Welfare gains and losses caused by clinical practice guidelines

Abstract

Clinical practice guidelines (CPGs) for health professionals can have a variety of welfare implications. These may result from a reduction in practice variation in the form of overuse, underuse and misuse or a shift in resources between patient groups. The purpose of this article is to discuss welfare gains and losses caused by CPGs for health professionals. To this end, the article distinguishes between CPGs with and without the inclusion of economic evidence. Based on a framework, this article shows that CPGs, which include economic evidence, can actually lead to a welfare loss by misjudging the maximum cost–effectiveness threshold or ignoring altruistic concerns for patients. Given that a significant portion of CPGs currently considers costs and cost–effectiveness of treatment, this practice may need to be reassessed in jurisdictions where a cost–effectiveness threshold has not been appropriately defined and a public consensus on the trade-off between cost–effectiveness and equity does not yet exist.

Keywords::

• budget
• cost–effectiveness
• evidence-based medicine
• equity
• practice guideline

Financial & competing interests’ disclosure

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Clinical practice guidelines (CPGs) for health professionals can have a variety of welfare implications

• Based on a framework, this article shows that CPGs, which include economic evidence, can actually lead to a welfare loss, by misjudging the maximum cost–effectiveness threshold or ignoring altruistic concerns for patients

• A literature search in a US and German clearinghouse demonstrates that a significant portion of CPGs consider costs and cost–effectiveness of treatment

• This practice of considering costs and cost–effectiveness of treatment may need to be reassessed in jurisdictions where a cost–effectiveness threshold has not been appropriately defined and a public consensus on the trade-off between cost–effectiveness and equity does not yet exist

Notes

i In the following, clinical evidence presupposes statistical significance at an alpha level of 0.05 and clinical significance.

ii Equity means social justice or fairness; it is an ethical concept, grounded in principles of distributive justice.

iii A conflict of interest is a set of conditions in which professional judgment concerning a primary interest (such as a patient’s welfare) tends to be unduly influenced by a secondary interest (such as financial gain).

iv ‘Value’ is something worthwhile or something we believe to have merit.

v A budget-holder perspective requires the consideration of full costs, including institutional overhead as overhead costs may change in the long run and cost–effectiveness analysis should have a long-run perspective.

vi Underuse is the failure to provide a health-care service when it would have produced a favorable outcome for a patient. Overuse occurs when a health-care service is provided under circumstances in which its potential for harm exceeds the possible benefit. Misuse occurs when an appropriate service has been selected, but a preventable complication occurs and a patient does not receive the full potential benefit of the service.