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ANALYSIS: Gordon H Guyatt, Andrew D Oxman, Regina Kunz, Roman Jaeschke, Mark Helfand, Alessandro Liberati, Gunn E Vist, Holger J Schünemann for the GRADE working group Incorporating considerations of resources use into grading recommendations BMJ 2008; 336: 1170-1173 [Full text]

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GRADEing opinions

Ivar S Kristiansen   (4 July 2008)

GRADEing opinions 4 July 2008
Ivar S Kristiansen, Professor University of Oslo, 0317 Oslo Send response to journal: Re: GRADEing opinions	Increasingly, health authorities around the world use economic evaluation, typically cost-effectiveness analyses, in order to set priorities in health care. Priority setting involves much wider consideration than medical effectiveness. Long term health consequences, valuation of health states, and value of resources are key elements when societies set priorities. Few clinical trials explore all of these issues, and clinicians and policy makers may in practice make implicit assumptions when they make recommendations. Such assumptions are usually made explicit in economic evaluation, and this may leave the impression that such evaluation is much more uncertain than clinical practice based on “best medical evidence”. In the 24 May 2008 edition of the British Medical Journal Gordon Guyatt and co-workers suggest a system for ”rating quality of evidence and strength of recommendations” in relation to ”considerations of resource use” [1]. Surprisingly, they conclude that “a guideline panel may legitimately choose to omit costs as a consideration”, presumably because resource use and unit costs vary across jurisdictions. In fact, it would be against the law not to consider costs in some countries such as Norway. Here, the Patient’s Rights Act states that “the patient has the right to therapy only when the costs are reasonable in relation to the health benefit”. The Health Personnel Act requires that health personnel shall not incur unnecessary expenses for patients or the health care system. The simple and compelling argument for such regulations is that “resources that are used for an intervention cannot be used for something else and not affect the ability of the health system to best meet the needs of those it serves” [1]. Guyatt and co-workers state that “published cost effectiveness analyses, particularly of drugs, have a high probability of being flawed or biased. This sweeping statement is based on a review of 44 economic analyses published 1988-98 of six different pharmaceuticals. In the review the authors conclude that “although we did not identify bias in individual studies, these findings indicate that pharmaceutical company sponsorship of economic analyses is associated with reduced likelihood of reporting unfavorable results” [2]. In comparison, the Centre for Reviews and Dissemination in York encompasses 7000 quality assed economic evaluations (www.york.ac.uk/inst/crd/crddatabases.htm). It is surprising that advocates of evidence based medicine are able to draw conclusions about thousands of studies based on a review of 44 of them. Guidelines should be based on critical thinking and explicit value judgment rather than on opinions or prejudice. Conflict of interest: Ivar Sønbø Kristiansen has edited a critical book on evidence based medicine References 1. Guyatt G H, Oxman A D, Kunz R, Jaeschke R, Helfand M, Liberati A, Vist G E, Schunemann H J. Incorporating considerations of resources use into grading recommendations. BMJ 2008; (336): 1170-1173. 2. Friedberg M, Saffran B, Stinson T J, Nelson W, Bennett C L. Evaluation of conflict of interest in economic analyses of new drugs used in oncology. JAMA 1999; (282): 1453-1457. Competing interests: Ivar Sønbø Kristiansen has edited a critical book on evidence based medicine