The use of Quality-Adjusted Life Years in cost-effectiveness analyses in palliative care: Mapping the debate through an integrative review

Rotavirus is a major cause of gastroenteritis in children throughout Europe and the world. In addition to causing morbidity and mortality in children, rotavirus gastroenteritis (RVGE) creates a major economic burden on health care systems and families in Europe. The costs of hospital admissions for RVGE and nosocomial infections generate significant medical treatment costs throughout the region. Less information is available on the costs associated with less severe episodes and the costs borne by families, including lost time from work. The availability of rotavirus vaccines presents an effective opportunity to prevent RVGE and these associated economic costs, as well as providing protection to each child and hence benefiting the child's family. The adoption of rotavirus vaccine by health authorities in Europe will require a comparison of the costs and benefits. Economic evaluations that compare the costs of vaccination to the economic benefits of rotavirus vaccination will provide an estimate of its financial impact on health care systems and society. However, to provide a complete picture, economic evaluations of rotavirus vaccines will need to account for both the reduced costs and the reduced morbidity from prevented RVGE. Cost-effectiveness analyses based on quality-adjusted life years (QALYs) provide a systematic approach for assessing vaccination as a health investment, comparing the incremental costs associated with rotavirus vaccination and the reduced morbidity and mortality. QALYs provide a standardized approach for quantifying and comparing reductions in health-related quality of life and premature mortality. Although methodologic limitations exist in applying the QALY approach to childhood vaccines, their use in cost effectiveness analyses allows decision makers to consider the full health benefits of rotavirus and other vaccines.

Cost-effectiveness analysis in cardiac surgery: A review of its concepts and methodologies

BackgroundThe Quality-Adjusted Life Year (QALY) is internationally recognized as standard metric of health outcomes in cost-effectiveness analyses (CEAs) in healthcare. The ongoing debate concerning the appropriateness of its use for decision-making in palliative care has been recently mapped in a review. The aim was to report on and draw conclusions from two expert meetings that reflected on earlier mapped issues in order to reach consensus, and to advise on the QALY’s future use in palliative care.MethodsA nominal group approach was used. In order to facilitate group decision making, three statements regarding the use of the QALY in palliative care were discussed in a structured way. Two groups of international policymakers, healthcare professionals and researchers participated. Data were analysed qualitatively using inductive coding.Results1) Most experts agreed that the recommended measurement tool for the QALYs ‘Q’ component, the EuroQol-5D (EQ-5D), is inappropriate for palliative care. A more sensitive tool, which might be based on the capabilities approach, could be used or developed. 2) Valuation of time should be incorporated in the ‘Q’ part, leaving the linear clock time in the ‘LY’ component. 3) Most experts agreed that the QALY, in its current shape, is not suitable for palliative care.Conclusions1) Although the EQ-5D does not suffice, a generic tool is needed for the QALY. As long as no suitable alternative is available, other tools can be used besides or serve as basis for the EQ-5D because of issues in conceptual overlap. 2) Future research should further investigate the valuation of time issue, and how best to integrate it in the ‘Q’ component. 3) A generic outcome measure of effectiveness is essential to justly allocate healthcare resources. However, experts emphasized, the QALY is and should be one of multiple criteria for choices in the healthcare insurance package.

A Terminal Decline Model for Fast Track Palliative Care Trials (S757)

台灣地區呼吸器依賴病人之發生率、生活品質、及成本效果研究

23 Background: The objectives of the study were to determine whether a Palliative Care Unit (PCU) provides benefits not just from a cost perspective, but from a patient and caregiver quality of life (QOL) perspective. Methods: (1) Calculate the total costs of the PCU; (2) Leverage a threshold analysis to estimate the Quality-Adjusted Life Years (QALYs) required for the PCU to be cost effective; and (3) Determine whether it is feasible for the program to yield the required number of QALYs. Setting was the Johns Hopkins Health System Palliative Care Unit (PCU) in Baltimore, MD. Analysis was based on patient volume from March 2013-2014. Results: There were 209 palliative patients. The costs for the societal perspective was $2,044,364 and the required number of QALYs to deem it cost effective were 11.36. The net costs for the hospital perspective was $625,777 (gross cost was $993,528; however, the program generated $367,751 in savings for the hospital through treating patients in the PCU as opposed to other functional units), and the required number of QALYs to deem it cost effective were 3.48. To determine whether the program is able to achieve the number of QALYs required, the study team generated aggregated QALYs based on other studies’ evidence for palliative care’s improvement of quality of life for patients and their caregivers. Combining the QALYs generated from the aggregated calculations for patients (0.12) and caregivers (4.60), the program had the potential to yield a total of 4.73 QALYs. Conclusions: This analysis suggests that the PCU is cost effective from the hospital perspective in the sense that the benefits it provides to patients’ and caregivers’ quality of life outweighs the cost of care. Future studies should continue to evaluate palliative care from a cost effectiveness perspective that incorporates a consideration of the quality of life improvements, rather than just cost-reduction.

