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

doi:10.1059/0003-4819-151-9-200911030-00011

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

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.

Abstract

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.

Article and Author Information

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{at}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.