Defining & Assessing Benefits for Economic Evaluation

advertisement

Session 7: Defining & Assessing

Benefits for Economic Evaluation

1. Why, what and how of benefits.

2. Benefit assessment for CEA.

3. Benefit assessment for CUA.

4. Practical exercise in estimating benefits for CUA.

HEA PTP: M212 Economic Evaluation 1

Why Measure Benefits?

Efficiency

Maximise benefits for given resources

HEA PTP: M212 Economic Evaluation 2

Key Features of Economic Evaluation

Economic evaluation is

“The comparative analysis of alternative courses of action in terms of both their costs and consequences in order to assist policy decisions”.

1. Costs and consequences - efficiency!

2. Comparative relative efficiency

HEA PTP: M212 Economic Evaluation 3

Benefit Categories

Intervention

Direct Benefits Indirect Benefits

Reduced health services resource use eg. LoS.

Improved patient health status / utility.

HEA PTP: M212 Economic Evaluation

Savings in productivity.

Family and friends quality of life.

4

Should Changes in Productivity be

Included?

May depend upon viewpoint (govt., societal, NHS)

 Main issues are level of ‘true’ loss and comparability

• Measurement of value of loss (gross wage, friction cost)

• Double-counting, especially with CUA/CBA

• Comparability with ‘health’ focus (viewpoint again)

• Comparability with other studies (applies to other variables also)

Solution?

• Provide a good reason why they should be measured/included

• Report separately from other results

• Differentiate measurement and valuation

HEA PTP: M212 Economic Evaluation 5

Should Benefits be Discounted?

Why not discount?

• Health, unlike resources, cannot be traded over time

• Inter-generational equity (cf environmental economics)

• If are discounted, may be different rate to cost

Why discount?

• Inconsistent treatment costs and benefits

• Inconsistent policy, especially in comparison with other sectors

• Counter-intuitive conclusions for investment. eg always postpone!

• Individuals do trade health over time ((dis)invest in health)

HEA PTP: M212 Economic Evaluation 6

Negative And Positive Benefits

(and Costs!)

C/E ratio = net cost/ net benefits

Net cost

Net benefit

= positive cost + negative cost

= positive benefit + negative benefit

Negative cost =

Negative benefit =

HEA PTP: M212 Economic Evaluation cost saving, eg reduced LoS reduced health, eg adverse event

7

Types of Economic Evaluation

Type of Analysis Costs

Cost Minimisation

Cost Effectiveness

Cost Utility

Cost Benefit

Dollars

Dollars

Dollars

Dollars

HEA PTP: M212 Economic Evaluation

Consequences Result

Identical in all respects.

Least cost alternative.

Different magnitude of a common measure eg.,

LY’s gained, blood pressure reduction.

Cost per unit of consequence eg. cost per LY gained.

Single or multiple effects not necessarily common.

Valued as “utility” eg. QALY

Cost per unit of consequence eg. cost per QALY.

As for CUA but

valued in money. eg willingness-to-pay

Net $ cost: benefit ratio.

8

How Can Health Be Measured?

Length of life

• Mortality (numbers, rates, SMRs)

• Life expectancy

• Life years lost

Quality of life

• Numerous QoL measures (generic and specific)

• SF-36, Nottingham Health Profile, Guttman Scale, Rotterdam

Symptom Checklist, Hospital Anxiety and Depression scale etc….

HEA PTP: M212 Economic Evaluation 9

Process of Benefit Assessment

1.

Identification:

Mortality.

Quality of life.

2.

Measurement:

Measure in natural physical units

(eg. number of deaths averted).

3.

Valuation:

Value benefits if appropriate ie. if performing CUA or CBA.

HEA PTP: M212 Economic Evaluation 10

Issues in Assessing Benefits for CEA

1. Efficacy vs effectiveness vs efficiency.

2. Intermediate versus final outcome.

3. Sources of data for CEA.

HEA PTP: M212 Economic Evaluation 11

Efficacy Vs Effectiveness Vs

Efficiency

Efficacy = measure of effect under ideal conditions.

Effectiveness = effect under ‘real life’ conditions.

Efficacy does not imply effectiveness

Efficiency = relationship between costs & benefits.

Effectiveness does not imply efficiency

HEA PTP: M212 Economic Evaluation 12

Intermediate Vs Final Outcome

Measures

Final = change in health (status) resulting from the programme.

Intermediate = change in clinical indicator resulting from the programme.

Need to establish causal link between intermediate and final outcome measure.

