of Science and Engineering, Groningen Research Institute of Pharmacy, Groningen, The Netherlands.
- Centre for Public Health, Healthcare and Society, National Institute for Public Health and the Environment, Bilthoven, The Netherlands.
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Lakshmipathy D, Winter E, Fritz C, Harris J, Gentile M, Moreira A, Rajasekaran K. Managing vestibular schwannomas with radiosurgery and radiotherapy: AGREE II appraisal of clinical practice guidelines. J Med Imaging Radiat Oncol 2024. [PMID: 38477433 DOI: 10.1111/1754-9485.13640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 03/03/2024] [Indexed: 03/14/2024]
Abstract
INTRODUCTION Vestibular schwannomas (VSs) are rare, benign intracranial tumours that have prompted clinical practice guideline (CPG) creation given their complex management. Our aim was to utilize the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument to assess if such CPGs on the management of VSs with radiosurgery and radiotherapy are of acceptable quality. METHODS Relevant CPGs were identified following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocols. Experienced reviewers then extracted general CPG properties and rated their quality via the AGREE II instrument. Intraclass correlation coefficients (ICCs) were quantified to assess interrater reliability. RESULTS Nine CPGs on the management of VSs with radiosurgery and radiotherapy were identified. All CPGs were created in the past six years and developed recommendations based on literature review and expert consensus. One guideline was deemed as high quality with seven others being moderate and one being low in quality. The clarity of the presentation domain had the highest mean scaled domain score of 96.0%. The domains of stakeholder involvement and applicability had the lowest means of 49.2% and 47.2%, respectively. ICCs were either good or excellent across all domains. CONCLUSION Current CPGs on the management of VSs with radiosurgery and radiotherapy are of acceptable quality but would greatly benefit from improvements in applicability, stakeholder involvement, editorial independence and rigour of development. We recommend CPG authors reference the European Association of Neuro-Oncology (EANO) guideline as a developmental framework with the Congress of Neurological Surgeons/American Association of Neurological Surgeons (CNS/AANS) CPG being a valid alternative.
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Affiliation(s)
- Deepak Lakshmipathy
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eric Winter
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christian Fritz
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jacob Harris
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michelle Gentile
- Department of Radiation Oncology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alvaro Moreira
- Department of Paediatrics, University of Texas Health Science Centre at San Antonio, San Antonio, Texas, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology-Head & Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Gray J, McCarthy A, Samarakoon D, McMeekin P, Sharples L, Sastry P, Crawshaw P, Bicknell C. Costs of endovascular and open repair of thoracic aortic aneurysms. Br J Surg 2024; 111:znad378. [PMID: 38091972 PMCID: PMC10763539 DOI: 10.1093/bjs/znad378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 10/17/2023] [Accepted: 10/21/2023] [Indexed: 01/04/2024]
Abstract
BACKGROUND Repair of thoracic aortic aneurysms with either endovascular repair (TEVAR) or open surgical repair (OSR) represents major surgery, is costly and associated with significant complications. The aim of this study was to establish accurate costs of delivering TEVAR and OSR in a cohort of UK NHS patients suitable for open and endovascular treatment for the whole treatment pathway from admission and to discharge and 12-month follow-up. METHODS A prospective study of UK NHS patients from 30 NHS vascular/cardiothoracic units in England aged ≥18, with distal arch/descending thoracic aortic aneurysms (CTAA) was undertaken. A multicentre prospective cost analysis of patients (recruited March 2014-July 2018, follow-up until July 2019) undergoing TEVAR or OSR was performed. Patients deemed suitable for open or endovascular repair were included in this study. A micro-costing approach was adopted. RESULTS Some 115 patients having undergone TEVAR and 35 patients with OSR were identified. The mean (s.d.) cost of a TEVAR procedure was higher £26 536 (£9877) versus OSR £17 239 (£8043). Postoperative costs until discharge were lower for TEVAR £7484 (£7848) versus OSR £28 636 (£23 083). Therefore, total NHS costs from admission to discharge were lower for TEVAR £34 020 (£14 301), versus OSR £45 875 (£43 023). However, mean NHS costs for 12 months following the procedure were slightly higher for the TEVAR £5206 (£11 585) versus OSR £5039 (£11 994). CONCLUSIONS Surgical procedure costs were higher for TEVAR due to device costs. Total in-hospital costs were higher for OSR due to longer hospital and critical care stay. Follow-up costs over 12 months were slightly higher for TEVAR due to hospital readmissions.
