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Why Cost-Effectiveness?

Bartha, Erzsebet MD, PhD

doi: 10.1213/ANE.0000000000003776
Editorials: Editorial

From the Perioperative Medicine and Intensive Care, Karolinska University Hospital, Huddinge, Stockholm, Sweden; and Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden.

Accepted for publication August 8, 2018.

Funding: None.

The author declares no conflicts of interest.

Reprints will not be available from the author.

Address correspondence to Erzsebet Bartha, MD, PhD, Perioperative Medicine and Intensive Care, K32 Karolinska University Hospital Huddinge, SE-141 86, Stockholm, Sweden. Address e-mail to

In this issue of Anesthesia & Analgesia, Teja et al1 present a systemic review of cost-effectiveness research in anesthesiology. As noted by the authors, there is limited published health economic research by anesthesiologists. Although limited, Teja et al1 summarize the available evidence and advance our knowledge regarding cost-effectiveness research. The authors’ review describes several key features of cost-effectiveness analyses and what is currently known regarding cost-effective interventions, and encourages further research by identifying gaps in research areas. But what is the role of cost-effectiveness analyses and what is cost-effectiveness?

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Before moving forward, we first need to ask the questions, what is cost-effectiveness and what is the role of cost-effectiveness analyses in clinical practice? Choices between alternative interventions in medicine are unavoidable. The questions are how to choose among alternative interventions and what should the decision criteria be? Everyday, clinical decisions are made on an individual patient basis. Such decisions strive to choose the best option for the individual patient by weighing the clinical benefits against side effects or possible harms.

There are also other levels of decisions in health care. Such are adoption decisions on new technologies for a whole patient population or health care policy decisions on national level, or decisions when consensus recommendations are issued in nationwide or international guidelines. In such types of decisions or policy guidelines, the perspective is more complex because such decisions will influence patient populations, families, health care providers, and the whole society in a long-time perspective. To support such complex decisions, there is a need to analyze a wide range of consequences of treatments. Those are short- or long-term clinical outcomes, side effects, harms, survival, patient experienced quality of life, and the costs of all those consequences in a life-long perspective. Such analyses are the objectives of health economic evaluations. The aim of health economic evaluations is “always” to support policy decision to “improve the health” of population and the health care. In several countries, health economic evaluations are mandatory for policy decisions.2–5 Such analyses support the judgment of new treatments compared to current standards and may justify the additional costs for the gained health of the actual patient group. There are several types of health economic evaluations, and cost-effectiveness analysis is one of them.

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In general, the term “cost-effectiveness” is not always correctly used. When one states that an “intervention x” is cost-effective, the statement should always include “compared to intervention y.” Cost-effectiveness analyses “always compare” alternative treatment in terms of costs and consequences using a structured analytic method. Alternative treatments are always those that “improve” the patients’ health in a long-time perspective (usually life-long). The treatment consequences are expressed by a composite measure, which combines patient experiences and survival. The most common measure is the “quality-adjusted life year,” which is 1 life year with full health. The quality of life captures the experience of patients associated to the disease, and it “translates” the clinical outcomes, the clinical benefits and harms, into a single outcome. “Costs” are the used health care resources and the societal costs, which are the costs of lost productivity (lost working days) and the costs of social services.

Can a new, much costlier and much better treatment be cost-effective when it is compared with a current treatment? As Teja et al1 describe in the introduction, there is a ruling factor for judgment of cost-effectiveness. This is the amount of cost that public health care or health care stake holders are willing to pay for the additional costs for 1 additional life year with full health (willingness to pay). It must be emphasized that the aim of health economic evaluations is not to decrease the costs, but to identify which treatment option is the “best for the population” using the available/limited health care resources.

The aim of Teja et al1 was to identify which treatments in the perioperative care are cost-effective. They have performed an excellent literature review, with high quality of methodology, and the article is easy to follow. The strength of this article is that the authors used a trustworthy and powerful tool and achieved the intended aims, which was to specify cost-effective treatments in anesthesiology and perioperative medicine.

