Ubel P A, DeKay M L, Baron J, Asch D A
Veterans Affairs Medical Center, Philadelphia, PA, USA.
N Engl J Med. 1996 May 2;334(18):1174-7. doi: 10.1056/NEJM199605023341807.
One of the promises of cost-effective analysis is that it can demonstrate how to maximize health benefits attainable within a specific limited budget. Many people argue, however, that when there are budget limitations, the use of cost-effectiveness analysis leads to health care policies that are inequitable.
We asked prospective jurors, medical ethicists, and experts in medical decision making to choose between two screening tests for a population at low risk for colon cancer. One test was more cost effective than the other but because of budget constraints was too expensive to be given to everyone in the population. With the use of the more effective test for only half the population, 1100 lives could be saved at the same cost as that of saving 1000 lives with the use of the less effective test for the entire population.
Fifty-six percent of the prospective jurors, 53 percent of the medical ethicists, and 41 percent of the experts in medical decision making recommended offering the less effective screening test to everyone, even though 100 more lives would have been saved by offering the more expensive test to only a portion of the population. Most of the study participants justified this recommendation on the basis of equity. A smaller number stated either that it was not politically feasible to offer a test to only half the population or that the additional benefit of the more expensive test (100 more lives saved) was too small to justify offering it to only a portion of the public.
People place greater importance on equity than is reflected by cost-effectiveness analysis. Even many experts in medical decision making -- those often responsible for conducting cost-effectiveness analyses -- expressed discomfort with some of its implications. Basing health care priorities on cost effectiveness may not be possible without incorporating explicit considerations of equity into cost-effectiveness analyses or the process used to develop health care policies on the basis of such analyses.
成本效益分析的一个前景是它能够展示如何在特定的有限预算内实现健康效益最大化。然而，许多人认为，当存在预算限制时，使用成本效益分析会导致医疗保健政策不公平。
我们让潜在陪审员、医学伦理学家和医疗决策专家在针对患结肠癌低风险人群的两种筛查测试中做出选择。一种测试比另一种更具成本效益，但由于预算限制，对所有人进行该测试成本过高。对仅一半人群使用更有效的测试，在与对整个人群使用效果较差的测试挽救1000条生命相同的成本下，可以挽救1100条生命。
56%的潜在陪审员、53%的医学伦理学家和41%的医疗决策专家建议对每个人都采用效果较差的筛查测试，尽管对仅一部分人群采用更昂贵的测试可以多挽救100条生命。大多数研究参与者基于公平性为这一建议辩护。少数人表示，仅对一半人群进行测试在政治上不可行，或者更昂贵测试的额外益处（多挽救100条生命）太小，不足以证明仅对一部分公众采用该测试是合理的。
人们对公平性的重视程度高于成本效益分析所反映的程度。甚至许多医疗决策专家——那些通常负责进行成本效益分析的人——也对其一些影响表示不满。如果在成本效益分析或基于此类分析制定医疗保健政策的过程中不明确考虑公平性，可能无法将医疗保健重点基于成本效益。
