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Obituary: Sir John Peel

Publication bias We found relatively few published incremental cost effectiveness ratios between $50 000/QALY and $100 000/QALY. There are three possible explanations. Firstly, they may reflect the true distribution of cost effectiveness ratios for healthcare interventions. Secondly, analysts may not be interested in studying interventions with mid-range cost effectiveness ratios or some journals may not want to publish such studies. Thirdly, some cost effectiveness analyses may be modelled to yield favourable ratios or studies with unfavourable ratios may be suppressed. Our results support concerns about the presence of significant and persistent bias in both the conduct and reporting of cost effectiveness analyses. 5 It could be argued that all cost effectiveness analyses should be registered before they start, but this may be unrealistic given the way they are currently conducted. Recent attempts to standardise the conduct and reporting of economic analyses and modelling studies may help prevent the manipulation of studies. 8–10 Electronic publishing could enhance transparency in modelling by making technical appendices available. Furthermore, distribution of the underlying decision analysis models to the public should be considered. Journal editors and reviewers can help reduce publication bias. Potential conflicts of interest of study sponsors and authors need to be scrutinised. Journal editors may show bias by publishing studies with positive results but not studies with negative results, although this may not be common. However, differences between economic analyses may also reflect a more fundamental difference in the studies.