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Research in Review

Cost-Effectiveness of Non–Guideline-Adherent Treatments Varies

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JCP Editors 


J Clin Pathways. 2017;3(1):10-15.

Treatment preferences that do not adhere to clinical guidelines may still be cost-effective, according to a series of recently published case reports.


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Patients preferences for treatment sometimes divert from recommended clinical practice guidelines. These diversions are frequently regarded as errors, although little study has been undertaken to determine the cost-effectiveness of acquiescing to patient preferences.

William V Padula, PhD, MSc, MS, assistant professor of health policy and management at Johns Hopkins Bloomberg School of Public Health (Baltimore, MD), and colleagues analyzed four cases in which patients’ treatment choices differed from guideline recommendations. These included a patient with a high suspected risk for cancer who preferred to forgo colonoscopy; a bedridden postsurgical patient who preferred to forgo the use of an air-fluidized hospital bed; an anemic patient who wished to forgo blood transfusion for religious reasons; and an extreme elderly patient with multiple chronic ailments who requested all resuscitative measures in the event of medical emergency.

The researchers created decision trees to determine the cost-effectiveness of each alternative treatment option, utilizing a $100,000 per quality-of-life-year (QALY) willingness-to-pay threshold. The decision trees considered cost-effectiveness from the patient, provider, and societal perspectives.

Results showed that forgoing colonoscopy did not provide a clinically meaningful change in effectiveness when compared with colonoscopy receipt (18.175 QALYs vs 18.174 QALYs). Conversely, the use of an air-fluidized bed resulted in greater effectiveness per hospitalization than the use of a regular hospital bed (16.293 QALYs vs 16.158 QALYs), leading the researchers to determine that the guidelines were preferable to patient-centered modifications.

The use of alternative management for anemia produced a greater cost-per-hospitalization than transfusion; however, because the incremental cost-effectiveness ratios did not exceed $100,000 per QALY in this particular case, the researchers deemed them cost-effective. However, because the cost of resuscitative measures exceeded the cost of palliative care in all domains, palliative care was deemed a more cost-effective approach, despite going against patient preference.

Padula and colleagues acknowledged several study limitations, including their reliance on retrospective data and existing literature to develop their case studies and decision trees. They further noted that because health utilities did not exist for each individual case, they relied on representative index scores to determine utilities.

“Ultimately, extensive investigation will be required to support current efforts of customizing guidelines for patient-centeredness,” the researchers concluded. “In cases where patients vocalize their own preferences for care that are not economically or medically beneficial, the medical community must ensure appropriate education and disclosure of the risks and benefits pertaining to various care options.” – Cameron Kelsall

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