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Survivor costs in cost-effectiveness analysis?
Cost-per-life-year calculation requires to include all costs of life extension
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Yoav Golan, MD Tufts-New England Medical Center, John B. Wong, and Stephen G. Pauker
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ygolan{at}tufts-nemc.org Yoav Golan, et al.
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Dr. Gandjour raises an interesting point: in cost-effectiveness analysis the exclusion of survivor costs (costs associated with a treatment because it extends the patient's life) could impact upon the calculated cost-effectiveness ratio. He suggests that by excluding such costs, we calculated unduly favorable cost-effectiveness ratios. The purpose of cost-effectiveness analysis is to provide a metric of comparison of potential uses of limited resources (the "medical commons" [1]). There is no gold standard threshold willingness to pay. To be useful such analyses must use standard methodology, as we have done [2, 3]. In response to Dr. Grandjour's suggestion, we searched PUBMED to identify all cost-effectiveness analyses published from January 1st 2003 to December 31st 2005 in five major medical journals (JAMA, Annals of Internal Medicine, The New England Journal of Medicine, Lancet, and British Medical journal). Only two of 43 identified articles included survivor costs, both of which were partial and disease-unadjusted. Reading Nyman's paper [4], there is little consensus regarding the inclusion of survivor costs in cost-effectiveness analysis. Even those who favor the inclusion of such costs, disagree regarding the type of costs to be included. Consequently, a dependable methodology that enables the inclusion of survivor costs has not been developed. Furthermore, the inclusion of such costs would bias analyses toward non-intervention unless an adjustment of willingness-to-pay thresholds occurred. When the calculated cost-effectiveness ratio is close to the acceptable threshold and survivor's future cost-of-care is expected to offset future earnings, the addition of survivor costs could render an otherwise cost-acceptable intervention to an unacceptably expensive one. Invasive candidiasis in ICU patients, the subject to our analysis, is described to be associated with a high case-fatality rate and a lower survivor's life expectancy, both incorporated into the analysis, but not with impaired future productivity [2]. If one includes survivor costs, then such productivity might also be included. Hence, the inclusion of survivor costs would make our analysis less useful and generalizable, while not affecting our conclusion that selective empiric use of anti- candida therapy in patients in the intensive care unit is a reasonable strategy. References 1. Hiatt HH. Protecting the medical commons: who is responsible?. NEJM 1975; 293:235-241. 2. Golan Y, Wolf MP, Pauker SG, Wong JB, Hadley S. Empirical anti- Candida therapy among selected patients in the intensive care unit: a cost -effectiveness analysis. Annals of Internal Medicine, 2005;143:857-869 3. Gold MR, Siegel JE, Russell LB, Weinstein MC, eds. Cost- effectiveness in health and medicine. New York: Oxford University Press, 1996. 4. Nyman JA. Should the consumption of survivors be included as a cost in cost-utility analyses? Health Economics 2004;13:417-427. Conflict of Interest:None declared |
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Afschin Gandjour, MD, PhD Institute of Health Economics and Clinical Epidemiology, University of Cologne, Cologne, Germany
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afschin.gandjour{at}uk-koeln.de Afschin Gandjour
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Yoav Golan and colleagues present a cost-effectiveness analysis of several anti-Candida strategies for high-risk patients in the intensive care unit (1). They evaluate treatment effectiveness by the number of life years gained resulting from a reduction of hospital mortality. As a cost they include initial hospitalization costs. This approach, however, overestimates treatment cost-effectiveness and provides unduly favorable cost-effectiveness ratios. When assessing treatment effectiveness by the number of life years gained, costs for health care services required to provide this gain must be included too (2). After all, not only the anti- Candida therapy and the initial hospital stay are responsible for the life years gained, but also health care services delivered in the years between hospital discharge and death. Therefore, the appropriate approach is to include all health care costs - or at least those responsible for life extension - incurred during the period between hospital discharge and death. References 1. Golan Y, Wolf MP, Pauker SG, Wong JB, Hadley S. Empirical anti- Candida therapy among selected patients in the intensive care unit: a cost -effectiveness analysis. Ann Intern Med. 2005;143(12):857-69. 2. Nyman JA. Should the consumption of survivors be included as a cost in cost-utility analysis? Health Econ. 2004;13(5):417-27. Conflict of Interest:None declared |
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