Economic and resource use–related guidance was often mentioned somewhere in US clinical practice guideline documents but was much less commonly incorporated into individual recommendations, according to a cross-sectional study published in JAMA Network Open.
The findings come amid increasing emphasis on value-based care as US health care spending continues to rise. The study authors noted that value-based care compels health care organizations and clinicians to weigh economic data and resource use against anticipated health benefits when providing diagnostic and therapeutic services, and that patients facing rising out-of-pocket costs increasingly expect their clinicians to practice value-based care.
Researchers evaluated 309 clinical practice guideline documents containing 7,582 recommendations issued by 23 large US-based medical societies from 2019 to 2023. The guidelines were identified through the ECRI Guidelines Trust. Researchers also reviewed each society’s most recently available guideline development methods manual to determine whether economic or resource use–related evidence was addressed during recommendation development.
The study assessed whether each recommendation included economic or resource use–related guidance in either the upfront recommendation statement or the accompanying narrative discussion of supporting evidence. Upfront statements were considered a more visible and potentially actionable form of guidance and were counted as also having narrative discussion.
Researchers used a broad set of economic and resource use–related search terms, including terms such as cost, price, financial, resource, value, and economic. They manually confirmed that the terms reflected economic or resource use–related considerations and excluded mentions that appeared only in general sections of guideline documents. The researchers noted that the composite measure was intentionally broad and that a more conservative approach would likely identify a lower proportion of recommendations containing economic or resource use–related guidance.
Among the 23 medical societies, 14 explicitly suggested that economic or resource use–related evidence should be considered during guideline development, 6 ambiguously addressed the issue, and 3 did not address it.
Across all 7,582 recommendations, 1,706, or 22.5%, included a narrative discussion of economic or resource use–related evidence. Only 287 recommendations, or 3.8%, included an upfront economic or resource use–related statement within the recommendation itself.
At the guideline-document level, 236 of 309 clinical practice guideline documents, or 76%, included at least 1 recommendation with a narrative discussion of economic or resource use–related evidence. However, only 71 documents, or 23%, included at least 1 recommendation with an upfront economic or resource use–related statement.
In adjusted analyses, recommendations issued by societies that explicitly suggested considering economic or resource use–related evidence had more than 6 times the odds of including a narrative discussion of those considerations compared with recommendations from societies whose methods manuals did not address the topic. However, explicit society-level guidance was not independently associated with inclusion of an upfront economic or resource use–related statement.
Recommendations from primary care societies had nearly 13 times the odds of including upfront economic or resource use–related statements compared with recommendations from specialty societies. The researchers noted that all 3 primary care societies in the analysis explicitly suggested considering economic or resource use–related evidence, but primary care societies accounted for only 286 of the 7,582 recommendations.
Multisociety consensus recommendations were less likely than single-society recommendations to include either narrative economic or resource use–related discussion or upfront economic or resource use–related statements. Treatment-related recommendations were also more likely than diagnostic recommendations to include upfront statements in the primary adjusted analysis, although this association was no longer observed in a sensitivity analysis excluding multisociety recommendations.
The researchers also described signs of increased attention to economic and resource use–related evidence in guideline development over time. They noted that a prior 2013 analysis found that 3 US-based medical societies excluded economic or resource use–related considerations when developing clinical practice guidelines and 6 did not address them. In the current analysis, no societies excluded such evidence, and only 3 did not address how it should be considered. The researchers also noted that 76% of guideline documents in the current study contained at least 1 economic or resource use–related narrative discussion, compared with about 26% in a 2002 investigation.
The researchers cited several possible reasons economic evidence may be difficult to incorporate into guideline recommendations, including limited availability of high-quality health economic evidence, changing costs over time, variation in health care financing systems, and lack of consensus about whether economic considerations should be assessed from the perspective of patients, payors, governments, health care organizations, or society.
The study had several limitations. Economic and resource use–related guidance was assessed using a broad composite measure based on the presence of selected terms, and the researchers did not evaluate the quality, interpretability, or clinical usefulness of the identified guidance. About 45% of guideline documents underwent independent double extraction, with 91.5% agreement across extracted data elements; the remaining documents were extracted by a single reviewer using the consensus approach. The sample was limited to guidelines included in the ECRI Guidelines Trust and may not represent all guidelines produced by the included societies or by other US-based medical societies. In addition, 3 societies that published more than 25 guideline documents during the study period were represented by random samples rather than by all eligible documents.
The findings suggest that although many large US-based medical societies now address economic and resource use–related evidence in guideline development methods, those considerations remain infrequently incorporated into individual recommendation statements.
“Higher quality health economic evidence and societies’ more explicit consideration of such evidence may allow CPGs to better inform value-based care,” wrote lead study author Anand R. Habib, MD, of the University of California, San Francisco, and colleagues.
Disclosures: Dr. Ramachandran reported receiving grants, personal fees, and serving in an unpaid board position outside the submitted work. Dr. Ross reported receiving grants outside the submitted work. No other disclosures were reported. Dr. Habib was supported by the Yale National Clinician Scholars Program and a Clinical and Translational Science Awards Program grant from the National Center for Advancing Translational Science. The funders had no role in the study design, data collection, analysis, interpretation, manuscript preparation, or publication decision.
Source: JAMA Network Open