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Affiliation(s)
- Joanne Gray
- Faculty of Health and Life Sciences, Northumbria University, Newcastle Upon Tyne, UK
| | - Andrew McCarthy
- Faculty of Health and Life Sciences, Northumbria University, Newcastle Upon Tyne, UK
| | - Dilupa Samarakoon
- Faculty of Health and Life Sciences, Northumbria University, Newcastle Upon Tyne, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle Upon Tyne, UK
| | - Linda Sharples
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Priya Sastry
- Department of Cardiac Surgery, John Radcliffe Hospital, Oxford University Hospitals, Oxford, UK
| | - Paul Crawshaw
- School of Social Sciences, Humanities and Law, Teesside University, Middlesbrough, UK
| | - Colin Bicknell
- Department of Surgery and Cancer, Imperial College, London, UK
- Imperial Vascular Unit, Imperial Healthcare NHS Trust, London, UK
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Irving AH, Harris A, Petrie D, Higgins A, Smith JA, Tran L, Reid CM, McQuilten ZK. Economic Evaluation of National Patient Blood Management Clinical Guidelines in Cardiac Surgery. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:419-426. [PMID: 35227454 DOI: 10.1016/j.jval.2021.07.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 06/02/2021] [Accepted: 07/22/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES To the best of our knowledge, no published clinical guidelines have ever undergone an economic evaluation to determine whether their implementation represented an efficient allocation of resources. Here, we perform an economic evaluation of national clinical guidelines designed to reduce unnecessary blood transfusions before, during, and after surgery published in 2012 by Australia's sole public blood provider, the National Blood Authority (NBA). METHODS We performed a cost analysis from the government perspective, comparing the NBA's cost of implementing their perioperative patient blood management guidelines with the estimated resource savings in the years after publication. The impact on blood products, patient outcomes, and medication use were estimated for cardiac surgeries only using a large national registry. We adopted conservative counterfactual positions over a base-case 3-year time horizon with outcomes predicted from an interrupted time-series model controlling for differences in patient characteristics and hospitals. RESULTS The estimated indexed cost of implementing the guidelines of A$1.5 million (2018-2019 financial year prices) was outweighed by the predicted blood products resource saving alone of A$5.1 million (95% confidence interval A$1.4 million-A$8.8 million) including savings of A$2.4 million, A$1.6 million, and A$1.2 million from reduced red blood cell, platelet, and fresh frozen plasma use, respectively. Estimated differences in patient outcomes were highly uncertain and estimated differences in medication were financially insignificant. CONCLUSIONS Insofar as they led to a reduction in red blood cell, platelet, and fresh frozen plasma use during cardiac surgery, implementing the perioperative patient blood management guidelines represented an efficient use of the NBA's resources.
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Affiliation(s)
- Adam H Irving
- Centre for Health Economics, Monash University, Melbourne, Australia.