Background: Recent research shows that placebo mechanisms can be utilized in ethical and legal ways such as in open-label conditions, when patients know that they receive placebos, and through psychological interventions aiming to optimize patients’ expectations. Showing that placebo interventions are also cost-efficient could improve their acceptability. Objective: To review studies that performed health economic evaluations (HEEs) of intentional placebo interventions and to review studies that intentionally applied placebo interventions and reported outcomes eligible for HEEs. Methods: Two systematic reviews of the literature were performed. For the first review, we searched MEDLINE using “placebo” and Medical Subject Headings (MeSH) terms associated with HEEs such as “costs,” “cost–benefit analyses,” and “economics.” Studies were eligible if they employed patients, applied placebo interventions, included an appropriate control group, and reported results of cost analyses. For the second review, we searched the Journal of Interdisciplinary Placebo Studies (JIPS) database and MEDLINE using search terms for outcomes eligible for cost–utility analyses, such as “quality of life” or “quality-adjusted life years” (“QALYs”). Risk of bias of all studies found was assessed according to the Cochrane Handbook, and a narrative synthesis of the results is provided. Results: The first search resulted in 1,853 articles, which were screened for eligibility. Two studies were found only in which costs or cost-effectiveness analysis were reported, but with medium to high risks of biases. The second search yielded 164 articles particularly from the JIPS database of which 11 studies met our search criteria: in six studies, patients received placebo pills in open-label conditions; three studies investigated effects of patient–physician relationships; and two studies used psychological interventions to optimize treatment expectations, in patients with various diseases and disorders. These studies report outcomes potentially eligible for HEEs when costs of interventions were known. Risks of biases were low to medium, but patients were not blinded to the conditions in most studies. Conclusions: The state of knowledge about HEEs of placebo interventions is scarce. To gain more visibility and acceptability for placebo interventions, future studies should measure outcomes usable for HEEs and costs of interventions, and HEEs should be performed for existing studies if data are available.

Introduction: Strictures in Crohn's disease (CD) increase the likelihood of requiring surgery, which is costly and invasive. In the last two decades, endoscopic therapies including endoscopic balloon dilation (EBD) and endoscopic stricturotomy (ESt) have emerged as effective and less invasive therapies for CD strictures.1 ESt in particular is advantageous for longer, fibrotic strictures, or strictures adjacent to anatomic structures requiring precision, and has shown a high rate of surgery-free survival.2-4 We therefore assessed the cost-effectiveness of ESt as compared to surgical resection for CD strictures. Methods: A microsimulation state-transition model compared ESt to surgical resection for patients with primary or anastomotic CD strictures. Our primary outcome was quality-adjusted life years (QALYs) over ten years, and strategies were compared at a willingness to pay (WTP) of $100,000/QALY from a societal perspective. Costs (2022 $US) and ICERs were calculated. Deterministic 1-way and probabilistic analyses assessed model uncertainty. Results: The surgery strategy cost more than 2.5 times the endoscopic stricturotomy strategy, but resulted in nine higher QALYs per 100 persons (Table). Overall, surgery had an ICER of $308,787/QALY, making ESt more cost-effective. The median number of endoscopic stricturotomies was 4 in the ESt strategy and 0 in the surgery strategy; the median number of surgeries was 0 and 2 respectively. One-way sensitivity analyses showed that quality of life after ESt as compared to that after surgery, probabilities of requiring repeated interventions, and surgical mortality and cost were the most influential parameters in our model (Figure). Probabilistic sensitivity analyses favored ESt in 65.5% of iterations. Conclusion: Endoscopic stricturotomy is cost-effective for managing primary or anastomotic Crohn's disease strictures. Post-intervention quality of life and probabilities of requiring repeated interventions exert most influence on cost-effectiveness; the decision between ESt and surgery should be made considering patients' risk and quality of life preferences. 1. Lee KE et al. Dig Dis Sci. 2022 Mar 15.2. Lan N et al. Gastrointest Endosc. 2019 Aug;90:259-268.3. Zhang LJ et al. Gastroenterol Rep (Oxf). 2019 Oct;8:143-150. 4. Lan N et al. Inflamm Bowel Dis. 2018 Mar;24:897-907.Figure 1.: Tornado diagram showing main drivers (variables and sensitivity ranges) of the incremental cost-effectiveness ratio (ICER). †Multiplicative factor by which probability Tables are multiplied. Abbreviations: CD (Crohn's disease), ESt (Endoscopic stricturotomy), ICER (Incremental cost-effectiveness ratio), Max (Maximum), WTP (Willingness to pay) Table 1. - Base Case Cost-Effectiveness Analysis Results Cost ($) Incremental Cost ($) Effectiveness (QALY) Incremental Effectiveness (QALY) ICER ($/QALY) Endoscopic Stricturotomy 16,748 6.28 Resection Surgery 45,135 28,388 6.37 9 QALYs per 100 persons 308,787 Abbreviations: QALY (Quality-adjusted life year), ICER (Incremental cost-effectiveness ratio).

