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Value for money How to design RCTs to ensure their compatibility with economic evaluation September 2006 Kevin Marsh.

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Presentation on theme: "Value for money How to design RCTs to ensure their compatibility with economic evaluation September 2006 Kevin Marsh."— Presentation transcript:

1 Value for money How to design RCTs to ensure their compatibility with economic evaluation September 2006 Kevin Marsh

2 Introduction and overview Challenges measuring the cost of interventions standardised measure of effects generalising Source of evidence two recent NICE public health reviews Question: what are the methodological lessons from attempts to build economic evaluations on RCTs? 2 requests 1 question

3 Why are we concerned with value for money? Campbell Collaboration Economic Methods Group (CCEMG) Policy Brief (in press): Provision of evidence on cost-effectiveness, alongside evidence on the benefits and adverse effects of interventions, can significantly enhance […] decision-making by managers and policy makers.

4 Effectiveness plane yx +ve-ve effectiveness Should we invest in intervention ‘x’? yes – ‘x’ is more effective than ‘y’ but what is the opportunity cost of ‘x’?

5 Cost-effectiveness plane y +ve-ve effectiveness +ve -vecost

6 Cost-effectiveness plane y +ve-ve effectiveness +ve -vecost Should we invest in ‘x’? yes - ‘x’ dominates ‘y’

7 Cost-effectiveness plane y +ve-ve effectiveness +ve -vecost Should we invest in ‘x’? no - ‘y’ dominates ‘x’

8 Cost-effectiveness plane y +ve-ve effectiveness +ve -vecost Should we invest in ‘x’? ? – cost-effect trade off?

9 Aren’t we already doing economic evaluation? Number of studies identified in 2 recent reviews of effectiveness and economic studies

10 How do we model value for money from RCTs? Intervention £ pp  risk factor (e.g. cigarette use)  probability substance misuse  probability problematic SM  health,  crime,  unemploy. £ saved ppQALY gain pp

11 How do we model value for money from RCTs? Intervention £ pp  risk factor (e.g. cigarette use)  probability substance misuse  probability problematic SM  health,  crime,  unemploy. £ saved ppQALY gain pp (£ pp- £ saved pp) / QALY gained pp Cost /  risk factor

12 How do we model value for money from RCTs? Intervention £ pp  risk factor (e.g. cigarette use)  probability substance misuse  probability problematic SM  health,  crime,  unemploy. £ saved ppQALY gain pp Review of effectiveness (RCT)

13 How do we model value for money from RCTs? Step 1: cost intervention? Intervention £ pp  risk factor (e.g. cigarette use)  probability substance misuse  probability problematic SM  health,  crime,  unemploy. £ saved ppQALY gain pp

14 Good description of a simple intervention Facilitate referral to an external treatment agency 1.discuss negative consequences of personal drug use 2.discuss impediments to reducing negative consequences 3.advice about appropriate services 4.discuss possible impediments to treatment 5.arrange the first appointment with a named counselor 6.reminder telephone call prior to the first appointment 7.offer of transport to first appointment 8.offer to accompany then to their first appointment

15 Example: intervention description 1. Who provides the intervention? Facilitate referral to an external treatment agency 1.discuss negative consequences of personal drug use 2.discuss impediments to reducing negative consequences 3.advice about appropriate services 4.discuss possible impediments to treatment 5.arrange the first appointment with a named counselor 6.reminder telephone call prior to the first appointment 7.offer of transport to first appointment 8.offer to accompany then to their first appointment

16 Example: intervention description 2. How long does each element take? Facilitate referral to an external treatment agency 1.discuss negative consequences of personal drug use 2.discuss impediments to reducing negative consequences 3.advice about appropriate services 4.discuss possible impediments to treatment 5.arrange the first appointment with a named counselor 6.reminder telephone call prior to the first appointment 7.offer of transport to first appointment 8.offer to accompany then to their first appointment

17 Example: intervention description 3. % take up optional elements? Facilitate referral to an external treatment agency 1.discuss negative consequences of personal drug use 2.discuss impediments to reducing negative consequences 3.advice about appropriate services 4.discuss possible impediments to treatment 5.arrange the first appointment with a named counselor 6.reminder telephone call prior to the first appointment 7.offer of transport to first appointment 8.offer to accompany then to their first appointment

18 Request 1: resource use data 1.describe resource use: who does what, what equipment? 2.measure resource use: hours, units? 3.value resource use: £

19 How do we model value for money from RCTs? Step 2: CE? Intervention £ pp  risk factor (e.g. cigarette use)  probability substance misuse  probability problematic SM  health,  crime,  unemploy. £ saved ppQALY gain pp

20 Step 2: calculating cost-effectiveness Intervention 1: Cost - £100 Effect – YP not use cannabis in last month when would otherwise Intervention 2: Cost - £100 Effect – YP move from use cannabis 20 times/yr to only 5 times/yr

21 How do we model value for money from RCTs? Step 3: long- term effect? Intervention £ pp  risk factor (e.g. cigarette use)  probability substance misuse  probability problematic SM  health,  crime,  unemploy. £ saved ppQALY gain pp

22 Step 3: modelling long-term effect RCT: Change in YP risk factors Epidemiological: Impact risk factors on LR sub. misuse Use cannabis > 31 times/yr? Y/N Same risk factors Different measures E.g.Use cannabis in the last month? Y/N ?

23 NICE econ review: matching effect studies to epidemiological data 6 only model fraction of the effects identified

24 Request 2: use standard measures of effect compare between studies link with epidemiological data

25 How generalisable are our results? 1.RCTs: conflicting + inconsistent results 2.Heterogeneity

26 How generalisable are our results?

27 Question: how do we overcome the challenge of heterogeneity? Can an RCT only tell us about intervention X if implemented in way A, for population B, in social context C? If yes RCT for each combination of intervention, control, population, context? Alternative method? Quasi-exp? Other?


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