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i need two short papers. Read the attachment articles they are 2 and write a 300 to 500 word critique, reflection, insight, etc. Your analysis is expected to be well thought-out, with supporting rationale and documentation. DO NOT MERELY SUMMARIZE THE ARTICLE. I am looking for your thoughts and comments about the reading, what that was most important or relevant to you or your work and how it can be applied to your career in health care management. Include links/references to any resources that you used in researching your submission .PLEASE DO NOT WRITE ANYTHING FROM THE INTERNET DON’T QOUT ANYTHING FROM ANY OTHER ARTICLE .The deadline is 15 hours from now.


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Hill BMC Medicine 2012, 10:10
Open Access
Cost-effectiveness analysis for clinicians
Suzanne R Hill
In a climate of economic uncertainty, cost
effectiveness analysis is a potentially important tool
for making choices about health care interventions.
Methods for such analyses are well established, but
the results need to be interpreted carefully and are
subject to bias. Making decisions based on results of
cost-effectiveness analyses can involve setting
thresholds, but for individual patients, there needs to
be disaggregation of benefits and harms included in
a quality adjusted life year to ensure appropriate
consideration of benefits and harms as well as
personal preferences and circumstances.
The current economic news is bad. Expenditure on
health care is under scrutiny in every country and with
predictions of another economic crash comes pressure
on the funding of health care systems – systems that,
according to the World Health Organization http:// are meant to
deliver quality service to all people, when and where
they need them.
At the same time, new products – pharmaceuticals,
diagnostic tests, new technologies – continue to be
developed and launched. Health care systems are under
pressure to pay for all of the potential hope that these
provide, sometimes with good reason, sometimes without. This is where cost-effectiveness analysis comes in.
In 1990, Detsky and Naglie [1] published one of the first
guides to cost-effectiveness analysis for clinicians. As
they described it, cost-effectiveness analyses compare
the costs and outcomes for a new intervention with an
existing alternative treatment, strategy or intervention.
The two questions such analyses aim to answer are:
how much does the new intervention cost compared
Correspondence: [email protected]
World Health Organization, 20 Ave Appia, Geneva 27, Switzerland
with current practice and is it more effective, and if so,
how much more? The results of these analyses are presented as additional cost per additional benefit, that is,
additional dollars per unit benefit gained. This is the
incremental cost effectiveness ratio (ICER). Benefits can
be expressed as different outcomes: as change in a physiological or biological unit of measurement (for example, change in glycated hemoglobin (HbA1c)), difference
in lives gained (Life Year Gained, LYG), or differences
in quality adjusted life years (QALY). The choice of the
outcome depends on what data exist that can be used in
the evaluation and whether a mathematical model can
be developed that simulates the course of the disease or
condition and its effect on the quality of life. Inputs into
these models are usually derived from multiple sources,
including clinical trials, observational studies and routine databases, to name just a few. The degree of uncertainty associated with the primary source of information
will contribute to the uncertainty about the results from
the model.
The results of cost-effectiveness analyses should provide the same information as that used for making decisions about any purchasing choice in every day life. If a
new strategy or potential purchase is more effective and
costs less than the currently available option, it is almost
certainly worth doing. Likewise, if the new strategy is
less effective and more expensive, no one is likely to buy
it. However, the more usual outcome of a cost effectiveness analysis of a health technology is that the new
technology may be more effective, but costs more. The
judgment that then needs to be made is whether the
benefit obtained is worth the cost and how certain we
can be about that assessment.
A quick literature search suggests that if the number
of publications is an indicator of public interest, then
answering these questions is a key concern of health
care policy makers. A random selection of topics for
such analyses range from the evaluation of different
strategies for lipid lowering [2] to the use (or not) of
radiological evaluation of bronchiolitis in children [3];
from the use of surgical options in the treatment of
chronic back problems [4] to the use of pharmacogenetic tests to manage anticoagulation [5]. Health
© 2012 Hill; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (, which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
Hill BMC Medicine 2012, 10:10
technology assessment authorities, organizations making coverage decisions, and clinical guideline producers
are the ‘consumers’ of these publications. There has
been considerable debate about the reliability of the
versions published in journals. Udvarhelyi et al. [6]
published one of the first critiques of published costeffectiveness analyses in 1992, pointing out the problems with published analyses compared to optimal
methods and since then many authors have identified
problems with bias in evaluations [7-10]. As the analyses are often conducted by commercial entities, the
results may favor the product owned by the sponsor
[11-15] but there are also more simple problems
regarding the calculations. Translating a change in
blood pressure into survival gains and then quality
adjusting them requires translation, extrapolation and
mathematical modeling and can go wrong anywhere in
the equations. In the end, the estimate of the size of
the effect of the intervention, however expressed, is
one of the main determinants of the outcome of the
model, so it needs to be examined closely.