HEA PTP: M212 Economic Evaluation 13

Examples of Intermediate Vs Final

Outcomes Indicators (PBAC (PBS) Oz)

Condition being treated

Final outcome indicator

Surrogate Outcome

Coronary thrombosis Quality-adjusted Number surviving Number with specified

(thrombolysis survival level of left ventricular function

Stable angina

(various interventions)

Quality-adjusted survival

Number with acceptable quality of life

Number who can walk a specified distance

Asthma

(various drugs)

Depression

(various drugs)

Quality-adjusted survival

Number surviving Number with adequate control of bronchial hyperreactivity

Quality-adjusted Number avoiding Quality of life (may be survival suicide improved by drugs)

Indicators

Hypertension

(various drugs)

Quality-adjusted survival

HEA PTP: M212 Economic Evaluation

Number avoiding a stroke

Quality of life (may be worsened by drugs)

Number achieving coronary re-perfusion

Number with adequate relief of pain

Number achieving a target level of airways functions

Number achieving a target

Hamilton or Montgomery-

Asberg Depression Rating

Scale

Number achieving a target blood pressure

14

Sources of Effectiveness Data

1.

Clinical trials, eg RCT’s.

2. Epidemiological studies, eg cohort studies.

3. Synthesis methods, eg meta-analyses.

4. Use of modelling.

HEA PTP: M212 Economic Evaluation 15

Randomised Controlled Trials

‘Gold standard’ - minimal bias and confounding.

Disadvantages:

1. Often establishes efficacy, not effectiveness.

2. Selective subjects used.

3. Limited opportunity to conduct.

4. Limited time horizon.

5. Costly to conduct.

6. Often unethical and/or unfeasible.

HEA PTP: M212 Economic Evaluation 16

Epidemiological Studies

Real life setting - establish effectiveness

Disadvantages:

1. Potential for significant bias and confounding.

2. Causal link can be weak.

HEA PTP: M212 Economic Evaluation 17

Decision Rules: CEA

CEA result

Decision rule

Application =

Qst addressed =

=

=

CEI (c/e). eg cost per LY gained adopt lowest CEI technical efficiency

“Should we undertake program “X” or program “Y” to treat condition “A”?

HEA PTP: M212 Economic Evaluation 18

Limitations of Measurements/Need for Valuation

Ambiguity in assessing overall improvement or detriment in health

Allocative efficiency - value of benefits >

(opportunity) cost

HEA PTP: M212 Economic Evaluation 19

Valuation Versus Measurement

Value is determined by benefits sacrificed elsewhere (weighted preference)

Valuation requires a trade-off between benefits

- measurement does not

HEA PTP: M212 Economic Evaluation 20

Methods of Valuing Health

 ‘Utility’ or ‘preference’ assessment

• Quality-Adjusted Life Years (QALYs)

• Variants on QALY - Years of Health Life (YHL), Health-Adjusted

Person Years (HAPY), Health-Adjusted Life expectancy (HALE)

• Healthy-Year Equivalents (HYEs) (based on ‘sequence’ of SG)

• Saved-young-life equivalent (SAVE) (based on PTO)

Monetary terms eg WTP

• Willingness-to-pay (WTP)

• Human Capital

HEA PTP: M212 Economic Evaluation 21

Quality Adjusted Life Years

(QALYs)

Adjusts data on quantity of life years saved to reflect a valuation of the quality of those years

If healthy: QALY = 1

If unhealthy: QALY < 1

HEA PTP: M212 Economic Evaluation 22

Qol Profile

QL Weighting

0 5 10

No Life Years = 15

15

No QALYs

HEA PTP: M212 Economic Evaluation

= 11

23

QALY Procedure

Identify possible health states - cover all important and relevant dimensions of QoL

 Derive ‘weights’ for each state

 Multiply life years (spent in each state) by ‘weight’ for that state

HEA PTP: M212 Economic Evaluation 24

“Utility” Weight

Utility = satisfaction/well-being - reflects a consumers

(weighted) preferences

Utility weights are necessarily subjective - they elicit an individual’s preferences for, or value of, one or more health states.

Must: 1.

Have interval properties

2. Be ‘anchored’ at death and

‘good health’

HEA PTP: M212 Economic Evaluation 25

Techniques For Measuring “Utility”

Variety of techniques available, including:

Time Trade off

Person Trade Off

Standard Gamble

Rating Scale

HEA PTP: M212 Economic Evaluation 26

Obtaining “Utility” Weights

Two means of obtaining “utility” weights:

1.

Evaluation specific/’holistic’ measures - develop evaluation specific (‘holistic’) description of health state and then derive weight for that specific state directly by population survey

2.

Use ‘generic’ or ‘multi-attribute’ instruments - use predetermined weights, based on combination of dimensions of health yielding a finite number of health states/values

HEA PTP: M212 Economic Evaluation 27

Evaluation Specific/‘holistic’ Measure

Advantages: 1.

Sensitive

2.

