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Unbiased cost-effectiveness: an oxymoron?


"a rhetorical figure by which contradictory terms are conjoined so as to give point to the statement or expression (now often loosely = a contradiction in terms)" - Shorter Oxford English Dictionary.

Have you noticed how the arguments of the pharmaceutical companies have changed recently? No longer do they talk simply about a new drug being more effective; they emphasise that the drug is much more cost-effective for the health service, the argument being that even though the cost of prescribed medication is more expensive, savings are made elsewhere in the health care system.

With typical clarity and colour Robert Evans, one of the world's leading health economists, responds trenchantly to two letters in the Annals of Internal Medicine [1] which criticised a Leader he wrote nine months previously.

His leading article [2] is well worth reading for anyone who receives information about the cost-effectiveness of new drugs (and that must apply to all of us these days). It was written as a commentary and critique of a major ten-page report in the Annals of Internal Medicine on the principles of "Economic Analysis of Health Care Technology" [3].

Bob Evans' thrust was that this Taskforce was funded entirely by the pharmaceutical industry and that it was giving a verisimilitude of objectivity to a technique which should be assumed to be biased. His criticisms are typically forthright, for example saying that "a pseudodiscipline, pharmaco-economics, has been conjured into existence by the magic of money with its own practitioners' conferences and journals. There are a lot of drugs and there is a lot of money so the 'field' is booming."

Guidelines needed

A similar line was taken in a BMJ leader on "Promoting cost-effective prescribing" [4] published last year. This pointed out that both drug companies and those working for funders of health services can be criticised for being inevitably biased. The authors called for clear rigorous guidelines on cost-effectiveness, not only to be drawn up by both the Department of Health and the Association of British Pharmaceutical Industries but to be used as a "fourth hurdle" when efficacy had been demonstrated by randomised trials, as is the case in Australia.

The difficulty of doing this is emphasised by Bob Evans. In his response to the critical letters he finishes with a punchy question.
"In the end drug buyers and reimbursers will have to do their own evaluations and make their own purchasing decisions. Offers of participation and scientific co-operation from sellers always spring from the same underlying motive, to move the product. What else can they do?"

This seems a pessimistic line to take but this issue needs to be faced and Bandolier will carry more articles on cost-effectiveness methods in the forthcoming months.


  1. RG Evans. Principles of economic analysis of health care technology. Annals of Internal Medicine 1996 124: 536
  2. RG Evans. Manufacturing consensus, marking truth: guidelines for economic evaluation. Annals of Internal Medicine 1995 122: 59-60
  3. Task force on principles for economic analysis of health care technology. Economic analysis of health care technology. A report on principles. Annals of Internal Medicine 1995 123: 61-70.
  4. N Freemantle, D Henry, A Maynard, G Torrance. Promoting cost-effective prescribing. I. British Medical Journal 1995 310: 955-6.

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