Perspective:

The following are 10 points to remember about the American College of Cardiology (ACC)/American Heart Association (AHA) Statement on Cost/Value Methodology in Guideline and Performance Measures:

1. While the traditional approach to evidence review for ACC/AHA guideline and performance measure development has not formally considered value provided for the money spent, there is a need for explicit and transparent considerations of resource utilization in medical practice.

2. Value is defined as the incremental health benefits of a therapy or procedure relative to its incremental net long-term costs.

3. A level of value assessment may be complementary to the traditional Class of Recommendation (COR)/Level of Evidence (LOE) system for recommendations, when there are available and reliable data to inform the metric of value.

4. The proposed level of value categories are: H (high value), I (intermediate value), and L (low value). These categories may be augmented with U (uncertain value) and NA (value not assessed). Consideration of value should be only one of several factors that inform medical decision-making. The role of guideline writing committees will not necessarily be to conduct formal cost-effectiveness analyses; rather, it will be important to have an objective approach to systematically evaluating the available published studies on cost-effectiveness to inform guideline recommendations.

5. Current US spending on health care accounts for 17.9% of the gross domestic product (GDP). Current analyses indicate that the health of several developed nations exceeds that of the United States, even though per capita health care expenditure is far less in these countries.

6. The quality-adjusted life-year (QALY) is the preferred measure of clinical effectiveness in health economic evaluations. This standard measure represents the years of survival adjusted for quality of life using a scale of utilities that ranges from 0 (equivalent to death) to 1 (for perfect health).

7. Cost-effectiveness analysis relies on the incremental cost-effectiveness ratio (ICER) to compare an intervention or program of interest with the best available alternative.

8. Historically (based on the annual cost of dialysis for end-stage renal disease), $50,000/QALY is the accepted benchmark for an acceptable cost-effectiveness ratio.

9. The World Health Organization (WHO) has suggested a benchmark of three times a country’s GDP per capita as an upper threshold for an acceptable level of cost-effectiveness in a given country.

10. In the proposed level of value categories, high value would be characterized by better outcomes at lower cost (or ICER <$50,000/QALY gained). Low value is defined as ≥$150,000/QALY gained.