Research: increasing value, reducing waste The new venture from the evidencebased medicine movement promises to clean up the waste in biomedical research. The Lancet Series entitled Research: increasing value, reducing waste had such a promising title;1,2 what’s not to like? The authors claim that 85% of the investment in biomedical research is wasted because of inadequate production and reporting of research and that this accounts for its failure to deliver more clinical benefits. The group of authors is composed mostly of experts in qualitative research, concerned with reporting systematic reviews of previous work and so with study design and reporting methods that facilitate this. There will always be unanimity that reducing waste is good. Deciding what is wasteful in science might be more difficult. The middle period of the 20th century was one of remarkable medical progress when design and reporting methods would have been less regulated than now. The decrease in clinical discovery during the past three decades might have had more to do with the reconfiguration of clinical practice and clinical science, which occurred during that period. Ironically, these changes were also argued for by the group’s much-heralded icon, Archie Cochrane, who claimed that research done in the health service made no contribution to medical advances, was wasteful, and should be replaced by applied or qualitative research.3 The Lancet Series on research is emblematic of these changes: the views of a group largely composed of qualitative researchers cannot reflect those of the wider biomedical community. Consequently, its understanding of the purposes of different forms of research and the distinction between qualitative research and investigative science might be limited. The Series might have benefited from a stronger www.thelancet.com Vol 383 March 29, 2014
representation of clinicians and investigative scientists. But perhaps clinicians today might be more concerned with campaigns against the failures in public health that threaten to overwhelm their health service and the epidemics of obesity and misuse of tobacco and alcohol. I declare that I have no competing interests.
Desmond John Sheridan [email protected] Imperial College London, Faculty of Medicine, London W2 1NY, UK 1
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Macleod MR, Michie S, Roberts I, et al. Biomedical research: increasing value, reducing waste. Lancet 2014; 383: 101–04. Glasziou P, Altman DG, Bossuyt P, et al. Reducing waste from incomplete or unusable reports of biomedical research. Lancet 2014; 383: 267–76. Cochrane AL. Effectiveness and efficiency: random reflections on health services, 2nd edn. London: Nuffield Provincial Trust, 1972: 12, 44, 81, 83.
I read with interest the recent Lancet Series on research. The Series papers are of great interest and I hope they will be very influential, but there is a gap in the Series—namely, any contribution of economics to this fundamentally economic issue. The Series broadly considers the issue of technical efficiency—ie, either minimising the cost to obtain a given outcome, for example through avoidance of waste while undertaking a trial,1 or maximising the value of the research subject to the funds available by ensuring completeness of reporting both of trial results and associated protocols.2 Issues outside the control of individual researchers that might increase technical efficiency (such as appropriate regulation) are also considered in the Series. Iain Chalmers and colleagues 3 cover the issue of how to decide which research questions need answering, suggesting a number of approaches, particularly involving input from patients. Burden of disease is mentioned as an alternative. In addition to the limitations raised by the authors, this method has been criticised in the economics literature because
of its focus on the size of a problem, rather than ability to do anything about it or degree of uncertainty around treatment decisions.4 However, one important area omitted in the Series is the step between deciding which research questions need answering and how to do that research efficiently. This issue is that of allocative efficiency—ie, because we cannot fund all research that is worthwhile, which would provide the best return on investment for society as a whole? Methods exist to predict the expected value (in terms of health gain) of a particular research project. When this gain is compared with the cost, a set of projects can be selected that maximises expected health gain subject to the budget.5 Economics has various methods available that can assist with the decisions faced by research funding panels (and others interested in how public money is spent). While such technical solutions cannot—and should not—replace careful discussion within funding panels, they can provide a rational framework and starting point to help allocate scarce research funds to the greatest benefit of society. Drawing on economic theories and methods in future discussions could well help to shed light on possible approaches to assist clinicians, managers, patients, and others with these difficult decisions.
Phil Fisk/Science Photo Library
Correspondence
For the Lancet Series Research:
increasing value, reducing waste see http://www.thelancet. com/series/research
I declare that I have no competing interests.
