Uncertainty and Coverage With Evidence Development: Does Practice Meet Theory?

Value Health. 2019 Jul;22(7):799-807. doi: 10.1016/j.jval.2018.11.010. Epub 2019 Jan 11.


Objectives: In theory, a successful coverage with evidence development (CED) scheme is one that addresses the most important uncertainties in a given assessment. We investigated the following: (1) which uncertainties were present during the initial assessment of 3 Dutch CED cases, (2) how these uncertainties were integrated in the initial assessments, (3) whether CED research plans included the identified uncertainties, and (4) issues with managing uncertainty in CED research and ways forward from these issues.

Methods: Three CED initial assessment dossiers were analyzed and 16 stakeholders were interviewed. Uncertainties were identified in interviews and dossiers and were categorized in different causes: unavailability, indirectness, and imprecision of evidence. Identified uncertainties could be mentioned, described, and explored. Issues and ways forward to address uncertainty in CED schemes were discussed during the interviews.

Results: Forty-two uncertainties were identified. Thirteen (31%) were caused by unavailability, 17 (40%) by indirectness, and 12 (29%) by imprecision. Thirty-four uncertainties (81%) were only mentioned, 19 (45%) were described, and the impact of 3 (7%) uncertainties on the results was explored in the assessment dossiers. Seventeen uncertainties (40%) were included in the CED research plans. According to stakeholders, research did not address the identified uncertainty, but CED research should be designed to focus on these.

Conclusions: In practice, uncertainties were neither systematically nor completely identified in the analyzed CED schemes. A framework would help to systematically identify uncertainty, and this process should involve all stakeholders. Value of information analysis, and the uncertainties that are not included in this analysis should inform CED research design.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Clinical Decision-Making
  • Cost-Benefit Analysis
  • Drug Costs*
  • Evidence-Based Medicine / economics*
  • Humans
  • Insurance Coverage / economics*
  • Insurance, Health / economics*
  • Models, Economic
  • Models, Statistical
  • Netherlands
  • Patient Selection
  • Reimbursement Mechanisms / economics*
  • Rituximab / economics
  • Rituximab / therapeutic use
  • Stakeholder Participation
  • Trastuzumab / economics
  • Trastuzumab / therapeutic use
  • Uncertainty*
  • alpha-Glucosidases / economics
  • alpha-Glucosidases / therapeutic use


  • Rituximab
  • GAA protein, human
  • alpha-Glucosidases
  • Trastuzumab