domains of surgical value: the value of surgical interventions and the value of individual providers, including both surgeons and hospitals. He discusses methods of measuring costs and outcomes in both of these domains and additionally surveys public policy options for improving value in surgery.

Howard P. Forman explores the challenges to determining the cost-effectiveness of diagnostic imaging and argues that better, more widely available, cost-effectiveness information could be an important component of stemming the growth of unnecessary imaging. David O. Meltzer focuses on the medical cost-effectiveness of preventive services and wellness approaches, concluding that prevention can be, but is not invariably, a short- or long-term cost-effective approach to improving health. Newell E. McElwee examines the issue of determining the value of pharmaceuticals, specifically discussing decision points along the pharmaceutical life cycle. He also emphasizes that the value of pharmaceuticals varies depending on the specific decision considered and the preferences of the stakeholder making that decision.

Presenters also focus on assessing the value of diagnostic tools and devices. Ronald E. Aubert proposes a framework for evaluating the potential value of pharmacogenetic diagnostics, providing a case study of how applying pharmacogenetic data to the dosing of warfarin, a blood thinner, could reduce adverse events and yield cost savings to the healthcare system. Parashar B. Patel concludes the chapter by discussing the impact of evidence requirements for medical devices on innovation and assessment of value from a device manufacturer’s perspective and the need for cross-stakeholder collaborative efforts in order to preserve incentives for innovation and discovery.

MEASURING VALUE OF AMBULATORY CARE SERVICES

L. Gregory Pawlson, M.D., M.P.H., National Committee for Quality Assurance


Measurement of value in health care is an increasingly important goal, given assessments that indicate less benefit from and higher cost for services provided in the United States versus countries of comparable wealth, as well as multiple studies pointing out apparent waste and less than desirable quality of care (Fisher et al., 2003; McGlynn et al., 2003). However, defining value, let alone measuring it, is very challenging in health care, where neither benefits provided nor resources used to create the benefits are straightforward. Although there have been a considerable number of research studies using various econometric approaches to cost and benefit determination in health care, there is as yet no standard practice for measuring value or even an agreed-upon definition of value.



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