Economic evaluation to inform health care decision-making: promise, pitfalls and a proposal for an alternative path

Health economic evaluation aims at providing information on the efficiency of interventions. Since the 1980s, there have been major developments in the field, especially in terms of methodologies. As the field has expanded and developed, methodologies have become increasingly sophisticated. In parallel, over the past decade, the conduct of economic evaluations has become more and more institutionalized with, among other things, the creation of the National Institute for Health and Clinical Excellence (NICE) in England and Wales and a growing number of health technology assessment (HTA) agencies around the world. Yet the literature has identified important barriers to the use of economic evaluation in decision-making, among them the difficulty of deciphering economic evaluation research. The way the field expanded has thus created a paradox: whereas economic evaluation is seen as an insightful tool for achieving efficiency in health care, its methodological developments have decreased decision-makers' capacity to use it. In this paper, based on a literature survey, we explore this shift by first analyzing how the field of economic evaluation has developed in recent years. Second, we discuss how economic evaluation information is perceived and used in decision-making. Third, we consider a possible direction for reconciling economic evaluation and decision-making. The originality of this article is that it not only highlights the increasing gap between the aim of economic evaluation and its effective use in decision-making but also proposes, based on existing methodologies, a competing approach to the currently dominant paradigm.