: PPI prescriptions in the Emergency Room Canadian Optimal Medication Prescribing & Utilization Service (COMPUS) Presented by: Chris Cameron October 26, 2007
What is Health Economics? Health economics is a discipline that analyses the economic aspects of health and health care and that usually focuses on the costs (inputs) and the consequences (outcomes) of health care interventions using methods and theories from economics and medicine. Health care cost, quality, and outcomes: ISPOR book of terms. Lawrenceville: International Society for Pharmacoeconomics and Outcomes Research; 2003.
$160B $120B $80B $90B 64% $148B 110% $40B $0B $21B $10B Health Care System Prescribed Drugs 1999 2006 Source: CIHI
Principles of Health Economic Evaluation An economic evaluation is a systematic comparison of two or more treatments or care alternatives in which both the costs and outcomes of the alternatives are examined What is Cost-effectiveness? London: Hayward Medical Communications, 2001.
There are five principal types of analyses: cost-minimization analysis cost-effectiveness analysis cost-utility analysis cost-consequence analysis cost-benefit analysis Health care cost, quality, and outcomes: ISPOR book of terms. Lawrenceville: International Society for Pharmacoeconomics and Outcomes Research; 2003.
There are five principal types of analyses: cost-minimization analysis cost-effectiveness analysis cost-utility analysis cost-consequence analysis cost-benefit analysis Health care cost, quality, and outcomes: ISPOR book of terms. Lawrenceville: International Society for Pharmacoeconomics and Outcomes Research; 2003.
There are five principal types of analyses: cost-minimization analysis cost-effectiveness analysis cost-utility analysis cost-consequence analysis cost-benefit analysis Health care cost, quality, and outcomes: ISPOR book of terms. Lawrenceville: International Society for Pharmacoeconomics and Outcomes Research; 2003.
What is a Cost-Utility Analysis? A cost-utility analysis is a specific type of economic evaluation that compares two or more alternative choices in units of utility or preference, often a quality-adjusted life year (QALY) Health care cost, quality, and outcomes: ISPOR book of terms. Lawrenceville: International Society for Pharmacoeconomics and Outcomes Research; 2003.
What is a Quality Adjusted Life Year (QALY)? Outcome measure that incorporates both quantity of life (mortality) and health-related quality of life (morbidity) Quantity how long person lives Quality factor that represents a preference for a health state one year of perfect health = one QALY one year less than perfect health < one QALY death = zero
What is a Utility? A utility is a quantitative expression of an individuals preference for a particular health state. Utilities can be measured by direct or indirect techniques. What is a QALY? London: Hayward Medical Communications, 2001
Standard Gamble If you had to live with severe dyspepsia for the remainder of your life, would you accept a therapy option with 20% chance of immediate death, for a 80 % chance of regaining ideal health? a) I would try new therapy b) I would rather live with severe dyspepsia c) Too hard to choose between strategies
Standard Gamble If you had to live with severe dyspepsia for the remainder of your life, would you accept a therapy option with 20% chance of immediate death, for a 80 % chance of regaining ideal health? a) I would try new therapy b) I would rather live with severe dyspepsia c) Too hard to choose between strategies
Standard Gamble If you had to live with severe dyspepsia for the remainder of your life, would you accept a therapy option with 15% chance of immediate death, for a 85 % chance of regaining ideal health? a) I would try new therapy b) I would rather live with severe dyspepsia c) Too hard to choose between strategies
Standard Gamble If you had to live with severe dyspepsia for the remainder of your life, would you accept a therapy option with 15% chance of immediate death, for a 85 % chance of regaining ideal health? a) I would try new therapy b) I would rather live with severe dyspepsia c) Too hard to choose between strategies
Standard Gamble If you had to live with severe dyspepsia for the remainder of your life, would you accept a therapy option with 10% chance of immediate death, for a 90 % chance of regaining ideal health? a) I would try new therapy b) I would rather live with severe dyspepsia c) Too hard to choose between strategies
Standard Gamble If you had to live with severe dyspepsia for the remainder of your life, would you accept a therapy option with 10% chance of immediate death, for a 90 % chance of regaining ideal health? a) I would try new therapy b) I would rather live with severe dyspepsia c) Too hard to choose between strategies
EQ-5D The EQ-5D or EuroQol is an one indirect method of utility measurement. Another widely used indirect measurement technique is the health utilities index (HUI) What is a QALY? London: Hayward Medical Communications, 2001.
EQ-5D Health State 11111 11221 Description No Problems No problems walking about; no problems with self care; some problems with performing usual activities; moderate pain or discomfort; not anxious or depressed Valuation 1.000 0.760 What is a QALY? London: Hayward Medical Communications, 2001.
