Being Led Down the Wrong Garden PATH: the Importance of Knowledge and Facts for the Crossroads
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Pharmacoeconomics 2007; 25 (6): 528-532 1170-7690/07/0006-0528/$44.95/0 © 2007 Adis Data Information BV. All rights reserved.
Being Led Down the Wrong Garden PATH: the Importance of Knowledge and Facts for the Crossroads The Program for Assessment of Technology in Health (PATH) welcomes the opportunity to respond to the letter by Gafni and Birch[1] on the article by Goeree and Levin[2] in which was described an innovative and comprehensive new process in Ontario that facilitates the creation of more evidence-based recommendations for the funding of new health technologies. Goeree and Levin[2] also described a complementary programme, PATH’s Reduction of Uncertainty through Field Evaluation (PRUFE) framework. The PRUFE collects additional information on safety, effectiveness, patient outcomes and costs in a ‘real world’ setting to help reduce uncertainty when the existing evidentiary base is either conflicting, of poor quality, or when there are generalisability concerns about ‘local’ effectiveness or implementation of a new technology. Those involved in decision making for large healthcare systems, such as in Ontario, are well aware of the complexities and difficulties of incorporating numerous competing issues and values into a comprehensive decision-making process. Similarly, those involved in advising for these difficult decisions are well aware that there is no panacea that will simultaneously satisfy all competing demands, that will function smoothly within an imperfect political process and that will also be consistent with an idealistic theoretical economic framework. As such, administrators, researchers and decision-making bodies who are actively involved in attempting to make these difficult choices and decisions more transparent, evidence-based, equitable and efficient will always be easy targets for criticism. Gafni and Birch have been very active in this type of criticism of various decision-making processes.[3-8] It is not surprising therefore, that they have waded in on the new decision-making process in Ontario. Constructive feedback and comments are important and are extremely helpful to improve
processes. However, the arguments provided in their commentary are based on a number of critical false allegations and assumptions. As will be shown below, not only are the assumptions underpinning their arguments fallacious, but their use of overly simplistic examples completely ignores the complexities of ‘real world’ decision making. A cornerstone of the Gafni and Birch ongoing criticism of decision-making processes is the incremental cost-effectiveness ratio (ICER), which they describe as “Information Created to Evade Reality.”[9] We argue below that using overly simplistic irrelevant examples and creating false assumptions and allegations is, ironically, Gafni and Birch’s own form of ‘ICER’. The main reason for this response is to set the record straight for those external to Ontario about the innovative and successful process developed in Ontario through the hard work and dedication of a vast network
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