Policy Rounds: A New Series and a Call for Papers

Abstract

In this issue of Medical Decision Making, David H. Howard, PhD, Associate Professor in the Department of Health Policy and Management at Emory University, and his colleagues describe a costeffectiveness analysis of expanding the size of the national cord blood bank. The analysis was commissioned for the Institute of Medicine’s Committee on Establishing a National Cord Blood Stem Cell Bank Program. To assist the Institute of Medicine (IOM) committee in identifying the optimal inventory level, the authors developed a model of the cord blood inventory level to estimate total costs as a function of the number of stored units. They found that the cost per life year gained associated with increasing inventory from 50,000 to 100,000 units is $44,000 to $86,000 and from 100,000 to 150,000 units is $64,000 to $153,000, depending on the assumption about the degree to which survival rates for cord transplants vary by match quality. They also concluded that increasing the inventory to greater than 150,000 units was not a good use of health care resources. The analysis was published in full by the IOM. In this issue of Medical Decision Making, the authors summarize the main findings, describe working with the Institute of Medicine committee’s members, and assess the impact of their model on the committee’s recommendations to Congress. The analysis appears to have influenced the committee’s recommendations to Congress that, ‘‘On the basis of preliminary analyses of all existing outcome data and an economic analysis of the costs and benefits of various inventory sizes, the committee made preliminary estimates of an efficient inventory size. The committee estimates that at least an additional 100,000 new, high-quality cord blood units are needed in the national inventory.’’ As Howard and his colleagues point out in their article, the impact on the legislation that Congress eventually passed—The Stem Cell Therapeutic and Research Act of 2005—is less clear. We are inviting other analysts whose work has had an impact on decision makers to submit articles for future installments of ‘‘Policy Rounds.’’ Two of Dr. Howard’s coauthors served on the IOM committee. Future ‘‘Policy Rounds’’ may feature this kind of collaboration, but we are also interested in considering paired articles, one by the analysts describing their work, the other from the perspective of a member of the policy-making group that used the work. A happy ending is not required: there is as much if not more to be learned from frustrated attempts at collaboration between researchers and policy makers. Why? Working on real-life problems with real decision makers is a great stimulus to innovation and refinement of modeling methods. Many of the best processes for making recommendations for coverage decisions, benefit design, and practice guidelines invite interested parties to critique the policy-making group’s decisions and the evidence the decisions were based on. Sometimes this public critique raises concerns about the structure of a model or its assumptions and analysis that influence decision makers. A robust process involving researchers, policy makers, and stakeholders exposes flaws in methods, uncertainties in data, and, sometimes, dogma that cannot survive the high standards that characterize the best policy-making environments. Although stressful, such scrutiny beats the alternative of being published, archived, and forgotten. Remember that it is the demand for explicit, fair, and defensible methods for making coverage decisions and other policies that opens the door to cost-effectiveness analysis (CEA) and other types of modeling in the first place. Working with suspicious policy makers or stakeholders creates opportunities for improving methods, especially when it exposes ways in which our methods fall short of our own standards for transparency and fairness. The record of economists and modelers involved in the United Kingdom’s National Institute for Health and Clinical Excellence illustrates how Note: Dr. Helfand is the Editor of Medical Decision Making. Dr. Sanders is the President of the Society for Medical Decision Making.