David Feeny

IMPORTANCE: Since publication of the report by the Panel on Cost-Effectiveness in Health and Medicine in 1996, researchers have advanced the methods of cost-effectiveness analysis, and policy makers have experimented with its application. The need to deliver health care efficiently and the importance of using analytic techniques to understand the clinical and economic consequences of strategies to improve health have increased in recent years. OBJECTIVE: To review the state of the field and provide recommendations to improve the quality of cost-effectiveness analyses. The intended audiences include researchers, government policy makers, public health officials, health care administrators, payers, businesses, clinicians, patients, and consumers. DESIGN: In 2012, the Second Panel on Cost-Effectiveness in Health and Medicine was formed and included 2 co-chairs, 13 members, and 3 additional members of a leadership group. These members were selected on the basis of their experience in the field to provide broad expertise in the design, conduct, and use of cost-effectiveness analyses. Over the next 3.5 years, the panel developed recommendations by consensus. These recommendations were then reviewed by invited external reviewers and through a public posting process. FINDINGS: The concept of a "reference case" and a set of standard methodological practices that all cost-effectiveness analyses should follow to improve quality and comparability are recommended. All cost-effectiveness analyses should report 2 reference case analyses: one based on a health care sector perspective and another based on a societal perspective. The use of an "impact inventory," which is a structured table that contains consequences (both inside and outside the formal health care sector), intended to clarify the scope and boundaries of the 2 reference case analyses is also recommended. This special communication reviews these recommendations and others concerning the estimation of the consequences of interventions, the valuation of health outcomes, and the reporting of cost-effectiveness analyses. CONCLUSIONS AND RELEVANCE: The Second Panel reviewed the current status of the field of cost-effectiveness analysis and developed a new set of recommendations. Major changes include the recommendation to perform analyses from 2 reference case perspectives and to provide an impact inventory to clarify included consequences.

BACKGROUND: The Health Utilities Index Mark 3 (HUI3) is a generic multiattribute preference-based measure of health status and health-related quality of life that is widely used as an outcome measure in clinical studies, in population health surveys, in the estimation of quality-adjusted life years, and in economic evaluations. HUI3 consists of eight attributes (or dimensions) of health status: vision, hearing, speech, ambulation, dexterity, emotion, cognition, and pain with 5 or 6 levels per attribute, varying from highly impaired to normal. OBJECTIVES: The objectives are to present a multiattribute utility function and eight single-attribute utility functions for the HUI3 system based on community preferences. STUDY DESIGN: Two preference surveys were conducted. One, the modeling survey, collected preference scores for the estimation of the utility functions. The other, the direct survey, provided independent scores to assess the predictive validity of the utility functions. MEASURES: Preference measures included value scores obtained on the Feeling Thermometer and standard gamble utility scores obtained using the Chance Board. RESPONDENTS: A random sample of the general population (> or =16 years of age) in Hamilton, Ontario, Canada. RESULTS: Estimates were obtained for eight single-attribute utility functions and an overall multiattribute utility function. The intraclass correlation coefficient between directly measured utility scores and scores generated by the multiattribute function for 73 health states was 0.88. CONCLUSIONS: The HUI3 scoring function has strong theoretical and empirical foundations. It performs well in predicting directly measured scores. The HUI3 system provides a practical way to obtain utility scores based on community preferences.

This is a review of the Health Utilities Index (HUI) multi-attribute health-status classification systems, and single- and multi-attribute utility scoring systems. HUI refers to both HUI Mark 2 (HUI2) and HUI Mark 3 (HUI3) instruments. The classification systems provide compact but comprehensive frameworks within which to describe health status. The multi-attribute utility functions provide all the information required to calculate single-summary scores of health-related quality of life (HRQL) for each health state defined by the classification systems. The use of HUI in clinical studies for a wide variety of conditions in a large number of countries is illustrated. HUI provides comprehensive, reliable, responsive and valid measures of health status and HRQL for subjects in clinical studies. Utility scores of overall HRQL for patients are also used in cost-utility and cost-effectiveness analyses. Population norm data are available from numerous large general population surveys. The widespread use of HUI facilitates the interpretation of results and permits comparisons of disease and treatment outcomes, and comparisons of long-term sequelae at the local, national and international levels.

To achieve lasting competitiveness through IT, according to the authors, companies face three enduring challenges: focusing IS efforts to support business strategies and using IT innovations to develop new, superior strategies; devising and managing effective strategies for the delivery of low-cost, high-quality IS services; and choosing the technical platform on which to mount IS services. Three strands of research ? on the CIO's role and experience, the CIO's capabilities, and IS/IT outsourcing ? demonstrate that businesses need nine core IS capabilities to address these challenges: 1. Leadership. Integrating IS/IT effort with business purpose and activity. 2. Business systems thinking. Envisioning the business process that technology makes possible. 3. Relationship building. Getting the business constructively engaged in IS/IT issues. 4. Architecture planning. Creating the blueprint for a technical platform that responds to current and future business needs. 5. Making technology work. Rapidly achieving technical progress ? by one means or another. 6. Informed buying. Managing the IS/IT sourcing strategy that meets the interests of the business. 7. Contract facilitation. Ensuring the success of existing contracts for IS/IT services. 8. Contract monitoring. Protecting the business's contractual position, current and future. 9. Vendor development. Identifying the potential added value of IS/IT service suppliers. IS professionals and managers need to demonstrate a changing mix of technical, business, and interpersonal skills. The authors trace the role these skills play in achieving the core IS capabilities and discuss the challenges of adapting core IS capabilities to particular organizational contexts. Their core IS capability model implies migration to a relatively small IS function, staffed by highly able people. To sustain their ability to exploit IT, the authors conclude, organizations must make the design of flexible IS arrangements a high-priority task and take an anticipatory rather than a reactive approach to that task.

The effect of total hip replacement on the health-related quality of life of patients who have osteoarthrosis was examined as part of a randomized, controlled trial comparing femoral head prostheses that were inserted with or without cement. One hundred and eighty-eight patients were followed for three months: 179 of them, for six months; 156, for one year; and ninety, for two years. The health-related quality of life was assessed with use of the Harris hip score, the Merle d'Aubigné hip score, the Sickness Impact Profile, the Western Ontario and McMaster University (WOMAC) Osteoarthritis Index, the McMaster--Toronto Arthritis (MACTAR) Patient Preference Disability Questionnaire, and the time trade-off technique as a measure of utility. Patients also took the six-minute-walk test. The mean age of the patients in the study was sixty-four years (range, forty to seventy-five years); ninety-seven patients (53 per cent) were men and ninety-four (50 per cent) had a prosthesis inserted with cement. Only three of 188 patients refused to return for quality-of-life assessments. There was significant improvement in all health-related quality-of-life measures and in the six-minute-walk test after the operation (p < 0.01 for all items, except for the work dimension of the Sickness Impact Profile at three months [p = 0.07]). Most of the improvement had occurred by three months postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)