Table A2.

Challenges with the use of economics

Level	Quotations
Macro	Funding conflict of interest
	“… you question the motives behind these studies. […] drug companies do these studies […] a lot of the studies aren't sound and they're not without bias”
	“… pharma has a vested interest in presenting the information in the best light.”
	“…if the report was written by the company who stands to gain from a decision to adopt their drug […] you have to accept an inherent bias in that.”
	“… the drug company […] can manipulate the data to make, I mean you can make anything look good.”
	“Some drug companies are going: Well, we know what it takes to get this drug approved so we're going to make sure the cost‐effectiveness is going to come in below what is reasonable.”
	“… the most important problem we face that most of the economic analyses are performed themselves by the companies interested in submitting and approving the drug or a group contracted by that particular company … so there is a conflict of interest.”
	Modeling
	“…pharmacoeconomic analysis is […] extrapolated […] makes it challenging […] the model is called into question […] the weaknesses of the information are presented …”
	“The number itself is an estimate at best […] I'm looking for validity […] basically whether I'm confident in that number”
	“…the formula for QALY, there is a subjective factor involved here …”
	“… a lot of the economics […] is based on a modeling system, and the systems make a lot of assumptions, and the assumptions are not always to my way of thinking appropriate…”
Meso	Lack of transferrability
	“… most of the economic reports are manufacture driven and they are not very good. A lot of the time they are not relative to the Canadian market or they're not reflecting Canadian prices and other health outcomes…”
	“…It's a little too abstract for my thinking, it's all based on a model […] you can poke holes in any of it”—a respondent discussing 100 healthy adults in Toronto, and using a ten year horizon when patients do not live this long.
	“…using comparators that are not close to what we would use in clinical practice. So this new treatment is better than that old treatment, but we discarded that old treatment five years ago with something else better.”
	Inconsistencies
	“…some analyses appear to be of better quality than others…”
	“…different for‐hire companies […] do variable jobs, some do a very good job, and some frighteningly bad.”
Micro	Lack of understanding
	“…it's really hard for me to understand but there is different utilities that you look at in terms of understanding benefits, I guess. I'm not sure exactly how to define utility.”
	“(cost utility) is the term I have a hard time with […] that cost utility piece is a difficult concept for me to understand.”
	“Cost utility […] fairly similar to cost‐effectiveness, but I am kind of drawing a bit of a blank here”
	“(cost utility) … this is where I start to break down a little bit […] putting a scientific value on the benefit of this drug compared to the cost of this drug …”
	“I am more of a science‐oriented person […] not saying this isn't scientific data but it's just to me it's too complex …”
	“Cost utility … don't quite know how to fit that in … not a term I consider very often.”
	“Cost utility, I've never been absolutely on top of.”
	“I get benefit and utility mixed up”