The hierarchy of evidence

As in clinical evaluation, an important consideration for the review, assessment, and interpretation of economic evidence is research design. For example, is the study a prospective controlled trial or a retrospective study with no control group? Two further features can be added to this for economic studies, namely the type of economic evaluation, and the scope or perspective of the study. The merit of an economic study in terms of coverage and generalizability is determined to a significant extent by these three parameters (Table,?).

Table 2 Economic evaluation—the hierarchy of evidence

Viewed as an interconnected hierarchy of evidence, the ideal type of study upon which to base decisions on cost-effectiveness and resource allocation is one conducted prospectively with two (or more) appropriately sized randomly allocated groups of patients, for whom all conceivable costs and outcomes are measured in a common currency. Such a study has yet to be completed in mental health care, largely because of the demanding requirement to convert all costs and consequences into monetary units. Most studies to date have in fact been cost-effectiveness or cost-consequences analyses, based on a range of clinical data sets and employing the cost perspective of the formal service sectors only.

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