- Email: [email protected]
Cost-benefit analysis: a helpful tool for decision makers?
Health Policy,
4 (1985)
321-330
321
Elsevier
HPE 00032
Cost-benefit analysis: a helpful tool for decision makers? Rolf H. Dinkel* Member of the Management
Committee. (Accepted
HealthEcon
Ltd.. Health
for publication
Service Consultants,
21 February
Basle, Switzerland
1985)
Summary
Cost-benefit analyses (CBA) claim to be an important basis for decision makers who are interested in a cost-effective approach to health care. But despite an increasing frequency in the number of CBA there is growing concern about their usefulness as a decision-making tool. Predominantly methodological controversies spread confusion and block their user-oriented development. The present article identifies and discusses necessary amendments of CBA from a practical point of view to narrow the existing gap between claim and actual efficiency: consideration of differing interests of differing parties in the health care sector, inclusion of qualitative aspects of medical events and a change in the temporal orientation towards prospective studies. cost-benefit analysis; cost-effectiveness analysis; decision makers
Background Throughout the world, health services are experiencing a widening of the gap between available resources on the one hand and the increasing demand for health care-goods and services on the other (Fig. 1). Decision makers are thus faced with a growing need for decision-making aids to guide them in distributing the limited means
This paper is an extended version of a paper presented at the IIIrd Science in Health
Care, held at Munich,
* Address for correspondence: Switzerland.
Telephone:
0168-8510/85/SO3.30
Dr.
Rolf
International
Conference
on System
16-20 July 1984. H. Dinkel,
HealthEcon
Ltd.,
P.O.
Box 1510, CH-4051
0041/61/226640.
c 1985 Elsevier Science Publishers B.V. (Biomedical
Division)
Basle,
322
-f& ,.‘:.:.:.:.:.:.:.~.’ :: .: :. ::
Dantaf. sf!Nim?s
t;
iI :: :: :: :: :: .::.
~
Fig. 1. Competition for resources in the health care sector. Adapted from: Die direkten und indirekten Kosten von Krankheiten, K.-D. Henke, Hanover, 1983.
available amongst the competing programmes, projects and inte~entions. Economic science offers a suitable tool for this in the form of cost-benefit analysis (CBA). Several years ago, CBA was regarded as a mere “way of thinking”. Today, however, it occupies a secure place in the armamentarium of decision-making techniques at the disposal of the health services. CBA’s claim to this position is supported by a large number of theoretical publications dealing with the subject, as well as by a growing number of practical examples.
323
It has however remained largely unclear to date whether and to what extent this device is actually being utilised in planning and decision-making. That is to say whether and to what degree it is being allowed to do justice to its claim in practice. From the point of view of the potential users there appear to be weak points in the conception and implementation which considerably limit CBA’s effectiveness as a decision-making tool, or which even render it totally useless. These weaknesses are generally the result of CBA’s inability to adapt to the changing conditions. Theoretical deliberation and development has, in the majority of cases, concentrated on methodological problems of CBA [ 11. These, among others, concern the following issues: Costs arising from morbidity and mortality Inability to work because of temporary or permanent morbidity as well as because of premature death means loss of resources and productivity. Methodologies for estimating this loss must assign a monetary figure to the human life. In the ‘willingness-to-pay’ approach the value of life is determined by the amount an individual is willing to pay to avert morbidity or mortality. The ‘human capital’ approach estimates life as an economic commodity of which the value is measured in accordance with its inherent potential for producing goods or rendering services. This methodology identifies the time lost as a result of a medical event and values this time by estimating the employment earnings or the market values of the individual’s activities or output in the same amount of time. Both methodologies have generated considerable controversy owing to their inherent problems. Discount rates Most CBA employ the human capital approach to estimate the value of human life lost by morbidity or mortality. But since a simple summing up of future earnings overstates the present value of lifetime earnings, a discount rate is used to convert future earnings into its present value. Considerable controversy still takes place as to which rate is the appropriate one. Equality of human lives The human capital method values human life according to employment earnings. The question is under discussion if this approach potentially tends to undervalue the elderly and other persons not active in the workforce (e.g. housewives) and may result in distinctions of value of life between sexes and races. Consumption The equation between the value of life and productive output raises the question whether the potential consumption of goods and services should not be deducted from the future earnings when calculating the loss of productivity due to morbidity or premature mortality. Assumptions about future trends In addition, the human capital method requires assumptions
about future life
324
expectancy and work force participation rates. Since the figures chosen have a profound influence on the cost-results the discussion about the continuation of historical trends or their change is still a major issue in the context of the use of CBA. The outlined academic controversy on methodological problems has ignored the fact that conditions in the health service sector changed rapidly -we only have to think here of the increasing tendency towards regulation - and as a logical consequence the problems to be solved with the help of CBA changed rapidly, too. Therefore nowadays there are discrepancies between claims and actual efficiency of CBA. The aim of this paper is to describe three of these “trouble spots”: the spheres of interest, the content, and the temporal design of CBA. These “trouble spots” pinpoint those areas towards which efforts for further development of CBA should be directed.