Account for wider QoL

(eg process, duration, prognosis)

Disadvantages 1.

Cost and time intensive

2.

Lack of comparability

HEA PTP: M212 Economic Evaluation 28

Generic (MAU) Instruments

Advantages: 1.

Supply weights “off the shelf”

2.

Comparability

Disadvantages: 1.

Insensitive to small changes in health

2.

Dimensions may not be sufficiently comprehensive

3.

Weights may not be transferable across groups

HEA PTP: M212 Economic Evaluation 29

Some Other Issues

Choosing respondents for utility estimation - whose values count?

 What constitutes a ‘correct’ health state description?

 What is the appropriate ‘measurement’ technique?

Aggregation of values?

Biases - ageist, life enhancing versus life-saving etc.

HEA PTP: M212 Economic Evaluation 30

Decision Rules: CUA

CUA result

Decision rule

=

=

CEI (c/e). eg cost per QALY gained adopt lowest CEI

Application = 1. technical efficiency

2. possibly allocative efficiency within health care sector

Qst addressed =

HEA PTP: M212 Economic Evaluation

1. Should we undertake program “X” or “Y” to treat condition “Z”?

2. Should we treat condition “A” or “B”?

31

Decision Rules: Issues

1. Perspective -

-

-

Health Care Sector

Purchaser/Provider

Societal

2. Comparator

3. Budget constraint/indivisibility

4. NPV vs BCI

5. Limited nature of economic evaluation

HEA PTP: M212 Economic Evaluation 32

CUA and Rationing

Market system - price mechanism establishes equilibrium

(efficient allocation)

Non-market system - absence of price as allocative tool leads to other, non-price, techniques

Issue is one of: (i) philosophical basis for rationing; and (ii) applied technique for rationing

HEA PTP: M212 Economic Evaluation 33

Methods of Explicit Rationing

Explicit rationing

Political processes

Technical methods

Lay participation

Medical paternalism

Equity Efficiency

(

Coast et al, Priority setting: the health care debate, John Wiley, 1996)

HEA PTP: M212 Economic Evaluation 34

Explicit Rationing: Technical Methods

Single principle

Little distinction between setting priorities at different levels

Examples

• maximising health gain

• need-based rationing

• lotteries

• age-based rationing

HEA PTP: M212 Economic Evaluation 35

Technical Method: ‘QALY League

Tables’

Economic evaluation produces information on cost-effectiveness

If using comparable outcomes (eg QALY) can

‘rank’ according to c/e

 Can use resultant ‘league table’ to allocate resource to most c/e first

HEA PTP: M212 Economic Evaluation 36

League Tables: Handle With Care!

Studies show differences in methodology

• choice of discount rate

• method of estimating utility values

• range of costs included

• choice of comparator

 Requires consistent methodology, ‘admission criteria’ for inclusion, applicability in local decision context

HEA PTP: M212 Economic Evaluation 37

The Oregon Plan

HEA PTP: M212 Economic Evaluation

1987 - decision to stop funding for organ transplantation

1989 - Oregon Health Services

Commission begins work

1990 - List 1

1991 - List 2

1994 - plan begins

38

Oregon List Version 1

Efficiency principle

1600 condition/treatment pairs

Cost/QALY gained

• social values

• outcome

• cost

HEA PTP: M212 Economic Evaluation 39

Oregon List Version 1

“... looked at the first two pages of that list and threw it in the trash can”

“... the presence of numerous flaws, aberrations and errors”

(Harvey Klevit, member, Oregon Health Services Commission)

HEA PTP: M212 Economic Evaluation 40

Oregon List Version 2

Equal treatment for equal need

709 condition/treatment pairs

Method:

• Development & ranking of categories

• Ranking C/T pairs within categories

– Public preferences

– Outcome

• Professional judgement

HEA PTP: M212 Economic Evaluation 41

Oregon List Version 2

Top Five C/T pairs

1 Pneumonia - medical

2 Tuberculosis - medical

3 Peritonitis - medical/surgical

4 Foreign body - removal

5 Appendicitis - surgical

Bottom Five C/T pairs

705 Aplastic anaemia - medical

706 Prolapsed urethral mucosa - surgical

707 Central retinal artery occlusion paracentesis of aqueous

708 Extremely low birth weight, < 23 weeks - life support

709 Anencephaly - life support

HEA PTP: M212 Economic Evaluation 42

Summary

1. Benefits must be assessed to establish efficiency.

2. Breadth and depth of benefits measured (& valued) varies across type of economic evaluation.

3. Difference between valuation and measurement .

4. Debate on role of CUA (& CEA) in allocative efficiency

5.

Beware ‘league tables’!

HEA PTP: M212 Economic Evaluation 43

Download