Modelling the “bigger picture” Using Service-Level Modelling to support consistent resource allocation decisions across whole disease areas HTAi 2008 Paul Tappenden, Jim Chilcott, Alan Brennan, Hazel Pilgrim School of Health and Related Research (ScHARR)

Funding and disclaimer This work forms part of an ongoing study funded through a Department of Health Researcher Development Award (RDA) fellowship. The views expressed here are those of the authors and do not necessarily reflect those of the Department of Health. 16/01/2019 © The University of Sheffield

Research aims To develop, implement and evaluate a methodological framework for modelling whole diseases to inform decisions concerning balancing investments across entire care pathways. Approach consistent with the principles of economic evaluation and opportunity cost. Develop health economic models which are more useful for decision-makers. “Service-Level Modelling” Piloted in bowel cancer, transferable to any disease area. 16/01/2019 © The University of Sheffield

The “typical” HTA model Theoretically correct approach to maximising health gains. Threshold determined by CE of last technology purchased. HTA models involve forward projection from single decision node. Comparison against threshold/range. 16/01/2019 © The University of Sheffield

Economic evaluation Non-economic economic evaluations Development of complex models We build increasingly more sophisticated models… …and then we reduce the whole thing down to an ICER... …and then compare it against an arbitrary threshold. The cost-effectiveness of one technology is dependent on other decisions made throughout the pathway. Taking a systems view may address these problems. 16/01/2019 © The University of Sheffield

Systematic review What evidence is currently available to policy-makers? Systematic review of all UK economic evaluations of technologies for the prevention, detection, diagnosis, treatment and follow-up of colorectal cancer. Detailed systematic searches of 10 electronic databases (Medline, Premedline, EMBASE, Cinahl, Cochrane, Econlit etc) plus conference proceedings (ASCO & ESMO). Included studies mapped against conceptual model of current UK bowel cancer service to identify any gaps. 16/01/2019 © The University of Sheffield

Conceptual model 16/01/2019 © The University of Sheffield

QUOROM flow diagram 16/01/2019 © The University of Sheffield

Availability of economic evidence 16/01/2019 © The University of Sheffield

Availability of economic evidence 16/01/2019 © The University of Sheffield

Availability of economic evidence 16/01/2019 © The University of Sheffield

Preliminary review findings Strong economic evidence base for screening (13); surgery (9); adjuvant chemotherapy for colon cancer (4); follow-up (3); and palliative chemotherapy (15). Limited evidence for diagnosis (3) and liver resection (1). No economic evidence relating to RT/CRT; FAP/HNPCC; increased-risk surveillance; and end-of-life care. Heterogeneity in terms of: scope natural history detail/inclusion of downstream service provision and its costs & effects Very limited evaluation of how services should be provided. Very difficult to see how this could inform consistent decisions. 16/01/2019 © The University of Sheffield

Service-Level Models Usefulness of models is in part determined by the scope of the decision it is intended to inform. Single isolated point versus whole pathway model. Economic analysis of any technology/configuration of services. 16/01/2019 © The University of Sheffield

Service-Level Models Usefulness of models is in part determined by the scope of the decision it is intended to inform. Single isolated point versus whole pathway model. Economic analysis of any technology/configuration of services. 16/01/2019 © The University of Sheffield

Service-Level Models Usefulness of models is in part determined by the scope of the decision it is intended to inform. Single isolated point versus whole pathway model. Economic analysis of any technology/configuration of services. 16/01/2019 © The University of Sheffield

Pilot Service-Level Model - Scope Population Individuals with/without bowel cancer who consume bowel cancer resources Interventions Comparator (baseline) The current bowel cancer service in England Outcomes Cost per LYG, cost per QALY gained Screening Public awareness campaigns Improved referral criteria Increased use of endoscopy Increased use of stenting Improved surgery/pathology Enhanced recovery programmes Adjuvant treatments Follow-up regimens Treatments for mets 16/01/2019 © The University of Sheffield

Model structure Soft elicitation of model structure via leading experts DES model using SIMUL8 Populated using best available evidence 16/01/2019 © The University of Sheffield

Cost-effectiveness results 16/01/2019 © The University of Sheffield

Future direction and challenges Some future challenges Problem-structuring. Identifying decision-making needs and how SLM may address these. Identifying, selecting and synthesising evidence across disease areas. Service-Level Modelling may provide a balanced assessment of whole service configurations, accounting for knock-on impacts and opportunity cost. may help foster consistent investment decisions. may help draw out important gaps in the current evidence base. is feasible. 16/01/2019 © The University of Sheffield