Many medical guidelines don't consider costs
By Andrew M. Seaman
NEW YORK | Tue May 7, 2013 5:08pm EDT
(Reuters Health) - Professional medical societies don't often consider costs when they're developing their treatment guidelines for specific conditions, according to a new study.
Researchers found that just over half of the top medical societies with at least 10,000 members considered costs when developing best practices. The other half either implicitly considered costs or didn't address them at all.
"Even when they said they looked at costs, they didn't seem to have a clear, consistent or rigorous way to do so," said Dr. Steven Pearson, the study's senior author and a visiting scientist in the Department of Bioethics at the National Institutes of Health in Bethesda, Maryland.
Pearson and his colleague Dr. Jennifer Schwartz write in JAMA Internal Medicine that while a lot of debate has focused on the cost of healthcare in the U.S., few researchers have looked at whether professional societies develop their treatment recommendations with costs in mind.
Clinical guidelines are often crafted by professional medical societies to help doctors decide which therapies are best for certain conditions. But saying a treatment is not worth the cost may spark fears of care rationing.
"It's obviously very controversial about when costs should be included in the discussion of healthcare," Pearson said.
But the professional practice recommendations may factor into reimbursement policies among organizations that pay for treatment, like the Centers for Medicare and Medicaid Services.
For the new study, the researchers examined the publicly available clinical guidelines issued by the 30 largest U.S. medical societies between 2008 and 2012 to see which ones discussed costs.
More than half - 17 of the 30 societies - explicitly included costs in their discussion of clinical guidelines, four at least implicitly considered costs, three purposely excluded costs and six did not mention prices.
The researchers then examined the 279 guidelines published by the 17 societies that included costs in their decisions. Based on that review, they found nine had a formal evaluation system for costs. The other eight societies had several methods to evaluate costs or didn't mention their process.
"I think it's encouraging the societies are now starting to include costs into their guidelines. And when they decide not to, I think it's important to be transparent about that," said Schwartz, a research fellow in the NIH Department of Bioethics.
Dr. Joseph Drozda, from the Center for Innovative Care at Mercy in Chesterfield, Missouri, said he believes more and more societies will be including cost analyses in their guidelines.
"(The researchers) caught it on the upslope so I think we're going to see more attention to cost in guidelines," said Drozda, the chair of the American College of Cardiology Foundation's Clinical Quality Committee who wrote a commentary accompanying the new study.
"I think clearly there is - over time - more of an interest in incorporating cost issues into guidelines," said Dr. Steven Weinberger, executive vice president and CEO of the American College of Physicians in Philadelphia.
"What a lot of organizations are doing - and certainly what we're doing - is recognizing that there are so many areas of overuse and misuse of care," said Weinberger, who has written about cost-conscious care but was not involved in the new research.
He added that the discussion of costs in healthcare is not about rationing, but finding which treatments offer the best value.
"I would really like to see a much more open dialogue between physicians and patients about costs," Weinberger said.
SOURCE: JAMA Internal Medicine, online May 6, 2013.
Cost Consideration in the Clinical Guidance Documents of Physician Specialty Societies in the United States
Jennifer A. T. Schwartz, MD; Steven D. Pearson, MD, MSc
JAMA Intern Med. 2013;():1-7. doi:10.1001/jamainternmed.2013.817.
Importance Despite increasing concerns regarding the cost of health care, the consideration of costs in the development of clinical guidance documents by physician specialty societies has received little analysis.
Objective To evaluate the approach to consideration of cost in publicly available clinical guidance documents and methodological statements produced between 2008 and 2012 by the 30 largest US physician specialty societies.
Design Qualitative document review.
Main Outcomes and Measures Whether costs are considered in clinical guidance development, mechanism of cost consideration, and the way that cost issues were used in support of specific clinical practice recommendations.
Results Methodological statements for clinical guidance documents indicated that 17 of 30 physician societies (57%) explicitly integrated costs, 4 (13%) implicitly considered costs, 3 (10%) intentionally excluded costs, and 6 (20%) made no mention. Of the 17 societies that explicitly integrated costs, 9 (53%) consistently used a formal system in which the strength of recommendation was influenced in part by costs, whereas 8 (47%) were inconsistent in their approach or failed to mention the exact mechanism for considering costs. Among the 138 specific recommendations in these guidance documents that included cost as part of the rationale, the most common form of recommendation (50 [36%]) encouraged the use of a specific medical service because of equal effectiveness and lower cost.
Conclusions and Relevance Slightly more than half of the largest US physician societies explicitly consider costs in developing their clinical guidance documents; among these, approximately half use an explicit mechanism for integrating costs into the strength of recommendations. Many societies remain vague in their approach. Physician specialty societies should demonstrate greater transparency and rigor in their approach to cost consideration in documents meant to influence care decisions.
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