Spheres of interest of CBA
Historically speaking, the first demand for CBA came from public administration. Nowadays, particularly in the health service sector, the parties interested in CBA, cover a broad spectrum (Table 1): - government authorities and politicians in general require guidance when allocating budgets for preventive and curative medicine, ambulatory or in-patient treatment, etc.; - health insurance schemes and other third-party payers require guidance when deciding which health-care goods and services to admit to reimbursement lists; - hospitals and medical practitioners require guidance when deciding whether to extend or to restrict their arsenal of therapeutic measures; - media and general public require information referring to efficacy and efficiency of true or claimed therapeutic innovations. The diversity of these interested parties has entailed a differentiation of the viewpoints involved in the evaluation of therapeutic measures. For a long time, it was the viewpoint of society as a whole which was accepted as decisive, whereas nowadays the individual parties involved are making their positions more and more strongly felt. The decision makers’ primary interest is in the effects on their own expenses and revenues. “Costs” and “benefits” mean something different for each party involved
[a These varying aspects become very clear when we consider the example of hospitalisation in the Federal Republic of Germany [3] (Table 2). For theparienr, a stay in the hospital involves a self-retention cost of DM 5 per stay for the first 2 weeks. In addition to this come any expenses or losses incurred either privately or professionally which are not reimbursed by a third party (e.g., supplementary insurance premiums). The cost for the health insurance scheme consists of the amount it is contractually obliged to pay to the hospital. This is, nowadays, the daily hospitalallowance, which is a flat rate irrespective of the actual cost of treatment for the patient in question. The costs as far as the hospital is concerned are the effective running costs, which
325 TABLE
1
PARTIES IN
THE
INTERESTED
HEALTH
IN
SERVICE
CBA SECTOR
GOVERNMENT AUTHORITIES,POLITICIANS
Allocation of budgets for competing
HEALTH INSURANCE AUTHORITIES Admission
of health
care goods and services
to reimbursementlists
HOSPlTALS, MEDICAL pERsolr(NEL Extensionor restriction of therqxutic measures
Assessment of true or claimed therapeutic innovations
326 TABLE 2
DIFFERENT PERSPECTIVES OF IN-PATIENT
ON COSTS
CARE
(FEDERAL REPUBLIC OF GERM/WY
1983)
Patient * s costs - 5 DM deductible for the first two weeks - Uninsuredprivate and professional expenses Statutory health insurancescheme ?? s costs - Average hospital allowance : All hospitals : University clinics
DM 207.DM 360.-
Hovital * s costs - Runningcosts : : :
Personnel costs Non-personnelcosts Interest on credits
Society‘s costs - Runningcosts of hospital - Investment expenses of hospital - Loss of productivity for the economy due to illness of patient
327
according to the current system of hospital financing comprise: personnel costs, non-personnel costs, and interest on working capital credits. Not included in these costs are investment expenses since these are met by the Federal Government, the individual Federal States, the municipal authorities, etc. costs cover a variety of areas. These As far as society as a whole is concerned, include, over and above the effective running costs of the hospital, investment expenses since these must be met by society in the form of fees and taxes. In addition, society must bear costs in the form of the loss of productivity that is suffered by the economy as a result of the hospitalisation of an employed person or housewife. The willingness to introduce a new therapy merely because it is profitable in