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In Response

Macario, Alex MD MBA; Carvalho, Brendan MBBCh, FRCA; Tan, Jonathan M. MD MPH; Sultan, Pervez MBChB, FRCA; El-Sayed, Yasser Y. MD

doi: 10.1213/ANE.0000000000000114
Letters to the Editor: Letter to the Editor

Department of Anesthesiology, Stanford University School of Medicine, Palo Alto, California,

Department of Anesthesiology, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania

Department of Anesthesiology, Royal Free Hospital, London, United Kingdom

Department of Obstetrics and Gynecology, Stanford University School of Medicine, Palo Alto, California

We agree with Tsai and Grondin1 that the time frame of the cost-effectiveness analysis is an important parameter that investigators need to carefully choose when creating a computer model of the impact of a treatment or intervention. A long-term time horizon incorporating an expansive array of possible outcomes and expenses is ultimately preferable since limiting the analysis to only a brief period after the intervention may miss important potential developments such as an increased risk of complications (e.g., increased risk of developing placenta accreta in a subsequent pregnancy if the external cephalic version (ECV) is unsuccessful, and a cesarean delivery is required). When designing the computer model to study the economics of an intervention, the investigator must decide on a time frame that is long enough (such as hospital discharge) to be helpful for the clinician, but not so long that analytical and modeling errors are introduced. This balance is complex; expanding the time horizon results in increased possibilities of patient outcomes that become very difficult to quantify.

Another real challenge existing for public health users is implementing the cost-effectiveness intervention and organizing the system of care to make certain that all patients that should receive the intervention actually receive it on a consistent basis. Just because an intervention such as neuraxial anesthesia to facilitate ECV is deemed cost-effective may not necessarily lead to increased use. Many patients in the United States and the world may not receive neuraxial anesthesia to facilitate ECV for a variety of reasons, including those specific to the individual physician, the hospital, or related to the broader structure of the entire health care system. Implementation science, or the study of methods to promote the integration of research findings and evidence into health care practice, is the next important step for economic analyses in health care to actually impact patient care.

Finally, although the cost-effectiveness analysis result may support an intervention for a large group of hypothetical patients, the findings may not apply to an individual patient. This is because patients may have very different preferences about their care. For example, if a patient has a strong preference to avoid a cesarean delivery, then an ECV trial with neuraxial anesthesia may be more desirable than for another patient with breech fetal presentation who does not have a strong preference against a cesarean delivery. Real-world application of cost-effectiveness analysis needs to consider and incorporate patient preferences and societal values toward the intervention or treatment.

Alex Macario, MD MBA

Brendan Carvalho, MBBCh, FRCA

Department of Anesthesiology

Stanford University School of Medicine

Palo Alto, California

Jonathan M. Tan, MD MPH

Department of Anesthesiology

Children’s Hospital of Pittsburgh

Pittsburgh, Pennsylvania

Pervez Sultan, MBChB, FRCA

Department of Anesthesiology

Royal Free Hospital

London, United Kingdom

Yasser Y. El-Sayed, MD

Department of Obstetrics and Gynecology

Stanford University School of Medicine

Palo Alto, California

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1. Tsai MH, Grondin LS. Building a Value-Based Platform. Anesth Analg. 2014;118:884
© 2014 International Anesthesia Research Society