Reply to: Brough CEP, Haycox A. Resource Use In Rectifying Pacemaker Complications. Journal of Medical Economics 2018. doi: 10.1080/13696998.2017.1423075

Original article: Waweru C, Steenrod A, Wolff C, Eggington S, Wright DJ, Wyrwich KW. Global health resource utilization associated with pacemaker complications. Journal of Medical Economics 2017;20:732-739.

We appreciate the comments made on our article and would like to address the questions raised about our study methodology. First, regarding the selection of study participants for the Delphi panel, our goal was to maximize the internal validity by including electrophysiologists (EPs) with expert knowledge and experience in managing pacemaker complications. As our focus was to understand health resource utilization (HRU) in the management of pacemaker complications, it was imperative that we minimized recall bias by only enrolling EPs who regularly managed pacemaker complications. The authors assert that this select group of EPs possibly had access to expensive technologies that might not be available to other healthcare institutions. We would like to point out that few of our survey questions touched on technologies used, with most focused on outpatient visits, hospital stay, cath lab use, medication use, and personnel involved. The authors correctly observe that our study findings may not be generalizable to all EPs due to the small study sample size; a point that we underscore in the Discussion section of our article. Nonetheless, proponents of Delphi techniques assert that Delphi participants must be highly trained and competent in the topic of interest, to produce high quality results^1,2. We believe that, by including EPs who were highly experienced in managing pacemaker complications, we were able to generate estimates of HRU that were valid and reliable.

Second, regarding the formulation of complication scenarios in the surveys, it behooved us to create scenarios that provided comprehensive information on HRU without overly burdening the respondent. The survey scenarios were created and vetted with the help of two EPs, both of whom were not included as panelists. The scenarios were crafted to ascertain how physicians managed pacemaker complications in general, while recognizing that there may be nuances depending on patient characteristics. An analogy for our approach is the clinical trial whose objective is to estimate the efficacy of treatment in the general patient population, even though the effect on individual patients may vary. Regarding the treatment of upper extremity DVTs, we asked our respondents to consider only symptomatic events in their responses (see study questionnaire in Supplementary Materials). We, nonetheless, acknowledge that we should have clarified this in the main text to avoid confusion.

We affirm that several cost parameters were not included from the study, mainly to minimize respondent burden. Nonetheless, our results can be considered as providing conservative estimates of HRU in pacemaker complications. We countenance the design of observational studies that can provide real-world data on HRU, although such studies might be prohibitively expensive to implement on a global scale. In conclusion, where economic data is lacking, the Delphi technique is a useful and acceptable approach for providing country-specific estimates of HRU necessary for decision-making.

Transparency

Declaration of funding

There is no funding to report for this letter.

Declaration of financial/other relationships

CWW, SE, and CW are employees of Medtronic. DJW has received honoraria from Boston Scientific, Medtronic, and St Jude Medical and a research grant from Boston Scientific for an investigator initiated study. KWW and AS are employees of Evidera, who were paid consultants by Medtronic in connection with the study and manuscript referred to in the letter to the editor.

Acknowledgments

None.