National Consensus Project for Quality Palliative Care: Clinical Practice Guidelines for Quality Palliative Care, Executive Summary

PCN76 COST-EFFECTIVENESS OF VENETOCLAX AND RITUXIMAB COMBINATION THERAPY VERSUS IBRUTINIB IN RELAPSED/REFRACTORY CHRONIC LYMPHOCYTIC LEUKEMIA (R/R CLL) IN COLOMBIA

The National Institute for Health and Clinical Excellence (NICE) is a decision-maker. Where NICE reaches a positive conclusion about the use of a particular health technology (such as a pharmaceutical product) in the National Health Service (NHS), there is a legal requirement for the service to make it available if a patient's physician considers it clinically appropriate [1]. Although this legal obligation does not apply to technologies recommended in NICE's clinical guidelines, there is still a reasonable expectation by the Care Quality Commission for NHS healthcare professionals to use NICE's clinical guidelines as the basis, where appropriate, for their clinical practice. NICE's independent advisory bodies (the Appraisal Committees, the Public Health Advisory Committee and Guideline Development Groups) are required to take account of both clinical and cost-effectiveness in reaching their conclusions about the use of health technologies generally and of pharmaceuticals in particular [2–4]. These advisory bodies must fully assess the available evidence on benefits and costs in order to come to a decision as to whether the use of a technology is considered a cost-effective use of resources. However, the scientific evidence underpinning any decision about the use of a particular health technology is never perfect. Nor is it all-embracing. Advisory bodies therefore need to use their experience to make judgements beyond the existing evidence. These judgements are of two types [5]: Scientific value judgements are ones about what can be inferred from the available evidence base; and the extent to which imperfections in the evidence base should influence decisions. Social value judgements are concerned with what is appropriate and acceptable for society in delivering healthcare across the NHS. Health technologies, including pharmaceuticals, can be considered to be clinically effective if, in normal clinical practice, they confer an overall health benefit (taking account of any harmful effects) when compared with relevant alternative treatments [6]. This is the central concern of patients for whom the treatment might be indicated. Technologies can be considered to be cost-effective if their health benefits are greater than the opportunity costs of services, in the NHS, that may be displaced were they to be adopted [3]. This is the central concern of all other NHS patients whose treatments might be displaced by prioritized spending on the new technology. The evidence for clinical effectiveness may be derived from experimental or observational studies [7]. These are usually pooled in a systematic review that often includes one or more meta-analyses. NICE as a decision-maker, however, needs to consider: The strengths and limitations of the systematic evidence review. Although systematic reviewing is based on well-accepted principles, judgment is required in deciding which studies should be included as well as in the interpretation of the results. Thus different inclusion and exclusion criteria used for the review, as well as for the meta-analyses, will yield different results. The absence of direct comparisons. Many randomized controlled trials for new pharmaceutical products are compared with placebo rather than with the active comparators used in current clinical care. The use of indirect or mixed treatment comparisons adds an additional layer of complexity to the analysis [8]. The end-points used in the relevant studies. Only a minority of trials measure health-related quality of life together with reliable estimates of the period for which it is 'enjoyed'. Frequently the data for effectiveness rely heavily (or exclusively) on surrogate outcomes or other biomarkers. The time scale of the studies. Randomized controlled trials rarely last more than 6–12 months, but chronic diseases and their treatments often persist throughout life. External validity (generalizability) of the available data. Despite the advantages of randomized controlled trials, in respect of their internal validity, their small scale and often homogeneous patient populations can render the real impact of treatment uncertain [4]. Observational evidence, which could assist generalizability, is likely to be limited for new products. All of these considerations, and more, demand judgements on the part of the particular advisory body. These judgements are informed by the science, but are nevertheless judgements. NICE's preferred measure of cost-effectiveness is the incremental cost-effectiveness ratio (ICER) [6]. This relates the increased marginal gain in health, expressed as the quality-adjusted life year (QALY), to the increased (or decreased) marginal costs less the savings attributable to the use of the product. This almost invariably requires the use of an economic model that has normally been developed specifically for the particular decision problem. Economic modelling requires judgements to be made by both modellers and decision-makers. The inputs to the model will be all those necessary to derive both the QALY and cost differences. The QALY differences include overall survival, the time in several different health states, and the valuation of those states on a 'utility' scale. The cost differences include not only the acquisition costs of the product but administrative costs (such as the requirements for hospital admission, the input from nursing or other healthcare staff) as well as additional costs of monitoring the response and the costs of treating adverse effects. These inputs are subject to considerable uncertainty both qualitatively and quantitatively. For example, what is currently considered to be standard UK clinical practice on the management of febrile neutropenia with a new anticancer drug? NICE takes into account the views of clinical experts and patients in order to decide the best estimates of the various inputs that yield, in turn, the most plausible estimate (or estimates) of the ICER. But the judgements of NICE's own advisory bodies are critical. Once NICE's advisory bodies have reached a conclusion about the most plausible modelled ICER for a product's particular indication, they must then decide whether the increased benefits are worth the added costs. In this they are influenced by the principles of distributive justice, but they ultimately decide on a case-by-case approach. Distributive justice is the term used by moral and political philosophers in discussing what is just, or right, in allocating goods within a society. Two moral theories of distributive justice – utilitarianism and egalitarianism – have a particular place in allocating healthcare resources in the NHS [9]. Utilitarians consider distributive justice to be best served by seeking to maximize the health of the population as a whole [9]. Utilitarianism is often expressed, in shorthand, as 'the greatest good for the greatest number'. Egalitarians want healthcare to be distributed, in so far as is possible, so that each person receives a fair share of the opportunities available in society [9]. NICE favours an approach based on maximizing benefit per unit cost, but recognizes that this can conflict with the considered moral convictions of many people (including