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Journal of Clinical Oncology, Vol 25, No 6 (February 20), 2007: pp. 609-610 © 2007 American Society of Clinical Oncology. DOI: 10.1200/JCO.2006.08.8278
Cost Effectiveness in ContextDepartment of Family and Social Medicine, Albert Einstein College of Medicine, Bronx, NY In this issue of the Journal of Clinical Oncology, Woo, Kim, and Leung1 present an extensive and detailed analysis of the cost effectiveness of various approaches to cancer screening for women in Hong Kong. This article includes much more information than is typically reported in cost-effectiveness analyses in the medical literature, and the difference is worthy of both commendation and comment. A typical medical cost-effectiveness article considers only a single intervention in comparison to no intervention or to some representation of usual practice. Such an article typically presents a cost-effectiveness ratio and explicitly or implicitly concludes that the intervention is (or, less commonly, is not) sufficiently cost effective to warrant adoption. Another segment of the cost-effectiveness literature will examine a single intervention in varying degrees of intensity (typically frequency), and calculate the incremental cost-effectiveness ratio for each step-up in intensity. In either situation, the criterion of cost-effectiveness is either an arbitrary figure (often $100,000 or $50,000 per quality adjusted life year [QALY]) or is based on comparability to the cost-effectiveness ratios of practices believed to be widely in use. The problem with those approaches is that they ignore the context within which cost-effectiveness analysis is applied. Cost effectiveness analysis was developed to guide decision makers in the optimal allocation of a fixed budget of resources.2 The greatest health benefit can be extracted from a given budget by starting with the activity that has the lowest cost per QALY, and working one's way up the league table, adding the activity with the lowest remaining cost per QALY as far as one can go until the budget is consumed. The remaining activities cannot be undertaken without exceeding the budget or displacing other, more productive, activities. This is the approach taken by Woo et al.1 By performing these analyses using common assumptions and approaches, the rank ordering of the programs they suggest is more reliable than one deriving from a league table filled in from numerous, separate single-intervention analyses.3 The underlying concept that available resources are limited by a budget is necessary for cost effectiveness to be truly meaningful. If unlimited resources are available, why should one even consider cost—everything that offers even minimal benefit would be done. Cost takes on its meaning as a concept in the context of having to make choices. Indeed, economists define costs in terms of lost opportunities: the opportunity cost of choosing A is the value of the next most valuable alternative, B, which must be foregone to have A.4 If resources are unlimited, we can always have it all and there is no opportunity cost attached to anything we do. The commonly held notion that an intervention can be considered cost effective, and therefore should be adopted, if its cost-effectiveness ratio is similar to that of other interventions commonly used, or falls below some stipulated threshold is fallacious. Except in the rare event that the intervention produces net savings in addition to improving health, the conclusion of a full analysis would be that the league table must be reconstructed, with the analyzed intervention in its appropriate position, and a new allocation of the budget made. If this leads to the conclusion that the newly analyzed intervention should be adopted, then it also leads to the conclusion that some other activity must be abandoned to stay within budget. To fail to report this second conclusion is to conceal half of the results. Woo et al1 embrace the framework of the fixed budget and provide a complete analysis of how it should be spent. They appropriately abstain from concluding that some activities are, or are not, cost effective. Rather, they set out lists of the most effective combinations of women's cancer screening activities that can be encompassed within current and hypothetically increased spending levels. Their results are derived specifically from local cancer epidemiology, and the budgets they consider are derived from local expenditure patterns; so the specific screening recommendations apply only to Hong Kong. But, the overall approach is generalizable, and analogous conclusions would likely be reached in other situations as well. For example, they demonstrate that the same amount of money currently being spent on cancer screening in Hong Kong could reap more than twice as many life-years were it allocated more systematically. This is likely to be true in much of the world, especially the United States. Here, as in Hong Kong, there is no systematic approach to cancer screening. Screening practice is the result of decisions made by individual physicians and patients, complicated by access issues for some population segments. The physicians and patients may harbor vague or