Challenges in synthesising cost-effectiveness estimates
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COMMENTARY
Open Access
Challenges in synthesising costeffectiveness estimates Gemma E. Shields1*
and Jamie Elvidge2
Abstract Economic evaluations help decision-makers faced with tough decisions on how to allocate resources. Systematic reviews of economic evaluations are useful as they allow readers to assess whether interventions have been demonstrated to be cost effective, the uncertainty in the evidence base, and key limitations or gaps in the evidence base. The synthesis of systematic reviews of economic evaluations commonly takes a narrative approach whereas a meta-analysis is common step for reviews of clinical evidence (e.g. effectiveness or adverse event outcomes). As they are common objectives in other reviews, readers may query why a synthesis has not been attempted for economic outcomes. However, a meta-analysis of incremental cost-effectiveness ratios, costs, or health benefits (including quality-adjusted life years) is fraught with issues largely due to heterogeneity across study designs and methods and further practical challenges. Therefore, meta-analysis is rarely feasible or robust. This commentary outlines these issues, supported by examples from the literature, to support researchers and reviewers considering systematic review of economic evidence. Keywords: Meta-analysis, Systematic review, Cost-effectiveness analysis, Economic evaluation
Background Cost-effectiveness analysis evaluates and compares the expected costs and health benefits of two or more healthcare interventions and supports decision-makers in assessing value for money. With growing and ageing populations, and an ever-expanding range of healthcare interventions, decision-makers face growing pressure to effectively distribute scarce resources. Systematic reviews of economic evaluations allow readers to consider whether healthcare interventions have been demonstrated to be cost effective, uncertainty in the evidence base and key limitations of the evidence. The synthesis of economic evaluations in a systematic review most commonly takes a narrative approach, and subsequently, a query from non-health economists may * Correspondence: [email protected] 1 Manchester Centre for Health Economics, Division of Population Health, Health Services Research, and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester M13 9PY, UK Full list of author information is available at the end of the article
be why a meta-analysis has not been considered or conducted, as this is the norm in systematic reviews with clinical outcomes. Version 5.1 of the Cochrane handbook for Systematic Reviews of Interventions discussed that there are no agreed methods for pooling estimates of cost effectiveness, but did not expand on the issues [1]. The most recent version of the handbook (version 6.0) does not discuss meta-analysis in the context of economic evidence [2]. A review found that out of 202 systematic reviews of health economic evaluations, only 3 used quantitative synthesis [3].
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