Clinical Application - Economic Analysis Unit

(Cost-Effectiveness Studies)

A.Goal:

To be able to assess the applicability and validity of published economic analyses and to appropriately apply them to the care of individual patients, as well as to the development of clinical policies.

B.Clinical Scenario:

You are the resident on call for internal medicine and a patient Mr. Jones has just been admitted to your service. The emergency room attending has called you earlier about him and described him as having an uncomplicated right proximal deep vein thrombosis (DVT) confirmed by ultrasound.

Mr. Jones is a 54 year old male with no significant past medical history, who presented to the ED complaining of right lower extremity pain and swelling after a long cross-country train ride. He denies any previous history of a DVT or any family history of clotting problems. His physical exam is significant for a slightly swollen and tender right calf but is otherwise unremarkable. The patient is very eager to get home. The emergency room has started him on IV heparin and a PTT is pending. He has been away for over a week on vacation and he needs to attend to some very important business related issues. You suggest to him that there may be an alternative to staying in the hospital but that it wound entail him injecting himself at home twice a day, which the patient was willing to do.

After discussing the case with your attending, who was in agreement and stressed that LMWH is safe and efficacious, you decide to start him on coumadin 10 mg p.o. QD and start him on LMWH. Shortly after writing the order, however, the nurse pages you and explains that LMWH has been removed from the pharmacy because it was considered too costly. You explain this to Mr. Jones and reluctantly restart his heparin.

You feel confident however, that while the drug itself is costly its use would reduce hospital costs and reduce adverse events. You briefly discuss this with the medical director, who says it was removed because of its high costs but is willing to re-evaluate the situation if you can come up with evidence that it would save the hospital money. You decide to research the issue. You search MEDLINE using the search terms ‘DVT’ as an exploded MeSH and cross it with MeSH heading, ‘cost analysis’. You locate 8 articles, of which one constitutes a cost effectiveness analysis. You decide to present this paper to the next meeting of your division’s practice committee.

C.Teaching Scenario:

Outpatient Practice Committee made up of physician and nursing representatives of the Departments of Emergency Medicine and Internal Medicine charged with formulating clinical policies and pathways within the outpatient service. The OPC meets once a month.

D. References

Gould MK, Dembitzer AD, Sanders GD, et al. Low molecular-weight heparins compared with unfractionated heparin for treatment of acute deep venous thrombosis. Ann Intern Med 1999; 130:789-799.

Drummond MF, Richardson WS, O’Brien BJ et al. Users Guide to the Medical Literature. XIII. How to Use an Article on Economic Analysis of Clinical Practice. A. Are the results of the study valid? JAMA 1997; 277:1552-7.

O’Brien BJ, Heyland D, Richardson WS, et al. Users Guide to the Medical Literature. XIII. How to Use an Article on Economic Analysis of Clinical Practice. B. What are the results and will they help me in caring for my patients? JAMA 1997; 277:1802-6.

CRITICAL REVIEW FORM FOR ECONOMIC EVALUATION

Guide

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Comments

I. Are the Results Valid?

1.Did the analysis provide a full economic comparison of effective health care strategies?
a.Was a broad enough viewpoint adopted?
b.Were all the relevant clinical strategies compared?
2.Were the costs and consequences properly measured and valued?
a.Was Clinical effectiveness established?
b.Were costs measured accurately?
c.Were data on costs and consequences appropriately integrated?
3.Was appropriate allowances made for uncertainties in the analysis?
4.Are estimates of costs and consequences related to the base line risk in treatment population?

II. What were the results?

1.What were the incremental costs and effects of each strategy?
2.How much does an allowance for uncertainty change the results?
3.Do incremental costs and effects differ between sub-groups?

III. Will the results help me in caring for my patients?

1.Are the treatment benefits worth the harms and the costs?

2.Could my patient expect similar health outcomes?

3.Could I expect similar costs??

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