seriously inaccurate ideas about both the costs and benefits of the available cancer screening tests. Their decisions are also subject to the influence of publicity about the health of famous people,5 or marketing campaigns. In short, there is little or nothing in our environment that encourages us to expend our resources optimally and much that propels us in the opposite direction. Why do we not see more publications like the article by Woo et al? I see several reasons arising from different sources. First, because this article had to do cost-effectiveness analysis for three different interventions under a variety of scenarios, it is an order of magnitude more work to produce than the typical single-intervention analysis. With single-intervention articles well-received in the medical literature and the perception among academics that there is more career value to publishing several adequate articles than one outstanding one, there is little incentive to undertake the extra effort.6 It is probably not just a coincidence that the analysis by Woo et al, constituted part of the lead author's doctoral studies. Second, many cost-effectiveness analyses are carried out or sponsored by the health care industry, an industry that seldom perceives as an advantage comparative research that would lead to one product's being displaced by a competing product. Witness how few comparative drug-effectiveness trials are carried out, notwithstanding the pressing need for such comparative information in clinical practice. The industry, understandably, prefers to convey the message that we can produce more health if more dollars are made available. This links with the third—and I think most important—reason we see so little of this type of research. In the Western World, we have operated for many decades as if there are no limits to health care spending. Whether measured as dollars per capita or percent of gross domestic product, the health care sector of our economy has enjoyed sustained, roughly exponential growth since the end of World War II.7 Despite numerous policy initiatives aimed at constraining this growth, only brief periods of deceleration have been achieved. The many reasons for this are beyond the scope of this editorial. But let us not forget that the illusion of unlimited resources is, in fact, an illusion. For example, manpower, materials, and facilities dedicated to carrying out frequent prostate-specific antigen testing in men are resources made unavailable for extending cervical Pap smears to women who currently are not getting them. And, if at some point we manage to do both these things concurrently, the additional resources to accomplish that will be siphoned away from some other potentially useful activity, within or outside of health care. Our health care payment system goes to great lengths to obscure these real costs, but it does not actually eliminate them. Nobody knows how long this pattern of spiraling health care costs will continue. There is no theoretical or empirical basis for identifying a maximum acceptable level of health care spending. At some point, health care services begin to crowd out other important components of the economy. A sign of this is the growing numbers of employers who are reducing or eliminating their employees' health care benefits. In some industries, the cost of providing employee health care is said to be a major contributor to relocating manufacturing abroad. The sooner we get accustomed to analyzing how to most effectively spend our health care dollars, the easier it will be to adjust when the era of ever-increasing spending levels eventually ends. Even if fixed health care budgets will not come soon, analyses like those by Woo et al can still guide us to improved health care. If we take the current expenditures (plus projected increases, assuming the trends of the recent past continue) as a given, full-context cost-effectiveness analyses could help us use these same dollars to greater effect. We should not pass up this opportunity. AUTHOR'S DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The author indicated no potential conflicts of interest. REFERENCES
1. Woo PPS, Kim JJ, Leung GM: What is the most cost-effective population-based cancer screening package for Chinese women? J Clin Oncol 25:617-624, 2007 2. Gold MR, Siegel JE, Russell LB, et al: Cost Effectiveness in Health and Medicine. New York, NY, Oxford University Press, 1996, pp 26-53 3. Brown ML, Fintor L: Cost-effectiveness of breast cancer screening: Preliminary results of a systematic review of the literature. Breast Cancer Res Trt 25:113-118, 1993 4. Fryback DG, Craig BM: Measuring economic outcomes of cancer. J Natl Cancer Inst Monographs 33:134-141, 2004 5. Hankey BF, Miller B, Curtis R, et al: Trends in breast cancer in younger women in contrast to older women. J Natl Cancer Inst Monographs 16:7-14, 1994 6. Angell M: Publish or perish: A proposal. Ann Intern Med 104:261-262, 1986 7. Iglehart JK: The American health care system: Expenditures. N Engl J Med 340:70-76, 1999
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Copyright © 2007 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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