the members of its advisory bodies). Consequently, NICE uses a flexible approach that treats decisions on a case-by-case basis. NICE is careful to avoid the use of an absolute threshold to distinguish cost-effective from cost-ineffective technologies. The reasons are fourfold: To set a threshold would imply that efficiency has an absolute priority over other objectives (such as fairness). The empirical basis for deciding the value at which a threshold might be set is still very weak. Many health technology suppliers are monopolists and a threshold could be taken to imply a definite price that could discourage price competition. Rigid adherence to a cost-effectiveness threshold would create the impression that NICE's advisory bodies accept all the calculations that have gone into estimating a technology's cost-effectiveness. It would therefore remove their discretion to assess costs and benefits appropriately when modelling has reached its limits. NICE's case-by-case approach is shown stylistically in Figure 1. As the ICER increases, the likelihood of rejection on grounds of cost ineffectiveness rises in a dose–response manner [5]. The critical issues are the values of the ICERs at inflections A and B. NICE and its advisory bodies have made the judgement that inflection A corresponds to an ICER of around £20 000 per QALY and inflection B at around £30 000 per QALY. Consequently, NICE's advisory bodies would be unlikely to reject, as cost ineffective, an intervention <£20 000 per QALY; and increasingly likely to reject, as cost ineffective, interventions >£20 000 per QALY. Relation between the likelihood of a technology being considered as cost ineffective plotted against the log of the incremental cost-effectiveness ratio The Institute thus provides its advisory bodies with some flexibility in deciding whether to commend technologies as cost-effective interventions costing <£20 000 per QALY or >£20 000 per QALY [6]. It does so for two reasons. First, NICE appreciates that the usual tools (such as the EQ-5D) used to calculate the QALY may not invariably capture the totality of an intervention's benefits. The EQ-5D is, for example, relatively insensitive to the quality of life decrement attributable to sensory loss and to cognitive impairment. Second, there are various legal obligations that are placed on the Institute, as a public body, that it is required to uphold. These include promoting equality, eliminating unlawful discrimination, and actively considering the implications for human rights legislation [6]. Third, there are special circumstances, based on social value judgements, that reflect societal preferences in the allocation of resources. These preferences are, predominantly, based on the views of the Institute's Citizens Council and reflected in the guidance given to the Institute's advisory bodies [10]. There have been to date six special circumstances to which the Institute's advisory bodies have given special weighting when making judgements about cost-effectiveness. Some of the conditions, and the associated treatments that reflect these circumstances, are shown in Table 1. Severity of the underlying illness. Although the relatively inexpensive relief of a mild discomfort may be calculated to give an equivalent ICER to the expensive relief of a very serious condition, society would give priority to the latter. NICE's advisory bodies have therefore often given more generous consideration to the acceptability of an ICER in serious conditions. End-of-life treatments. The Institute recognizes that the public, generally, places special value on treatments that prolong life – even for a few months – at the end of life, as long as that extension of life is of reasonable quality (at least pain-free if not disability-free). NICE has therefore provided its advisory bodies with supplementary advice about the circumstances under which they should consider advising, as cost-effective, treatments costing >£30 000 per QALY. Stakeholder persuasion. Patients and their advocates play an important role in shaping the views of NICE's advisory committees. Most particularly, they can explain where, in their experience, the symptomatology of their condition is poorly reflected in either the clinical trials (because the most severely affected were not distinguished or even included), or inadequately reflected in the measure of health-related quality of life that has been used (because the instrument was too insensitive). Significant innovation. The Institute considers an innovative technology as one where the use of the product produces a demonstrable and distinct benefit, of a substantial nature, that may not have been adequately captured in the quality of life measure used. Disadvantaged populations. The NHS gives special priority to improving the health of the most disadvantaged members of the population. This particularly applies to poorer people and ethnic minorities. Children. The Institute recognizes that compilation of the evidence, and assessment of improvements in the quality of life in children are methodologically challenging. It understands that society would generally favour 'the benefit of the doubt' being afforded to sick children. In taking account of these factors, when reaching conclusions about cost-effectiveness NICE does not typically expect them to be used to 'weight', quantitatively, the QALYs attributable to an intervention. First, the methodology for developing and applying 'equity weightings' (as they are sometimes called) is largely untried and untested. Second, there is no methodology available to take account of more than one 'weight' when more than one special factor exists (as in many instances in Table 1). Should they, for example, be additive, multiplicative, or something else? Third, there would be much less scope for advisory bodies to use their own judgement. Appraisal Committees frequently meet new circumstances, or unique combinations of circumstances, where quasi-scientific weighting would have far less merit than the collective judgement of a balanced group of experienced people. NICE's Appraisal Committee considered that, in the case of pemetrexed for malignant mesothelioma, there was a combination of factors: a disadvantaged population; an urgent but time-limited problem; and also, arguably, a corporate responsibility to provide treatment for an occupational hazard that at the time workers were exposed to asbestos was unrecognized. Rather than apply 'equity weightings', the Institute expects the members of its advisory bodies to exercise their collective judgement in the application of these special considerations to conclusions about cost-effectiveness when the ICER exceeds £20 000–30 000 per QALY. Decision-makers have to make judgements when deciding whether interventions are clinically and cost-effective. There is a need for a level playing field for different technologies across different diseases. NICE uses a standard approach to calculating costs and benefits in the form of QALYs that satisfies this requirement for broad consistency. It is essential, though, that the approach is used as a tool, not a rule. Recommendations need to be based on scientific judgements about clinical and cost-effectiveness, but also to take into account societal preferences as expressed through social value judgments. MDR is Chairman of NICE (1999–present). DBB was Chairman of NICE's Appraisal Committee (1999–2009). AS is a Chairman of NICE's Appraisal Committee (2002–present).

