Value now a component in development of guidelines and performance measures

Recognizing the rising cost of healthcare and the importance of providing value to patients, resource utilization and value assessments will now be explicitly considered in the development of clinical practice guidelines and performance measures from the American College of Cardiology/American Heart Association (ACC/AHA).  

The goal of this shift in methodology is to achieve the best possible health outcomes in cardiovascular care with finite healthcare resources.

Assessment of value or cost-effectiveness of specific treatments or diagnostic techniques will be based on data from published studies identified through a thorough, independent literature search and reviewed for quality and bias. The published evidence will be synthesized to generate ratings for both the level of value and the level of evidence that will be used to inform recommendations.

Level of value will be categorized as high (better outcomes at lower cost or incremental cost-effectiveness ratio <$50,000 per quality-adjusted life-year gained), intermediate ($50,000 to <$150,000 per quality-adjusted life-year gained), low (≥$150,000 per quality-adjusted life-year gained), uncertain (data insufficient to draw a conclusion), or not assessed. Level of evidence will be categorized via the same rating system used to describe scientific level of evidence (A, B, C), taking into account the robustness of the value database.  The committee also noted that the designation “high-resource utilization” may be preferred over “low value” if a treatment represents the only effective option available for a rare or advanced condition.

The new ratings are intended to complement the existing class of recommendation/level of evidence ratings derived from assessments of clinical trial evidence that are used for developing recommendations. Value category ratings will be presented separately. Although it is recognized there may be a paucity of high-quality data on cost and value currently, the situation is expected to change because economics endpoints are increasingly being included in clinical trials. In addition, the move to incorporate value assessments in clinical guidelines may spur relevant research. Recognizing that the value of a care practice is sensitive to changes in its cost and benefits, it is believed that inclusion of the value determinations in formulating guideline recommendations will increase the need for periodic reviews and updates.

The full ACC/AHA statement on cost/value methodology in clinical practice guidelines and performance measures is published in Circulation and the Journal of the American College of Cardiology, and can be accessed through the websites of the ACC (www.cardiosource.org ) and AHA (www.my.americanheart.org.) The report describes the rationale for considering resource utilization and value in recommendations for guidelines and performance measures, key economic concepts, the proposed value assessment, recommendations for its implementation, special considerations for performance measures, and future directions.