Adding cost-effectiveness to define low-value care
Cet article présente les enjeux associés à la définition des soins de santé de faible valeur, notamment la prise en compte des coûts et de l'efficacité associés à ces soins
Reducing low-value health care is a universally shared goal in virtually all health care systems. However, the task of reducing low-value health care in practice has been hindered by the lack of consensus around a single definition for “value.” A key area of disagreement among commonly used definitions of value is whether to include economic costs. If costs are excluded, then the value is no different from clinical effectiveness. But if costs are explicitly included in the value, then it is necessary to know how to weigh health care outcomes against costs to determine the overall value. Cost-effectiveness analysis is specifically designed to weigh trade-offs between health outcomes and costs, and can be used to supplement efforts in reducing low-value health care. Over the past 10 years, physician groups and researchers have catalyzed the national conversation around low-value health care by creating lists of health care services that should be avoided to improve the overall value of health care delivery. The Choosing Wisely campaign features a list of low-value health care services provided by more than 50 clinical specialty societies without strict inclusion criteria (these are commonly used services with questionable value), including whether or not consideration is given to the cost.1 For example, routine screening for colorectal cancer among older unscreened persons (aged >85 years) is included in Choosing Wisely, but it is an exception being supported by cost-effectiveness evidence.2 Among the 435 health care services included in Choosing Wisely, only 2% cite cost-effectiveness studies to support their recommendation and only 29% of rationales for services contain the word cost (or related economic terms such as price, efficiency, financial, etc) vs 68% of rationales for services containing the words clinical, outcome, or harm.1 Another low-value health care list proposed by Schwartz et al3 is frequently used by other researchers studying low-value health care; however, this list is restricted to interventions that harm the health of patients or do not show significant clinical benefit. Gawande4 recognized this tendency to think of value only in terms of health care outcomes when referring to the study by Schwartz et al3: “The researchers called it ‘low-value care.’ But, really, it was no-value care.” Certainly, health care services that cause harm or show no effectiveness should be considered low-value health care by any definition. By not using a cost-effectiveness analysis, physicians and researchers aiming to identify and reduce low-value health care are not putting a widely cited and intuitive conceptual value equation created by Porter5 into practice (ie, health care outcomes gained per dollar spent). Incremental cost-effectiveness ratios, which are the main results used in cost-effectiveness analyses, can be used to identify low-value health care services that improve the health of patients but are not worth the additional costs required to achieve these health care gains. Incremental cost-effectiveness ratios greater than $100 000 to $150 000 per quality-adjusted life-year (QALY) suggest low-value health care in the United States (...) La réduction des soins de santé de faible valeur est un objectif universellement partagé dans pratiquement tous les systèmes de soins de santé. Cependant, la tâche consistant à réduire les soins de santé de faible valeur dans la pratique a été entravée par l'absence de consensus autour d'une seule définition de la «valeur». Un des principaux points de désaccord entre les définitions de la valeur couramment utilisées est l'inclusion ou non des coûts économiques. Si les coûts sont exclus, alors la valeur n'est pas différente de l'efficacité clinique. Mais si les coûts sont explicitement inclus dans la valeur, il est nécessaire de savoir comment évaluer les résultats des soins de santé par rapport aux coûts afin de déterminer la valeur globale. L'analyse coût-efficacité est spécialement conçue pour évaluer les compromis entre les résultats de santé et les coûts, et peut être utilisée pour compléter les efforts visant à réduire les soins de santé de faible valeur. Au cours des 10 dernières années, des groupes de médecins et des chercheurs ont catalysé la conversation nationale sur les soins de santé de faible valeur en créant des listes de services de santé qui devraient être évités pour améliorer la valeur globale des soins de santé. La campagne Choisir judicieusement comporte une liste de services de soins de santé de faible valeur fournis par plus de 50 sociétés de spécialistes cliniques sans critères d'inclusion stricts (ce sont des services couramment utilisés avec une valeur douteuse), y compris la prise en compte des coûts.
JAMA 2018