Deeper Implications for Implementation and Practice
The joint nature of research and reimbursement decisions with consideration of ENG for DT versus AN locally and DT versus AN and AT versus AN globally can be refined to more generally consider degree of implementation of new and existing interventions given cumulative strength of evidence (Willan and Eckermann 2010). Choice of DT, AN and AT may act as shift factors on this relationship.
However, the primary shift factor is incentives faced by providers and whether they align with maximising net benefit in practice. In this respect when considering the extent to which implementation of decisions in practice can be improved, note that in Chap. 9, net benefit correspondence theorem methods for efficiency comparison are illustrated that enable net benefit-maximising incentives in practice (Eckermann 2004; Eckermann and Coelli 2013).
It should also be noted that while local trial designs reinforce differences in standards and regulations for evidence across jurisdictions, optimal global trials explicitly support recruitment to allow translation of evidence across jurisdictions and rationalization of regulatory differences. As a general principle, the only case where optimal global trials do not have advantages over optimal local solutions is where globally optimal solutions are the same as locally optimal solutions. This can arise when there is enough current evidence that AN at the current threshold price is the optimal solution globally as well as locally in each jurisdiction. At this point, evidence is globally sufficient. Therefore, empirically optimal global trials should differ from, and improve on, locally optimal trials whenever a trial is optimal.