Nonsense on Stilts


It is unusual for a discipline if that is the right word, to survive and thrive for over 30 years where the principal product is a framework for creating imaginary value claims for pharmaceutical products. Yet this is the situation that health technology has been promoted, and continues to promote, through professional associations such as the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) with organizations such as the Institute for Clinical and Economic Review. (ICER) and the National Pharmaceutical Council (NPC). The latest gem is the publication of the Consolidated Health Economic Evaluation Reporting Standards 2022, otherwise known as CHEERS 22, although from the perspective of the standards of normal science there is little to cheer about.

The persistence of what we call the approximate information meme (not paradigm) is not surprising. For 30 years academic institutions and their support in government and professional associations have drilled into generations of graduate students in pharmacy and healthy economics the role of modeling to meet evidence gaps at product launch. This is achieved by rejecting the tiresome and more difficult task of setting the stage for ongoing disease area and therapeutic class reviews through hypothesis testing and the discovery of new facts, replacing it by the simpler process of creating assumption driven simulation models to invent blanket claims for comparative cost-effectiveness. The underlying belief is that formulary committees are willing to accept invented claims for new products as key inputs to formulary decisions. The fact that these claims are divorced from the real world and, as tautologies, lack any substance, is not apparently an issue.

The outcome is that practitioners in health technology assessment have a unique claim: the only discipline in the physical sciences and mature social science that rejects the notion of progress in the discovery of new, yet provisional facts in favor of inventing claims which are designed deliberately to fail any possibility of empirical evaluation.

The CHEER 22 contribution, setting standards for presenting imaginary modeled cost-effectiveness claims to journals, is the epitome of this failure; a failure that is recognized but ignored. After all, with 30 years of proselytizing to a global audience, it is extremely difficult for leaders in the field to walk them back from the edge of the abyss.


Langley PC. ICER, ISPOR, and QALYs: A Tale of Imaginary Worlds, Inov Pharm. 2019:10(4): No. 10

Langley P. Nonsense on Stilts – Part 1: The ICER 2020-2023 value assessment framework for constructing imaginary worlds. Inov Pharm. 2020;11(1):No. 12

Langley P. Let a Thousand Models Bloom: ICER Analytics Opens the Floodgates to Cloud Pseudoscience. Inov Pharm. 2021;12(1):No. 5

Langley P. Peter Rabbit is a Badger in Disguise: Deconstructing the Belief System of the Institute for Clinical and Economic Review in Health Technology Assessment. InovPharm. 2021; 12(2): No. 20

Langley P. Supping with the Devil: Belief and the Imaginary World of Multiple Myeloma Therapies Invented by the Institute for Clinical and Economic Review. Inov Pharm. 2021; 12(3): No. 6