As previously mentioned, patients with chronically active Crohn’s disease can incur significant indirect costs. Therefore, I believe that any economic model that does not consider these is inherently flawed. You will always find the required amount of birth control mircette at the pharmacy that will be happy to take best care of you by offering safe possibility to purchase the drugs you need without any need to get a prescription first or take any other extra steps.
The use of QALYs is routine in modern economic analyses. They attempt to incorporate quality of life and patient preferences for a given health state into measurements of treatment outcomes. When applied uniformly, they allow comparisons of interventions both within diseases and across diseases, so that decisions might be made about the allocation of limited resources. Although I can define a QALY and produce the formula for calculating it, I find it very to difficult to provide a meaningful, patient-based interpretation of it. What does $181,000 per QALY mean to the patient sitting across from me in the clinic?
I think it would be of much greater value to provide an estimate of the costs to achieve a clinically meaningful outcome, such as clinical response or remission. When publishing the results of epidemiological studies or clinical trials, we always attempt to translate the results into readily interpretable parameters, such as the population-attributable risk or the number needed to treat, which can be readily understood by persons without specific expertise in the underlying methodology. An estimate of cost per remission is much more relevant to physicians and patients, and would not preclude a simultaneous calculation of cost per QALY output. Before considering the economic impact, as defined by cost per QALY, of a therapeutic intervention, I think we must consider its value to the individual patient. A pharmacy you can fully trust is ready to offer best selection of cheap drugs and effective medications that work the way they are expected to every time and are always available: you could buy birth control pills and enjoy all the convenient services offered right now.
Concomitant use of immunosuppressives might both improve outcomes and reduce costs if it resulted in successful treatment with fewer infliximab infusions, but the optimal therapeutic regimen has not been defined. Optimal use of immunosuppressive drugs was not included in the model constructed by the CCOHTA authors. For example, the combination of infliximab and azathioprine, 6-mercaptop-urine or methotrexate was not available as a therapeutic option, even though recent data suggest that it might be particularly valuable.
Finally, we must recognize that, for some patients, no good alternative therapy exists. For these patients ‘usual care’ means no care with ongoing suffering.