Reply to the Editor

Article Outline

• Reference
• Copyright

CTSNet classification: 4.3, 23.1, 41.1

We naturally agree with Dr Al-Ebrahim that avoiding complications in cardiac surgery is far better than treating them as they occur; however, we believe that some key messages of our research have been misunderstood. Dr Al-Ebrahim states, “Quality improvement in this multidisciplinary and delicate service requires comprehensive understanding of the basics and details of the surgical procedures, and the incremental costs of complications. Morbidity and mortality can not be “priced” financially, because there is no winner in this deal. Both the patient and the health service are losers. Knowing the added cost will never reduce the complications. Death, the most disastrous complication, is actually the cheapest, with no extra cost to be paid.” Although it is correct that morbidity and mortality cannot be priced, the costs of treating medical complications and even of saving lives can certainly be estimated.¹ Indeed, the very cornerstone of the health economic discipline is to do exactly such estimations across the most common diseases to determine how limited health care resources can be used most effectively to benefit the most patients. Knowing the economic consequences of medical complications is a highly essential step in our efforts to identify cost-effective clinical interventions to address them. In health care systems with limited resources, policy makers, health insurers, hospital administrators, and practicing physicians need to consider carefully the cost-effectiveness of medical interventions, both in the daily practice of medicine and as part of long-term evaluation and planning of quality improvement initiatives.

As we describe in our article, medical interventions can either be cost saving (if the hospital's cost savings are greater than the cost of the intervention), cost-effective (when the incremental cost of a clinical intervention is reasonable with regard to the clinical benefits obtained), or cost enhancing (if the clinical intervention induces higher hospital costs without any clinical benefit). In the context of excessive hemorrhage in cardiac surgery, knowledge of the medical and economic consequences of this complication is the very first step in the identification of safe, effective, and cost-effective clinical interventions to address this complication. Additionally, awareness of the costs of excessive hemorrhage may compel health care professionals to apply preventive and therapeutic measures as early as possible. In our research we used simple and objective criteria for excessive postoperative hemorrhage to allow early identification of patients at risk for severe morbidity or even a fatal outcome. Early identification of bleeding facilitates early treatment and thereby improves outcome. This is the very basis for improvement in clinical care and applied quality improvement.

Of course, health care providers must primarily keep the individual patient's health in mind. In addition, however, we need to be aware of the costs of complications to provide the highest standard of care for all patients. This may be even more important in the future, when rationing of health care resources is likely to become an even more dominant part of our health care services.

Back to Article Outline

Reference 

1. Dolan P, Metcalfe R, Munro V, Christensen MC. Valuing lives and life years: anomalies, implications, and an alternative. Health Econ Policy Law. 2008;3(Pt 3):277–300
   • View In Article