AHRQ series commentary 3: the United States addresses comparative effectiveness but not cost-effectiveness through the effective health-care program.

In this issue of the journal, authors from the Effective Health-Care Program of the Agency for Healthcare Research & Quality (AHRQ) outline their approach for appraising research evidence and providing ‘‘. understandable and actionable information for patients, clinicians, and policy makers’’ [1]. The methods outlined are not controversial, and it is clear that the program of work is of a high standard. However, in matters of health technology appraisal, the devil is often in the detail or at least in the implementation, and it is interesting to observe controversy emerging when vested interests are challenged. Slutsky et al. [1] argue that ‘‘providing quality evidence that can be easily understood and used in decision making by patients, clinicians, and policy makers is essential to judicial and rational decision making.’’ It is a common belief that the reason we do not always do the rational thing is that we are poorly informed. But, does international experience support the concept that better evidence will lead to better decisions? We argue that the evidence provided by the Effective Health-Care Program is a necessary, but not sufficient, requirement for improved health care resource allocation. In 1992, the Pharmaceutical Benefits Scheme (PBS) in Australia introduced a fourth hurdle in pharmaceutical reimbursement, where, in addition to the conventional regulatory criteria (focusing on efficacy, safety, and quality of manufacture), only drugs considered clinical and costeffective were to be reimbursed by the state [2]. This scheme was considered by some to be a major advance [3] and was followed in several other jurisdictions with