Cost-Utility Analysis: An interesting pharmacoeconomic method is cost-utility analysis; it compares the cost of a procedure, t

Cost-Utility Analysis: An interesting pharmacoeconomic method is cost-utility analysis; it compares the cost of a procedure, test or method with the outcome as rated or assessed by the recipient - the patient. Compared to cost-benefit analysis, which compares the cost of a process to the dollar value of its attributable outcome, or cost-effectiveness as measured in dollar or non-dollar units, C-U allows disparate procedures to be compared. E.G., a procedure with a 0.5 quality of life outcome (QOL) or quality adjusted life year (QALY) costing $4,000 equals in C-U analysis an $8,000 procedure with a QOL result of 0.25. Similarly, unlike treatment alternatives with the same QOL outcome, but costing different amounts can be compared with C-U analysis

Examples:

$17000/yr. Life diuretics for BP

$55000 CABG

$25K for IGg treatment of RSV

Further example:

When investigating patients with possible cardiac chest pain

In patients with a high probability of CAD, such as males with typical angina, it may be preferable to perform angiography without prior noninvasive testing.
Where the probability of CAD is low, then the cost effectiveness (C:E) of any testing is poor compared with most well accepted medical interventions.
For those patients with a moderate risk of CAD, initial exercise echocardiography can often a reasonably C:E initial strategy.

However, one must consider the total cost of an episode – see other sections of this Web site referring to Clinical Risk Groups or CRGs.

Policy Cost-Effectiveness
"In general, policy cost-effectiveness is always less attractive than treatment cost-effectiveness. Consequently trying to improve the uptake of underused cost-effective care or reduce the overuse of new and expensive treatments may not always make economic sense." This article presents a method for calculating policy cost-effectiveness of educational outreach by community pharmacists to influence physician prescribing in England.

From a 1997 and 1998 trial (England):
1) Angiotensin-converting enzyme (ACE) inhibitors are underused in the care of patients with heart failure.5
a) Economic Message: Patients with heart failure not treated with an ACE inhibitor are denied a cost-effective treatment,7 valued at $2156 per life-year gained.8 Costings, originally conducted in pounds sterling, have been converted to US dollars (£1 = $1.50) for ease of exposition."
2) Newer classes of antidepressants have achieved widespread first-line use without demonstrating added value.4
a) Economic Message: Every patient with depression treated first-line with a selective serotonin reuptake inhibitor (SSRI) instead of a tricyclic antidepressant costs an additional $75 per episode without demonstrable clinical benefit.6

"Clinical practice guideline development groups, having studied the profile of costs, benefits, and harms for these conditions, have recommended that physicians should address these shortcomings… . "Implementation requires a clear and deliverable evidence-based message, evidence that current care is suboptimal and the message is not being applied, a robust estimate of the cost and impact of alternative methods of behavioral change, and understanding of the local organization of health care.9"

"The cost per guideline per practice per unit change in behavior (delta CEi) is $11 690 (95% CI, $6980-$35 740). The effect of the implementation loading ($446/life-year gained) upon the treatment cost-effectiveness of ACE inhibitors ($2156/life-year gained) for heart failure is small and a policy of implementation is cost-effective ($2602/life-year gained). Academic outreach to promote a reduction in use of SSRIs in favor of tricyclic antidepressants is not estimated to be cost-saving: the cost per patient of outreach ($82) exceeds the cost-saving from behavioral change ($75). This would not be worth pursuing by educational outreach."

"The impact of educational outreach on small practices (1 or 2 partners) is modeled as a subgroup analysis (Table 2). Although an increase in outreach effectiveness reduces the loading factor, this is partially offset by a reduction in numbers of patients per practice targeted by each guideline. Nonetheless, intervention to reduce the use of SSRIs has become cost-saving, although the magnitude of saving is imprecise."

References:
Mason J, Freemantle, N, Nazareth I, et al. When Is It Cost-effective to Change the Behavior of Health Professionals? JAMA. 2001;286:2988-2992.
4. Freemantle N, Mason JM. Is all publicity good publicity? a review of the Prozac years. Pharmacoeconomics. 2000;17:319-324.
5. Mason J, Young P, Freemantle N, Hobbs R. Safety and costs of initiating angiotensin converting enzyme inhibitors for heart failure in primary care: analysis of individual patient data from studies of left ventricular dysfunction. BMJ.2000;321:1113-1116
6. Eccles M, Freemantle N, Mason JM. North of England Evidence-Based Guideline Development project: summary version of guidelines for the choice of antidepressants for depression in primary care. Fam Pract.1999;16:103-111.
7. Eccles M, Freemantle N, Mason JM. North of England Evidence-Based Guideline Development project: guideline for angiotensin converting enzyme inhibitors in primary care management of adults with symptomatic heart failure. BMJ. 1998;316:1369-1375.
8. National Electronic Library for Health: Clinical Guidelines Database. North of England Evidence-Based Guideline Development Project. Primary care management of secondary prophylaxis for patients who have experienced a myocardial infarction: drug treatment, cardiac rehabilitation and dietary manipulation. Link (Accessibility cannot be verified Dec. 21,2001).
9. Mason JM, Wood J, Freemantle N. Designing evaluations of interventions to change professional practice. J Health Serv Res Policy. 1999;4:106-111. [correction appears in J Health Serv Res Policy. 1999;4:192].

In one study--46 patients who had chest pain, but normal ECG results--SPECT was speculated to be an ''economically efficient'' tool. All patients underwent SPECT, but in ½, the SPECT results were used to decide whether the patient should undergo further testing. Those in that group were charged about $1,843 less partially because without the SPECT results, patients stayed 1 day longer in the ICU and 2 days longer in the hospital. Those treated on the basis of SPECT results were no more likely than conventionally treated patients to have a heart attack. Clearly, they stayed the extra time because the physicians felt reassured by the SPECT results. Do outcome studies support the medical necessity of an ICU stay (assuming the other tests are negative and the family is reliable, close by, etc.)?

Annals of Emergency Medicine 2000;35:17-25