The use of health economic evaluations in pharmaceutical priority setting - The case of Sweden

Sammanfattning: The production of health economic evaluations of pharmaceuticals is a global, multibillion dollar industry. Despite this fact, little is known about what happens after a health economic evaluation has been produced. Will it be used at all, and if so, how? Who uses economic evaluations and for what purposes? Are there differences in the use patterns between decision makers at macro, meso and micro levels? Are decision makers willing and able to use them, and to what extent can the patterns be explained by contextual factors? This dissertation aims to provide answers to these questions. The concepts "use" and "barriers to use" are developed and the influence of contextual factors, demands for transparency, internal and external institutions, and logics on the use patterns are investigated. The use and barriers to use are addressed by an empirical investigation of Swedish pharmaceutical decision makers at the Dental and Pharmaceutical Benefits Agency (TLV), a county council formulary committee and prescribing physicians. Differences in the use patterns and the barriers to use are found among the Swedish macro (TLV), meso (county council formulary committee) and micro (physicians) decision makers. The findings from the empirical research on Swedish decision makers are also contrasted with decision makers in other countries in a systematic literature review. Through triangulation of observations, interviews and analysis of documents it is suggested that the use may be defined according to the purpose of the use and consequently the phase of the priority setting process (i.e. preparation, expert comments, decision making or launch). In addition, a conceptual model of the use and barriers related to the acceptability of health economic evaluations among decision makers is suggested, integrating findings from research in health economics, priority setting and institutional theory. According to this model, barriers to use may be explained by six factors ; 1) budget restrictions, 2) decision making rules used to reduce uncertainty, 3) demand for transparency, 4) internal institutions, 5) external institutions, and 6) the existence of prevailing templates.