The art and science of incorporating cost effectiveness into evidence-based recommendations for clinical preventive services

As medical technology continues to expand and the cost of using all effecti ve clinical services exceeds available resources, decisions about health ca re delivery may increasingly rely on assessing the cost-effectiveness of me dical services. Cost-effectiveness is particularly relevant for decisions a bout how to implement preventive services, because these decisions typicall y represent major investments in the future health of large populations. As such, decisions regarding the implementation of preventive services freque ntly involve, implicitly if not explicitly, consideration of costs. Cost-ef fectiveness analysis summarizes the expected benefits, harms, and costs of alternative strategies to improve health and has become an important tool f or explicitly incorporating economic considerations into clinical decision making. Acknowledging the usefulness of this tool, the third U.S. Preventiv e Services Task Force (USPSTF) has initiated a process for systematically r eviewing cost-effectiveness analyses as an aid in making recommendations ab out clinical preventive services. In this paper, we provide an overview and examples of roles for using cost-effectiveness analyses to inform preventi ve services recommendations, discuss limitations of cost-effectiveness data in shaping evidence-based preventive health care policies, outline the USP STF approach to using cost-effectiveness analyses, and discuss the methods the USPSTF is developing to assess the quality and results of cost-effectiv eness studies. While this paper focuses on clinical preventive sen;ices (i, e., screening, counseling, immunizations, and chemoprevention), the framewo rk we have developed should be broadly portable to other health care servic es.