However, when it comes to the section of Results, for some of the specified cost-effective interventions, the authors do not mention explicitly the comparators, that is, the treatment options, that the interventions of interest have been compared to by the original articles. Thus, the use of the term cost-effectiveness is in some cases flawed, and consequently, the Discussion section is not easy to follow. The reader must keep in mind that the judgment of cost-effectiveness is possible “only” when explicit information about alternative option is given. How can we judge the fact that the smoking cessation program had a strong cost-effectiveness? With which types of alternative options was the program compared? Were individual patient-guided cessation or alternative smoking cessation programs used as comparators?

Teja et al1 found and concluded that the “most successful interventions from a cost-effectiveness perspective are multidisciplinary pathways and strategies supporting the development of the multidisciplinary perioperative surgical home.” Also, this conclusion is difficult to judge without knowing the comparator.

The required information about comparators can be found in Supplemental Tables, where Teja et al1 list the comparators for each of the cost-effectiveness analysis included in the review. So, it is strongly recommended to use this Supplemental Table while reading the sections of Results and Discussion.

One contribution of the review is that it highlights the lack of cost-effectiveness research in anesthesiology in the past and the substantial increase of interest during the last decade. The lack of cost-effectiveness research is not fully explored by the authors of this review, which could be attributed to several factors. Traditionally, anesthesia research addressed physiological or short-term outcomes, for example, intensity of postoperative pain, hemodynamic changes, time to extubation, time to recovery, nausea, etc. These short-term outcomes are difficult to translate into long-term outcomes and they do not necessarily capture the patients’ experiences, the quality of life, or even less the caregiver’s perspective. Modern anesthesiology has an increasing role in perioperative medicine and has new research areas. Examples are preoperative risk assessment, risk management, and perioperative enhanced recovery program. Subsequently the postoperative morbidity and the long-term consequences on patients’ health became of interest. So, the increased participation in perioperative medicine could contribute to the increase of cost-effectiveness research performed by anesthesiologists.

Another contribution of this systematic literature review is that it is a powerful method to identify areas where cost-effectiveness research should be encouraged, and indeed the authors specify those areas, which wait for evaluation. Examples they give are pain treatment, treatment of postoperative nausea and vomiting, use of ultrasound for a variety of purposes, or anesthesia service to endoscopic procedures. So, the first step to bridge that gap was done by Teja et al,1 but what are the further steps? The authors shortly mention that the quality-adjusted life years could probably be an inappropriate measure of outcome for many perioperative or anesthesia-related interventions. To identify appropriate outcomes that reflect the patients’ experiences and changes of health is essential for health economic evaluations. It is possible that the postoperative quality-of-life measure is not sensitive enough and does not capture the benefits of anesthesia-related interventions. However, there are other patient-reported or patient-experienced outcome measures that are used by many specialties, as rheumatology, pediatrics, cardiology, cardiovascular surgery, orthopedic surgery, and urology. Future anesthesia research needs to shift the focus from surrogate short-term outcomes to patient-reported or patient-experienced outcomes. Patient-reported outcomes are assessed by questionnaires measuring the patients’ views of their health status.6-9 Patient-reported experiences are measured by questionnaires measuring the patients’ perceptions of their experience while receiving care. A systematic review of Barnett et al10 highlighted that several studies have used nonvalidated questionnaires in anesthesiology and perioperative medicine, and there are only few validated tools that are available and future validation studies that are required. Consequently, future validation studies are needed, with the aim to identify valid questionnaires to assess patient-reported/experienced outcomes. A further step could be to choose between those validated measures that could be appropriate for cost-effectiveness analysis or other types of health economic evaluations in anesthesiology and perioperative medicine.

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Name: Erzsebet Bartha, MD, PhD.

Contribution: This author wrote this manuscript.

This manuscript was handled by: Nancy Borkowski, DBA, CPA, FACHE, FHFMA.

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1. Teja BJ, Sutherland TN, Barnett SR, Talmor DS. Cost-effectiveness research in anesthesiology. Anesth Analg. 2018;127:1196–1201.
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