NICE AAA Guidelines. Professor Andrew W. Bradbury

Transcription

1 NICE AAA Guidelines Professor Andrew W. Bradbury Sampson Gamgee Professor of Vascular Surgery University of Birmingham, UK Thursday 29 November Alsh

2 NICE Guidelines: international reputation for rigour, independence and transparency UK (not Scotland) only but very considerable international reach Many other countries use NICE guidance NICE HE analyses widely respected (transparent)

3 Health Economics: A Dark Art? Misunderstood and mistrusted

4 Simples really

5 UK National Health Service NHS %GDP, per capita (US$) US 18%, $10-11K UK 7%, $3-4K Demand >> Supply Healthcare expenditure health outcomes? Value for money: must surely use limited resources in the most clinically and cost-effective manner?

6 Simples really Total money a nation spends on healthcare (c. 150,000,000,000 per year) / Total health benefit (1 year of perfect health = 1 QALY) (c. 750,000 QALYs per year) = Incremental Cost-Effectiveness Ratio (ICER) ( /QALY) = About 20,000 per QALY overall (= Willingness to pay, WTP, threshold) Treatments > WTP threshold = net population harm

7 If you had to buy one of these cars with your own money which one would you buy? Bentley Intercontinental GT 20,000 Dacia Sandero 100,000

8 Assuming now that the government provides free cars would you be happy to pay more tax so I can choose the Dacia? Bentley Intercontinental GT 20,000 Dacia Sandero 100,000

9 EVAR-1: OSR dominates EVAR (cheaper and more QALYs) ICER is infinity - robust to the most extreme sensitivity testing Highly unlikely that a re-run of EVAR-1 would show EVAR to be cost-effective at current WTP thresholds (Ethical? Funding?) Science incontestable (largely uncontested) so why so difficult? Patient choice? Would a patient (if properly informed) choose the Dacia and, if they do, should the NHS (your taxes) pay for it? Bias? (experience and many other forms)

10 Experience bias Many things that seem obvious turn out to be completely wrong

11 EVAR-1 no-brainer : no NICE advisory committee could advise the NHS to purchase EVAR if OSR is suitable Have we not known this for some time?

12 EVAR-2: > K per QALY Every EVAR-2 intervention denies at least other people clinically and cost-effective NHS treatment One EVAR-2 = c. 50+ venous leg ulcer patients endovenous ablation, EVRA trial c IC patients having a supervised exercise programme No- Brainer Why have we largely ignored this?

13 Patient choice? Utilitarianism It is the greatest happiness of the greatest number that is the measure of right and wrong HE Consideration Does this treatment / intervention produce more health than its cost will take away (or vice versa)? Exercise for IC vs intervention Immediate cataract surgery for asymptomatic patients vs delayed surgery with visual loss 1946 Jeremy Bentham

14 NICE guideline committees NICE guideline advisory committees do the science and not the politics Committees can only work in accordance with the policies and procedures (social value judgements) agreed by NICE and DoH Colleagues, and the patients with lived experience, who sit on these multi-disciplinary committees have no CoI, and give a very considerable amount of their valuable time, completely unpaid, over a 2-3 year period

15 NICE AAA guideline committee All of the recommendations were unanimously agreed (without and without the vascular and endovascular surgeons, including the Chair, in the room)

16 NICE Guidance Opportunity, not a threat Condition Venous ulcer Intermittent Claudication AAA (EVAR2) AAA (EVAR1) Intervention Surgical and Endovenous Intervention Supervised Exercise EVAR EVAR Trials ESCHAR EVRA Many!!! EVAR-2 EVAR-1 ICER < 6K < 2K K Infinity Clinically and cost-effective Very Very Nowhere near Dominated NICE YES YES NO NO Implementation and Research

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