1. What is the relative importance of cost-effectiveness information? Results from a Discrete Choice Experiment among Swedish medical decision makers. Sandra Erntoft (PhD) Project Manager The Swedish Institute for Health Economics (IHE) P.O. Box 2127, 220 02 Lund +46 46 32 91 21 www.ihe.se

2. Background Previous research suggests that the relative importance of cost-effectiveness information varies between reimbursement-, formulary-, and prescribing - decisions. Little research has, however, investigated all three priority setting context simultanously… …and often used different methodologies and methods to investigate this question. Does the potential differences in the importance influence the threshold values of cost per QALY? 2

3. Purpose The purpose of the experiment was to investigate the relative importance of cost-effectiveness information (cost/QALY) compared with four other criteria; health status, expected size of medical effect, type of medical effect, budget impact, AND which values of a QALY are acceptable to the TLV, formulary committees and prescribing physicians? 3

4. Methods A sample of 996 questionnaires (TLV 53; formulary committee members 362; physicians 581). Previous study (Johnson & Backhouse 2006) and focus group consisting of 5 senior experts). 5 criteria – three reflecting need and two economics - 3 levels each. Two questions; A (ranking – ”forced choice”) and B (decision) in order to identify threshold values. 243 possible combinations or approx. 29 000 questions – main effects only + division into three blocks. Orthogonal design – iterative computer search algorithms in order to maximize D-efficiency. Conditional logit models. 4

5. Example of a D C question directed towards the TLV CriteriaTreatment ATreatment B The average health status in patient population High degree of pain/discomfort Low degree of pain/discomfort Type of medical effectIncreased QoLLife-sustainment Expected size of medical effect (effectiveness) Avoid loss of 1 QALYAvoid loss of 0.2 QALY Cost per QALY102 000 €28 000 € Budget Impact280 000 € per 100 000 inhabitants 18 600 € per 100 000 inhabitants 5 A) Which treatment is better? (A is better, B is better) B) Which treatment do You think TLV should reimburse? (A, B, both A and B, neither A or B)

6. Formulas 6 A question (ranking): Uij=αpain*PAIN+αtype_eff*TYPE_EFF+αQALYgain*QALY_GAIN+αcost/QAL Y*COST_QALY+αbudg.imp.*BUDG_IMP B question (decision): V ij =βpain*PAIN+βtype eff* TYPE_EFF+ β QALYgain*QALY_GAIN+ β cost/QALY*COST_QALY+ β budg.imp.*BUDG_IMP

7. Descriptive statistics TLVForm. Com.Physicians Age (mean)52,254,947,3 Sex ( % males)786243 Education: Physician Economist Lawyer Pharmacist Other/no answer 25 50 0 25 86 0 2 12 83 N/a 17 HE education (% yes)583512 Budget/ Operational responsibility (% yes)N/a2223 7 Response rate: 21 %

8. Result 1: Relative importance when ranking pharmaceutical treatments 8

9. Result 2: Relative importance when making a decision 9

10. Result 3: Cost-effectiveness threshold values 41 cases of statistically significant differences between decision makers. In 28 cases the cost-effectiveness threshold values were lower rated by the TLV, than by formulary committee members and prescribing physicians. Cost per QALY TLV: Lowest 43 600 € ; Highest 107 500 €. Formulary committees: Lowest - 5 400 € ; Highest 304 200 € Physicians: Lowest 4 900 € ; Highest 240 800 €. 1€ = 10,75 SEK (December 2009) ~ 1.3 U.S. $ 10

11. Discussion Cost-effectiveness information more important in reimbursement- than in formulary- and prescribing- decisions. Confirms results from previous research. Threshold values are lower in reimbursment- than in formulary- and prescribing decisions. Can this be explained by differences in educational backgrounds? Higher threshold values in Sweden than in for instance the Netherlands. Willingness to reimburse (WTR) rather than willingness to pay (WTP) – social utilities rather than individual utilities. The WTR is based on the relative value of the public program (the treatment option rejected) foregone. 11

12. Conclusions Both the relative importance of cost-effectiveness information and the threshold values of the cost/QALY varies between decision makers at national, regional and local level. The relatively high threshold values among formulary committee members and prescribing physicians may be a sign of a lack of social learning regarding the necessity of setting priorities due to scarce resources…. …or a result of the fact that priority setting is more difficult the closer the decision maker is to the patient. 12

13. Thank you for your attention! Sandra Erntoft Email: Sandra.Erntoft@ihe.seSandra.Erntoft@ihe.se Phone: +46 46 32 91 21 13