macro-economic terms is decreasing. Those involved are increasingly competing for the limited means available. It is clear that one interest group can only win when another loses: each gain is at someone else’s expense. Against this background, it is easy to understand why surgery is still carried out in cases where pharmaceuticals are more efficient, or that patients are still kept in hospitals at great expense when a cheaper method of home treatment is available [4]. Thus, CBA can no longer evaluate new therapies purely from the perspective of society as a whole. In view of the struggle among those concerned for the resources available, CBA can only be a reliable decision-making tool when: - every interest group affected by a decision is identified, and - the cost-benefit differential is made clear for each of the parties in question. When the terms “cheap” and “expensive” are used with respect to public health services, they are meaningless unless it is also explained for whom something is “cheap” or “expensive”. This necessity can be illustrated by a practicalexample (Table 3): a cost-comparison study of parenteral nutrition in the hospital and at home in the Federal Republic of Germany came to the conclusion that parenteral nutrition in the hospital is cheaper from the viewpoint of the health insurance scheme,, whereas parenteral nutrition at home is economically more advantageous from the point of view of society as a whole. Above all, a CBA graduated in accordance with the interest groups involved offers the decision maker (e.g., government authorities or other third-party payers) the opportunity to recognise areas of potential resistance in the health service system to a new technology. By means of appropriate measures, for example by introducing incentives or prohibitions, ‘the decision maker can ensure that the potential for cost savings is in fact realised.
Content of CBA The content of a CBA is not standardised. The question as to which and how many criteria should be included in an analysis can only be answered in very general terms: as many as possible to ensure that no relevant effects are overlooked [5]. This principle of CBA has not, however, always been followed in practice. It has been far more often the case that an effect has been included or omitted according to whether or not it could be quantified. Against the background of changing goals in the health service sector, this tendency is becoming increasingly more questionable.
328
329
Until today the extension of life expectancy has been given priority, but now that the theoretical limits of life expectancy are being approached the aim of enhancing the quality of life is gaining in importance. Today one aims at reducing limitations on mobility, easing pain, and eliminating discomfort, in short: establishing health in the sense of “effective functioning”. A CBA that is restricted to the quantitative measurement of days in hospital, reductions in cost or in the number of years of life saved must necessarily fail to assess whether and to what extent a new therapy contributes to qualitative aspects of life. In order to accomplish this goal, it is necessary to include additional social and medical criteria which are difficult to express in quantitative terms [6]. Purely economic or quantitative considerations give only limited information in the case of modern therapeutic measures and objectives. CBA require a global index which includes all the dimensions of an illness and which can adequately measure not only the state of health, but also any changes therein [7]. If it is not felt to be desirable to take this course towards a one-dimensional formulation, then it is more honest at least to list the negative and positive social and medical effects for the decision maker before they are ignored altogether.
