The conventional premise governing performance measures and guideline recommendation…is that all healthcare professionals should act in the best interests of their patients without regard to costs.
However, as the cost of medical care has increased, specialty societies are increasing considering the cost of care when selecting treatments. For instance,
A recent survey reported that slightly more than half of the largest US physician societies explicitly consider costs in developing their guideline documents, although their approach remains vague.
If one considers the patient-physician relationship as a principal-agent relationship, does the physician need to consider cost when making treatment recommendations? Shouldn’t the physician have the patients best interest at heart?
The ACC/AHA statement on the value of treatments notes that “Protecting patients from financial ruin is fundamental to the precept of ‘do no harm.’”
If economic studies are used to measure treatment, what is the appropriate threshold? There is clearly not single correct answer. “The World Health Organization (WHO) has suggested a rough benchmark of 3 times the GDP per capita as an upper threshold for an acceptable level of cost-effectiveness in a given country.24
Economic analysis requires high quality data on the benefits and cost of treatment. Determining the quality of a study, however, is not easy. One of the earliest and most frequently cited criteria was
developed for the British Medical Journal. Another approach—the Quality of Health Economic Studies (QHES) instrument—examines the clarity of the publication, identifies the study’s perspectives, examines whether subgroup analyses were performed, identifies relevant time frame for the outcomes measured, describes validity and reliability of the study, and a number of other factors. In fact, the ACC/AHA guidelines recommend using QHES.
The ACC/AHA recommends evaluating evidence as follows:
“This system synthesizes the data to establish the benefit of diagnostic approaches and treatments compared with risk (COR, ranging from the highest [I] to the lowest [III]) and integrates the precision and, implicitly, the quality of the underlying evidence (LOE, from the best [A] to the poorest [C]). In comparing risks and benefits, the writing committees ultimately develop a qualitative determination as to whether the benefits outweigh the risks. In general, this assessment is based on the number and types of supportive studies and their statistical significance rather than the absolute magnitude of the benefit or the value provided (cost-effectiveness).” Using this approach, ACC/AHA would categorize treatments as high value (<$50,000/QALY gained), intermediate value ($50,000-$150,000/QALY gained), low value (>$150,000/QALY gained), Uncertain value (in the case where the evidence base is weak), or not assessed. This approach is derived from the WHO-CHOICE (Choosing Interventions that are Cost-Effective) initiative, which provides a framework for cost-effectiveness thresholds that can be applied globally to a wide range of health interventions.
- Anderson JL, Heidenreich PA, Barnett PG, Creager MA, Fonarow GC, Gibbons RJ, Halperin JL, Hlatky MA, Jacobs AK, Mark DB, Masoudi FA, Peterson ED, Shaw LJ. ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures: a report of the American College of Cardiology/American Heart Association Task Force on Performance Measures and Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Jun 3;63(21):2304-22. doi: 10.1016/j.jacc.2014.03.016. Epub 2014 Mar 27.
- Drummond MF, Jefferson TO. Guidelines for authors and peer reviewers of economic submissions to the BMJ. The BMJ Economic Evaluation Working Party. BMJ. 1996;313:275–83.
- Ofman, Joshua J., et al. “Examining the value and quality of health economic analyses: implications of utilizing the QHES.” Journal of Managed Care Pharmacy 9.1 (2003):53–61.
- Schwartz JA, Pearson SD. Cost consideration in the clinical guidance documents of physician specialty societies in the United States. JAMA Intern Med. 2013;173:1091–7.
- World Health Organization. CHOosing Interventions that are Cost Effective (WHO-CHOICE): cost-effectiveness thresholds. Available at: http://www.who.int/choice/costs/CER_thresholds/en/index.html