Marten J. Poley - Erasmus Universiteit Rotterdam

110Chapter 7In the early 2000s, our research group performed economic evaluations oftreatment of congenital anorectal malformations (ARM) and congenitaldiaphragmatic hernia (CDH). 24-26 The results may briefly be summarized asfollows. The direct medical costs were found to be considerable, with long-termcosts after the initial treatment being only a fraction of these costs. HRQoL inpatients once treated for ARM and now between 1 and 4 years of age was lowerthan that of the general population. The older children showed better HRQoL.Although surgery for ARM was associated with substantial residualsymptomatology, patients aged 16 years and over showed hardly any HRQoLdifferences with population standards. We found CDH to be still associated withhigh mortality rates, despite the many advances in treatment over recentdecades. Although respiratory difficulties and stomach aches were reported,HRQoL in CDH survivors did not differ significantly from that of the generalpopulation. Costs per quality-adjusted life year (QALY) amounted to € 2,482 forARM and € 2,434 for CDH treatment.How to interpret cost-effectiveness ratios?Seeing that cost-effectiveness ratios like these are not very informative inthemselves, we need to bring in figures from other health care programs forcomparison to draw meaningful conclusions. Put in the perspective of the manytimes higher cost-effectiveness thresholds that seem to guide public authorities indecisions to accept or reject a technology, the costs per QALY we calculated forARM (€ 2,482) and CDH (€ 2,434) are clearly very modest. Examples of suchthresholds are those of the UK National Institute for Clinical Excellence (about£ 35,000 or £ 40,000 per QALY, which equals € 52,000 or € 60,000 at currentexchange rates) 27 or the Australian Pharmaceutical Benefit Advisory Committee(between AU$ 42,000 and AU$ 76,000 per life-year, which is approximately€ 27,000 and € 48,000). 28 In the Netherlands, a threshold of approximately€ 18,000 per life-year is sometimes seen as an acceptable cost-effectivenessratio. 29In the context of this chapter, we shall assume that our encouraging results alsoapply to surgical treatment of other congenital anomalies. This assumption seemsfairly plausible, since ARM and CDH were not selected randomly but purposefullychosen as being opposite extremes in terms of mortality and morbidity. ARM ischaracterized by relatively low mortality and relatively high morbidity intoadulthood, whereas for CDH the opposite applies. Notwithstanding the diversity ofthe conditions, treatments are remarkably close in terms of cost-effectiveness.So, treatments for other 'isolated' anomalies such as Hirschsprung's disease andesophageal atresia are likely to be cost-effective as well. Because most neonateshaving to undergo surgery present with just one major anomaly, the overallconclusions drawn from our research are favorable for neonatal surgery ingeneral.