Prioritising HTA funding: The benefits and challenges of using value of information in anger CENTRE FOR HEALTH ECONOMICS K Claxton, L Ginnelly, MJ Sculpher, Z Philips. Centre for Health Economics, University of York, UK

Overview Overview of methods Screening for age-related macular degeneration –Considered by NCCHTA diagnostic and screening panel Manual chest physiotherapy techniques for asthma and chronic obstructive pulmonary disease –Considered by NCCHTA therapeutic procedures panel long-term antibiotic treatment for preventing recurrent urinary tract infections (UTI) in children –Considered by Prioritisation Strategy Group (PSG)

An overview of methods Background Other methods –Research as a means changing clinical practice Statistical decision theory –Reduction in the costs of decision uncertainty –Value consistent with objective and constraints of service provision Methods Constructions of decision analytic model Probabilistic analysis to characterise decision uncertainty Value of information analysis

Identifying research priorities EVPI –Maximum return to research (decision problem) –Comparing the EVPI to the costs of research –Comparing EVPI across technologies Partial EVPI –Maximum return to research (endpoint) –Comparing partial EVPIs –Considering the costs of research

Options Weekly self screening with Amsler grid No screen but self referral on decline in visual acuity No PDT treatment and no screening Indications 1 st eye neovascular AMD 20/40 and 20/80 visual acuity Male and female (age 55-64) Eligibility of PDT consistent with NICE guidance Time horizon of 10 years NHS Perspective Screening for age-related macular degeneration (AMD)

Model structure for AMD screening

Patient groups Children treated in the community Adults treated in the community Children treated in hospital Options Massage therapy Chiropractic spinal manipulation (CSM) Physical therapy No manual therapy Time horizon of 30-days NHS perspective Manual chest physiotherapy techniques for asthma

Patient groups Adults with stable COPD Options Autogenic drainage Active breathing, Heat lamp Chest percussion with drainage No manual therapy Time horizon of 30-days NHS perspective Manual Chest Physiotherapy Techniques for adults with Chronic Obstructive Pulmonary Disease (COPD)

Structure of the asthma and COPD model

Patient groups Infants of 1 year and children age 3 Girls and boys Recurrent UTI (no abnormalities) Mild VUR (grade I and II) Options Long-term low dose antibiotics (Cochrane review) (Trimethoprim, Nitrofurantoin, Cotrimoxazole) Intermittent treatment of UTIs Time horizon 3 years of long-term antibiotics and follow-up to end stage renal disease NHS perspective long-term antibiotic treatment for preventing recurrent urinary tract infections (UTI) in children

Model Structure for UTI

The evidence Effectiveness Existing reviews (variable quality) Meta analysis, Multiple parameter synthesis Probabilistic trial based model Natural history Epidemiological studies Pooled trial baselines Registry studies Clinical judgement Quality of life Published studies Survey Costs Published studies Published unit costs and dosage (BNF, PSSRU, CIPFA)

Results: cost-effectiveness acceptability curve

Results: population EVPI (girls age 3 with no VUR)

Partial EVPI (girls age 3 with no VUR)

Results: EVPI TopicPatient GroupPopulation EVPIPartial EVPI AMD Screening20/40 20/80 £6,950,000 £18,220,000 Quality of life with and without PDT Asthma Physiotherapy COPD Physiotherapy Children in Community Adults in Community Children in Hospital Adults in Community £14,500,000 0 £1,200,000 0 Effect of massage - Effect on LOS and FEV - UTI prophylaxisGirls 3, no VUR Girls 3, VUR Girls 1, no VUR Girls 1, VUR Boys 3, no VUR Boys 3, VUR Boys 1, no VUR Boys 1, VUR £2,240,000 £613,000 £690,000 £544,000 £41,000 £23,000 £267,000 £176,000 Effect of prophylaxis on UTI Effect < 6 months Effect of: Trimethoprim Cotrimoxazole Nitrofurantoin

Conclusions Asthma Children treated in the community –Massage therapy may be cost-effective –Further research is potentially cost-effective –Effect of massage therapy on FEV 1 (no value in effect of CSM ) Manual physiotherapy for adults treated in the community –Manual therapy not cost effective –Further research not cost-effective Children treated in hospital –Physical therapy may be cost-effective –Further research is potentially cost-effective –Effect of physical therapy on hospital length of stay and FEV 1 COPD –Manual chest physiotherapy for stable COPD is not cost-effective. –Further research not cost-effective –Inpatient manual chest physiotherapy?

Conclusions AMD –Screening may be cost-effective –Further research appears to be potentially cost-effective –Evidence about the quality of life with and without PDT UTI Prophylaxis –Long-term antibiotics are cost-effective for all patient groups Which of the antibiotics should be used is uncertain –Primary research maybe required for selected patient groups girls age 3 with no VUR –Trials should include head to head comparisons Cotrimoxazole and trimethoprim or all three antibiotics –Longer follow-up would be worthwhile trials with 6 month follow-up are unlikely to be worthwhile

Feasibility and policy impact Feasibility –Completed despite not meeting selection criteria –Analysis conducted and presented within NCCHTA time lines Policy impact –Mixed responses from panel members –Potential (selective) role at PSG –Impact on commissioning decisions

Methods and implementation Methods –More complex and resource intensive than anticipated –Comprehensive searching for model parameters –Methods of evidence synthesis –Quality of evidence (bias and exchangeability) –Sensitivity analysis (evidence, model structure) Implementation –Communicating complex material –Requires an iterative process –Identifying topics where VoI should be conducted