Edward Wilson [email protected] Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, CB2 0SR, UK 1
2
3
4
Ioannidis JPA, Greenland S, Hlatky MA, et al. Increasing value and reducing waste in research design, conduct, and analysis. Lancet 2014; 383: 166–75. Glasziou P, Altman DG, Bossuyt P, et al. Reducing waste from incomplete or unusable reports of biomedical research. Lancet 2014; 383: 267–76. Chalmers I, Bracken MB, Djulbegovic B, et al. How to increase value and reduce waste when research priorities are set. Lancet 2014; 383: 156–65. Fleurence RL, Torgerson DJ. Setting priorities for research. Health Policy 2004; 69: 1–10.
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
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representation of clinicians and investigative scientists. But perhaps clinicians today might be more concerned with campaigns against the failures in public health that threaten to overwhelm their health service and the epidemics of obesity and misuse of tobacco and alcohol. I declare that I have no competing interests.
Desmond John Sheridan [email protected] Imperial College London, Faculty of Medicine, London W2 1NY, UK 1
2
3
Macleod MR, Michie S, Roberts I, et al. Biomedical research: increasing value, reducing waste. Lancet 2014; 383: 101–04. Glasziou P, Altman DG, Bossuyt P, et al. Reducing waste from incomplete or unusable reports of biomedical research. Lancet 2014; 383: 267–76. Cochrane AL. Effectiveness and efficiency: random reflections on health services, 2nd edn. London: Nuffield Provincial Trust, 1972: 12, 44, 81, 83.
I read with interest the recent Lancet Series on research. The Series papers are of great interest and I hope they will be very influential, but there is a gap in the Series—namely, any contribution of economics to this fundamentally economic issue. The Series broadly considers the issue of technical efficiency—ie, either minimising the cost to obtain a given outcome, for example through avoidance of waste while undertaking a trial,1 or maximising the value of the research subject to the funds available by ensuring completeness of reporting both of trial results and associated protocols.2 Issues outside the control of individual researchers that might increase technical efficiency (such as appropriate regulation) are also considered in the Series. Iain Chalmers and colleagues 3 cover the issue of how to decide which research questions need answering, suggesting a number of approaches, particularly involving input from patients. Burden of disease is mentioned as an alternative. In addition to the limitations raised by the authors, this method has been criticised in the economics literature because
of its focus on the size of a problem, rather than ability to do anything about it or degree of uncertainty around treatment decisions.4 However, one important area omitted in the Series is the step between deciding which research questions need answering and how to do that research efficiently. This issue is that of allocative efficiency—ie, because we cannot fund all research that is worthwhile, which would provide the best return on investment for society as a whole? Methods exist to predict the expected value (in terms of health gain) of a particular research project. When this gain is compared with the cost, a set of projects can be selected that maximises expected health gain subject to the budget.5 Economics has various methods available that can assist with the decisions faced by research funding panels (and others interested in how public money is spent). While such technical solutions cannot—and should not—replace careful discussion within funding panels, they can provide a rational framework and starting point to help allocate scarce research funds to the greatest benefit of society. Drawing on economic theories and methods in future discussions could well help to shed light on possible approaches to assist clinicians, managers, patients, and others with these difficult decisions.
Phil Fisk/Science Photo Library
Correspondence
For the Lancet Series Research:
increasing value, reducing waste see http://www.thelancet. com/series/research
I declare that I have no competing interests.
Edward Wilson [email protected] Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, CB2 0SR, UK 1
2
3
4
Ioannidis JPA, Greenland S, Hlatky MA, et al. Increasing value and reducing waste in research design, conduct, and analysis. Lancet 2014; 383: 166–75. Glasziou P, Altman DG, Bossuyt P, et al. Reducing waste from incomplete or unusable reports of biomedical research. Lancet 2014; 383: 267–76. Chalmers I, Bracken MB, Djulbegovic B, et al. How to increase value and reduce waste when research priorities are set. Lancet 2014; 383: 156–65. Fleurence RL, Torgerson DJ. Setting priorities for research. Health Policy 2004; 69: 1–10.
Submissions should be made via our electronic submission system at http://ees.elsevier.com/ thelancet/
1123
