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Academia and the Profession |

Much Cheaper, Almost as Good: Decrementally Cost-Effective Medical Innovation

Aaron L. Nelson, MD, PhD; Joshua T. Cohen, PhD; Dan Greenberg, PhD; and David M. Kent, MD, MS
[+] Article and Author Information

From the Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, and Tufts University School of Medicine, Boston, Massachusetts, and Ben-Gurion University of the Negev, Beer-Sheva, Israel.


Potential Conflicts of Interest: None disclosed.

Requests for Single Reprints: David M. Kent, MD, MS, 800 Washington Street, Box 63, Boston, MA 02111; e-mail, dkent1@tuftsmedicalcenter.org.

Current Author Addresses: Dr. Nelson: Novartis Institutes for Biomedical Research, 100 Technology Square, Room 4304, Cambridge, MA 02139.

Dr. Greenberg: Department of Health Systems Management, Ben-Gurion University of the Negev, PO Box 653, Beer-Sheva 84105, Israel.

Drs. Cohen and Kent: 800 Washington Street, Box 63, Boston, MA 02111.

Author Contributions: Conception and design: A.L. Nelson, D. Greenberg, D.M. Kent.

Analysis and interpretation of the data: A.L. Nelson, J.T. Cohen, D. Greenberg, D.M. Kent.

Drafting of the article: A.L. Nelson, D. Greenberg, D.M. Kent.

Critical revision of the article for important intellectual content: A.L. Nelson, J.T. Cohen, D. Greenberg, D.M. Kent.

Final approval of the article: A.L. Nelson, J.T. Cohen, D. Greenberg, D.M. Kent.

Statistical expertise: D. Greenberg.

Administrative, technical, or logistic support: A.L. Nelson, D.M. Kent.

Collection and assembly of data: J.T. Cohen.


Ann Intern Med. 2009;151(9):662-667. doi:10.7326/0003-4819-151-9-200911030-00011
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Under conditions of constrained resources, cost-saving innovations may improve overall outcomes, even when they are slightly less effective than available options, by permitting more efficient reallocation of resources. The authors systematically reviewed all MEDLINE-cited cost–utility analyses written in English from 2002 to 2007 to identify and describe cost- and quality-decreasing medical innovations that might offer favorable “decrementally” cost-effective tradeoffs—defined as saving at least $100 000 per quality-adjusted life-year lost. Of 2128 cost-effectiveness ratios from 887 publications, only 9 comparisons (0.4% of total) described 8 innovations that were deemed to be decrementally cost-effective. Examples included percutaneous coronary intervention (instead of coronary artery bypass graft) for multivessel coronary disease, repetitive transcranial magnetic stimulation (instead of electroconvulsive therapy) for drug-resistant major depression, watchful waiting for inguinal hernias, and hemodialyzer sterilization and reuse. On a per-patient basis, these innovations yielded savings from $122 to almost $12 000 but losses of 0.001 to 0.021 quality-adjusted life-years (approximately 8 hours to 1 week). These findings demonstrate the rarity of decrementally cost-effective innovations in the medical literature.

Figures

Grahic Jump Location
Figure.
The cost-effectiveness plane.

An innovation may fall into 1 of 4 quadrants on the cost-effectiveness plane, based on how its costs and effectiveness compare with those of a standard. The diagonal lines represent possible cost-effectiveness thresholds, with slopes corresponding to the acceptable ratio of costs to effectiveness. Only interventions in the northeast quadrant costing less than $50 000 per QALY gained and those in the southwest quadrant gaining more than $100 000 per QALY lost would be accepted. Although efficiency is optimized when the same threshold applies in both the southwest and northeast quadrants, empirical evidence suggests that the minimum acceptable savings per QALY lost in the southwest quadrant probably exceeds the maximum that people are willing to pay per QALY gained in the northeast quadrant. This difference suggests a “kink” in the cost-effectiveness threshold line at the origin (10). QALY = quality-adjusted life-year.

Grahic Jump Location

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TMS Not Almost As Good As ECT
Posted on January 4, 2010
Charles H. Kellner
Mount Sinai School of Medicine
Conflict of Interest: None Declared

To the Editor: In their article, Much Cheaper, Almost as Good: Decrementally Cost- Effective Medical Innovation, Nelson and colleagues (1) suggest that transcranial magnetic stimulation (TMS) is nearly as effective as electroconvulsive therapy (ECT) for the treatment of medication-refractory major depressive disorder. We believe this is misleading and not supported by the currently available data. Their contention is based on a single study from 2004 that proposed a theoretical model for the economic superiority of TMS over ECT (2). In that paper, Kozel et al. contended that TMS could be a highly cost effective substitute for ECT. They, in turn, cited a single, small, uncontrolled (open) study from 2000 that compared ECT with TMS (3). In that study, Grunhaus reported similar response rates for ECT and TMS in non-psychotic patients. Psychotically depressed patients did much better with ECT than TMS. Kozel et al. (2) commented that there was dearth of controlled data on the efficacy of either ECT or TMS at the time. Since then, more controlled data have been published, and they demonstrate a higher response rate for ECT (4) and a much lower response rate for TMS (5). Even more importantly, remission rates are reported to be much higher with ECT than TMS. In one of the largest ECT samples to date, Kellner et al. (4) reported a remission rate of 64%. In the largest sample of patients treated with TMS reported to date, the remission rate was 17% (5). TMS was approved for a very narrow indication (depressed patients who have failed a single trial of antidepressant medications) in a highly controversial decision by the FDA. Treatment with TMS is currently not reimbursed by insurance carriers and costs approximately $7000 for a typical treatment course. Outpatient ECT costs a comparable amount, inpatient ECT considerably more. We believe that there is no credible evidence to suggest that TMS is equally effective as ECT for seriously depressed patients. 17% is not almost 64% in our arithmetic. If very depressed and suicidal patients are offered TMS as an alternative to ECT, the costs are likely to be counted in lives, not just dollars.

References 1. Nelson AL, Cohen JT, Greenberg D, Kent DM. Much cheaper, almost as good: decrementally cost-effective medical innovation. Ann Intern Med. 2009;151:662-7. [PMID: 19884627] 2. Kozel FA, George MS, Simpson KN. Decision analysis of the cost- effectiveness of repetitive transcranial magnetic stimulation versus electroconvulsive therapy for treatment of nonpsychotic severe depression. CNS Spectr. 2004;9:476-82. [PMID: 15162090] 3. Grunhaus L, Dannon PN, Schreiber S, Dolberg OH, Amiaz R, Ziv R, et al. Repetitive transcranial magnetic stimulation is as effective as electroconvulsive therapy in the treatment of nondelusional major depressive disorder: an open study. Biol Psychiatry. 2000;47:314-24. [PMID: 10686266] 4. Kellner CH, Knapp RG, Petrides G, Rummans TA, Husain MM, Rasmussen K, et al. Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry. 2006;63:1337-44. [PMID: 17146008] 5. O'Reardon J P, Solvason HB, Janicak PG, Sampson S, Isenberg KE, Nahas Z, et al. Efficacy and Safety of Transcranial Magnetic Stimulation in the Acute Treatment of Major Depression: A Multisite Randomized Controlled Trial. Biol Psychiatry. 2007;62:1208-16. [PMID: 17573044]

Conflict of Interest:

None declared

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