Phillips K A, Hotlgrave D R
Department of General Internal Medicine Institute for Health Policy Studies, School of Medicine, University of California, San Francisco, USA.
Am J Prev Med. 1997 Jan-Feb;13(1):18-25.
Prevention is being promoted as a means to improve health status and to save health care costs. Economic evaluations of prevention (i.e., cost-effectiveness and cost-benefit analyses) indicate that some prevention activities, like many treatments, do not save money, although many are relatively cost-effective. It has been suggested, however, that prevention is held to a higher standard than treatment because prevention programs are expected to demonstrate cost savings, and that the methods of economic evaluation understate the cost-effectiveness of prevention. Although the converse assertion is less commonly made, economic evaluations may also overstate the cost-effectiveness of prevention. The purpose of this article is to examine how the methods of economic evaluation may systematically understate, or overstate, the cost-effectiveness (or net benefits) of prevention.
We examine three key methods: (1) how future costs and benefits are valued ("discounting"), (2) how costs and benefits to people beyond those who are the users of prevention are valued ("externalities"), and (3) how nonmonetary costs and benefits to individuals are valued ("intangibles").
We discuss several recommendations for each key method, and we use a hypothetical example of the cost-effectiveness of a vaccine to prevent human immunodeficiency virus (HIV) to illustrate our points.
We conclude that the methods of economic evaluation may both understate and overstate the cost-effectiveness of prevention.
预防被视为改善健康状况和节省医疗成本的一种手段。对预防措施的经济评估（即成本效益分析和成本效益分析）表明，与许多治疗方法一样，一些预防活动并不能节省资金，尽管许多预防活动具有较高的成本效益。然而，有人认为，预防措施的标准要高于治疗措施，因为预防项目预计要证明能节省成本，而且经济评估方法低估了预防措施的成本效益。虽然相反的观点较少被提及，但经济评估也可能高估了预防措施的成本效益。本文旨在探讨经济评估方法如何可能系统性地低估或高估预防措施的成本效益（或净效益）。
我们研究了三种关键方法：（1）如何对未来成本和效益进行估值（“贴现”），（2）如何对预防措施使用者以外的人群的成本和效益进行估值（“外部性”），以及（3）如何对个人的非货币成本和效益进行估值（“无形因素”）。
我们针对每种关键方法讨论了若干建议，并以预防人类免疫缺陷病毒（HIV）疫苗成本效益的假设示例来说明我们的观点。
我们得出结论，经济评估方法可能既低估也高估了预防措施的成本效益。
