Should Cost of Care be Considered in a Clinical Practice Guideline?
Bibliographic record
Abstract
The global increase in cancer has fueled a large investment into research for more effective treatment strategies.The payoff from this investment has been a knowledge explosion that is overwhelming to the average oncologist.In response, a knowledge-synthesis industry has developed that uses the tools of systematic searches and standardized analytic processes to make sense of the large volume of frequently contradictory literature.Experts review the evidence and provide interpretation in the context of their professional values to guide their colleagues in clinical practice.Typically, guideline developers focus on questions of clinical effectiveness and efficacy, but rarely, if ever, consider the budgetary impacts of implementing the guideline or the cost-effectiveness of a new treatment.This issue of JNCCN focuses on guidelines for small cell and non-small cell lung cancer produced by the NCCN; neither of these guidelines mentions cost.In this commentary, we look at guideline development processes in general and specifically in Ontario, Canada, to consider the question: Is this an important omission or an irrelevancy?For more than a decade, a multidisciplinary Lung Disease Site Group (LDSG) in the province of Ontario, Canada, has developed practice guidelines through Cancer Care Ontario's Program in Evidence-Based Care (PEBC), based at McMaster University.The LDSG has produced 25 clinical practice guidelines (CPGs), including 12 for non-small cell lung cancer and 4 for small cell lung cancer.Guidelines were also developed for each of the 8 new chemotherapeutic agents introduced since 1995 for the treatment of lung cancer, the radiotherapeutic management of lung cancer (10 guidelines), and the management of less common intrathoracic tumours (mesothelioma, thymoma).Guideline development has followed the practice guideline development cycle described by Browman et al. 1 Guideline development begins with a systematic review of the Englishlanguage literature with a focus on randomized clinical trials.The PEBC search strategy purposefully does not include a search for articles on cost or cost-effectiveness.Although a consideration of the cost-effectiveness of new interventions is not part of the formal process of guideline development, members of the LDSG sometimes raise concerns that expensive drugs may not be funded through the provincial drug funding mechanism.The draft guideline goes through a structured process of external review whereby clinicians involved in providing care to patients with lung cancer ensure that no relevant data were overlooked, provide comment on the level of support for the recommendations, and assist in knowledge transfer.2,3 This process asks practitioners to consider barriers to guideline implementation, and cost of the intervention is often a reported concern.The final guideline is submitted as a manuscript for publication and posted on Cancer Care Ontario's Web site (www.cancercare.on.ca).The original intent of the CPGs was to develop a convenient source of highquality information to guide clinicians providing care to patients.However, soon after the program was established, the guidelines became the key clinical data summary for those involved in making funding decisions about new anticancer drugs 224
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.028 | 0.191 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.003 | 0.003 |
| Bibliometrics | 0.003 | 0.003 |
| Science and technology studies | 0.003 | 0.002 |
| Scholarly communication | 0.006 | 0.007 |
| Open science | 0.004 | 0.002 |
| Research integrity | 0.023 | 0.019 |
| Insufficient payload (model declined to judge) | 0.004 | 0.002 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".