GRADE Series
GRADE guidelines: 10. Considering resource use and rating the quality of economic evidence

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Abstract

Objectives

In this article, we describe how to include considerations about resource utilization when making recommendations according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

Study Design and Settings

We focus on challenges with rating the confidence in effect estimates (quality of evidence) and incorporating resource use into evidence profiles and Summary of Findings (SoF) tables.

Results

GRADE recommends that important differences in resource use between alternative management strategies should be included along with other important outcomes in the evidence profile and SoF table. Key steps in considering resources in making recommendations with GRADE are the identification of items of resource use that may differ between alternative management strategies and that are potentially important to decision makers, finding evidence for the differences in resource use, making judgments regarding confidence in effect estimates using the same criteria used for health outcomes, and valuing the resource use in terms of costs for the specific setting for which recommendations are being made.

Conclusions

With our framework, decision makers will have access to concise summaries of recommendations, including ratings of the quality of economic evidence, and better understand the implications for clinical decision making.

Introduction

What is new?

Key points

  1. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) offers a transparent and structured process to include resource use in the development of health care recommendations.

  2. Important differences in resource use should be included along with other important outcomes in evidence profiles and Summary of Findings tables.

  3. Key steps in considering resource use are the identification of resource use that is potentially important to decision makers, rating the confidence in effect estimates for important effects on resource use, and valuation of resource use in terms of costs for the specific setting for which ecommendations are being made.

In previous articles of this series, we described the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to formulating a structured clinical question and rating the confidence in effect estimates (quality of evidence) for clinical outcomes. In this article, we highlight economic outcomes of alternative management strategies or interventions and describe how to include evidence on the impacts of interventions on resource use and costs in the GRADE approach. We focus on challenges with rating the confidence in effect estimates and its reporting in evidence profiles and Summary of Findings (SoF) tables.

Section snippets

Resource use and economic evaluation

Health care resources include inputs used at any point in a defined treatment management pathway (Box 1). Non-health care resources include all those inputs provided by other service sectors at any point in the treatment pathway, such as social welfare services (e.g., home adaptation, formal social care, housing) or crime and justice services. Patient and informal caregiver resources include all those inputs provided by patients, their families, or caregivers [1].

What resource use measures to

The GRADE approach

The GRADE recommends that important differences in resource use should be included along with other important outcomes in evidence profiles and SoF tables. Key steps in considering resources in making recommendations with GRADE are as follows:

  • 1.

    Identify items of resource use that may differ between alternative management strategies and that are potentially important to patients and decision makers;

  • 2.

    Find evidence for the differences in resource use between the options being compared;

  • 3.

    Rate the

Identifying potentially important resource use

The first step in identifying important resource use is to clearly state the viewpoint (perspective) from which recommendations are being made. One option is to adopt a societal perspective, that is, a broad viewpoint that includes all important health care, non-health care, and patient and informal caregiver resources, regardless of who pays for them (e.g., third-party payers, patients, families) [5]. This has the advantage of ensuring that who pays does not determine whether an item of

Making judgments regarding confidence in estimates of effect for resource use

There are more than 20 published checklists and instruments for assessing the quality of health economic analyses [17]. However, none are specifically constructed to assess the quality of a body of evidence as defined by GRADE—that is, the confidence in estimates of effect [18].

The GRADE recommends that the confidence in effect estimates for each important or critical economic outcome should be appraised explicitly using the same criteria as for health outcomes. Judgemnts about the confidence

Attaching monetary values to resource use

When a recommendation is made in a specific context, attaching appropriate monetary values to quantities of resource use can aid consistent and appropriate valuation of these outcomes by decision makers. In principle, the values should reflect opportunity costs.

So far as possible, monetary valuation of resource use should be made by applying up-to-date and locally relevant unit costs (i.e., applicable to the context of the guideline) to the measured quantity (i.e., number of units) of each item

Resource use and costs in SoF tables

Table 2 represents a SoF table for the comparison of buprenorphine and methadone for opioid maintenance treatment summarizing the effect estimates and the confidence in those estimates, including resource use and costs. The availability of the evidence profile makes all of the evidence considered for inclusion in the SoF table available to those who want it. In our example, there was little or no difference in health outcomes between buprenorphine and methadone, and buprenorphine cost more. For

Finding economic evidence

Evidence for resource use may be found in a range of research-based sources, including clinical trials, observational studies, technology appraisals, and economic evaluations. It may be published concurrently with, or separately from, reports of clinical studies. Methods for locating previously published and unpublished economic evaluations are summarized elsewhere [36]. Evidence for resource use in a specific setting may be also retrieved from national or local databases, such as drug use from

Conclusions

We described the GRADE approach to rating the quality of economic evidence and how the standard GRADE profile can capture both clinical evidence and data on the resource impact of interventions. Guidelines and recommendations have the potential to help decision makers, clinicians, and patients to improve the quality of care, ensuring the best use of limited resources. Although some guideline developers do not consider resource use and cost explicitly, resource use and costs are just other

Acknowledgments

This article is dedicated to the memory of Alessandro Liberati, a friend and colleague, who will be greatly missed.

The authors would like to thank Silvia Minozzi and Nick Clark for their help in developing the opioid maintenance treatment example and Mirella Longo for useful comments.

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    The GRADE system has been developed by the GRADE Working Group. The named authors drafted and revised this article. A complete list of contributors to this series can be found on the JCE Web site at www.jclinepi.com.

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