Temporal design of CBA The concept of “planning” has to date been far from common in the health service sector. Among other things, the so-called “cost-explosion” has demonstrated the fact that up to now planning has been neither serious nor carried out in accordance with the rules of the art. Any attempts made towards a conscious design for the future have mostly been outstripped by events. The parties involved have been left with the task of dealing with the resulting situation. This absence of planning is reflected in the temporal orientation of previous CBA. The majority of these are not prospective, but retrospective analyses. They have been concerned with projects that have already been carried out and programmes that have already been introduced. Their prime objective, therefore, has been tojustify developments which have already taken place, rather than to serve as a basis for decisionmaking. If CBA wants to do justice to its claims of being a decision-making tool, it must not be restricted to retrospective analysis, but must be carried out prospectively and completed before new therapies are brought onto the market. This requirement applies above all to new therapeutic measures (whether medicinal or technological) which: - have a comparatively high product price, and/or - are aimed at large groups of patients, and/or - replace a traditional therapy. One possible solution to this problem lies in linking CBA to clinical trials. Today, these trials are still restricted to gathering information concerning the effects, efficacy and safety of a new therapy. In the future, the study protocol should be designed to also provide the information necessary for a CBA at the same time. This is possible for both quantitative and
330
qualitative information: number of days in hospital, loss of working time, utilisation of other medications and services, and aspects of the quality of life. One major condition for this combined study is the elimination of the barriers which still exist today between physicians and economists by means of interdisciplinary co-operation in carrying out studies and analysing their results. Without doubt, combined studies of this kind have their limitations. The study takes place “in vitro” and deviations from the later “in vivo” situation of daily practice are inevitable. None of these limitations should, however, prevent such studies from being carried out. They are indispensable if CBA is not to degenerate into a mere theoretical mental exercise, but to remain a “helpful tool for planning and decision-making”.
References Pharmaceutical Manufacturers Association. Use of beta blockers in the treatment of angina: a costbenefit study. Arthur D. Little, Inc., Washington, 1984. Smith, G.T., Measuring the social benefits of medicine, Office of Health Economics, London, 1983. Dinkel, R.H., Parenteral nutrition in different settings: results of an economic study, International Journal of Technology Assessment in Health Care, 1 (1985) 2. Culyer, A.J. and Horisberger, B. (eds.), Economic and medical evaluation of health care technologies, Springer-Verlag, Berlin-Heidelberg-New York-Tokyo, 1983. Dinkel, R.H., ijkonomische Analyse eines neuen Therapiekonzeptes: Nitroderm TTS, Swiss Pharma, 5 (1983) 10. Wenger, N.K. et al., Assessment ofquality of life in clinical trials of cardiovascular therapies, Le Lacq, 1984. Leu, R.E. et al., Die quantitative Erfassung von Gesundheitszustand und Lebensqualitlt, SpringerVerlag, Berlin-Heidelberg-New York-Tokyo, 1984.
4 (1985)
321-330
321
Elsevier
HPE 00032
Cost-benefit analysis: a helpful tool for decision makers? Rolf H. Dinkel* Member of the Management
Committee. (Accepted
HealthEcon
Ltd.. Health
for publication
Service Consultants,
21 February
Basle, Switzerland
1985)
Summary
Cost-benefit analyses (CBA) claim to be an important basis for decision makers who are interested in a cost-effective approach to health care. But despite an increasing frequency in the number of CBA there is growing concern about their usefulness as a decision-making tool. Predominantly methodological controversies spread confusion and block their user-oriented development. The present article identifies and discusses necessary amendments of CBA from a practical point of view to narrow the existing gap between claim and actual efficiency: consideration of differing interests of differing parties in the health care sector, inclusion of qualitative aspects of medical events and a change in the temporal orientation towards prospective studies. cost-benefit analysis; cost-effectiveness analysis; decision makers
Background Throughout the world, health services are experiencing a widening of the gap between available resources on the one hand and the increasing demand for health care-goods and services on the other (Fig. 1). Decision makers are thus faced with a growing need for decision-making aids to guide them in distributing the limited means
This paper is an extended version of a paper presented at the IIIrd Science in Health
Care, held at Munich,
* Address for correspondence: Switzerland.
Telephone:
0168-8510/85/SO3.30
Dr.
Rolf
International
Conference
on System
16-20 July 1984. H. Dinkel,
HealthEcon
Ltd.,
P.O.
Box 1510, CH-4051
0041/61/226640.
c 1985 Elsevier Science Publishers B.V. (Biomedical
Division)
Basle,
322
-f& ,.‘:.:.:.:.:.:.:.~.’ :: .: :. ::
Dantaf. sf!Nim?s
t;
iI :: :: :: :: :: .::.
