TIPI di ANALISI ECONOMICHE Patrizia Berto
LASER Analytica - Milano
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DIFFERENCE BETWEEN
COST-CONTAINMENT AND COST-OPTIMIZATION
Prices & volumes control
Co-payments
Control on prescriptions
Allocation of resources to the interventions that
maximize benefits for
citizens, society, the NHS
SPENDING LESS
PHARMACOECONOMICS
SPENDING WELL
Types of HE analyses
•used to calculate the incremental cost that needs to be invested, to obtain one incremental unit of outcome (LY/QALY)
CEA/CUA cost-effectiveness/cost-utility
•doesn’t consider the outcome; it only compares costs for alternatives whose efficacy/effectiveness has been shown identical (eg. generic vs branded)
CMA cost-minimization
•reports “costs” and “consequences” separately without a final measure of economic value
CC cost-consequence
•can be applied only if the analyst can compute both costs and outcomes in monetary values
CBA cost-benefit
•only reports the COST of a specific disease of interest; doesn’t consider the outcome of treatment, just the cost of disease (prevented and/or treated with
COI cost-of-illness
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COST-EFFECTIVENESS ANALYSIS
IS THE COST OF THIS INTERVENTION JUSTIFIED BY ITS EFFECTS?
«COST»
NEEDS TO BE COMPLETE NEEDS TO INCLUDE
• Cost of drug
• Cost of administration
• Cost of adverse events
• Cost of failures
• ...
ALWAYS COMPARED TO AN ALTERNATIVE
• Do nothing
• Placebo
• Active comparator
• Gold standard
• …
«EFFECT» DEPENDS ON THE DISEASE, INDICATION …
• Parameters change
• Events change
• Disease control
• Life years (gained)
• QALYs
…and since new interventions are usually aimed at improving treatment…
ADDITIONAL
ADDITIONAL
IS THE COST OF THIS INTERVENTION JUSTIFIED BY ITS EFFECTS?
WE NEED TO KNOW
HOW MUCH ADDITIONAL MONEY WE HAVE TO PAY, TO GAIN
THAT MUCH ADDITIONAL EFFECT
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INCREMENTAL COST-EFFECTIVENESS RATIO
+ COST
+ EFFECT
B
- -
We look at the two alternatives considering their relative cost and outcome, ultimately we envisage TWO possibilities:
1. One of the two options is more effective and less costly, than the other (A vs B or vice versa)
2. One of the two options is more effective and more costly, than the other (A vs B or vice versa)
A
1
A
2
Let’s see an example…
> Consider 2 alternatives for chemotherapy in NSCLC
Cost A = € drug A + € adverse events + € follow-up + € failures= € 3.570
Outcome A = survival 16 weeks = 0,31 years
Cost B = € drug B + € adverse events + € follow-up + € failures = € 1.900
Outcome B = survival 12 weeks = 0,23 years
0,31 – 0,23 0,08
3.570 – 1.900 = 1.670 = 20.875€
ICER = Per additional
life year saved
Is this acceptable? Is it a lot?
How should we judge this result?
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LIFE YEARs (GAINED)
COST/LYG vs COST/QALY
> The example so far described is based on a ratio between costs and life years gained = cost/LYG
> Another very common and more advanced measure of the ICER is the cost/QALY where survival is weighed by the level of
dis/satisfaction expressed by patients in relation to
• discomfort, pain & symptoms experienced with the disease, and/or
• discomfort, pain & symptoms alleviated by treatments
> Although technically not (fully) appropriate, someone equals this to QoL
> The ICER based on a cost/QALY is the incremental amount of money which is needed to “gain” one additional Quality
Adjusted Life Year
> The QALY (and the cost/QALY) considers at the same time survival and patient preference, therefore it is the preferred measure for many decision-making bodies
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• The QALY combines in one single measure quantity &
quality of life
• Survival is weighed by utility, which is the level of dis/satisfaction expressed by patients in relation to
• discomfort, pain & symptoms experienced with the disease, and/or
• discomfort, pain & symptoms alleviated by treatments
QALY = Quality Adjusted Life Year
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UTILITY VALUES FOR SELECTED HEALTH CONDITIONS FROM PUBLISHED STUDIES
MIGLIORE STATO DI SALUTE POSSIBILE
1.00
PEGGIORE STATO DI SALUTE POSSIBILE
0.00 0.84
TRAPIANTO RENE
0.31 0.70
DEAMBULAZIONE MECC. ASS.
