Hillner B E
Department of Internal Medicine, Medical College of Virginia, Richmond 23298-0170, USA.
Semin Oncol. 1996 Feb;23(1 Suppl 2):98-104.
The need for cost-effectiveness analyses is based on the unfortunate but universal situation of limited financial resources that ideally should be used to maximal benefit. Formal cost-effectiveness analyses assume a societal utilitarian perspective with the objective of maximizing net health benefit for members of a population within a limited level of resources. This societal perspective is in stark contrast to the clinician's perspective, whose goal is to maximize his or her patient's health status (no matter what effect those decisions have on other patients or resources). This difference in perspective and objectives explains why many clinicians object to the use of cost-effectiveness analysis in setting policies. When considering the natural history of breast cancer from screening, evaluation of suspicious lesions, primary therapy, staging, adjuvant therapy, monitoring, metastatic disease, and palliative care, it is striking that most cost-effectiveness studies have been related to screening or the use of adjuvant drug therapies. In prior work our group has shown that the use of chemotherapy in node-negative breast cancer and of tamoxifen alone or in combination with chemotherapy in premenopausal women are cost-effective compared with other common medical treatments. Given the increasing pressure to contain costs in contemporary medicine, one should remember that cost effectiveness is related to value, value defined as quality/costs. Examples are discussed when the controversy focuses on increasing quality (eg, valued outcomes, such as additional years of life or years of breast preservation) and on controlling costs (eg, integrating multidisciplinary care, minimizing superfluous testing, or reducing surgical biopsy rates). Efforts should be directed at both sides of this ratio.
成本效益分析的必要性基于一种不幸但普遍存在的情况，即财政资源有限，而这些资源理想情况下应被用于实现最大效益。正式的成本效益分析采用社会功利主义视角，目标是在有限的资源水平内为人群成员最大化净健康效益。这种社会视角与临床医生的视角形成鲜明对比，临床医生的目标是最大化其患者的健康状况（无论这些决策对其他患者或资源有何影响）。这种视角和目标的差异解释了为什么许多临床医生反对在制定政策时使用成本效益分析。当考虑乳腺癌从筛查、可疑病变评估、初始治疗、分期、辅助治疗、监测、转移性疾病到姑息治疗的自然病程时，引人注目的是，大多数成本效益研究都与筛查或辅助药物治疗的使用有关。在先前的工作中，我们团队表明，与其他常见医疗治疗相比，在淋巴结阴性乳腺癌中使用化疗以及在绝经前女性中单独使用他莫昔芬或与化疗联合使用他莫昔芬具有成本效益。鉴于当代医学中控制成本的压力不断增加，人们应该记住，成本效益与价值相关，价值定义为质量/成本。当争议集中在提高质量（例如，有价值的结果，如额外的生命年或保乳年数）和控制成本（例如，整合多学科护理、尽量减少不必要的检查或降低手术活检率）时，会讨论相关示例。应该在这个比率的两个方面都做出努力。
