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A fascinating discussion - cost-effectiveness and value for money are hardly new phrases in publicly funded health systems like New Zealand, but there is certainly a renewed focus on it in economically tough times. I'd like to contribute 2 small bits. Agree price is important, especially when combined with the evidence of effectiveness. One example locally has been the use of statins in primary vs secondary prevention of CVD. With the price of 40mg of Simvistatin in New Zealand now ~6c a tablet, or $20 a year (around 10 pounds) the cost effectiveness threshold changes - normally treatment is recommended at a 15% absolute risk of an event in 5 years, you can probably justify dropping to 10% risk, which is getting into the primary prevention area. Second point is the numbers bandied around for costs in the last year of life, which tend to be grossly exaggerated. In one district in NZ the cost was about 5% of the total public system healthcare spend- that is the inpatient, outpatient, pharms and labs cost. http://www.nzma.org.nz/journal/124-1335/4689/ (attached). Yes it can be expensive caring for people in their last year of life (average $22k in this sample, but range up to $780k), and things like advanced care planning are a good thing to be promoting, but the total number of deaths is relatively small compared to the rest of the population - it is the tide of chronic disease that is the larger concern. Regards Gary Dr Gary Jackson Health Partners Consulting Group Consultant Clinical Planning M +64 21 286 1815 E [log in to unmask] A PO Box 147209, Ponsonby, Auckland -----Original Message----- From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Dr. Amy Price Sent: Wednesday, 20 July 2011 5:06 a.m. To: [log in to unmask] Subject: Re: AW: solution to health care cost crisis: technical vs.philosphical.. Dear Hilda and All, I completely agree with your statement and think it is a huge consideration. Some interventions are not so amenable to RCTs and the practitioners that specialise in this areas may not have the statistical experience to put together a good clinical trial. On the other hand RCTs may be avoided due to prohibitive cost, lack of facilities, or even that those making money already know the intervention is useless so avoid clinical trials. As far as vertebroplasty I worked with several patient based organisation and some of the patients did very well with this intervention and healed faster and with less pain in contrast to their peers. There are others who had devastating results. I imagine better quality study of the interventions could have saved a lot of time, pain and money. People outside the standard deviations are often dismissed but this does not negate the effectiveness for them. There were others RCTs on arthroplasty of the knee, brain training, psychotropic drugs etc where later studies were found to conflict with the initial RCT. A large clinical trial is great when it is well run on accurate assumptions but in the end it may not be as unbiased as it is made to appear. In these cases an RCT may be more like an N of 1. I read over some of the papers re technical vs philosophical and found that rather than extending bridge building resources most seemed to fall along the lines of the immorality of spending money and the drama of end life scenarios. There is little out there to guide the respective parties about how to initiate and time information choices that work for them or what processes are required if a change of mind takes place. Statements like 95% of health care is spent on end stage care were not objectively justified and really one is hardly going to need much healthcare while one is well. Best regards, Amy Amy Price Http://empower2go.org Building Brain Potential -----Original Message----- From: Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Bastian, Hilda (NIH/NLM/NCBI) [C] Sent: 19 July 2011 11:46 AM To: [log in to unmask] Subject: Re: AW: solution to health care cost crisis: technical vs.philosphical.. G'day! I like the terminology of "proven to be useless", because it reduces the danger of throwing babies out with bathwater (interventions where the issue is an absence of evidence, not evidence of absence of effect). Evidence of absence of effect is unfortunately not required it seems for many people to brand things useless. Often it seems to me that the equation can be "intervention I don't believe in + no evidence of effect = useless", instead of "likely to be harmful + no evidence of benefit" or "evidence of no benefit". (No comment on vertebroplasty here - just the general point.) Hilda From: Jeremy Howick <[log in to unmask]<mailto:[log in to unmask]>> Reply-To: Jeremy Howick <[log in to unmask]<mailto:[log in to unmask]>> Date: Tue, 19 Jul 2011 11:33:27 -0400 To: "[log in to unmask]<mailto:[log in to unmask] AC.UK>" <[log in to unmask]<mailto:[log in to unmask] AC.UK>> Subject: Re: AW: solution to health care cost crisis: technical vs.philosphical.. Dear All, I have very much enjoyed reading these useful contributions. Paul Glasziou showed us all up by stating what should be obvious to all of us - what everyone signed up to this list should be fighting for: CUT OUT TREATMENTS THAT HAVE PROVEN TO BE USELESS. It merits restating: "We might do this by doing less useless things (cutting waste). For example, vertebroplasty for osteoporotic fractures was costing the US about $1Billion per year, but the two RCTs that used a sham control showed no benefit. This is just one of a very long list. We could also cut costs by doing the same things better - which quality improvement aims to do .. Another example is Peter Pronovosts' work to reduce central line infections, which saved lives and money (from less ICU time)." Best wishes, Jeremy -- Jeremy Howick PhD, MSc, PGCert, DipSoc, BA MRC/ESRC Postdoctoral Fellow Centre for Evidence-Based Medicine University of Oxford Oxford OX3 7LF United Kingdom www.cebm.net www.primarycare.ox.ac.uk/dept_staff/jeremy-howick/ eu.wiley.com/WileyCDA/WileyTitle/productCd-140519667X,descCd-authorInfo.html