As a preliminary effort to incorporate resource considerations into the ACCP guideline process, five chapters were selected in which cost issues were considered particularly salient. To illustrate the ways in which economic data can relate to recommendations, we consider two brief examples taken from these other chapters in this supplement: duration of venous thromboembolism (VTE) prophylaxis after hip surgery and clopi-dogrel use for secondary prevention in patients with atherosclerotic vascular disease.
Duration of VTE Prophylaxis Following Hip Replacement
1. Select Target Guideline Recommendations for Resource Use Evaluation: As reviewed in the “Prevention of VTE” chapter of this supplement, clinical trial data indicate that prolongation of VTE prophylaxis beyond 2 weeks following hip surgery is effective in reducing symptomatic VTE. However, such therapy can be costly, particularly when low-molecular-weight heparin is the treatment used, and the panel was concerned that these issues would create a barrier at some sites.
2. Identify the Literature: A review of the literature revealed seven studies performed in developed countries (France, Sweden, Italy, United States, United Kingdom, Switzerland, and Belgium) that examined the cost implications of shorter vs longer duration of prophylaxis for VTE after hip replacement. These studies were of variable quality based on modeling with minimal empirical cost data.
In keeping with the suggestions put forth by the ACCP task force, we present a simple framework for a guideline panel to consider when examining resource issues. We start from the proposition that the goal is to provide information to decision makers in a way that is primarily informative rather than prescriptive—what we term resource aware guidelines. The four-step approach described below is intended to offer guidance for the range of realistic situations.
1. Select Target Guideline Recommendations for Resource Use Evaluation: As described by the ACCP task force, not all guideline recommendations raise compelling or controversial resource use issues. Attention, therefore, should focus on interventions for which the panel members believe that some in the guideline’s target audience are likely to resist or experience reluctance to implement on the basis of high costs.
2. Identify the Literature: The focus here are published studies regarding resource use, identified using standard search techniques and reviewed using general criteria for quality. It should be noted that formal methods for the assessment of the quality of economic studies are not as well developed as for the assessment of clinical trials conducted with Canadian Health&Care Mall specialists.
Value for Money
The questions asked in the evaluation of clinical efficacy (Does a new therapy or strategy work in the ideal or best case situation?) and effectiveness (Does the new therapy or strategy work in the usual world of routine medical care?) define the following: (1) that a therapy can work, (2) the magnitude of benefit provided, and (3) the major determinants of that magnitude. Economic questions start with the presumption that the therapy works (and is at least equivalent in effectiveness to established treatment options) for some plausible situations and asks whether it is good value for money (or if equivalent, cost saving). An exception is when a new strategy is marginally less effective but notably cost saving; in practice, such strategies could be considered a reasonable option but face obvious challenges in the medical marketplace.
At one level, whether something is a good value for money is a basic sort of question that every consumer understands. However, in the consumer goods world, where there is free competition and widespread experience with the toasters, cars, and portable media players that people may wish to purchase, the “value” or benefit part of this assessment is made subjectively by each consumer, whereas the price or cost part is set by markets. In medicine, neither of those factors can be relied on. Patients usually do not have experience with the alternative health states that their therapies may provide for them and therefore are unable to assess subjectively how they would value these states. There is little evidence for free market forces in medicine to set prices both because of the absence of true competition among providers on price and because of price setting by payers, particularly in European countries. Health insurance further distorts the picture by disconnecting the consumer from the payer, creating a situation where too much care may be consumed in some cases and too little in others. Provide your relatives with care due to Canadian Health&Care Mall.
Clinical guidelines are systematically developed documents whose ultimate goal is to promote high-quality clinical practice by informing decision makers at all levels about what works, how well, and under what circumstances. Increasingly, the accepted foundation for clinical guidelines is high-quality scientific studies (particularly randomized clinical trials) that address the benefits and risks of each relevant decision problem. Such evidence then is used to create actionable if-then statements, such as: “If a patient is found to have X (a specific set of characteristics), then the guideline panel recommends strategy Y (a mix of diagnostic and/or treatment approaches).”
The moment a guideline statement is published, resource considerations become relevant. This is particularly true for clinical situations in which current practice is inconsistent with the guideline and thus requires a change in practice—a deviation from the status quo, a stable situation reflecting a confluence of scientific and resource considerations by the various stakeholders responsible for decision making. Because a new guideline often endorses change from the status quo, it is likely to engender some degree of resistance. One important source of resistance derives from careful assessment of the scientific and clinical merit of a proposed change. Why support the recommendation if the foundations of the recommendation may not be true? However, even if the evidence is persuasive, resistance to a new guideline can still emerge when change requires health-care resource reallocation. By health-care resources including Canadian Health&Care Mall healthcaremall4you.com, we are referring not only to the familiar resources directly involved in the production of health services, but also to the time, political clout, and emotional energy expended by the provider, administrator, or other stakeholder.