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• W2780996979 abstract "Central MessageCost-effectiveness analyses should be performed and interpreted carefully and cautiously because they may be used to dictate the procedures and treatments we can offer our patients.See Article page 1671. Cost-effectiveness analyses should be performed and interpreted carefully and cautiously because they may be used to dictate the procedures and treatments we can offer our patients. See Article page 1671. Insurers, regulators, and clinicians use cost-effectiveness analyses (CEAs) in the hope of defining those drugs and forms of care that make the best use of our limited resources. Thus, it is very appropriate that Ferket and colleagues1Ferket B.S. Oxman J.M. Iribarne A. Gelijns A.C. Moskowitz A.J. Cost-effectiveness analysis in cardiac surgery: a review of its concepts and methodologies.J Thor Cardiovasc Surg. 2018; 155: 1671-1681Abstract Full Text Full Text PDF Scopus (16) Google Scholar provide a primer on these techniques in this issue of the Journal. Some judgments regarding cost-effectiveness seem obvious. Drug treatment of essential hypertension avoids the complications of heart, kidney failure, or stroke and is inexpensive, efficacious, and cost-effective.2Reboussin D.M. Allen N.B. Griswold M.E. Guallar E. Hong Y. Lackland D.T. et al.Systematic review for the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.Hypertension. November 13, 2017; ([Epub ahead of print])Google Scholar Similarly, drug treatment of chronic heart failure with angiotensin-converting enzyme inhibitors easily meets our tests for cost-effectiveness.3Biglane J.B. Becnel M.F. Ventura H.O. Krim S.R. Pharmacologic therapy for heart failure with reduced ejection fraction: closing the gap between clinical guidelines and practice.Prog Cardiovasc Dis. 2017; 60: 187-197Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar The decision-making is not always so clear cut when costs of supplies, personnel, hospitalizations, and complications must be estimated.1Ferket B.S. Oxman J.M. Iribarne A. Gelijns A.C. Moskowitz A.J. Cost-effectiveness analysis in cardiac surgery: a review of its concepts and methodologies.J Thor Cardiovasc Surg. 2018; 155: 1671-1681Abstract Full Text Full Text PDF Scopus (16) Google Scholar Outcome differences associated with medications can usually be attributed to the medication, not the clinician; however, surgeons have varying skills and experiences. Can one reasonably compare either the cost or the effectiveness of robot-assisted laparoscopic radical prostatectomy with “open” retropubic prostatectomy without regard for the operator's expertise?4Ilic D. Evans S.M. Allan C.A. Jung J.H. Murphy D. Frydenberg M. Laparoscopic and robot-assisted vs open radical prostatectomy for the treatment of localized prostate cancer: a Cochrane systematic review.BJU Int. October 24, 2017; ([Epub ahead of print])Crossref PubMed Scopus (71) Google Scholar, 5Leow J.J. Leong E.K. Serrell E.C. Chang S.L. Gruen R.L. Png K.S. et al.Systematic review of the volume-outcome relationship for radical prostatectomy.Eur Urol Focus. April 6, 2017; ([Epub ahead of print])Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar These concerns are even more vexing in cardiovascular and thoracic surgery. When we compare off-pump with on-pump coronary artery bypass grafting, are we actually comparing the same revascularization?6Puskas J.D. Williams W.H. Mahoney E.M. Huber P.R. Block P.C. Duke P.G. et al.Off-pump vs conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial.JAMA. 2004; 291: 1841-1849Crossref PubMed Scopus (485) Google Scholar What is the effectiveness outcome of interest? Mortality at 1, 3, or 5 years? Graft patency? Incidence of a combined endpoint?7Kirmani B.H. Holmes M.V. Muir A.D. Long-term survival and freedom from reintervention after off-pump coronary artery bypass grafting: a propensity-matched study.Circulation. 2016; 134: 1209-1220Crossref PubMed Scopus (38) Google Scholar Would our 50-year-old patient who enjoys mountain biking regard percutaneous coronary intervention, with a requirement for daily antiplatelet therapy, as more cost-effective than coronary artery bypass grafting when the former is associated with an increased risk of intracranial bleeding or death should he fall during a ride?8Mäkikallio T. Holm N.R. Lindsay M. Spence M.S. Erglis A. Menown I.B. et al.NOBLE study investigatorsPercutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial.Lancet. 