0.90 0.99
SINTOMI DI MENOPAUSA
0.95
IPERTENSIONE
0.59
DIALISI HOSP
0.450.50
DEPRESSIONE
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• The QALY combines in one single measure quantity &
quality of life
• Survival is weighed by utility, which is the level of dis/satisfaction expressed by patients in relation to
• discomfort, pain & symptoms experienced with the disease, and/or
• discomfort, pain & symptoms alleviated by treatments
• QALYs = N° years x UTILITY value
• Although technically not (fully) appropriate, people assimilate utility to QoL
• 1 QALY =1 year in perfect health
QALY = Quality Adjusted Life Year
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Introducing the QALY in our example…
> 2 alternatives for chemotherapy in NSCLC
0,31 – 0,23 0,08
3.570 – 1.900 = 1.670 = 20.875€
ICER =
Per incremental LYG Cost A = € drug A + € adverse events + € follow-up + € failures= € 3.570
Outcome A = survival 16 weeks = 0,31 years
Preference A = EQ5D index 0,6 = 0,186 QALYs
Cost B = € drug B + € adverse events + € follow-up + € failures = € 1.900
Outcome B = survival 12 weeks = 0,23 years
Preference B = EQ5D index 0,9 = 0,207 QALYs
no need to do any ICER as B is dominant vs A
ICER =
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But let’s change a bit the example…
> 2 alternatives for chemotherapy in NSCLC
Cost A = € drug A + € adverse events + € follow-up + € failures= € 3.570
Outcome A = survival 16 weeks = 0,31 years
Preference A = EQ5D index 0,6 = 0,186 QALYs
Cost B = € drug B + € adverse events + € follow-up + € failures = € 3.900
Outcome B = survival 12 weeks = 0,23 years
Preference B = EQ5D index 0,9 = 0,207 QALYs
ICER = Incremental LYG
no need to do any ICER as B is dominated by A 0,207 – 0,186 0,0213.900 – 3.570 = 330 = 15.714€
ICER =
Per incremental QALY
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COST/LYG vs COST/QALY
> The ICER is calculated as the ratio of incremental costs and incremental life years gained = cost/LYG
> The ICER based on a cost/QALY is the incremental amount of
money which is needed to “gain” one additional Quality Adjusted Life Year
> The QALY (and the cost/QALY) consider at the same time survival and patient preference, therefore it is the preferred measure for many decision-making bodies
> So, ultimately CEA and CUA represent the same type of analysis with the only difference of valuing the denominator (HEALTH benefit) using a clinical outcome measure (LY, events, clinical parameters) or the QALY
The NICE is one of the very few Agencies who decided to set a threshold and to make it public
Up to £30.000/QALY the Agency approves and recommends without additional discussions
Over the THRESHOLD there is more
discussion and the probability that the technology is
approved sensibly decreases.
£
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…while, in the US…
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Conclusions
> Various types of economic evaluations
• Of which, CEA/CUA is by far the most largely applied across countries and jurisdictions
• Specifically requested by «payers/regulators»
> The ICER alone doesn’t provide enough information
• The ICER needs to be challenged against a CE-
threshold which ultimately represents the willingness to pay of the society/NHS for the extra benefit
provided by a new treatment vs. existing ones.
Grazie per l’attenzione!
patrizia.berto@la-ser.com
“the first lesson of economics is scarcity:
there is never enough of anything to satisfy all those who want it…
…the first lesson of politics
is to disregard the first lesson of economics.”
Thomas Sowell, economist, social commentator and author
