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ACC/AHA to Include Cost/Value Assessments in Guidelines and Performance Measures

March 27, 2014

The ACC and the American Heart Association (AHA) will begin to include value assessments when developing guidelines and performance measures, in recognition of accelerating health care costs and the need for care to be of value to patients.

The ACC/AHA Statement on Cost/Value Methodology in Guidelines and Performance Measures External Link released March 27, states a key goal of achieving the best possible health outcomes with finite health care resources. Historically, value consideration and resource utilization were explicitly excluded from practice guidelines and performance measures formulations, though they were often implicitly considered.

"There is growing recognition that a more explicit, transparent, and consistent evaluation of health care value is needed," stated Paul Heidenreich, MD, FACC, writing committee co-chair and vice-chair for Quality, Clinical Affairs and Analytics in the Department of Medicine at Stanford University School of Medicine. "These value assessments will provide a more complete examination of cardiovascular care, helping to generate the best possible outcomes within the context of finite resources."

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The Writing Committee notes that economic evaluations can help decision makers appreciate the implications of choices and clarify factors influencing relative benefits. In addition to informing providers in the exercise of their responsibility to their patients, value analyses can guide those making coverage decisions and inform developers of practice guidelines to assure that recommendations yield the greatest value from available health care resources.

The ACC and AHA will determine whether the value or the cost-effectiveness of a given treatment or diagnostic strategy has been adequately evaluated on the basis of published studies. Initially, it is expected that relatively few treatments or diagnostic strategies will have had their value adequately evaluated through studies. In time, however, the number of evaluated treatments and strategies will increase as more studies are published. The statement notes that momentum is increasing in the area of health care cost-effectiveness and that incorporating value assessments in clinical guidance documents may further incentivize researchers, medical schools and other stakeholders to invest in the country's move toward greater care value.

"Despite the dearth of cost-effectiveness research, the evidence that is available is informative, and study quality is improving," stated Jeffrey L. Anderson, MD, FACC, writing committee co-chair and associate chief of cardiology, Intermountain Medical Center Heart Institute. "The hope of the Writing Committee is that this statement will further encourage researchers to include a value component in their study designs, providing an analysis of resource utilization and cost-benefit in multi-center trials."

Those treatments or diagnostic strategies that have been adequately evaluated will be given a rating. The proposed level of value categories are high value (H), intermediate value (I), low value (L) – possibly augmented where appropriate with uncertain value (U) – and value not assessed (NA). The proposed threshold for L and H are those recommended by the World Health Organization, which labels a care strategy as "poor value" if the cost per life year gained is greater than three times the gross domestic product (GDP) per capita, and a "good value" if the cost per life year gained is less than one times the GDP per capita. In the U.S., treatments that have a cost-effectiveness ratio of $150,000/QALY or more would be considered low value. The value category (i.e., H, I, L, U) would be augmented by a level of evidence, paralleling those for scientific LOE (i.e., A, B, C) and would be based on the robustness of the database supporting the value category.

The statement says the societies will not yet "be prescriptive" in how to best use the new value assessments, and that the new value category is to appear alongside the traditional effectiveness ratings, which remain unchanged. The Writing Committee stressed that the new value category is to be only one of several factors considered in resource allocation decisions.

"The ACC and AHA recognize that payers, providers and patients may have different views on how to incorporate value into medical care, but they all will benefit from having more cost and value data available," added Heidenreich.

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