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Global Cardiovascular Strategies
PRIORITIZATION IN CARDIOLOGY. IMPACT ON GUIDELINES
Nina Rehnqvist, MD, Sweden
National Board of Health and Welfare, Stockholm, Sweden
Proceedings on 14th International Congress
THE "NEW FRONTIERS" OF ARRHYTHMIAS 2000
Cost-Effectivness of Healthcare
The third principle is that of cost-effectiveness. In this respect the health economist Alan Williams set the stage2-6. He introduced the term cost per life year saved (LYS) or quality adjusted life year (QUALY). Although the term QUALY is imprecise and immature and in need of improvement both these endpoints have been very useful in comparing different treatment methods. Alan Williams also introduced a “rule of the thumb” by stating that treatments costing less than 10000 dollars per LYS or QUALY are to be considered as cost effective and worth their value for improvement of quality of life or postponement of death. On the other hand measures costing more than 100 000 dollars will not be considered worth while at any stage. Hemodialysis is at the upper end of the grey zone in between. Clopidogrel for the prophylactic treatment of patients with unspecified atherosclerotic disease will in this context not be considered cost- effective in comparison to ASA as one extra life year has been estimated to cost 150 000 dollars.Hierarchy of Healthcare Prioritization
The prioritization hierarchy can be used both when priortizations are to be made “horizontally” i.e between different areas, (cardiac disorders versus kidney disease, arrhythmia-patients as a group vs angina pectoris-patients) or “vertically” i.e within an area (prophylaxis of death due to VF).Allocation of resources in the form of personnel, equipment and availability will perhaps be dealt with in a little more rational way if these considerations are made in advance and professionals working on the floor may feel a little less frustrated if such discussions are made in advance and in a democratic way. On the other hand much research and epidemiological work needs to be done to define needs in relation to demands and current supply.Clinical Guidelines
Much time and effort are presently spent on the production of clinical guidelines. When after much work finally produced they are not are always adhered to. The reasons for this has been dealt with in the EHJ7. Impact and implementation of guidelines is mainly due to the level of legitimity of the guidelines. This in itself is dependant not only on the contents and statements but also on how the production of the guideline has been processed, the composition of the working group and whether the guidelines actually have a bearing on reality and not an expression either of wishful thinking by patients and profession or on the other hand only cost-containment. Guidelines often contain decision trees and recommendations regarding methods for diagnosing and treatment. In these instances priorities are to be made. When considering diagnostics Baye´s theorem is an expression of need or rather probability. The test chosen should of course first of all be based on the pre- test probability, then on the sensitivity and specificity of the test complemented with cost effectiveness evaluations. When dealing with treatments cost effectiveness may be calculated as above, but before that, when it comes to horizontal prioritization, the second principle, that of the relative need must be taken into account.
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