TIPI di ANALISI ECONOMICHE Patrizia Berto LASER Analytica - Milano

Transcription

1 TIPI di ANALISI ECONOMICHE Patrizia Berto LASER Analytica - Milano 1

2 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 SPENDING WELL PHARMACOECONOMICS 2

3 Types of HE analyses CEA/CUA cost-effectiveness/cost-utility used to calculate the incremental cost that needs to be invested, to obtain one incremental unit of outcome (LY/QALY) CMA cost-minimization doesn t consider the outcome; it only compares costs for alternatives whose efficacy/effectiveness has been shown identical (eg. generic vs branded) CC cost-consequence reports costs and consequences separately without a final measure of economic value CBA cost-benefit can be applied only if the analyst can compute both costs and outcomes in monetary values COI cost-of-illness 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 all the possible alternatives) and quantifies this cost to the society (or to the NHS or to the HC provider). 3

4 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 4

5 and since new interventions are usually aimed at improving treatment ADDITIONAL IS THE COST OF THIS INTERVENTION JUSTIFIED BY ITS EFFECTS? ADDITIONAL WE NEED TO KNOW HOW MUCH ADDITIONAL MONEY WE HAVE TO PAY, TO GAIN THAT MUCH ADDITIONAL EFFECT 5

6 INCREMENTAL COST-EFFECTIVENESS RATIO 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 - A + COST 1 B 2 A + EFFECT and more costly, than the other (A vs B or vice versa) - 6

7 Let s see an example > Consider 2 alternatives for chemotherapy in NSCLC Cost A = drug A + adverse events + follow-up + failures= Outcome A = survival 16 weeks = 0,31 years Cost B = drug B + adverse events + follow-up + failures = Outcome B = survival 12 weeks = 0,23 years Is this acceptable? Is it a lot? How should we judge this result? ICER = = = ,31 0,23 0,08 Per additional life year saved 7

8 LIFE YEARs (GAINED) 8

9 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 9

10 QALY = Quality Adjusted Life Year 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 10 10

11 UTILITY VALUES FOR SELECTED HEALTH CONDITIONS FROM PUBLISHED STUDIES PEGGIORE STATO DI SALUTE POSSIBILE MIGLIORE STATO DI SALUTE POSSIBILE DEPRESSIONE DIALISI HOSP TRAPIANTO RENE IPERTENSIONE SINTOMI DI MENOPAUSA DEAMBULAZIONE MECC. ASS. ANGINA GRAVE ANGINA ACUTA ANGINA MODERATA 11

12 QALY = Quality Adjusted Life Year 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 12 12

13 Introducing the QALY in our example > 2 alternatives for chemotherapy in NSCLC Cost A = drug A + adverse events + follow-up + failures= 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 = Outcome B = survival 12 weeks = 0,23 years Preference B = EQ5D index 0,9 = 0,207 QALYs ICER = ICER = = = ,31 0,23 0,08 Per incremental LYG no need to do any ICER as B is dominant vs A 13

14 But let s change a bit the example > 2 alternatives for chemotherapy in NSCLC Cost A = drug A + adverse events + follow-up + failures= 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 = Outcome B = survival 12 weeks = 0,23 years Preference B = EQ5D index 0,9 = 0,207 QALYs ICER = ICER = Incremental LYG no need to do any ICER as B is dominated by A = 330 = ,207 0,186 0,021 Per incremental QALY 14

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16 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 16

17 The NICE is one of the very few Agencies who decided to set a threshold and to make it public Up to /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. 17

18 while, in the US 18

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20 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 CEthreshold which ultimately represents the willingness to pay of the society/nhs for the extra benefit provided by a new treatment vs. existing ones. 20

21 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 Grazie per l attenzione! patrizia.berto@la-ser.com 21