~
Fig. 1. Competition for resources in the health care sector. Adapted from: Die direkten und indirekten Kosten von Krankheiten, K.-D. Henke, Hanover, 1983.
available amongst the competing programmes, projects and inte~entions. Economic science offers a suitable tool for this in the form of cost-benefit analysis (CBA). Several years ago, CBA was regarded as a mere “way of thinking”. Today, however, it occupies a secure place in the armamentarium of decision-making techniques at the disposal of the health services. CBA’s claim to this position is supported by a large number of theoretical publications dealing with the subject, as well as by a growing number of practical examples.
323
It has however remained largely unclear to date whether and to what extent this device is actually being utilised in planning and decision-making. That is to say whether and to what degree it is being allowed to do justice to its claim in practice. From the point of view of the potential users there appear to be weak points in the conception and implementation which considerably limit CBA’s effectiveness as a decision-making tool, or which even render it totally useless. These weaknesses are generally the result of CBA’s inability to adapt to the changing conditions. Theoretical deliberation and development has, in the majority of cases, concentrated on methodological problems of CBA [ 11. These, among others, concern the following issues: Costs arising from morbidity and mortality Inability to work because of temporary or permanent morbidity as well as because of premature death means loss of resources and productivity. Methodologies for estimating this loss must assign a monetary figure to the human life. In the ‘willingness-to-pay’ approach the value of life is determined by the amount an individual is willing to pay to avert morbidity or mortality. The ‘human capital’ approach estimates life as an economic commodity of which the value is measured in accordance with its inherent potential for producing goods or rendering services. This methodology identifies the time lost as a result of a medical event and values this time by estimating the employment earnings or the market values of the individual’s activities or output in the same amount of time. Both methodologies have generated considerable controversy owing to their inherent problems. Discount rates Most CBA employ the human capital approach to estimate the value of human life lost by morbidity or mortality. But since a simple summing up of future earnings overstates the present value of lifetime earnings, a discount rate is used to convert future earnings into its present value. Considerable controversy still takes place as to which rate is the appropriate one. Equality of human lives The human capital method values human life according to employment earnings. The question is under discussion if this approach potentially tends to undervalue the elderly and other persons not active in the workforce (e.g. housewives) and may result in distinctions of value of life between sexes and races. Consumption The equation between the value of life and productive output raises the question whether the potential consumption of goods and services should not be deducted from the future earnings when calculating the loss of productivity due to morbidity or premature mortality. Assumptions about future trends In addition, the human capital method requires assumptions
about future life
324
expectancy and work force participation rates. Since the figures chosen have a profound influence on the cost-results the discussion about the continuation of historical trends or their change is still a major issue in the context of the use of CBA. The outlined academic controversy on methodological problems has ignored the fact that conditions in the health service sector changed rapidly -we only have to think here of the increasing tendency towards regulation - and as a logical consequence the problems to be solved with the help of CBA changed rapidly, too. Therefore nowadays there are discrepancies between claims and actual efficiency of CBA. The aim of this paper is to describe three of these “trouble spots”: the spheres of interest, the content, and the temporal design of CBA. These “trouble spots” pinpoint those areas towards which efforts for further development of CBA should be directed.
