Cost-effectiveness of multidisciplinary management of tinnitus at a specialised tinnitus centre Maes I, Cima R, Vlaeyen J, Anteunis L, Baguley D, El Refaie A, Scheyen D, Joore M
Table of contents Part I Economic evaluation: how does it work? Part II Study design and objective Methods Results Conclusion
Economic Evaluation The comparative analysis of alternative courses of action in terms of both their costs and their benefits. Drummond et al., 1996 Economic evaluation is not choosing the cheapest A bridge between the scientific evidence and policy decision making
Economic Evaluation Cost A Intervention A Effects A Cost B Intervention B Effects B Difference in costs? Relationship? Difference in effects?
Economic Evaluation New intervention Alternative costs effects costs effects Incremental Cost effectiveness ratio (ICER): C n C a E n E a Methods
Economic Evaluation Decline Difference in costs? Difference in effects? Accept
Economic Evaluation Decline Difference in costs λ = 80.000 λ = 35.000 λ = 18.000 Difference in effects Accept
Objective To determine the cost-effectiveness of a specialised integral multidisciplinary tinnitus treatment, compared to care as usual, in an audiological centre in the Netherlands
Design Randomized controlled clinical trial: Multi-disciplinary treatment versus care as usual Patients (>18 years) referred to audiological centre in the Netherlands Data collection Baseline Follow-up at 3, 8 and 12 months
Methods: effects Generic instruments: Health Utilities Index Mark III Utilities Quality Adjusted Life Years Disease specific questionnaires: Tinnitus Questionnaire
Methods: Health Utilities Index mark III 18 questions 8 dimensions with 5 or 6 levels: Vision (6) Dexterity (6) Hearing (6) Emotion (5) Speech (5) Cognition (6) Ambulation (6) Pain / complaints (5) Possible health state: 1, 4, 1, 1, 1, 5, 4, 3
Methods: utilities Patient HRQOL Questionnaire Health state (description) Utility (value) Formula reference population
Methods: Quality Adjusted Life Years Utility 1 (0.9 + 0.8)/2 * (3/12) = 0.21 (0.8 + 0.2)/2 * (5/12) = 0.21 (0.2 + 0.2)/2 * (4/12) = 0.07 Total QALY = 0.49 0 3 months 8 months 12 months
Methods: Costs Societal perspective: Health care costs (CRF; questionnaire) Out of pocket costs (questionnaire) Productivity losses (PRODISQ) Interpolation to yearly cost Costi C ( Ci, t 2 / 3) *5 ( Ci, 3) / i, t1 t 3) * 4
Methods: analysis Missing data: Multiple imputation Sensitivity analysis: Complete cases Utilities based on predicted values from mixed multilevel regression analysis
Results: effects 0.64 0.64 0.65 0.62 0.62 0.63 0.62 0.61
Results: Effects 0.64 0.62
Results: costs Mean Costs SC UC First level tinnitus care 1675 1480 Pure tone audiometry 66.30 65.23 Speech audiometry 46.34 45.60 Tympanometry: incl. stapdial reflexes 55.09 54.21 Tinnitus analysis: PMF, MML 30.41 29.92 Uncomfortable Loudness Levels 122.37 120.41 Individual consult by clinical physicist in audiology 296.55 291.80 Hearing aid fitting 154.90 150.20 New hearing aid 271.35 252.33 Hearing aid check and optimisation 60.40 86.10 Fitting tinnitus masker 102.86 111.94 New tinnitus masker 253.06 259.11 BERA 11.84 11.75 Intake psychologist 191.62 0.65 Tinnitus Educational Group session 11.49 0.90 Second level tinnitus care 693 292 Individual trajectory 14.21 - Treatment group A 198.55 - Treatment group B 282.18 - Social work trajectory (incl. intake) 198.55 292.43
Results: costs Mean Costs SC UC N 240 242 First level tinnitus care 1675 1480 Second level tinnitus care 693 292 General practitioner practice 78 133 Hospital care 384 450 Other health care 540 753 professionals Prescribed medication 24 29 Health care costs 3231 3110 Patient & family costs 85 108 Productivity losses 2605 2417 Total societal costs 5921 5636 Increment= 122 Increment= 286
Results: Cost-effectiveness Cost-effectiveness plane Societal perspective - HUI MI data 3000,00 λ = 35.000 2000,00 Incremental costs 1000,00 0,00-0,10-0,05 0,00 0,05 0,10 0,15-1000,00-2000,00-3000,00 incremental QALY
Results: Cost-effectiveness Cost-effectiveness plane Societal perspective - HUI MI data 3000,00 λ = 35.000 2000,00 Incremental costs 1000,00 0,00-0,10-0,05 0,00 0,05 0,10 0,15-1000,00-2000,00-3000,00 incremental QALY
Results: Cost-effectiveness Cost-effectiveness plane Health care perspective - HUI MI data 3.000 λ = 35.000 2.000 Incremental costs 1.000 0-0,10-0,05 0,00 0,05 0,10 0,15-1.000-2.000-3.000 incremental QALY
Results: Cost-effectiveness Cost-effectiveness plane Health care perspective - HUI MI data 3.000 λ = 35.000 2.000 Incremental costs 1.000 0-0,10-0,05 0,00 0,05 0,10 0,15-1.000-2.000-3.000 incremental QALY
Results: Cost-effectiveness Cost-effectiveness plane Societal perspective - HUI complete cases analysis 3.000 λ = 35.000 2.000 Incremental costs 1.000 0-0,10-0,08-0,06-0,04-0,02 0,00 0,02 0,04 0,06 0,08 0,10-1.000-2.000-3.000 incremental QALY
Results: Cost-effectiveness Cost-effectiveness plane Societal perspective - HUI complete cases analysis 3.000 λ = 35.000 2.000 Incremental costs 1.000 - -0,10-0,08-0,06-0,04-0,02 0,00 0,02 0,04 0,06 0,08 0,10-1.000-2.000-3.000 incremental QALY
Results: Cost-effectiveness Cost-effectiveness plane Health care perspective - HUI complete cases analysis 3000 λ = 35.000 2000 Incremental costs 1000-0,10-0,08-0,06-0,04-0,02 0,00 0,02 0,04 0,06 0,08 0,10-1000 - 2000-3000 incremental QALY
Results: Cost-effectiveness Cost-effectiveness plane Health care perspective - HUI complete cases analysis 3.000 λ = 35.000 2.000 Incremental costs 1.000 - -0,10-0,08-0,06-0,04-0,02 0,00 0,02 0,04 0,06 0,08 0,10-1.000-2.000-3.000 incremental QALY
Conclusion 1. Increase in utility in SC; decrease in UC 2. QALY UC < QALY SC 3. SC more costly than UC 4. SC is more cost-effective than UC
Questions? Iris.maes@mumc.nl