Author + information
- Matthew E. Oster, MD, MPH∗ (, )
- Michael Kelleman, MPH and
- Yinn Khurn Ooi, MD
- ↵∗Children’s Healthcare of Atlanta, Division of Cardiology, 1405 Clifton Road Northeast, Atlanta, Georgia 30322
We appreciate the insightful comments by Drs. O’Byrne and Glatz regarding our paper “Transcatheter Versus Surgical Closure of Atrial Septal Defects in Children: A Value Comparison” (1). We now take this opportunity to expound upon the concept of value in healthcare. Specifically, with value being defined as outcomes relative to costs (2), it is inherently important to have appropriate definitions and measurements of outcomes and costs in any value assessment.
First, the choice of which outcomes to measure is often dictated by convenience for the researcher or analyst, but may not be what matters most to the patient. Short-term, objective measures such as survival, length of stay, or readmission are often readily captured by the medical system and thus are ripe for analyses. However, what matters most to patients are typically the long-term, subjective outcomes such as functional status and quality of life. This measurement is particularly difficult in pediatrics, as appropriately determining a quality-adjusted life-year in this population is controversial (3). Nevertheless, having common, well-established outcome measures can help steer outcomes research toward those factors that matter most to patients. While such measures have been determined for cardiovascular diseases such as coronary artery disease and stroke, but no such determinations have been made for congenital heart disease (4).
Even when outcome measures can be agreed on, it is the cost comparison that often complicates the value assessment. First, one must decide whose costs are at stake: The hospital? The insurance company? The patient? Society? Each of these stakeholders will view costs through a different lens. Second, assessing these costs can be fraught with difficulty. Cost-to-charge ratios are the norm when comparing costs between different hospitals, but these are by no means a perfect measure. Using microcosting measures can help to most accurately measure the costs of delivering care, but such methods can be expensive to implement (5). The choice of cost measures can have profound effects on the integrity of the analysis and thus determination of value.
Without ideal methods for measuring outcomes and costs, there is no ideal method for determining true value. However, if we can choose those outcomes that matter most to patients, and if we can be transparent about what costs we are measuring and how we are measuring them, we can at the very least compare the outcomes and costs of various interventions to provide an estimation of their relative value.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation
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