Background: In recent years, increased longevity, poor dietary habits, and the rising prevalence of metabolic syndrome and hypertension have increased the prevalence of gout. Gout significantly increases direct and indirect costs and reduces the quality of life. Allopurinol and febuxostat are the most commonly used drugs for reducing uric acid levels and controlling this disease with different cost-effectiveness. The present systematic review compares the cost-effectiveness of these drugs. Methods: This was a systematic review of economic evaluations. Cochrane CENTRAL, Web of Science, PubMed, Embase, and the Cost-Effectiveness Analysis (CEA) Registry were searched up to April 30, 2018, based on the specific search strategy of each database. Keywords used in the search include gout, cost-effectiveness, allopurinol, and febuxostat in MeSH and free-text forms. Screening of identified studies, data extraction, and quality assessment were done independently by 2 reviewers. The quality of studies was assessed based on Drummond Checklist. Finally, a qualitative analysis was done to analyze the results. Results: A total of 94 studies were identified through database search and the review of references. After screening the titles, abstracts, and full-texts, 6 economic evaluations were included in the review. The majority of the studies had been conducted in the US using the Markov model, within a 5-year horizon, and from the payer’s perspective, with the quality of life as a measure of effectiveness. In most studies, the incremental cost-effectiveness ratios (ICERs) of febuxostat per quality-adjusted life year (QALY) were below the threshold (10 000$/QALY and 30 000€/QALY). Conclusion: Febuxostat has been shown to be more cost-effective than allopurinol in all treatment sequences in studies that have used uric acid levels as the measure of effectiveness. Furthermore, in studies with the quality of life as the measure of effectiveness, febuxostat has been shown to be very cost-effective as the second-line treatment.

