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Cost-effectiveness analysis in heart disease Part I: General principles

1994; Elsevier BV; Volume: 37; Issue: 3 Linguagem: Inglês

10.1016/s0033-0620(05)80041-6

1873-1740

Joel Kupersmith, Margaret Holmes‐Rovner, Andrew J. Hogan, D R Rovner, Joseph C. Gardiner,

Healthcare Policy and Management

T H E COSTS AND problems of delivering medical care have captured public and political attention in an unprecedented manner. Probably the most quoted statistic of the past year is that health care accounts for 14% of the gross domestic product, up from 9.4% in 1980.1 It is the highest in the world, we are told, and increasing rapidly. Although this statistic does not take into account the contribution of health care and good health to the economy, it is impressive. There is no doubt that We are moving into an era of scarce, even restricted, resources. In these discussions, heart disease and its treatments play a prominent role, because it is not only very common but also subsumes a variety of costly high-tech interventions. In the aggregate, it is estimated that cardiovascular disease accounts for $128 billion in medical expenses and lost productivity. 2 Although we have effective interventions to prolong life and reduce suffering in heart disease, it is clear that we will have to justify allocating scarce resources to these therapies amidst the general array of medical interventions. Therefore, we need methodologies to help define, categorize, and appropriately prioritize the various cardiac treatments, one with another and with treatments for all other diseases. Cost-effective offers just this. It is a method to inform policy and more efficiently allocate fixed health care resources. The term is often used loosely to denote any intervention that has some benefit. 3,4 However, formal in the medical arena is a very specific methodology that has grown from efforts of certain investigators, in particular, Weinstein, Stason, Goldman, and others. 4-9 It is a method in which the total cost of a particular health intervention is compared with its benefit or effectiveness. 4-19 Cost is, of course, expressed in dollars. Health benefit is expressed in years of life, prolonged or saved (cost-effectiveness analysis). When health benefits include quality of life, the method is called cost-utility and when the health benefits are translated into terms (dollars), it is defined as cost-benefit In all of these approaches, one makes not 0nly an assessment but also, importantly, a medical evaluation of health care outcomes as an integral part of the analysis. The analyses are all grouped under the overall rubric economic evaluation, m6,17,2~ though often cost-effectiveness analysis has been used loosely to encompass the entire grouping. 7,a1,21 By comparing costs and clinical outcomes in a standard unit, one attempts to arrive at the ultimate goal of analysis, to put all health care interventions on the same scale and to compare and evaluate trade-offs to obtain the most benefits for the least revenues. 68,10,n For example, in its ideal form and given sufficient data, one may compare chemotherapy for Hodgkin's disease with coronary artery bypass graft (CABG) surgery, with antibiotic therapy for bacterial endocarditis, or with any new technology in terms of dollars per year of life saved or prolonged, adjusted for quality of life. In this review, Part I will discuss the general and evolving methodology of cost-effective as well as provide a glossary of terms. Parts I122 and II123 will review published studies using this technique in the evaluation of cardiovascular disease. Part II will deal with preventive interventions, and Part III with ischemic heart disease, congestive heart failure (CHF), and arrhythmias. Because it represents a merging of medicine with economics, this discussion may produce some discomfort to the clinician. However, it is an area of increasing importance as concerns impinge on previously unfettered clinical practice.