Spheres of interest of CBA
Historically speaking, the first demand for CBA came from public administration. Nowadays, particularly in the health service sector, the parties interested in CBA, cover a broad spectrum (Table 1): - government authorities and politicians in general require guidance when allocating budgets for preventive and curative medicine, ambulatory or in-patient treatment, etc.; - health insurance schemes and other third-party payers require guidance when deciding which health-care goods and services to admit to reimbursement lists; - hospitals and medical practitioners require guidance when deciding whether to extend or to restrict their arsenal of therapeutic measures; - media and general public require information referring to efficacy and efficiency of true or claimed therapeutic innovations. The diversity of these interested parties has entailed a differentiation of the viewpoints involved in the evaluation of therapeutic measures. For a long time, it was the viewpoint of society as a whole which was accepted as decisive, whereas nowadays the individual parties involved are making their positions more and more strongly felt. The decision makers’ primary interest is in the effects on their own expenses and revenues. “Costs” and “benefits” mean something different for each party involved
[a These varying aspects become very clear when we consider the example of hospitalisation in the Federal Republic of Germany [3] (Table 2). For theparienr, a stay in the hospital involves a self-retention cost of DM 5 per stay for the first 2 weeks. In addition to this come any expenses or losses incurred either privately or professionally which are not reimbursed by a third party (e.g., supplementary insurance premiums). The cost for the health insurance scheme consists of the amount it is contractually obliged to pay to the hospital. This is, nowadays, the daily hospitalallowance, which is a flat rate irrespective of the actual cost of treatment for the patient in question. The costs as far as the hospital is concerned are the effective running costs, which
325 TABLE
1
PARTIES IN
THE
INTERESTED
HEALTH
IN
SERVICE
CBA SECTOR
GOVERNMENT AUTHORITIES,POLITICIANS
Allocation of budgets for competing
HEALTH INSURANCE AUTHORITIES Admission
of health
care goods and services
to reimbursementlists
HOSPlTALS, MEDICAL pERsolr(NEL Extensionor restriction of therqxutic measures
Assessment of true or claimed therapeutic innovations
326 TABLE 2
DIFFERENT PERSPECTIVES OF IN-PATIENT
ON COSTS
CARE
(FEDERAL REPUBLIC OF GERM/WY
1983)
Patient * s costs - 5 DM deductible for the first two weeks - Uninsuredprivate and professional expenses Statutory health insurancescheme ?? s costs - Average hospital allowance : All hospitals : University clinics
DM 207.DM 360.-
Hovital * s costs - Runningcosts : : :
Personnel costs Non-personnelcosts Interest on credits
Society‘s costs - Runningcosts of hospital - Investment expenses of hospital - Loss of productivity for the economy due to illness of patient
327
according to the current system of hospital financing comprise: personnel costs, non-personnel costs, and interest on working capital credits. Not included in these costs are investment expenses since these are met by the Federal Government, the individual Federal States, the municipal authorities, etc. costs cover a variety of areas. These As far as society as a whole is concerned, include, over and above the effective running costs of the hospital, investment expenses since these must be met by society in the form of fees and taxes. In addition, society must bear costs in the form of the loss of productivity that is suffered by the economy as a result of the hospitalisation of an employed person or housewife. The willingness to introduce a new therapy merely because it is profitable in macro-economic terms is decreasing. Those involved are increasingly competing for the limited means available. It is clear that one interest group can only win when another loses: each gain is at someone else’s expense. Against this background, it is easy to understand why surgery is still carried out in cases where pharmaceuticals are more efficient, or that patients are still kept in hospitals at great expense when a cheaper method of home treatment is available [4]. Thus, CBA can no longer evaluate new therapies purely from the perspective of society as a whole. In view of the struggle among those concerned for the resources available, CBA can only be a reliable decision-making tool when: - every interest group affected by a decision is identified, and - the cost-benefit differential is made clear for each of the parties in question. When the terms “cheap” and “expensive” are used with respect to public health services, they are meaningless unless it is also explained for whom something is “cheap” or “expensive”. This necessity can be illustrated by a practicalexample (Table 3): a cost-comparison study of parenteral nutrition in the hospital and at home in the Federal Republic of Germany came to the conclusion that parenteral nutrition in the hospital is cheaper from the viewpoint of the health insurance scheme,, whereas parenteral nutrition at home is economically more advantageous from the point of view of society as a whole. Above all, a CBA graduated in accordance with the interest groups involved offers the decision maker (e.g., government authorities or other third-party payers) the opportunity to recognise areas of potential resistance in the health service system to a new technology. By means of appropriate measures, for example by introducing incentives or prohibitions, ‘the decision maker can ensure that the potential for cost savings is in fact realised.
Content of CBA The content of a CBA is not standardised. The question as to which and how many criteria should be included in an analysis can only be answered in very general terms: as many as possible to ensure that no relevant effects are overlooked [5]. This principle of CBA has not, however, always been followed in practice. It has been far more often the case that an effect has been included or omitted according to whether or not it could be quantified. Against the background of changing goals in the health service sector, this tendency is becoming increasingly more questionable.
