Economics of coronary artery bypass grafting. 1985.

Abstract

Introduction The report of a consensus development conference on coronary artery bypass surgery recommended a large increase in the number of such operations in the United Kingdom, to 300 for every million of the population, "if this represents provision for high benefit patients."[1] The report acknowledged, however, that such a development would require considerable funds and that "the problem of assessment of priorities remains. This in turn should take account of estimations of the relative cost effectiveness of other procedures competing for resources." The report went on to say "We were impressed by one method of measurement combining quality and duration of life. Further development of this approach is recommended so that it can be of help not only in comparison between coronary artery bypass surgery and other priorities but also between the various subgroups of patients whom it is proposed should be treated by coronary artery bypass surgery. Such techniques would also help to identify health service estimates which are being continued despite low benefit." This paper presents the economic analysis given to the panel at the consensus development conference in the hope that this will lead to a better understanding of the methodology and enable better data to be collected and deployed than the rather crude data used here. The problem The objective of economic appraisal is to ensure that as much benefit as possible is obtained from the resources devoted to health care. In principle the benefit is measured in terms of the effect on life expectancy adjusted for the quality of life. The resources for health care should include not only costs to the service but also costs borne by patients and their families. Given the amount of unemployment, which is expected to persist in the near future, increases in production that might be associated with employment gains have been disregarded. Procedures should be ranked so that activities that generate more gains to health for every [pounds sterling] of resources take priority over those that generate less; thus the general standard of health in the community would be correspondingly higher. Coronary artery bypass grafting is one of many contenders for additional resources. Ideally, all such contenders should be compared each time a decision on allocation of resources is made to test which should be cut back and which should be expanded. The central issue before the conference was whether the number of operations for coronary artery bypass grafting should be increased, decreased, or maintained at its present level. To address this problem three factors need to be considered: firstly, which groups of patients stand to gain the most and the least from such operations; secondly, whether any of these groups of patients gain more for every [pounds sterling] of resources than patients awaiting other types of cardiac surgery--for example, transplantation, replacement of valves, insertion of pacemakers, and percutaneous transluminal coronary angioplasty; and, thirdly, whether other specialties have procedures that are more important than any of these--for example, kidney transplantation, renal dialysis, and hip replacement. In an ideal world a better standard of care for the elderly, mentally ill, and mentally handicapped, diagnostic methods such as computed tomography and nuclear magnetic resonance, and preventive measures should also be considered. I shall restrict attention here to the more costly therapeutic technologies. Measuring benefits Generally, clinical trials compare rates of survival at various arbitrarily selected times after treatment has started. For our purposes we need to translate these comparative rates of survival into information on the change in life expectancy, which must then be adjusted for the effects on quality of life: some patients are willing to sacrifice a measure of life expectancy for a better quality of life. …