Discipline of Public Health, The University of Adelaide, South Australia, Australia.
BMC Health Serv Res. 2012 Aug 21;12:266. doi: 10.1186/1472-6963-12-266.
Methods for the cost-effectiveness analysis of health technologies are now well established, but such methods may also have a useful role in the context of evaluating the effects of variation in applied clinical practice. This study illustrates a general methodology for the comparative analysis of applied clinical practice at alternative institutions--risk adjusted cost-effectiveness (RAC-E) analysis--with an application that compares acute hospital services for stroke patients admitted to the main public hospitals in South Australia.
Using linked, routinely collected data on all South Australian hospital separations from July 2001 to June 2008, an analysis of the RAC-E of services provided at four metropolitan hospitals was undertaken using a decision analytic framework. Observed (plus extrapolated) and expected lifetime costs and survival were compared across patient populations, from which the relative cost-effectiveness of services provided at the different hospitals was estimated.
Unadjusted results showed that at one hospital patients incurred fewer costs and gained more life years than at the other hospitals (i.e. it was the dominant hospital). After risk adjustment, the cost minimizing hospital incurred the lowest costs, but with fewer life-years gained than one other hospital. The mean incremental cost per life-year gained of services provided at the most effective hospital was under $20,000, with an associated 65% probability of being cost-effective at a $50,000 per life year monetary threshold.
RAC-E analyses can be used to identify important variation in the costs and outcomes associated with clinical practice at alternative institutions. Such data provides an impetus for further investigation to identify specific areas of variation, which may then inform the dissemination of best practice service delivery and organisation.
健康技术的成本效益分析方法现在已经很成熟，但这些方法在评估应用临床实践变化的效果方面也可能具有有用的作用。本研究说明了一种在不同机构评估应用临床实践的比较分析的一般方法——风险调整成本效益（RAC-E）分析——并应用于比较南澳大利亚主要公立医院收治的中风患者的急性医院服务。
利用 2001 年 7 月至 2008 年 6 月期间所有南澳大利亚医院分离的链接、常规收集数据，使用决策分析框架对四家大都市医院提供的服务进行了 RAC-E 分析。对不同人群的观察（加外推）和预期终生成本和生存进行了比较，从而估计了不同医院提供的服务的相对成本效益。
未经调整的结果表明，一家医院的患者比其他医院的患者成本更低，生存时间更长（即它是主导医院）。风险调整后，成本最小化的医院成本最低，但获得的生命年数少于另一家医院。在最有效的医院提供的服务中，每增加一个生命年的增量成本低于 20000 美元，相关的 65%的概率在 50000 美元/生命年的货币阈值内是具有成本效益的。
RAC-E 分析可用于识别不同机构临床实践相关成本和结果的重要变化。此类数据为进一步调查提供了动力，以确定具体的变化领域，然后为最佳实践服务提供和组织的传播提供信息。