EQ-5D Health State 11111 11221 Description No Problems No problems walking about; no problems with self care; some problems with performing usual activities; moderate pain or discomfort; not anxious or depressed Valuation 1.000 0.760 What is a QALY? London: Hayward Medical Communications, 2001
Calculating QALYs Length of time in health state 10 years Utility value for health state 0.89 Number of QALYs (equivalent to years in perfect health) 8.9 QALYs 5 days 0.48 0.0065 QALYs
Calculating QALYs Length of time in health state 10 years Utility value for health state 0.89 Number of QALYs (equivalent to years in perfect health) 8.9 QALYs 5 days 0.48 0.0065 QALYs
Incremental Cost-Utility Ratio What is Cost-effectiveness? London: Hayward Medical Communications, 2001.
Decision Problem #1 Decision Problem Determine whether the use of PPIs is cost-effective, relative to no prophylaxis, in preventing recurrent ulcer bleeding in elderly patients that require NSAID therapy
Decision Problem #1 Input parameters for model An elderly patient with a history of GI bleeding has a 30% risk of recurrent bleeding in the next year while on nsnsaids We will assume that a PPI yields a 40% RR reduction The daily cost of generic omeprazole is C$1.10; Naproxen costs $0.42 per day In-patient management for a GI bleed costs C$4006 We will assume that the average EQ-5D score of an elderly arthritis patient is 0.77 We will assume that patients undergoing in-patient management for a GI bleed have a utility of 0.48 (over 5 days)
Decision Problem: #1 Cost* 4159 QALYs 0.766 153 1355 4561 0.77 0.7688 0.766 555 0.77 Includes both medication and management costs 1276 0.7693
Decision Problem #1 Table 1: Results for Economic Evaluation examining whether co-prescribing a PPI is cost-effective, relative to no prophylaxis, in preventing recurrent GI bleeding in patients that require nsnsaid therapy nsnsaid nsnsaid + PPI Difference Costs ($C) 1355 1276-79 QALYs 0.7688 0.7693 0.0005 ICER ( Costs/ QALYs) Cost Saving Cost saving refers to a strategy that is less costly and more effective ICER= incremental cost-effectiveness ratio (cost per QALY gained)
Decision Problem #1 What is a sensitivity analysis? A sensitivity analysis is a way to analyze the impact of uncertainty on an economic analysis or decision. Health care cost, quality, and outcomes: ISPOR book of terms. Lawrenceville: International Society for Pharmacoeconomics and Outcomes Research; 2003.
Decision Problem #1 What is a sensitivity analysis? PPI Unit Cost per day Incremental Cost* of nsnsaid + PPI strategy Cost per QALY gained Generic Omeprazole $1.10 -$79 Cost Saving Omeprazole $2.20 $322 $676,000 Includes both medication and management costs
Decision Problem #1 What is a sensitivity analysis? Risk of GI Bleed per annum Incremental Cost of nsnsaid + PPI* strategy Cost per QALY gained 1% $386 24 million 30% -$79 Cost Saving * Generic omeprazole ($1.10 per day)
Decision Problem #2 Decision Problem Determine which management strategy is optimal (in terms of cost and effectiveness) in the management of non-heartburn dominant, uninvestigated dyspepsia
Decision Problem #2 Six alternative strategies were compared: Test and treat all (omeprazole) Test and treat all (ranitidine 150 mg bid) Prompt endoscopy, PPI Prompt endoscopy, H2RA Empirical therapy (omeprazole) Empirical therapy (ranitidine 150mg bid)
Decision Problem #2 Time Horizon of 1-year Clinical inputs derived from CADET clinical study data Perspective of Canadian health care system 2006 Canadian medical costs obtained from Province of Ontario Utility weights for health states obtained from published literature
Decision Problem: #2 Patients with non-heartburn predominant uninvestigated dyspepsia Strategy Cost Incr Cost QALYs Empirical therapy (PPI) 219 0.9455 Incr QALYs ICER Test and Treat all (PPI) 239 20 0.9475 0.0020 10,004 Empirical therapy (H2RA) 259 20 0.9420-0.0055 Dominated Test and Treat all (H2RA) 290 51 0.9444-0.0031 Dominated Prompt endoscopy (H2RA) Prompt endoscopy (PPI) 1221 982 0.9523 0.0048 205,643 3083 1862 0.9550 0.0027 688,990 ICER= incremental cost-effectiveness ratio (cost per QALY gained)
Case Study:#2
Economic conclusions Patients with non-heartburn predominant uninvestigated dyspepsia Strategy Cost Incremental Cost QALYs Incremental QALYs ICER * Empirical Antisecretory Therapy (omeprazole) 219 Test and treat all (omeprazole) 239 20 0.9475 0.0020 10,004 Prompt Endoscopy (H 2 RA) 1222 982 0.9523 0.0048 205,643 Prompt Endoscopy (PPI) 3083 1862 0.9550 0.0027 688,990 *ICER=incremental cost-effectiveness ratio (cost per QALY gained); PPI=proton pump inhibitor; H2RA=histamine-2 receptor antagonists; QALY=Quality-adjusted life year CADTH Economic Models 2007
Economic terminology How much is a QALY worth? There is no simple answer The debate on appropriate value (i.e. $50,000) of a QALY continues* Resource allocation decisions must take this question into consideration * Hirth et al (2000) Medical Decision Making