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  1. M A de Belder
  1. Dr M A de Belder, Cardiothoracic Division, The James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, UK; mark.debelder{at}stees.nhs.uk

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Dr Mohindra raises interesting points.

As regards clinical-effectiveness, we must not confuse effectiveness in reducing restenosis and the need for repeat treatment (about which there is no doubt) and the potential for a reduction in later morbidity and mortality (about which there is continuing debate). The point is that we cannot exclude the latter possibility and this raises the question of sensitivity analyses in cost-effectiveness analyses. The NICE models of cost-effectiveness usually result in a black and white view of the world, when there are many criteria that influence treatment decisions in individual patients. There is considerable uncertainty in these economic models, which should be recognised.

Dr Mohindra writes that any balance to be struck is between value and cost, not between clinical-effectiveness and cost-effectiveness, with value being seen both in terms of effectiveness and how the patient perceives this. Many others have discussed the limitation of relying wholly on an assessment of cost per …

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