| | - Anthony Harris
- Centre for Health Economics, Monash University, Melbourne, Australia
| | - Dennis Petrie
- Centre for Health Economics, Monash University, Melbourne, Australia
| | - Alisa Higgins
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Julian A Smith
- Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Australia; Department of Cardiothoracic Surgery, Monash Health, Monash University, Melbourne, Australia
| | - Lavinia Tran
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher M Reid
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; School of Public Health, Curtin University, Perth, Australia
| | - Zoe K McQuilten
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Haematology, Monash Health, Monash University, Melbourne, Australia
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Barnett ML, Stadnick NA, Proctor EK, Dopp AR, Saldana L. Moving beyond Aim Three: a need for a transdisciplinary approach to build capacity for economic evaluations in implementation science. Implement Sci Commun 2021; 2:133. [PMID: 34863315 PMCID: PMC8642890 DOI: 10.1186/s43058-021-00239-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 11/03/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Understanding the costs and economic benefits of implementation has been identified by policymakers and researchers as critical to increase the uptake and sustainment of evidence-based practices, but this topic remains relatively understudied. Conducting team science with health economists has been proposed as a solution to increase economic evaluation in implementation science; however, these recommendations ignore the differences in goals and perspectives in these two fields. Our recent qualitative research identified that implementation researchers predominantly approach health economists to examine costs, whereas the majority of health economists expressed limited interest in conducting economic evaluations and a desire to be more integrated within implementation science initiatives. These interviews pointed to challenges in establishing fruitful partnerships when health economists are relegated to the "Third Aim" (i.e., lowest-priority research objective) in implementation science projects by their research partners. DISCUSSION In this debate paper, we argue that implementation researchers and health economists need to focus on team science research principles to expand capacity to address pressing research questions that cut across the two fields. Specifically, we use the four-phase model of transdisciplinary research to outline the goals and processes needed to build capacity in this area (Hall et al., Transl Behav Med 2:415-30, 2012). The first phase focuses on the development of transdisciplinary research teams, including identifying appropriate partners (e.g., considering policy or public health researchers in addition to health economists) and building trust. The conceptual phase focuses on strategies to consider when developing joint research questions and methodology across fields. In the implementation phase, we outline the effective processes for conducting research projects, such as team learning. Finally, in the translation phase, we highlight how a transdisciplinary approach between health economists and implementation researchers can impact real-world practice and policy. The importance of investigating the economic impact of evidence-based practice implementation is widely recognized, but efforts have been limited due to the challenges in conducting team science across disciplines. Training in team science can help advance transdisciplinary efforts, which has the potential to increase the rigor and impact of economic evaluations in implementation science while expanding the roles taken by health economists.
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Affiliation(s)
- Miya L Barnett
- Department of Counseling, Clinical, & School Psychology, University of California, Santa Barbara, Santa Barbara, CA, 93106-9490, USA.
| | - Nicole A Stadnick
- Department of Psychiatry, University of California, San Diego, La Jolla, CA, 92093, USA
- Child and Adolescent Services Research Center, San Diego, CA, 92123, USA
- UC San Diego Altman Clinical and Translational Research Institute Dissemination and Implementation Science Center, La Jolla, CA, 92093, USA
| | - Enola K Proctor
- Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO, 63130, USA
| | - Alex R Dopp
- Department of Behavioral and Policy Sciences, RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA
| | - Lisa Saldana
- Oregon Social Learning Center, 10 Shelton McMurphey Blvd., Eugene, OR, 97401, USA
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Barnett ML, Dopp AR, Klein C, Ettner SL, Powell BJ, Saldana L. Collaborating with health economists to advance implementation science: a qualitative study. Implement Sci Commun 2020; 1:82. [PMID: 33005901 PMCID: PMC7523377 DOI: 10.1186/s43058-020-00074-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 09/14/2020] [Indexed: 01/13/2023] Open
Abstract
Background Implementation research infrequently addresses economic factors, despite the importance of understanding the costs of implementing evidence-based practices (EBPs). Though partnerships with health economists have the potential to increase attention to economic factors within implementation science, barriers to forming these collaborations have been noted. This study investigated the experiences of health economists and implementation researchers who have partnered across disciplines to inform strategies to increase such collaborations. Methods A purposeful sampling approach was used to identify eight health economists and eight implementation researchers with experience participating in cross-disciplinary research. We used semi-structured interviews to gather information about participants' experiences with collaborative research. Thematic analysis was conducted to identify core themes related to facilitators and barriers to collaborations. Results Health economists and implementation researchers voiced different perspectives on collaborative research, highlighting the importance of increasing cross-disciplinary understanding. Implementation researchers described a need to measure costs in implementation studies, whereas many health economists described that they seek to collaborate on projects that extend beyond conducting cost analyses. Researchers in both disciplines articulated motivations for collaborative research and identified strategies that promote successful collaboration, with varying degrees of convergence across these themes. Shared motivations included improving methodological rigor of research and making a real-world impact. Strategies to improve collaboration included starting partnerships early in the study design period, having a shared interest, and including health economists in the larger scope of the research. Conclusions Health economists and implementation researchers both conduct research with significant policy implications and have the potential to inform one another's work in ways that might more rapidly advance the uptake of EBPs. Collaborative research between health economists and implementation science has the potential to advance the field; however, researchers will need to work to bridge disciplinary differences. By beginning to develop strong working relationships; increasing their understanding of one another's disciplinary culture, methodology, and language; and increasing the role economists have within research design and execution, both implementation researchers and health economists can support successful collaborations and robust and informative research.
