Methodological experiences in development of cost-conscious guidelines

Objectives: Discussing ethical, legal and economic aspects of resource allocation is an ongoing process in times of steadily increasing demand for health-care services with limited or even declining financial resources. In this context priority setting and rationing are often mentioned strategies. If health care rationing should become inevitable in medium term, it has to be discussed which methods could be used for implementation. In context of explicit rationing cost-conscious guidelines are described as a possible strategy for implementation. The aim of this project was to identify the chances and limits of cost-conscious guidelines regarding different technologies in cardiology and intensive care. Methods: For defined technologies in cardiology and intensive care systematic literature researches regarding efficacy, effectiveness and cost-effectiveness were done. The chosen technologies were in context of cardiology implantable cardioverter defibrillator (ICD) and drug eluting stents (DES), in terms of intensive care activated factor VII and activated protein C. In addition a systematic research of clinical guidelines was performed. Regarding guidelines and results of systematic literature research groups of patients should be identified with different benefit if applying one of the chosen technologies. Furthermore we analyzed the cost-effectiveness in term of these subgroups of patients and developed exemplarily cost-conscious guidelines. Results: Evidence for the chosen technologies was identified and analyzed. Subgroups which showed different results concerning cost-effectiveness were found in the indications congestive heart failure treated with ICD and the technology DES. For both technologies cost-conscious guidelines were developed exemplarily. Conclusion: The development of cost-conscious guidelines – as a method for implementation of explicit rationing – is possible. However a high resource use for realization is necessary. Sufficient data regarding efficacy, effectiveness and cost-effectiveness are needed. Especially data regarding specific subgroups of patients are requested. Altogether it is hard to consider if cost-conscious guidelines will find a way in daily routine.