Faculty peer reviewed
If you’ve seen the news or even the cover this week’s Economist on newsstands (Obama as surgeon with a very large needle promising that yes, it’s going to hurt- a lot), you may think that healthcare in the U.S. is all about the money. In keeping with this theme the journals this past week have included a flurry of Markov models and QALY’s to answer the same question- is it worth it?
In this week’s Archives of Internal Medicine, Losina et al examined total knee arthroscopy as a treatment for Americans over the age of 65 with end stage osteoarthritis of the knee including a particular focus on the effects of hospital volume and patient risk profile. The quality of life indicators were not measured directly in this Medicare population but they were derived from prior studies of TKA in order to assign utilities for each outcome. Overall the authors concluded that TKA is highly cost effective at a ratio of $18,300 per QALY and that high volume centers consistently show better clinical outcomes.
A pair of articles in the latest British Medical Journal focuses on the cost and benefits of screening for abdominal aortic aneurysms. The first by Thompson et al takes another look at the UK Multicentre Aneurysm Screening Study data (MASS), a large randomized control trial which included 67770 men ages 65-74. Now with 10 years of follow up data, it appears that the initial mortality benefit holds up over time (155 deaths in screening group-AR 0.46% vs 296 deaths in the control group-AR 0.87 %). Since much of the cost of screening is incurred upfront with invitations, surgery and recall scans, the cost effectiveness analysis revealed that screening got cheaper and was now estimated at £7600 ($12,543) per life year gained as a weighted average for the group, well below the NHS guideline for acceptable cost set at £25000 ($41,258) per life year gained. This was countered by Ehlers et al in a study using a hypothetical Danish population. Using a Markov model and decision tree analysis, they estimated that screening for abdominal aortic aneurysms had an incremental cost effectiveness ratio of £32640 to £66 001 ($53,869 to $108,937) per QALY. The differing conclusions between the two studies are discussed in an editorial by Buxton in the same issue.
As part of a series on Alcohol and Global Health, The Lancet published a review on the effectiveness and cost-effectiveness of several alcohol related policies and programs. One of the major conclusions of the article states that policies which make alcohol more expensive and more difficult to obtain are highly cost effective.
Proving that it is not all about the money, other journals this week included some good ol’ RTC’s with no mention of cost. The Annals of Internal Medicine published a randomized placebo controlled trial by Yanovski et al examining the effects of calcium supplementation on body weight in a population of 340 overweight and obese patients. After 2 years of follow-up, there were no statistically significant differences in body weight between those treated with 1500mg elemental ca++ daily vs placebo.
This issue also included a small randomized control trial of patients with atherosclerotic renal artery stenosis and renal insufficiency comparing conservative medical management to stenting. The primary endpoint was a 20% reduction in creatinine clearance and the authors concluded that there were no differences between the two groups, although procedure related complications including some deaths would imply that conservative medical therapy is safer.
Finally this week marked the deaths of several celebrities including Michael Jackson, Farrah Fawcett, Ed McMahon and Billy Mays. Their impact on the health and well being of our patients is not measured in QALY’s but, judging from a recent CCU admission H&P beginning, “…upon hearing the news of Mr. Jackson’s sudden death, the chest tightness intensified …”, it hurts just the same.
Dr. Moore is a 2nd year resident in internal medicine at NYU Medical Center.
Losina E, et al. Cost-effectiveness of Total Knee Arthroplasty in the United States: patient risk and hospital volume. Arch Intern Med. 2009;169(12):1113-1121.
Thompson S G, Ashton H A, Gao L, et al. Screening men for abdominal aortic aneurysm: 10 year mortality and cost effectiveness results from the randomised Multicentre Aneurysm Screening Study. BMJ 2009;338: b2307.
Ehlers L, Overvad K, Sorensen J, et al. Analysis of cost effectiveness of screening Danish men aged 65 for abdominal aortic aneurysm. BMJ 2009;338: b2243.
Anderson P, Chisholm D, Fuhr D C. Effectiveness and cost effectiveness of policies and programs to reduce the harm caused by alcohol. The Lancet 2009;373(9682):2234-2246.
Yanovski J, et al. Effects of Calcium Supplementation on Body Weight and Adiposity in Overweight and Obese Adults. Annals of Internal Medicine 2009;150(12):821-829.
Bax L, et al. Stent Placement in Patients with Atherosclerotic Renal Artery Stenosis and Impaired Renal Function. Annals of Internal Medicine 2009; 150 (12):840-848.