Introduction. Onco-Pharmacoeconomy Training Course. Turkey ISPOR Training Course

Transcription

1 Onco-Pharmacoeconomy Training Course Turkey ISPOR Training Course Introduction Dr Alan Haycox Reader in Health Economics Health Economics Unit University of Liverpool Management School

2 Course objectives The two course objectives are: Understanding the basics of health economics and the underlying rationale Understanding the application of health economics to oncology especially the concept of opportunity costs

3 Course timetable Rationale behind health economics including opportunity costs Understanding health economics, health benefit of current cancer drugs and end of life concepts Workshop around the concept of opportunity costs based on HERCEPTIN in adjuvant breast cancer in the UK

4 Rationale for Health Economics Brian Godman University of Liverpool Mario Negri Institute, Milan, Italy Karolinska Institute, Stockholm, Sweden

5 Why growing use of Health Economics? Healthcare represents a significant proportion of national expenditure New initiatives needed to maintain comprehensive and equitable healthcare with increased volumes and new expensive drugs especially new oncology drugs Health economics provides a basis for evaluating different options when resources are scarce concept of opportunity costs

6 Billion SEK New specialist drugs key cost driver in Sweden requiring additional measures 8 Total drug expenditures in Stockholm County (prescriptions, hospital, OTC) Specialist drugs Non-specialist drugs Ref: Godman and Wettermark 2009

7 The cost of new oncology drugs in Sweden is accelerating matching UK concerns Ref: Specialist drug project Stockholm, Godman 2009

8 The cost of new cancer drugs is a growing concern in other EU countries One UK cancer expert (Professor Sikora at the Hammersmith Hospital) recently estimated that the next generation of cancer drugs could cost the UK alone up to 50billion a year within four years - equivalent to raising the basic tax rate by 15% (15p in the ) New expensive products (especially new cancer drugs) now account for over 50% of the in-patient hospital drug budget in Marseilles hospitals, with sales growing at over 20% per year. This is leading to a reduction in other services As a result, use of health economics and concept of opportunity costs will grow especially in cancer Ref: Sikora 2008, Sermet, Andrieu and Godman et al 2010

9 The Basis of Health Economics Demand for healthcare is infinite Increased expectations, ageing populations and technological change Resources are scarce Doctors, nurses, hospitals, pharmaceuticals Choices are necessary Do we increase the drug budget, pay for more surgeons, increase radiotherapy services or improve pain managements? Prioritisation is required On what basis? Who should make decisions? Costs and benefits must be compared How do we measure benefits?

10 Cost measurement: 3 Stages Resource identification Resource measurement Resource valuation

11 Resource Identification Typically all relevant resource (cost ) items that are used (consumed) during the care process are identified in any health economic evaluation These are recorded and subsequently costed during the course of undertaking the HE evaluation

12 Resource Measurement The amount of each resource consumed (used) is measured: Capital Items (items that provide services over more than 1 year), e.g. Equipment Buildings Recurrent Items (items consumed within 1 year or less) Materials/ supplies/consumables such as pharmaceuticals Labour, Utilities (gas, electricity, water, etc.)

13 Resource Valuation A value is attached to each resource consumed Resources can be valued differently Average costs Marginal costs Opportunity costs Health economists and policy makers emphasise the importance of opportunity costs in valuing overall expenditure as budgets are finite

14 The most important concept: Opportunity Cost The opportunity cost of using resources to produce a good or service is the benefits foregone from those resources not being used in their next best alternative. The concept of opportunity cost lies at the heart of all economic analyse The health policy goal is to maximise patient outcomes with available resources. This means some benefits will be foregone but these should be minimised

15 Opportunity cost in practice - The opportunity cost of one course of IVF One-third of a cochlear implant 1 heart bypass operation 11 cataract removals One-third of a junior school teaching assistant for a year 150 vaccinations for Measles, Mumps and Rubella 2000 school dinners

16 Case History Adjuvant HERCEPTIN in Breast Cancer in one UK Hospital Currently 355 patients receive adjuvant treatment in Norfolk and Norwich at GB 0.503mn/ year (16 cured at a cost/ cure ranging from ,000) Treating 75 patients with early stage breast cancer with HERCEPTIN would cost GB 1.94mn/ year rising to GB 2.3mn with testing, monitoring and administration at a cost/ cure of 650,000 Finite budgets mean tough decisions need to be made on which treatments should be funded and which should be terminated or reduced Ref: Barrett et al BMJ 2006

17 Costs and potential benefits of adjuvant cancer treatments in Norfolk Hospital Treatment and number of patients Adjuvant chemotherapy for lung cancer (15 patients) Oxaliplatin as adjuvant therapy for colon cancer compared with fluorouracil alone (20 patients) Neoadjuvant chemotherapy for oesophageal cancer (25 patients) Rituximab in addition to CHOP for non-hodgkin lymphoma in patients over 60 (25) Drug cost (GB 000) Cost/cured patient (GB 000) Adjuvant aromatase inhibitors in postmenopausal breast cancer (270 patients) [NB drug costs will fall substantially in Europe once generics routinely available] Total 355 patients and 16 cured Ref: Barrett et al BMJ 2006

18 Possible lessons for Turkey Other countries have approached the fact of finite resources through a variety of initiatives including: o Setting value criteria for funding new drugs, e.g. cost/ QALY and minimum effectiveness criteria o Establishing pre-launch the potential budget impact of new drugs along with potential savings, e.g. new generics becoming available. Subsequently agreeing patient characteristics/ prescribing criteria ahead of launch with key clinicians and monitoring their effectiveness and utilisation post launch

19 Minimum effectiveness criteria for funding new drugs in UK cancer hospitals 3 Levels of effectiveness and data quality chosen Effectiveness A B C D Data Quality alpha + alpha - beta Criteria Median survival improved > 9months + improved QoL Median survival improved 3-6 months + improved QoL Improved QoL, no impact on survival Minimal impact QoL, no impact survival Criteria Meta analysis or two high quality RCTs One high quality RCTs and supporting Phase II data One poor quality RCT and/or several Phase II studies Key stakeholders including leading cancer clinicians agreed only new cancer products with A and B effectiveness criteria and alpha data quality should be funded and prescribed at premium prices in view of resource constraints Ref: Ferguson et al 2000

20 Survival data important as limited additional benefits for most cancer drugs Primary efficacy end point in main studies Overall survival Time to progression (TTP)/ Progression free survival (PFS) Response rate, e.g. OR, PR Other Number % 7% 41% 48% 4% Survival data (when available overall 13 trials): o Range: months additional survival versus comparator o Mean: 1.5 months, Median: 1.2 months Ref: Apolone et al 2005

21 There are 4 Methods of economic evaluation The four methods are Cost Minimisation Analysis (CMA) Cost Effectiveness Analysis (CEA) Cost Utility Analysis (CUA) Cost Benefit Analysis (CBA) These four approaches will be discussed after the coffee break Any questions?