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Incorporating economic analysis into clinical practice guidelines: a guide for hopeful users
  1. Scott D Ramsey, Md PhD
  1. Fred Hutchinson Cancer Research Center
 University of Washington
 Seattle, Washington, USA

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    A large health plan has asked you to help them develop a clinical practice guideline for colon cancer screening. The plan currently covers annual fecal occult blood testing (FOBT) and flexible sigmoidoscopy every 5 years as screening methods. Member rates for both types of screening are very low (hence the impetus for the guideline). At the behest of several local gastroenterologists, the plan is also considering whether to cover colonoscopy every 10 years for average-risk people ≥50 years of age. Part of the process involves reviewing the cost-effectiveness literature, because the chief executive officer of the health plan is skeptical that colonoscopy represents a wise use of their ever-tightening budget. You are familiar with US Preventive Services Task Force Guidelines for colon cancer screening. After reviewing several recent cost-effectiveness studies, however, you find them daunting in terms of methodological complexity, terminology, and representation of outputs (a confusing array of large numerical tables and graphs that strongly resemble something you studied in first-year college economics). Is it possible to translate these studies into something you understand, believe reflects sound clinical practice, and believe would be useful to the health plan for their decision making?

    The situation just described, an apparent disconnect between costs and clinical practice guidelines and the confusion it causes for readers, is not unusual. Economic analyses are rarely included in guidelines, mostly because each discipline has different and often conflicting views of what constitutes “best practice”.1,2 This exclusion is unfortunate, because both guidelines and cost-effectiveness studies offer important information to help us practice more effective and efficient health care. Decision makers today have a need to synthesise and interpret these studies rapidly and efficiently. This editorial offers suggestions to help clinicians understand cost-effectiveness studies and to use them in developing guidelines. Its approach is similar to …

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    • a One-way sensitivity analyses generally understate the uncertainty in the cost-effectiveness ratio. One should check to see if the article presents confidence intervals around the cost-effectiveness ratio. New tecniques that can estimate confidence intervals are being used more frequently today.