Prevention Treatments and Costs: To the Heart of the Matter
Cost-effectiveness considerations are an important factor for clinicians choosing between different treatments, according to an article by Aleksandra Torbica and Giovanni Fattore (both CERGAS and Department of Institutional Analysis and Public Management).
In Understanding the Impact of Economic Evidence on Clinical Decision Making: A Discrete Choice Experiment in Cardiology (Social Science & Medicine 70, 2010, 1536-1543, doi:10.1016/j.socscimed.2009.12.030) they conducted an experiment on a sample of 129 Italian cardiologists asking them to choose between paired scenarios presenting alternative treatments which differed in three key dimensions: the quality of clinical evidence (namely the number and size of favourable randomized clinical trials), the size of health gain (namely the reduction of relative and absolute risk) and the economic impact (namely the incremental cost-effectiveness ratio, which measures the cost of the treatment per life year gained). In particular, the cardiologists had to decide whether to adopt an innovative treatment to reduce the risk of cardiovascular mortality in a patient with specific characteristics. "The underlying assumption", the two scholars write in the article, "was that, faced with competing pieces of information on alternative treatments, clinicians perform trade-offs between them and choose the option they prefer".
The economic dimension was found to be extremely significant, especially for clinicians aged below 45 and for those with a good self-assessed level of knowledge regarding economic valuation techniques (a specific question was included in the form). "In the present study", Torbica and Fattore write, "achieving a very favourable cost-effectiveness ratio appeared to play a more important role in clinicians' decisions than improvements in the quality of clinical evidence through the results of larger clinical trials. Indeed, achieving a very favourable cost-effectiveness ratio appeared to be even more important than an increase in the size of health gain associated with the drugs under evaluation".
The authors concede that, since their sample included only Italian cardiologists and was referred to a very specific clinical situation, the generalizability of the results could be challenged, but they regard the situation depicted as a paradigmatic example of a more general trend in healthcare towards the use of medical treatments to reduce a large variety of risk factors.
Evidence from Italy, the authors assert, may help to understand the role of cost-effectiveness data in clinical decision making in a health system in which cost containment dominates both the policy and the management agenda, even though it has been less explicit than other countries' systems in endorsing economic criteria in policy making. The most part (70%) of the cardiologists in the sample agreed that economic analyses should be used more frequently in the field.
Since clinicians will always be the ones making decision at the patient level, the authors conclude, economic evaluations should be conceptualized and disseminated with clinicians and the clinical perspective in mind. A final concern is the quality of economic information: whereas the quality of clinical evidence is subject to a range of established quality-control mechanisms, the quality of economic evidence is still surrounded by considerable uncertainty and the field is in need of guidelines, peer-review mechanisms and effective dissemination products and activities.