Gafni A, Birch S
Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.
CMAJ. 1993 Mar 15;148(6):913-7.
The guidelines proposed by Laupacis and associates do not stem from economic theory and are a prescription for uncontrolled growth in health care expenditure. In particular, cost-effectiveness ratios provide information relevant to allocation decisions only in very special circumstances that do not usually apply in practice. When two interventions are compared a positive cost-effectiveness ratio (the common case) can tell us, at best, what additional costs will be incurred to generate the additional outcomes. From an economic perspective the information required to determine the attractiveness of a new technology is different: the source of the additional resource requirements must be identified and the opportunity cost of their redeployment estimated. Because the cost-effectiveness ratio (cost/-QALY) is sensitive to the method chosen to calculate QALYs, guidelines that do not specify (or justify) the appropriate method for calculating outcomes are unlikely to produce comparable results (or common yardsticks). In a health care system such as Canada's in which there is always pressure to introduce more effective technology, even if it is more costly, there is a risk of using such noncomparable data to justify adoption of particular technologies. The method of technology evaluation proposed by us is consistent with the stated goal of maximizing the community's health-related well-being for a given level of resources allocated to health care and ensures that new technologies are adopted only if this adoption represents an improvement in resource allocation.
劳帕西斯及其同事提出的指导方针并非源于经济理论，而是医疗保健支出无节制增长的一个药方。特别是，成本效益比率仅在非常特殊的情况下（而这些情况在实际中通常并不适用）才提供与资源分配决策相关的信息。当比较两种干预措施时，正的成本效益比率（常见情况）充其量只能告诉我们，为产生额外的结果将产生多少额外成本。从经济角度来看，确定一项新技术吸引力所需的信息是不同的：必须确定额外资源需求的来源，并估计其重新调配的机会成本。由于成本效益比率（成本/质量调整生命年）对计算质量调整生命年所选用的方法很敏感，因此未明确规定（或说明理由）计算结果的适当方法的指导方针不太可能产生可比的结果（或通用标准）。在像加拿大这样的医疗保健系统中，总是存在引入更有效技术的压力，即使其成本更高，存在使用此类不可比数据来证明采用特定技术合理性的风险。我们提出的技术评估方法与在分配给医疗保健的给定资源水平下使社区与健康相关的福祉最大化这一既定目标相一致，并确保仅在采用新技术代表资源分配有所改善时才采用新技术。
