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Clarifying the Principles of Cost-Effectiveness Analyses
IN RESPONSE:
Cost-effectiveness analysis enables policymakers to maximize outcomes without exceeding available resources by determining either the greatest possible benefit for a given resource or the lowest resource cost for a given benefit. To illustrate, Pletcher and colleagues (1) estimated average annual discounted health care costs of $897.64 billion (Table 2) for 138.6 million men and women age 35 to 85 years at baseline, yielding an average cost of $6477 per treated or untreated person. The next most expensive policy options were treating persons with 10-year coronary heart disease (CHD) risk greater than 15% or adhering to Adult Treatment Panel III (ATP III) guidelines, which would cost $6487 or $6503 per person, respectively. So for all 3 of these policies, about 154 individuals could be covered per year for statin primary prevention with an annual budget of $1 million.
These alternative policies affect who receives treatment and where health dollars are consumed. Changing policies would increase the proportion of the population receiving statins from 35% to 42% and would result in up to 33% of persons older than 65 years starting statin therapy. By increasing the proportion of patients receiving statins, drug-related costs increase by $2 to $6 billion, but $1 to $3 billion less would be spent on CHD-related complications, such as hospitalizations and procedures. Because annual deaths from heart disease would decrease, annual non-CHD health expenditures would increase by $270 to $560 million annually.
Put simply, divide $1 million by each incremental cost-effectiveness ratio. Spending $1 million increases population health by 27 years by treating persons with 10-year CHD risk greater than 15% and by 22 years in patients treated according to ATP III guidelines. Focusing on treatment of persons with 10-year CHD risk greater than 15% is a more efficient use of resources, so it should be preferred. Spending $1 million on hemodialysis, with its cost-effectiveness ratio of $60 000 per quality-adjusted life-year gained (2), yields 17 years, so relative to hemodialysis, adhering to ATP III guidelines provides similar health value for its costs.
Can the United States “raise health care's quality and lower its costs” (3)? Similar to its financial system, the U.S. health care system is complex and adaptive, with individual agents acting independently and not predictably (4). In such a system, instead of overspecifying a solution, targeting a few simple, flexible goals may enable the complex interacting parts of our health delivery and research enterprise to self-adjust and arrive at creative solutions (5, 6) involving such issues as coverage, malpractice, and payment reform for health policy to align economic incentives for improving health and move from a fee-for-service system (in which more is presumed to be better) to a system that provides quality care at a sustainable and affordable cost.
Article and Author Information
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Potential Financial Conflicts of Interest: Dr. Wong is a medical editor for the Foundation for Informed Medical Decision Making.
