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The article discusses the cost-effectiveness analysis in the public health care system in the U.S. It mentions that the cost-effectiveness analysis in public healthcare concerns the measurement and the propeer communication of the value of the new drugs and other medical interventions. It adds that the cost-effective analyses is primarily concerned with the trade-offs related on the choice of alternative medical interventions.

A response by researcher Gillian D. Sanders and his colleagues to letters to the editor about their article on the cost-effectiveness of implantable cardioverter defibrillator (ICD) therapy in the October 6, 2005 issue is presented.

Background: Eight randomized trials have evaluated whether the prophylactic use of an implantable cardioverter–defibrillator (ICD) improves survival among patients who are at risk for sudden death due to left ventricular systolic dysfunction but who have not had a life-threatening ventricular arrhythmia. We assessed the cost-effectiveness of the ICD in the populations represented in these primary-prevention trials. Methods: We developed a Markov model of the cost, quality of life, survival, and incremental cost-effectiveness of the prophylactic implantation of an ICD, as compared with control therapy, among patients with survival and mortality rates similar to those in each of the clinical trials. We modeled the efficacy of the ICD as a reduction in the relative risk of death on the basis of the hazard ratios reported in the individual clinical trials. Results: Use of the ICD increased lifetime costs in every trial. Two trials — the Coronary Artery Bypass Graft (CABG) Patch Trial and the Defibrillator in Acute Myocardial Infarction Trial (DINAMIT) — found that the prophylactic implantation of an ICD did not reduce the risk of death and thus was both more expensive and less effective than control therapy. For the other six trials — the Multicenter Automatic Defibrillator Implantation Trial (MADIT) I, MADIT II, the Multicenter Unsustained Tachycardia Trial (MUSTT), the Defibrillators in Non-Ischemic Cardiomyopathy Treatment Evaluation (DEFINITE) trial, the Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure (COMPANION) trial, and the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) — the use of an ICD was projected to add between 1.01 and 2.99 quality-adjusted life-years (QALY) and between $68,300 and $101,500 in cost. Using base-case assumptions, we found that the cost-effectiveness of the ICD as compared with control therapy in these six populations ranged from $34,000 to $70,200 per QALY gained. Sensitivity analyses showed that this cost-effectiveness ratio would remain below $100,000 per QALY as long as the ICD reduced mortality for seven or more years. Conclusions: Prophylactic implantation of an ICD has a cost-effectiveness ratio below $100,000 per QALY gained in populations in which a significant device-related reduction in mortality has been demonstrated. N Engl J Med 2005;353:1471-80. [ABSTRACT FROM AUTHOR]

A response by Gillan D. Sanders and colleagues to several letters to the editor about their article "Cost-Effectiveness of Screening for HIV," published in the February 10, 2005 issue is presented.

Background: The costs, benefits, and cost-effectiveness of screening for human immunodeficiency virus (HIV) in health care settings during the era of highly active antiretroviral therapy (HAART) have not been determined. Methods: We developed a Markov model of costs, quality of life, and survival associated with an HIV-screening program as compared with current practice. In both strategies, symptomatic patients were identified through symptom-based case finding. Identified patients started treatment when their CD4 count dropped to 350 cells per cubic millimeter. Disease progression was defined on the basis of CD4 levels and viral load. The likelihood of sexual transmission was based on viral load, knowledge of HIV status, and efficacy of counseling. Results: Given a 1 percent prevalence of unidentified HIV infection, screening increased life expectancy by 5.48 days, or 4.70 quality-adjusted days, at an estimated cost of $194 per screened patient, for a cost-effectiveness ratio of $15,078 per quality-adjusted life-year. Screening cost less than $50,000 per quality-adjusted life-year if the prevalence of unidentified HIV infection exceeded 0.05 percent. Excluding HIV transmission, the cost-effectiveness of screening was $41,736 per quality-adjusted life-year. Screening every five years, as compared with a one-time screening program, cost $57,138 per quality-adjusted life-year, but was more attractive in settings with a high incidence of infection. Our results were sensitive to the efficacy of behavior modification, the benefit of early identification and therapy, and the prevalence and incidence of HIV infection. Conclusions: The cost-effectiveness of routine HIV screening in health care settings, even in relatively low-prevalence populations, is similar to that of commonly accepted interventions, and such programs should be expanded. N Engl J Med 2005;352:570-85. [ABSTRACT FROM AUTHOR]