Pharmacoeconomic guidelines should prescribe inclusion of indirect medical costs! A response to Grima et al.

Recently, Grima and colleagues [1] made a case for excluding unrelated medical costs in life-years gained from economic evaluations of life-prolonging interventions. They provide an insightful overview of several economic evaluations in patients with chronic kidney disease (CKD) on dialysis and convincingly show that inclusion or exclusion of dialysis costs has an enormous impact on the cost effectiveness of any intervention in this patient group (and that there is considerable practice variation in this respect). This results in life-prolonging interventions such as statin treatment, which are highly cost effective in some target groups, becoming cost ineffective (if judged against conventional thresholds), in CKD patients when including the costs of dialysis in life-years gained. Grima and colleagues [1] argue that the inclusion of dialysis costs in lifeyears gained in CKD patients thus places an ‘‘unreasonable … barrier’’ to demonstrating cost effectiveness in this patient group. Hence, they advocate exclusion of these costs from economic evaluations of therapies for CKD patients on dialyses. They indicate that this solution would be methodologically correct in light of current pharmacoeconomic guidelines, which commonly advocate the exclusion of so-called unrelated medical costs [2].1 In this response, we demonstrate the rather absurd consequences of the line of reasoning by Grima et al. [1] (indeed supported by many guidelines) and how these are in sharp contrast with the underlying goals of economic evaluations. The solution for the problems signalled by Grima and colleagues should be found in changing guidelines on the point of inclusion of indirect medical costs and a sound appraisal phase in which ethical dilemmas are addressed explicitly.

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