Comments

Health Affairs encourages readers to engage in discussion via comments on our Web site.

• To RESPOND to a particular article: Click on the link "Submit a response to this article" in the box at the top right-hand corner of the article.
• To READ responses to a particular article: Click on the link "View responses" in the box at the top right-hand corner of the article.

Comments to:

Sean R. Tunis Reflections On Science, Judgment, And Value In Evidence-Based Decision Making: A Conversation With David Eddy Health Affairs, July/August 2007; 26(4): w500-w515. [Abstract] [Full Text] [Figures Only] [PDF] [Reprints & Permissions]

Comments:Submit a response to this article

Comments published:

Revisiting Anatomy of Decisions in Context of EBM Judgments

Richard E Ward   ( 29 June 2007 )

Revisiting Anatomy of Decisions in Context of EBM Judgments 29 June 2007
Richard E Ward, VP, Clinical Programs and Medical Informatics Blue Cross Blue Shield of Michigan Send comment to journal: Re: Revisiting Anatomy of Decisions in Context of EBM Judgments rward1{at}bcbsm.com Richard E Ward	It is confusing to conceptualize the ACC/AHA determination “that the weight of evidence is in favor of the technology” (page w504) to be a “scientific judgment” that occurs in the first box of the anatomy of a decision diagram. It is cleaner to frame explicit decision-making methods as follows: 1. Agree on the alternatives being considered. 2. Agree on the health and economic outcomes that differ across alternatives. 3. Agree on estimates of the magnitude and uncertainty of each outcome for each alternative. This can be accomplished by stating each outcome estimate as a range such that all of the decisionmakers are confident that the true value lies within the range. This step does involve scientific judgments, but it should not be stated in terms of whether or not the technology is “favored” by evidence. 4. Apply value/preference judgments regarding which alternative is favored. In this step, both the magnitude and the uncertainty of the outcomes are considered together. People intuitively apply this approach to investment decisions. When deciding to purchase a bond, they simultaneously consider the price, the expected yield, and the associated uncertainty, described in terms of “bond ratings.” They summarize the magnitude and uncertainty of outcomes by considering the “risk-return ratio.” The p < 0.05 threshold that is part of the established EBM judgment framework is analogous to deciding to buy a bond because it has a good bond rating. Likewise, “cost- effectiveness” analysis, as it has been commonly framed by CEA advocates, is analogous to buying a bond based on the return. The ideal framework must simultaneously consider the magnitude and uncertainty of outcomes.