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World Journal of Surgery
Published in: World Journal of Surgery 6/2017

01-06-2017 | Scientific Review

Cost-Effectiveness in Global Surgery: Pearls, Pitfalls, and a Checklist

Authors: Mark G. Shrime, Blake C. Alkire, Caris Grimes, Tiffany E. Chao, Dan Poenaru, Stéphane Verguet

Published in: World Journal of Surgery | Issue 6/2017

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Abstract

Introduction

Cost-effectiveness analysis can be a powerful policy-making tool. In the two decades since the first cost-effectiveness analyses in global surgery, the methodology has established the cost-effectiveness of many types of surgery in low- and middle-income countries (LMICs). However, with the crescendo of cost-effectiveness analyses in global surgery has come vast disparities in methodology, with only 15% of studies adhering to published guidelines. This has led to results that have varied up to 150-fold.

Methods

The theoretical basis, common pitfalls, and guidelines-based recommendations for cost-effectiveness analyses are reviewed, and a checklist to be used for cost-effectiveness analyses in global surgery is created.

Results

Common pitfalls in global surgery cost-effectiveness analyses fall into five categories: the analytic perspective, cost measurement, effectiveness measurement, probability estimation, valuation of the counterfactual, and heterogeneity and uncertainty. These are reviewed in turn, and a checklist to avoid these pitfalls is developed.

Conclusion

Cost-effectiveness analyses, when done rigorously, can be very useful for the development of efficient surgical systems in LMICs. This review highlights the common pitfalls in these analyses and methods to avoid these pitfalls.
Appendix
Available only for authorised users
Footnotes
1
Revised United States Preventative Services Task Force recommendations are due in late 2017; whether this recommendation persists in the United States remains to be seen.
 
2
One important exception exists to this rule. If a cost is completely identical in both the intervention and its comparator, it can be ignored. This is because the numerator is a subtraction. As an example, if patients undergoing the intervention incur a $100 cost for a consultation, which is identical to a $100 cost for consultation in patients undergoing the comparator, then the numerator becomes:
\(\$ 100 + c_{\text{intervention}} {-}\left( {\$ 100 + c_{\text{comparator}} } \right) = c_{\text{intervention}} - c_{\text{comparator}}\)
and the $100 drops out.
 
3
Note that YLD is included as a possibility after death with treatment. Although this is likely zero, including it in the calculation allows for accounting of any disability occurring between unsuccessful treatment and death.
 
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Metadata
Title
Cost-Effectiveness in Global Surgery: Pearls, Pitfalls, and a Checklist
Authors
Mark G. Shrime
Blake C. Alkire
Caris Grimes
Tiffany E. Chao
Dan Poenaru
Stéphane Verguet
Publication date
01-06-2017
Publisher
Springer International Publishing
Published in
World Journal of Surgery / Issue 6/2017
Print ISSN: 0364-2313
Electronic ISSN: 1432-2323
DOI
https://doi.org/10.1007/s00268-017-3875-0

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