To ensure robust analyses and reliable results, those
interested in conducting them have defined methods
and checklists that specify the gold standard for methods for cost-effectiveness evaluations [16-18]. However,
there are still challenges in applying the results of an
analysis to decisions. For decisions that apply to a public
health care sector, ‘thresholds’ for ‘acceptable’ cost-effectiveness estimates, that is, a specified value for the ICER,
have been suggested by the World Health Organization
(WHO) and used by organizations such as the National
Institute for Health and Clinical Excellence (NICE) in
the UK, and have also been hotly debated [19-22]. One
crucial problem with thresholds is how to set them and
how to apply them. Values and preferences of communities are much more difficult to determine or quantify,
but may have greater weight in choices about health
care, particularly in tax-payer-funded systems.
One challenge in interpreting and applying the results
from cost-effectiveness analyses is the difference
between the value of an intervention for the population
and the value for an individual patient. For a clinician,
the response and cost and benefit from a particular
intervention for an individual patient may not be well
represented by a cost-effectiveness ratio from a population. Ioannidis and Garber [23] point out that cost-effectiveness estimates, particularly those that express the
results as incremental cost per QALY, combine several
different outcomes in the ‘QALY’, including estimates of
benefits and harms that may mean quite different things
for different individuals. Differences in background
health, a person’s aversion to risk, or their personal circumstances are likely to have a significant effect on how
an individual interprets the tradeoff between benefits,
Page 2 of 3
harms and costs, and thus chooses between treatment
strategies. The solution suggested by Ioannidis and Garber is to ‘individualize’ the ICER by presenting a per
person benefit in QALYs expressed as days, a ‘per person cost’ as well as evaluating subgroup responses
within populations to allow estimates of variance within
the ‘average’ ICER, to match an individual to a population that may be more or less likely to benefit. It would
be interesting to test this approach in real life – personalized medicine based on personalized health economics.
A new discipline to develop, to satisfy the needs of individual patients and clinicians, as well as payers and politicians simultaneously!
Methods for cost effectiveness analysis are well established, but published analyses need to be interpreted
carefully. For clinicians, disaggregating the benefits and
harms incorporated into estimates of QALY may inform
judgments about use of health interventions for individual patients.
Author information
The author was a staff member of the World Health
Organization and is now Chair of the Australian Pharmaceutical Benefits Advisory Committee. She alone is
responsible for the views expressed in this publication
and they do not necessarily represent the decisions, policy or views of the World Health Organization or the
Department of Health and Aging, Australia.
HbA1C: glycated hemoglobin; ICER: incremental cost effectiveness ratio; LYG:
life year gained; NICE: National Institute for Health and Clinical Excellence;
QALY: quality adjusted life year; WHO: World Health Organization.
Authors’ contributions
The author is the sole author of this manuscript, and prepared and
approved the final version.
Competing interests
The authors declare that they have no competing interests.
Received: 12 October 2011 Accepted: 1 February 2012
Published: 1 February 2012
1. Detsky AS, Naglie IG: A clinician’s guide to cost-effectiveness analysis. Ann
Intern Med 1990, 113:147-154.
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Lightwood J, Williams L, Goldman L: Comparing impact and costeffectiveness of primary prevention: strategies for lipid-lowering. Ann
Intern Med 2009, 150:243-254.
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Ungar WJ: A cost effectiveness analysis of omitting radiography in
diagnosis of acute bronchiolitis. Pediatr Pulmonol 2009, 44:122-127.
4. North RB, Kidd D, Shipley J, Taylor RS: Spinal cord stimulation versus
reoperation for failed back surgery syndrome: a cost effectiveness and
cost utility analysis based on a randomized, controlled trial. Neurosurgery
2007, 61:361-369.
Hill BMC Medicine 2012, 10:10
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Eckman MH, Rosand J, Greenberg SM, Gage BF: Cost-Effectiveness of using
pharmacogenetic information in warfarin dosing for patients with
nonvalvular atrial fibrillation. Ann Intern Med 2009, 150:73-83.
Udvarhelyi IS, Colditz GA, Rai A, Epstein AM: Cost-effectiveness and costbenefit analyses in the medical literature. Are the methods being used
correctly? Ann Intern Med 1992, 116:238-244.
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conflict of interest in economic analyses of new drugs used in oncology.
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Baker CB, Johnsrud MT, Crismon ML, Rosenheck RA, Woods SW:
Quantitative analysis of sponsorship bias in economic studies of
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The pre-publication history for this paper can be accessed here:
Cite this article as: Hill: Cost-effectiveness analysis for clinicians. BMC
Medicine 2012 10:10.