2016; 388: 2743-2752Abstract Full Text Full Text PDF PubMed Scopus (538) Google Scholar, 9Stone G.W. Sabik J.F. Serruys P.W. Simonton C.A. Généreux P. Puskas J. et al.EXCEL Trial InvestigatorsEverolimus-eluting stents or bypass surgery for left main coronary artery disease.N Engl J Med. 2016; 375: 2223-2235Crossref PubMed Scopus (725) Google Scholar, 10Poder T.G. Erraji J. Coulibaly L.P. Koffi K. Percutaneous coronary intervention with second-generation drug-eluting stent versus bare-metal stent: systematic review and cost-benefit analysis.PLoS One. 2017; 12: e0177476Crossref PubMed Scopus (24) Google Scholar Fundamentally, CEA seeks “fairness,” and we certainly support this aim. In contrast, we wonder whether it makes sense to assume that all patients would place the same dollar value on a quality-adjusted life year in a country with no “single payer” and in which “concierge” medical services are proliferating. Would all patients agree with our cost estimate of a periprocedural stroke? Would they agree with our estimate of the financial benefit from avoiding blood transfusion or an extra day of hospitalization? Unfortunately, the marked variation in costs of care within the United States and the marked differences in costs of supplies and services in the United States versus other countries ultimately make CEAs less generalizable than would be desired.11Wakeam E. Molina G. Shah N. Lipsitz S.R. Chang D.C. Gawande A.A. et al.Variation in the cost of 5 common operations in the United States.Surgery. 2017; 162: 592-604Abstract Full Text Full Text PDF PubMed Scopus (27) Google Scholar, 12Guduguntla V. Syrjamaki J.D. Ellimoottil C. Miller D.C. Prager R.L. Norton E.C. et al.Drivers of payment variation in 90-day coronary artery bypass grafting episodes.JAMA Surg. August 23, 2017; ([Epub ahead of print])Google Scholar, 13Silva G.S.D. Colósimo F.C. Sousa A.G. Piotto R.F. Castilho V. Coronary artery bypass graft surgery cost coverage by the Brazilian Unified Health System (SUS).Braz J Cardiovasc Surg. 2017; 32: 253-259PubMed Google Scholar Another limitation is that source data for CEA are typically “mined” from national databases. These sources provide data of varying quality and validity and usually lack the clinical information that actually drives decisions regarding which medical procedure will be performed. CEA needs to address clinical decision-making, patient outcomes, and satisfaction data. A primary focus on costs may benefit our bottom line but may be detrimental to our patients. CEA does not produce a static number: we must be prepared to redo our calculations when the relative costs of a treatment changes radically (eg, when the patent life of a drug or robot expires and market competition drives down costs). CEA analyses should be performed carefully and cautiously because they may be used by third-party payers to dictate the procedures and treatments we can offer our patients. CEA is an important field of study, and our readers must be prepared to address these issues as they arise in their health systems. Thus, we welcome the contribution of Ferket and colleagues to the Journal.1Ferket B.S. Oxman J.M. Iribarne A. Gelijns A.C. Moskowitz A.J. Cost-effectiveness analysis in cardiac surgery: a review of its concepts and methodologies.J Thor Cardiovasc Surg. 2018; 155: 1671-1681Abstract Full Text Full Text PDF Scopus (16) Google Scholar Cost-effectiveness analysis in cardiac surgery: A review of its concepts and methodologiesThe Journal of Thoracic and Cardiovascular SurgeryVol. 155Issue 4PreviewMore than 80 million adults in the United States suffer from some form of cardiovascular disease, accounting for close to 1 in 3 US deaths annually and more than $300 billion in direct and indirect costs.1 Coronary heart disease has been estimated to affect more than 6% of the US adult population. Moderate-to-severe aortic stenosis (AS) and mitral regurgitation (MR) have been estimated to affect close to 3% and 9% of US adults ages 75 and older, respectively.1,2 Atrial fibrillation (AF) and heart failure (HF) each affect up to 6 million Americans. Full-Text PDF Open ArchiveMaximizing society's overall health in the face of budgetary constraintsThe Journal of Thoracic and Cardiovascular SurgeryVol. 156Issue 5PreviewButterworth and Cassano1 highlight the importance of context and perspective when interpreting a cost-effectiveness analysis (CEA). The authors endorse a patient's perspective when questioning whether all patients would place the same value on a gain in quality-adjusted life years (QALYs). We agree that patients would, undoubtedly, place different values on treatments and outcomes and, certainly should not be prevented from paying for such interventions. Individualized CEA explores this perspective and the different conclusions it can lead to relative to population decision making. Full-Text PDF Open ArchiveChallenges to make cost-effectiveness studies usable by decision makersThe Journal of Thoracic and Cardiovascular SurgeryVol. 156Issue 5PreviewI read with interest the editorial by Butterworth and Cassano1 and second most of their statements about cost-effectiveness analysis (CEA), especially with respect to the need to perform rigorous analyzes with appropriate choices of comparators and outcomes. This is all the more important because these choices may bias the results and mislead decision making in health care in a context of hard budget constraints. This is well recognized by health economists and is a major point in various methodologic handbooks. Full-Text PDF Open Archive" @default.
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