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Value for Money in Changing Clinical Practice: Should Decisions about Guidelines and Implementation Strategies Be Made Sequentially or Simultaneously?

Department of Health Organisation, Policy, and Economics, Maastricht University, Maastricht, the Netherlands, t.hoomans{at}beoz.unimaas.nl

Johan L. Severens, PhD

Department of Health Organisation, Policy, and Economics, Maastricht University, Maastricht, the Netherlands, Department of Clinical Epidemiology and MTA, University Hospital Maastricht, Maastricht, the Netherlands

Silvia M. A. A. Evers, PhD

Department of Health Organisation, Policy, and Economics, Maastricht University, Maastricht, the Netherlands

Andre J. H. A. Ament, PhD

Department of Health Organisation, Policy, and Economics, Maastricht University, Maastricht, the Netherlands

Decisions about clinical practice change, that is, which guidelines to adopt and how to implement them, can be made sequentially or simultaneously. Decision makers adopting a sequential approach first compare the costs and effects of alternative guidelines to select the best set of guideline recommendations for patient management and subsequently examine the implementation costs and effects to choose the best strategy to implement the selected guideline. In an integral approach, decision makers simultaneously decide about the guideline and the implementation strategy on the basis of the overall value for money in changing clinical practice. This article demonstrates that the decision to use a sequential v. an integral approach affects the need for detailed information and the complexity of the decision analytic process. More importantly, it may lead to different choices of guidelines and implementation strategies for clinical practice change. The differences in decision making and decision analysis between the alternative approaches are comprehensively illustrated using 2 hypothetical examples. We argue that, in most cases, an integral approach to deciding about change in clinical practice is preferred, as this provides more efficient use of scarce health-care resources.

Key Words: clinical practice change • guideline implementation • clinical guidelines • implementation strategies • economic evaluation • health-care decision making • health-care decision analysis. (Med Decis Making 2009;29:207—216)

This version was published on March 1, 2009

Medical Decision Making, Vol. 29, No. 2, 207-216 (2009)
DOI: 10.1177/0272989X08327397


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