Thyroid lobectomy as a cost-effective approach in low-risk papillary thyroid cancer versus active surveillance

THU0341 Cost Effectiveness Analysis of Abatacept Compared with Adalimumab on Background Methotrexate in Biologic-Naïve RA Adult Patients by Anti-Cyclic Citrullinated Peptide-Positive Subgroups

This study compared the deep inferior epigastric perforator (DIEP) flap and the free transverse rectus abdominis myocutaneous (TRAM) flap in postmastectomy reconstruction using a cost-effectiveness analysis. A decision analytic model was used. Medical costs associated with the two techniques were estimated from the Ontario Ministry of Health Schedule of Benefits for 2002. Hospital costs were obtained from St. Joseph's Healthcare, a university teaching hospital in Hamilton, Ontario, Canada. The utilities of clinically important health states related to breast reconstruction were obtained from 32 "experts" across Canada and converted into quality-adjusted life years. The probabilities of these various clinically important health states being associated with the DIEP and free TRAM flaps were obtained after a thorough review of the literature. The DIEP flap was more costly than the free TRAM flap ($7026.47 versus $6508.29), but it provided more quality-adjusted life years than the free TRAM flap (28.88 years versus 28.53 years). The baseline incremental cost-utility ratio was $1464.30 per quality-adjusted life year, favoring adoption of the DIEP flap. Sensitivity analyses were performed by assuming that the probabilities of occurrence of hernia, abdominal bulging, total flap loss, operating room time, and hospital stay were identical with the DIEP and free TRAM techniques. By assuming that the probability of postoperative hernia for the DIEP flap increased from 0.008 to 0.054 (same as for TRAM flap), the incremental cost-utility ratio changed to $1435.00 per quality-adjusted life year. A sensitivity analysis was performed for the complication of hernia because the DIEP flap allegedly diminishes this complication. Increasing the probability of abdominal bulge from 0.041 to 0.103 for the DIEP flap changed the ratio to $2731.78 per quality-adjusted life year. When the probability of total flap failure was increased from 0.014 to 0.016, the ratio changed to $1384.01 per quality-adjusted life year. When the time in the operating room was assumed to be the same for both flaps, the ratio changed to $4026.57 per quality-adjusted life year. If the hospital stay was assumed to be the same for both flaps, the ratio changed to $1944.30 per quality-adjusted life year. On the basis of the baseline calculation and sensitivity analyses, the DIEP flap remained a cost-effective procedure. Thus, adoption of this new technique for postmastectomy reconstruction is warranted in the Canadian health care system.