Transcript Intro QALY & need assessment

Value of Information
in relation to risk management
 Prof.
Dr. Jan J.V. Busschbach
1
Change in policy
 Now:
evaluate all new medication
 Future: only when risk are high
 When
is an economic evaluation useful?
 When there is doubt about cost effectiveness
 Low on information about cost effectivenesss
2
The 3 meanings of doubt
1. The cost effectiveness might be invalid
 Methodologically unsound
 The CFH judges the validity using guidelines
2. The cost effectiveness might be to high
 To high = bad
 The ACP values the height of cost effectiveness
 The CFH has no judgment
3. The cost effectiveness might be uncertain
 Much error variance
 Unclear who is dealing with this….ACP? CFH?
 Room for more risk management
3
Uncertainty is linked to CE-ratio
4
Interested in both costs and effect
High costs
Not cost effective
cost effective
Less effective
More
effective
Low costs
(savings)
5
Sensitivity analysis
High costs
Forget it!
Good
Better
Less effective
Difficult…
More effective
Superb!
Low costs
(savings)
6
Cost-effectiveness plane
€ 250,000
Not cost effective
€ 200,000
Cost
€ 150,000
€ 100,000
€ 50,000
Cost effective
€0
QALYs
7
Cost Effectiveness
Acceptability Curve (CEAC)
8
Risk management
 We
can judge if we are in need of more
information
 Value of Information analysis
9
Value of Information (VoI)
High reduction
High VoI of risk
Low reduction
Low VoI of risk
Low reduction
Low VoIof risk
10
Risk management
 Make
prototype cost effectiveness analysis
 Do a value of information analysis
 Triage:
 Unconditional reimbursement:


• If CE-ratio is far much below threshold
• Value of information is (most likely) low
Conditional reimbursement
• If CE-ratio is close to threshold
• Value of information is high
Unconditional reject of reimbursement
• Value of information is low
11
Arguments not to do so…
 We
should reimburse all effective drugs
 We should evaluate all (new) effective drug
 Assumes that we have the resources to do so
 We
do not have a threshold
 We can not make acceptable prototypes
12
We have an indication of a
threshold…
Wetenschappelijke Raad voor het
Regeringsbeleid, 2006
13
Example prototype model:
Lucentis evaluated in the ACP
14
Patel et al, 2010
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Avastin versus Lucentis
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Conclusion
 Risk
management relates to value of
information
 Conditional reimbursement can be done on
prototype cost effectiveness analysis
 Only invest in (cost-) effectiveness, if
 Risks are high
 Value of Information is high
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CFH procedure
 Standard
procedure
 Test of the validity of the cost effectiveness analysis
 Using the guidelines
 Orphan
and expensive hospital drugs
 Conditional reimbursement
 Approval of a four year data collection


• To arrive ad a valid cost effectiveness analysis
After 4 years
• Test of the validly of the cost effectiveness analysis
Using guidelines
 Valuing
cost effectiveness = other committee
 Advies Commissie Pakket (ACP)
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Uncertainty relates to threshold

If:

But what if CE-ratio is an interval:

If:

If:
 CE-ratio = € 15.000 per QALY
 Threshold = € 25.000 per QALY
 Then intervention is cost effective
 Threshold = € 25.000 per QALY
 CE-ratio = € 10.000 till € 30.000 per QALY
 Then intervention might be cost effective
 Threshold = € 11.000
 Then intervention most likely not cost effective
 Threshold = € 29.000
 Then intervention is most likely cost effective
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65 Citations in PubMed
1997 [pdat] AND "value of information analysis"
12
Publications
10
8
6
4
2
0
1996
1998
2000
2002
2004
2006
2008
2010
2012
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How much evidence?
Why is evidence valuable?
How things
could turn out
Net Health Benefit
Treatment A
Treatment B
Best choice
Best we could
do if we knew
Possibility 1
8
12
B
12
Possibility 2
16
8
A
16
Possibility 3
9
14
B
14
Possibility 4
12
10
A
12
Possibility 5
10
16
B
16
Average
11
12
What’s the best we can do now?
Choose B
Expect 12 QALYs, gain 1 QALY
14
Could we do better?
If we knew
Expect 14 QALYs
But uncertain
Wrong decision 2/5 times
Maximum value of more evidence is 2 QALYs per patient
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Methods
Model Structure
Clinical
effect
QALY
Random
Disease
Progression
sampling
Treatment A
Asymptomatic
Progressive
Dead
Treatment B
Asymptomatic
Costs
Progressive
Dead
Treatment A
QALY
Cost
1
£10,000
0
£ 5,000
2
£15,000
1
£10,000
Treatment B
QALY
Cost
2
£30,000
3
£20,000
4
£40,000
3
£30,000
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Would more
evidence
improve
health?
Is the evidence sufficient?
How things
could turn out
Net Health Benefit
Treatment A
Treatment B
Best choice
Best we could
do if we knew
Possibility 1
9
12
B
12
Possibility 2
12
10
A
12
Possibility 3
14
17
B
17
Possibility 4
11
10
A
11
Possibility 5
14
16
B
16
Average
12
13
13.6
What’s the best we can do now?
Choose B, expect additional net benefit of 1 QALY
Could we do better?
Get an extra 0.6 QALY
Right decision 3/5 times (p = 0.6)
Wrong decision 2/5 times (1-p = 0.4)
Maximum benefit of more evidence is
0.6 QALYs or £12,000 per patient
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How uncertain is the decision?
1
Choose A
Choose B
0.9
B
0.8
Probability cost-effective
0.7
0.6
0.5
0.4
0.3
0.2
A
ICER = £25,000 per QALY
0.1
C
0
£0
£10,000
£20,000
£30,000
£40,000
£50,000
£60,000
Cost-effectiveness threshold
24
Do we need more evidence?
Cost of research
£25,000,000
Maxium benefit of evidence
.
£20,000,000
£15,000,000
£10,000,000
Cost of research
£5,000,000
Choose A
Choose B
£0
£0
£10,000
£20,000
£30,000
£40,000
£50,000
£60,000
Cost-effectiveness threshold
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Alan Williams
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