Objectives
To describe recent federal sponsorship of cost-effectiveness and related health economics research to provide insight into the functioning of existing research support systems and assess the roles of federal health agencies.
Methods
Using the PubMed database, we identified cost-effectiveness and related publications citing support from a US government entity and published during the period of 1997 through 2001, and audited them for information on funding sources, study type, and content focus.
Results
Five Department of Health and Human Services agencies and centers and the Veterans Administration are cited as funders in 74% of 520 federally supported health economics publications we identified. Three-fourths of federally supported publications address five areas of high disease burden: infections, cancer, HIV/AIDS, cardiovascular disease, and substance abuse. Other high burden diseases, including mental health, diabetes, and injuries, receive less attention. Federal support of health economics studies of health education and care delivery—intervention types underexamined in the field—is relatively strong but most often focuses on substance abuse or mental health services. Each of the top federal funders has a distinct funding pattern, but there are substantial areas of overlap within which we could not identify content domains specific to one funder or another.
Conclusions
Federal support of health economics research has paralleled growth in the field. Federal funders support projects consistent with their mission and focus on high-burden disease areas. However, overlapping funding areas, ambiguity concerning agency interests within overlapping content areas, and gaps in some disease and intervention areas suggest that the coordination of health economics research funding could be improved.
During the past several years, the costs of health
care and particularly of prescription drugs have
once again begun to rise at an increasing rate. At
the same time, consumers’ concern for the quality of
health care has never been greater, reflecting both
increased access to information about health care
and a growing awareness of the multiple consequences
of medical interventions. The combination
of these factors has spurred purchasers’ interest in
assessing the value of clinical and public health
interventions—in assuring that their health-care
investments return a measurable, positive, and
valuable health outcome.
In an effort to address these concerns, health
services researchers in academia, the pharmaceutical
industry, consulting firms, and in government
have produced a growing number of cost-effectiveness,
cost–benefit, and related analyses quantifying
the cost per unit of outcome of health policies
and clinical interventions. These studies are often
referred to as health economics studies. (The term
health economics is used in two ways in the literature:
to refer to studies of consumer, firm and market
behaviors applying economic theory to examine
health care, and to describe the field of economic
evaluation examining costs and outcomes of interventions
to inform resource allocation decisions.
We use the term to refer to the latter field of study.)
Health economics studies of health-care services are
intended to address specific questions regarding the
value of newly developed and existing interventions
and to provide summary information linking health
outcomes and economic impact for use in clinical
and policy decisions. Between 1979 and 1984, an
average of 113 cost-effectiveness analyses (CEAs)
and cost–benefit analyses (CBA) were published
each year [1]. A decade later, these studies werebeing published about three times that rate [2], with
growth occurring across medical modalities and in
the United States, as well as internationally.
Although its role in using and promoting health
economic considerations in health-care decision
making has been fraught with controversy [3], the
federal government has been a significant funder
of health economics studies for nearly two decades.
Although health economics is often listed among
agency research interests, most federal efforts in
this area have been opportunistic. Funders, by and
large, have offered only general guidance as to
their interests and priorities for applied health economics
research or methods. With few exceptions,
health economics studies have been supported
within research portfolios addressing broad substantive
areas. This has led to some confusion
among health-care researchers about agency interests
and about where to seek funding for a given
study. It is also unclear whether federal funders
are addressing important topics and supporting a
coherent and cohesive base of health economics
information.
This report reviews the recent federal sponsorship
of health economics research focusing on
health-care services to provide insight into the functioning
of the research support systems that are currently
in place. We examine whether the output of
federally sponsored studies is keeping pace with the
increased level of interest in health economics, the
substantive focus of this research, and the specific
roles of the federal agencies.
Recent growth in the field of health economics is
reflected in an increasing number of health economics
publications supported by the federal government.
Dozens of agencies and institutes throughout
the federal government contribute to health economics
research. The most frequently cited supporters
of this research, however, are several agencies
and institutes within the DHHS and the VA.
A central concern in reviewing federally funded
health economics research is the appropriateness of
the level of emphasis that funders place on various
disease areas. We found that recent federally
funded health economics research has focused on
infections, cancer, HIV/AIDS, cardiovascular disease,
and substance abuse. These are all important
topics based on at least one measure of disease burden
or health research priority. Cancer, heart disease,
and substance abuse are three of the leading
causes of death, years of potential life lost, and
economic burden on the US population. Infectious
diseases and HIV/AIDS are important but lowerranking
priorities based on measures of disease burden.
The notable attention devoted to these two
areas may be justified based on considerations such
as the relative recentness of HIV/AIDS and measures
to combat it, or in the case of infectious
diseases, factors such as an implicit requirement
to provide evidence of cost-effectiveness for population-
based preventive services or the strong
traditional role of government in combating communicable
diseases.
What is more questionable is the relative lack
of attention given to health economics analyses in
other important disease areas. In 5 years, federal
entities were cited as funders of only 13 studies each
in the areas of diabetes and injuries. In mental
health, an area ranking high in terms of disease and
economic burden, the number of publications is considerably
higher—28—but still much lower than the
numbers of studies focusing on other high-burden
disease areas. Similarly, arthritis, COPD, asthma,
and dementia all rank high in terms of disease burden
but are the subject of few health economics studies.
It is possible that there are fewer studies in these
areas for valid reasons—e.g., because of an underlying
shortage of data on the effectiveness of interventions
or because cost-effectiveness is not relevant
to decisions in these areas—but the unevenness in
research productivity is cause, at least, for proactive
federal scrutiny of research in these areas. Finally,
we could not identify a funder that emphasized studies
that cut across traditional disease areas.
In assessing the health economics research examining
different types of interventions, previous studies
have found a strong emphasis on studies of
pharmaceuticals and surgical interventions and significantly
less on health education and care delivery
[2,9]. The latter areas may be “softer” and more
difficult to evaluate in both clinical and health economics
studies, but they are highly relevant to
needed change in the current health and health-care
environment. Further, given the intense public focus
on costs and quality of health care, it seems logical
that the assessment of health-care delivery strategies
should be a priority for health services research,
including economic analysis.
Federally supported health economics studies do,
in fact, appear to emphasize different areas than
found in previous reviews. Publications addressing
pharmaceuticals are the most numerous interventions
in the articles we examined, but they represent
a noticeably lower proportion than Elixhauser et al.
[2] found in their study of CEA/CBA studies or than
Chapman et al. [9] found in their review of CUAs, a
finding consistent with the increasing role of pharmaceutical
company sponsorship of CEAs [2]. The
federally supported portfolio also included a much
lower proportion of articles considering surgical
interventions. At the same time, articles considering
health education and behavioral interventions represent
a greater proportion of the federal portfolio
than in these two studies. Studies of health-care
delivery are not identified in Elixhauser et al. [2],
but they represent a greater proportion of the federal
portfolio than found in the CUA database.
