Clinical Guidance Documents and Cost Considerations

Health spending per capita in the United States is higher than in any other developed country, however, studies have not shown any associated benefits such as increased life expectancy or other better health-related outcomes. The need to control healthcare costs is widely acknowledged, but questions remain about who should take responsibility for reining in healthcare-associated spending.

Noting that little attention has been paid to the role of an important source of clinical and health system policy, namely physician specialty societies, researchers recently conducted a qualitative document review. The review was designed to determine what percentage of societies explicitly consider costs in developing clinical guidance documents, how costs are considered by those developing guidance documents for the societies that consider costs explicitly, and how cost considerations are manifested in formal recommendations in the documents themselves.

The researchers utilized the National Guideline Clearinghouse^TM, an Agency for Healthcare Research and Quality initiative, to identify all physician specialty societies in the United States that produced clinical guidance documents in the past 5 years. After applying inclusion and exclusion criteria, the final study cohort included 30 US physician societies. Results of the study were reported in JAMA Internal Medicine [2013;173(12):1091-1097].

The primary outcomes and measures were whether costs were considered in the development of clinical guidance documents, the mechanism of cost consideration, and the ways cost issues were used in support of specific clinical practice recommendations.

Of the 30 societies in the review, 57% (n=17) indicated in a document outlining general guideline development strategy or at least 1 of their specific clinical guidance documents that they “explicitly integrated cost considerations.” Among the remaining societies, 20% (n=6) did not indicate whether or how costs were considered, 13% (n=4) indicated that costs “might be considered” in the development of guidance documents, but did not provide further information (implicit cost consideration), and 10% (n=3) said that as a rule they excluded costs from consideration in any clinical guidance development.

The researchers limited the review to 50 clinical guidance documents per society. Of the 17 societies that explicitly indicated that they considered costs when developing clinical guidance, there were 279 clinical guidance documents produced within the last 5 years. Of the 279 documents, 35% (n=38) had at least 1 specific recommendation that used cost issues as part of its justification.

Of these 17 societies, 57% (n=9) consistently used a formal grading system in which the strength of recommendation was influenced in part by costs. The remaining 47% (n=8) used various methods for incorporating costs (or did not mention the exact mechanism) in the individual documents.

Cost was mentioned in 138 specific recommendations within the 279 documents. Of those, 36% (n=50) encouraged use of an intervention because of equal effectiveness and lower cost compared with alternatives, 19% (n=26) advised nonuse because there was no clinical benefit and costs could be avoided, and 17% (n=24) recommended nonuse because the incremental clinical benefit did not justify the higher costs. In addition, 17% (n=230) favored use because the incremental clinical benefit did justify the extra cost and 11% (n=15) encouraged use to prevent future costs.

In summary, the researchers commented, “Slightly more than half of the largest US physician societies explicitly considered costs in developing their clinical guidance documents; among those, approximately half used an explicit mechanism for integrating costs into the strength of recommendations.”