Improving Quality and Efficiency in Health Care through Comparative Effectiveness Analyses: An International Perspective

The combination of rising health care costs, efforts to achieve universal or near-universal coverage globally, and growing drive for better outcomes brings an urgent demand to spend health care funds efficiently and in accordance with each country's priorities. A response to such demand requires, first, an understanding of what technologies and interventions (drugs, devices, procedures, diagnostics, and health care services) increase the quality and value of health care and, second, knowledge of the policy levers that encourage health care systems to adopt appropriate technologies. Comparative Effectiveness Research (CER) and Health Technology Assessment (HTA) are important tools used in different ways by countries to achieve these goals. CER is primary research that compares the effectiveness of alternative interventions, with the intent of determining whether one technology or service works better than another for a given population or group of patients. In the United States, CER studies have been publicly funded for a number of years; 1 however, public investment significantly expanded beginning in 2009. In contrast, the publicly financed comparative effectiveness entities in most other high income countries are focused on HTA, which typically involves coupling the synthesis of existing evidence on clinical comparative effectiveness with an assessment of the cost-effectiveness. This paper provides an overview of HTA activities in Europe, Canada, and Australia and examines the new public investments in CER in the United States. It also seeks to place the new United States federal investments in evidence generation in the context of the rather different investments that are predominantly focused on HTA in other industrialized countries. Overview of CER and HTA Activities in the United States and Other Countries Figure 1 illustrates a simplified pathway from CER to medical practice to demonstrate the relationship between CER and HTA activities. CER can provide evidence to inform patients' medical decisions and clinicians' recommendations to their patients, but CER also may feed into HTA and then into health plan coverage decisions, which shape care delivery and clinical decisions. In high-income countries other than the United States, most comparative effectiveness analysis activities focus on HTA, the second step in Figure 1 and are conducted by government agencies. In essence, HTA programs in Europe, Canada, and Australia, among others, assess the comparative clinical effectiveness of technologies while asking if a particular technology is worth its cost to that country's national health system. Clinical practice guidelines for incorporating the results of these analyses are often …