Constrained Health Care Resources Research Articles

Integrating Economic Evaluation Methods Into Clinical and Translational Science Award Consortium Comparative Effectiveness Educational Goals

With the ongoing debate over health care reform in the United States, public health and policy makers have paid growing attention to the need for comparative effectiveness research (CER). Recent allocation of federal funds for CER represents a significant move toward increased evidence-based practice and better-informed allocation of constrained health care resources; however, there is also heated debate on how, or whether, CER may contribute to controlling national health care expenditures. Economic evaluation, in the form of cost-effectiveness or cost-benefit analysis, is often an aspect of CER studies, yet there are no recommendations or guidelines for providing clinical investigators with the necessary skills to collect, analyze, and interpret economic data from clinical trials or observational studies. With an emphasis on multidisciplinary research, the Clinical and Translational Science Award (CTSA) consortium and institutional CTSA sites serve as an important resource for training researchers to engage in CER. In this article, the authors discuss the potential role of CTSA sites in integrating economic evaluation methods into their comparative effectiveness education goals, using the Columbia University Medical Center CTSA as an example. By allowing current and future generations of clinical investigators to become fully engaged not only in CER but also in the economic evaluations that result from such analyses, CTSA sites can help develop the necessary foundation for advancing research to guide clinical decision making and efficient use of limited resources.

An introduction to pharmacoeconomic evaluation in rheumatology

AbstractPharmacoeconomics is a relatively new healthcare discipline that borrows from several disciplines including health economics, decision analysis and evidence‐based medicine. By using various techniques such as cost‐minimization analysis (CMA), cost‐effectiveness analysis (CEA), cost‐utility analysis (CUA) and cost‐benefit analysis (CBA), pharmacoeconomic evaluation attempts to instil the element of cost‐effectiveness into the clinical decision‐making process beyond the traditional approach of considering efficacy and safety. The ultimate aim of pharmacoeconomics is to assist the decision makers in achieving allocation efficiency in the healthcare system. This is in response to the increased need for accountability during the age of cost‐containment in healthcare. The rapidly increasing healthcare costs and the ageing of populations in the developed countries have contributed significantly to the need for consideration of effectiveness in the evaluation of any healthcare treatment, particularly in pharmaceuticals. The growth of this field has proceeded rapidly in the past decade as health policy makers have faced a continuing series of decisions about funding new clinical therapies in an era of increasingly constrained healthcare resources. However, economics of healthcare includes not just an assessment of the cost of a new therapy, but an assessment of its overall economic and clinical impact. The discipline of pharmacoeconomics is developed to fulfil this role. To date, the most successful applications of the principles of pharmacoeconomics are in the areas of purchase decision (e.g. decision for formulary inclusion), subsidy decision (e.g. level of subsidy for pharmaceuticals), establishing practise standards (e.g. development of clinical practise guidelines) and assessment of technologies (e.g. medical procedures and technologies). The proper application of pharmacoeconomic evaluation in clinical medicine would necessitate a multidisciplinary approach requiring expertise and inputs from practitioners from clinical medicine, biostatistics and psychometrics, among others. A properly conducted pharmacoeconomic evaluation would provide valuable insights for clinicians to allow the choosing of options representing the best value‐for‐money without compromising the quality of care delivered. The application of pharmacoeconomic principles in the practise of rheumatology will be illustrated using the example of a hypothetical example of evaluating an application for formulary inclusion of a COX‐2 inhibitor.

Impact of declining reimbursement and rising hospital costs on the feasibility of total hip arthroplasty

Total hip arthroplasty, although a very successful clinical treatment, remains an expensive procedure in an era of constrained health care resources. Hospitalization cost, charge, and reimbursement data were compared between all patients who underwent elective, primary, unilateral total hip arthroplasty in 1988 and 1993 at the UCLA Medical Center. Although length of hospitalization decreased by 36%, increases both in unit supply costs and in the intensity of hospital services prevented a statistically significant reduction in total hospitalization cost. Reimbursement declined by 27% after calculating inflation with the Consumer Price Index for Medical Care. Further, the margin by which reimbursement exceeded cost decreased from 66% in 1988 to 8% in 1993. These trends constitute a serious threat to the financial feasibility of total hip arthroplasty.

The impact of new clinical guidelines on the North American blood economy.

H UMAN BLOOD is a limited and perishable resource with high usage, high costs, and an extensive industry framed by increasingly constrained health care resources. More than 13 million units of whole blood are collected yearly in the United States, with components subsequent1y transfused to 3 to 4 million patients. I ,2 Approximately 12 million units of whole blood and red blood cells were transfused annually in the United States between 1982 and 1989. 3 The cost of collecting, processing, distributing, and transfusing blood products was estimated to be 1% of all health care expenditures in 1985 and $3.25 billion in 1987.3,4 In 1986, costs to patients of all transfused blood products was estimated at $4.5 to $7.2 billion. 5 Recent1y, traditional elinical ru1es for red blood cell transfusion have been questioned, and studies are current1y in progress to define more precisely the risks, benefits, and indications for transfusion. This research should lead to more specific elinical guidelines and likely a call for reductions in red blood cell transfusion and greater uniformity of elinical practice. The economic implications of new, evidence-based elinical guidelines are extensive.Thus, there is a need for a bridge between elinical science and health economics to make informed decisions for allocation of resources for patient care. Health economics, as a resource for informed decision making, rests on three basic concepts: scarcity, the need for choices, and opportunity costs. Scarcity refers to the fact that there are insufficient resources to satisfy all needs. As a re-