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Affiliation(s)
- Miya L Barnett
- Department of Counseling, Clinical, & School Psychology, University of California, Santa Barbara, Santa Barbara, California, 93106-9490 USA
| | - Alex R Dopp
- Department of Behavioral and Policy Sciences, RAND Corporation, 1776 Main Street, Santa Monica, CA 90401 USA
| | - Corinna Klein
- Department of Counseling, Clinical, & School Psychology, University of California, Santa Barbara, Santa Barbara, California, 93106-9490 USA
| | - Susan L Ettner
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA 90095 USA.,Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA 90095 USA
| | - Byron J Powell
- Brown School, Washington University in St. Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO 63130 USA
| | - Lisa Saldana
- Oregon Social Learning Center, 10 Shelton McMurphey Blvd, Eugene, OR 97401 USA
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Knies S, Severens JL, Brouwer WBF. Integrating clinical and economic evidence in clinical guidelines: More needed than ever! J Eval Clin Pract 2019; 25:561-564. [PMID: 29700903 PMCID: PMC6767471 DOI: 10.1111/jep.12936] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 03/23/2018] [Indexed: 11/27/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES In recent years, several expensive new health technologies have been introduced. The availability of those technologies intensifies the discussion regarding the affordability of these technologies at different decision-making levels. On the meso level, both hospitals and clinicians are facing budget constraints resulting in a tension to balance between different patients' interests. As such, it is crucial to make optimal use of the available resources. Different strategies are in place to deal with this problem, but decisions on a macro level on what to fund or not can limit the role and freedom of clinicians in their decisions on a micro level. At the same time, without central guidance regarding such decisions, micro level decisions may lead to inequities and undesirable treatment variation between clinicians and hospitals. The challenge is to find instruments that can balance both levels of decision making. DISCUSSION Clinicians are becoming increasingly aware that their decisions to spend more resources (like time and budget) on 1 particular patient group reduce the resources available to other patients. Involving clinicians in thinking about the optimal use of limited resources, also in an attempt to bridge the world of economic reasoning and clinical practice, is crucial therefore. We argue that clinical guidelines may prove a clear vehicle for this by including both clinical and economic evidence to support the recommendations made. The development of such guidelines requires cooperation of clinicians, and health economists are cooperating with each other. CONCLUSION The development of clinical guidelines which combine economic and clinical evidence should be stimulated, to balance central guidance and uniformity while maintaining necessary decentralized freedom. This is an opportunity to combine the reality of budgets and opportunity costs with clinical practice. Missing this opportunity risks either variation and inequity or central and necessarily crude measures.
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Affiliation(s)
- Saskia Knies
- National Health Care Institute, PO Box 320, 1110 AH, Diemen, The Netherlands.,Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA, Rotterdam, The Netherlands
| | - Johan L Severens
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA, Rotterdam, The Netherlands.,Institute of Medical Technology Assessment, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA, Rotterdam, The Netherlands
| | - Werner B F Brouwer
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA, Rotterdam, The Netherlands.,Institute of Medical Technology Assessment, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3062 PA, Rotterdam, The Netherlands
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