328
329
Until today the extension of life expectancy has been given priority, but now that the theoretical limits of life expectancy are being approached the aim of enhancing the quality of life is gaining in importance. Today one aims at reducing limitations on mobility, easing pain, and eliminating discomfort, in short: establishing health in the sense of “effective functioning”. A CBA that is restricted to the quantitative measurement of days in hospital, reductions in cost or in the number of years of life saved must necessarily fail to assess whether and to what extent a new therapy contributes to qualitative aspects of life. In order to accomplish this goal, it is necessary to include additional social and medical criteria which are difficult to express in quantitative terms [6]. Purely economic or quantitative considerations give only limited information in the case of modern therapeutic measures and objectives. CBA require a global index which includes all the dimensions of an illness and which can adequately measure not only the state of health, but also any changes therein [7]. If it is not felt to be desirable to take this course towards a one-dimensional formulation, then it is more honest at least to list the negative and positive social and medical effects for the decision maker before they are ignored altogether.
Temporal design of CBA The concept of “planning” has to date been far from common in the health service sector. Among other things, the so-called “cost-explosion” has demonstrated the fact that up to now planning has been neither serious nor carried out in accordance with the rules of the art. Any attempts made towards a conscious design for the future have mostly been outstripped by events. The parties involved have been left with the task of dealing with the resulting situation. This absence of planning is reflected in the temporal orientation of previous CBA. The majority of these are not prospective, but retrospective analyses. They have been concerned with projects that have already been carried out and programmes that have already been introduced. Their prime objective, therefore, has been tojustify developments which have already taken place, rather than to serve as a basis for decisionmaking. If CBA wants to do justice to its claims of being a decision-making tool, it must not be restricted to retrospective analysis, but must be carried out prospectively and completed before new therapies are brought onto the market. This requirement applies above all to new therapeutic measures (whether medicinal or technological) which: - have a comparatively high product price, and/or - are aimed at large groups of patients, and/or - replace a traditional therapy. One possible solution to this problem lies in linking CBA to clinical trials. Today, these trials are still restricted to gathering information concerning the effects, efficacy and safety of a new therapy. In the future, the study protocol should be designed to also provide the information necessary for a CBA at the same time. This is possible for both quantitative and
330
qualitative information: number of days in hospital, loss of working time, utilisation of other medications and services, and aspects of the quality of life. One major condition for this combined study is the elimination of the barriers which still exist today between physicians and economists by means of interdisciplinary co-operation in carrying out studies and analysing their results. Without doubt, combined studies of this kind have their limitations. The study takes place “in vitro” and deviations from the later “in vivo” situation of daily practice are inevitable. None of these limitations should, however, prevent such studies from being carried out. They are indispensable if CBA is not to degenerate into a mere theoretical mental exercise, but to remain a “helpful tool for planning and decision-making”.
References Pharmaceutical Manufacturers Association. Use of beta blockers in the treatment of angina: a costbenefit study. Arthur D. Little, Inc., Washington, 1984. Smith, G.T., Measuring the social benefits of medicine, Office of Health Economics, London, 1983. Dinkel, R.H., Parenteral nutrition in different settings: results of an economic study, International Journal of Technology Assessment in Health Care, 1 (1985) 2. Culyer, A.J. and Horisberger, B. (eds.), Economic and medical evaluation of health care technologies, Springer-Verlag, Berlin-Heidelberg-New York-Tokyo, 1983. Dinkel, R.H., ijkonomische Analyse eines neuen Therapiekonzeptes: Nitroderm TTS, Swiss Pharma, 5 (1983) 10. Wenger, N.K. et al., Assessment ofquality of life in clinical trials of cardiovascular therapies, Le Lacq, 1984. Leu, R.E. et al., Die quantitative Erfassung von Gesundheitszustand und Lebensqualitlt, SpringerVerlag, Berlin-Heidelberg-New York-Tokyo, 1984.