The Cost of Critical Care Economic Analysis

Four different types of economic analysis are quoted in the literature:

Cost minimisation analysis: this looks only at resources used and assumes that the benefit is self evident. The value of this technique is questionable and it’s standing, in an economic framework, is poor.

Cost Benefit Analysis (CBA): this looks at two aspects – the costs and the benefits and equates the in monetary terms, discounting as necessary. A single figure is obtained and this can be used for comparison between programs. Unfortunately, this technique is limited by uneasiness expressed by ethicists and clinicians about converting clinical outcomes to a pound, euro or dollar value. Actually assigning a dollar value to outcome is very difficult. Consequently a subtype of this technique, willingness to pay (WTP), is the most popular way of expressing cost-benefit in a healthcare environment, but there remains the issue of different populations having different spending power.

Cost-effectiveness analysis (CEA) has emerged as the de-facto method of economic evaluation in the medical literature. Like CBA cost effectiveness analysis attempts to link economic consumption and clinical utility in one "summary" measure to facilitate comparisons among competing endeavours; however, it does not require the conversion of all units of outcome, benefit, or effectiveness to monetary terms

Instead, a summary measure, the cost-effectiveness ratio, is developed. Essentially, CEA estimates the incremental cost required to improve the clinical outcome by 1 unit. The cost per year of life saved (or gained) is the most commonly quoted measure. Lower ratios imply improved cost effectiveness, as fewer resources are expended to procure the desired level of benefit. Cost-effectiveness ratios for all alternatives under investigation can be compared for all available choices, and the decision maker can rank all programs according to the ratios that are obtained and subsequently recommend or select the program from the lowest to the highest ratios, taking into account diminishing returns, until all available resources are exhausted.

Cost-utility analysis (CUA)
Although CEA is relatively straightforward, often the results yield rather blunt information; for example about morbidity. A more sophisticated measure is Cost Utility Analysis (CUA) which attempts to factor in morbidity and quality of life into a single cost effectiveness measure. This is very useful, as many patients discharged from ICU (alive) may require extensive intervention, such as home dialysis, home ventilation or full nursing support in a specialist facility (for example spinal injuries), and the quality of life may be very low indeed.

Quality adjusted life years (QALYs)
Intensive care patients are heterogeneous, and single simple economic measures have little power to reflect the true economic reality. The most effective method of facilitating comparisons across diseases, that is, breaking the diseases down to the lowest common denominator, is to measure health benefit as the gain in quality adjusted life years (QALYs). This measure captures the effects of an intervention on both length and quality of life. Time spent in less ideal health is adjusted downwards. If a patient with chronic lung disease considers 2 years of his disease ridden life to be worth one year of perfect health, then each year in his present health state is worth 0.5 QALYs.

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