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Cost-effectiveness Analysis in Clinical Practice
The Case of Heart Failure
Michael W. Rich, MD; Robert F. Nease, PhD
eart failure is the leading cause of hospitalization in adults older than 65 years, and it is
currently the most costly cardiovascular disorder in the United States, with estimated
annual expenditures in excess of $20 billion. Recent studies have shown that selected
pharmacological agents, behavioral interventions, and surgical therapies are associated
with improved clinical outcomes in patients with heart failure, but the cost implications of these diverse treatment modalities are not widely appreciated. In this review, a brief outline of costeffectiveness analysis is provided, and current data on the cost-effectiveness of specific approaches to
managing heart failure are discussed. Available evidence indicates that angiotensin converting enzyme inhibitors, other vasodilators, digoxin, carvedilol, multidisciplinary heart failure management
teams, and heart transplantation are all cost-effective approaches to treating heart failure; moreover,
some of these interventions may result in net cost savings. Arch Intern Med. 1999;159:1690-1700
Heart failure affects an estimated 4.9 million Americans, and approximately
400 000 new cases are diagnosed each
year.1,2 In 1995, there were 872 000 hospital admissions attributed primarily to
heart failure, and there were an additional 1.8 million admissions with heart
failure as a secondary diagnosis.2,3 Approximately 80% of all heart failure admissions occur in individuals older than
65 years, and one fifth of all admissions
in that age group have a primary or secondary diagnosis of heart failure.2,3 As a
result, heart failure is the leading indication for hospitalization in older adults.1-3
From 1980 through 1993, the number of physician office visits for heart failure increased by 71%, from 1.7 million to
2.9 million annually.2 In addition, more
than 65 000 patients with heart failure receive home health care each year.2 Moreover, in 1995, heart failure was listed as
the primary cause of death in more than
43 000 cases and as a contributory cause
in an additional 220 000 cases,1,2 and more
than 90% of heart failure deaths occurred in patients older than 65 years.4
From the Geriatric Cardiology Program and the Division of General Medical Sciences,
Barnes-Jewish Hospital, Washington University School of Medicine, St Louis, Mo.
Because of its high prevalence and associated high medical resource consumption, heart failure is now the single most
costly cardiovascular illness in the United
States, with total costs for 1998 estimated at $20.2 billion.1 Remarkably, heart
failure hospitalization costs in 1991 exceeded those for all cancers and all myocardial infarctions combined.5 Moreover,
in contrast to recent declines in ageadjusted mortality rates from coronary
heart disease and hypertensive cardiovascular disease,6,7 the incidence and prevalence of heart failure are increasing, largely
owing to the aging of the population.8 As
a result, the costs of caring for patients with
heart failure are expected to escalate well
into the 21st century.
For these reasons, the last 2 decades
have witnessed a remarkable explosion in
heart failure research, and many new therapeutic options are now available. In addition, there has been considerable interest in
defining the costs associated with heart failure management and identifying those interventions that are most efficacious from
both the clinical and cost perspectives. In
this review, a brief discussion of costeffectiveness analysis is provided, followed by a summary of currently available
ARCH INTERN MED/ VOL 159, AUG 9/23, 1999
©1999 American Medical Association. All rights reserved.
Downloaded From: on 01/11/2019
data relevant to the costs of treating
patients with heart failure.
The goal of cost-effectiveness analysis is to estimate the monetary
cost required to achieve a gain in
health benefit. More specifically,
cost-effectiveness analysis estimates the incremental cost
required to improve a selected
clinical outcome by 1 unit (eg, cost
per year of life saved, cost per
stroke prevented).9,10 The goal is
not to define the greatest benefit at
the lowest cost, since in most cases
it will not be possible to achieve
both simultaneously.
Calculating the cost-effectiveness ratio requires estimating
the change in cost associated with a
given intervention (ie, the numerator of the ratio), as well as the
change in health benefit provided
by that intervention (ie, the
denominator of the ratio). The
notion of incremental costs and
incremental benefits is crucial for
cost-effectiveness analysis. Thus,
the question posed is often of the
form: “What is the monetary cost
of moving from intervention X to
intervention Y in relation to the
associated change in health benefit
in moving from X to Y?”
In estimating the cost-effectiveness ratio, cost is typically measured in dollars. Health benefit, however, may be expressed in a variety
of ways. In cost-benefit analysis, both
the costs and benefits are expressed in monetary terms (ie, the
cost outlay is compared with the
monetary value of the benefits obtained).11 Because it is often difficult to place a monetary value on a
clinical benefit (eg, how much is 1
year of life or 1 less stroke worth?),
cost-benefit analysis is used infrequently in the medical arena. When
a study measures health benefit in
disease- …
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