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Chapter 2: Making Decisions in Health Care
2.1 Some Basics:
- Who should do what, to whom and with what health care resources?
- These questions will be made whether they are based on evidence, analysis and explicit
social values within an accountable process, or they are implicit decisions based on what
was done before or gut feelings
- Informing decisions in health care requires a careful distinction between questions of fact
(what are the effects likely to be including what will be give up) and questions of social
value (which effects should count and how should they be measured and valued)
2.2 Informing Health Care Choices:
- Most contexts decisions about health care are made on behalf of others
- The cost of providing a service or intervention to these patients will fall to others
- Additional costs are resources that are no longer available to offer effective care that
would benefit others with very different health care needs
- Thinking about how social choices ought to be made
o Health care questions pose stark questions about social choice
 Real question is often who gets to live a little longer and who is to die a
little sooner than they otherwise would
- Decisions in health care should be subject ot the greatest possible scrutiny by a range of
stakeholders and inkling patient groups representing those who can benefit from the
o Also need to include clinicians concerned that there is access to the range of
interventions that can improve the health of patients they are responsible for
- Also includes manufactures of drugs and devices
o Concerned about the prices they can achieve for their products and the returns
they can expect from future research and development
- Relevant stakeholders also include those with responsibility for the patient with
legitimate claims on health care resources beyond the immediate beneficiaries
o Hospital admin, administrators of health care plans, reimbursement authorities,
and national ministries of health
- Wider society also has a stake in these decisions
o Decisions are made in a way that is fair to all those eligible to make a claim on the
resources of the health care system
 All are potential future patients
o Those ultimately responsible for health care provision by directly raising and
allocating tax revenue or by setting the rules for how a private or social insurance
health care system function are representing social values
 What health care can and cannot be provided to whom
- Patients unlike consumers are not in a positions where they know that type of health care
is needed
- Patients don’t know what the benefits are likely to be
o They rely on specialist expertise
 To diagnose, advise, and to help select alternative courses of action
o Clinicians act as agents for patients
- Asymmetry of information between patient and clinician and limited opportunities for the
patient to find out if they have been well or poorly supervised
o Agency relationship is not perfect and there is conflict between the patient and
- Even with no conflict the clinicians may not necessarily be best placed to identify and to
synthesize all relevant evidence and to undertake the computation required to fully assess
all the effects of alternatives
- Even if assessments were possible with perfect agency
o The benefits of the alternative interventions at the point of care would be
o Individuals also face uncertainty about when and what type of health care might
be needed
 Incur a risk of potentially catastrophic costs associated with it
 This is why there is always some form of insurance
o Once insured much or all of the cost will fall on another
when at the point of choosing between alternatives
- Economic evaluations often inform decision taken on behalf of others by those with
responsibility for other patients as well as the immediate beneficiaries
- Even when there’s no restriction decisions will increase of costs of social or private
o An increase in the cost of health care will also reduce access and health outcomes
for others
- Whether or not these indirect health effects of increased health care costs are of
concerned depends on whether one believes that the value of the health effects is fully
reflected in these individual choices about whether to pay the higher cost
o If they believe that health is lost is forgone because it is less valuable than the
increase in cost but the health that is gained by incurring these additional costs is
gained because it is more valuable
- Economic evaluations are also useful to clinicians when advising patients about
appropriate treatment at the point of care
o And when individuals are choosing a health insurance plan
- Economic evaluations offer an organized consideration of the range of possible
alternative courses of action and the evidence of the likely effects of each
o Scientific judgements needed to interprets evidence
- Not about the changing the decisions that are ultimately made but about changing how
these decisions are made
2.3 Requirements for Economic Evaluation
- Requires a comparison of two or more alternative courses of action while considering
both inputs (costs) and outputs (consequences) associate with each
- Outcome description, cost description and cost-outcome description only look at a single
course of action
o Are missing the comparative component
- Partial evaluations only looking at either cost or consequences for 2 courses of action are
o Randomized trials or cost analyses
o Efficacy or effectiveness evaluation’s or cost analysis
Which Alternatives Should Be Compared?
- Need to identify the possible alternative courses of action that could be taken to improve
the health of patients who find themselves in a particular situation
o Patients with a particular diagnosis, at a specific stage of disease, and after
treatment with other interventions
- Need to compare interventions that are mutually exclusive
o Either/or decision
- In many situations an intervention can be offered in combination with others
o Question is then in what sequence or where it should be offered with others
currently available
o Relevant comparison between alternative strategies
- Different decisions about which alternative to offer can be made for different types of
patients who may have the same condition or indication but where the effects of the
intervention are likely to differ
o There will be a number of subgroups of patients where the effects of the
intervention are likely to differ and for which different decisions about the use of
an intervention can be made
o Relative alternatives to compare are the mutually exclusive alternatives within
each subgroup not comparison between subgroups
- One important alternative is existing care
o But need to consider if existing care is the best that could be done in the absence
of the intervention being compared
o Without considering the other alternatives that are available may wrongly
conclude that a new intervention is worthwhile just because it’s better than a
costlier less effective alternative than others available
- Relevant alternatives include all those that have some possibility that they might be
- Might also be restricted by the responsibilities of a particular decision maker
What evidence is currently available?
- Much of this evidence is drawn from the results of clinical studies usually randomized
clinical trials
- It would be wrong to select a single clinical study to estimate the likely effects when
other relevant evidence is available
- Economic evaluation can be conducted alongside or within a single clinical study
- Most the time look at several relevant studies, several alternative to compare, a selection
of different types of evidence required from different types of studies to estimate the
longer-term effects on health and costs
- Systematic approach to searching for published evidence is need so that the evidence
used is not selected in a potentially biased way
- Results from relevant studies must be extracted, interpreted, and then combined or
synthesized to provide estimated of the key parameters required to estimate expected
- Methods of meta-analysis are well developed and introductory guides to their use and
interpretation of methods are available
- Economic evaluation provides a means to bring together and to make best use of the
published results of clinical studies and other relevant evidence through systematic
review and meta-analysis
What perspective should be adopted?
Which costs and consequence should count and how they should be measured and
valued, depends to a large extent on which of the many different types of decision makers
in health care is intended to be informed by the evaluation
- Potential decision makers:
o Individual patients and their clinicians
o Those with a wider responsibility for other patients beyond the immediate
 Hospital admin, admin for health care plans, ministry of health
o Those ultimately responsible for health care provision
- Alternatives that might appear attractive from one perspective may not be from another
- One pragmatic answer is the perspective of those who commissioned or who are intended
to be informed by the analysis
- Focus should be on the decisions that are within their remit and the costs and
consequences that are relevant to them
- But need to think about which perspective inform he social choices
What will be given up as a consequence of additional cost?
- To decide whether the additional benefits offered are sufficient to justify any additional
costs depends critically on the value of what is given up by others as a consequence
o The opportunity cost
- To conl