{ Challenges in cost-utility analysis in the critical care setting Ville Pettilä MD, PhD, A/P Helsinki University Hospital VP SFAI- veckan / Kalmar

CCM 2006

- only 19 papers - max $958,423/ QALY -$1,150 - $575,000 / life-year - many < $50,000 /QALY -

  41 studies in critical/intensive care   quality assessed as poor to moderate

Boston- CEA Registry- Quality of cost-utility analyses

{.. In the ideal world VP

Sintonen 1994

{

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Angus D AMJRCCM 2001 ARDS N=200

Angus DC et al. CCM 2006 Quality-adjusted survival

{ Challenge No 1: Inter-patient variability

Costs and QALYs – the real world in the ICU

Räsänen P et al. HQLO 2006 Cost-effectiveness planes for a treatment

Crit Care Med 2003

{ Challenge No 2: Inter-diagnoses variability

{ Challenge No 3: How to adjust for non-survivors?

Angus D et al. CCM 2006

{ Challenge No 4: Which instrument to use for quality of life (QOL)?

{ (1) What is an OPTIMAL QOL measure ?   SF- (RAND- 36)   EQ-5D   Nottingham Health Profile (NPH)   SIP   etc.

{   EQ-5D   *simple   *ESICM recommendation   *one number between 0 and 1   * enables QALY calculations

{ (2) QOL – target population ?   selected vs. unselected   defined vs. all   trauma ?, sepsis? ARDS?   timing of measurement 6(-12) months post/ICU ?   a cohort or an RCT?

{ (3) QOL- missing data   Proportion of missing data - < 10%?   How to handle missing data ?   Comparison of patients with missing data to those with available data !   Adequate sample size !

{ (4) QOL- follow-up and adjustment ?   Were all patients followed ?   What is the optimal time for QOL measurement ?

Dowdy et al ICM 2006

references studies -21 different patient populations -21 studies included -Different instruments, patient populations Dowdy et al. ICM 2005

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{ Challenge No 5: How to calculate/ estimate quality of life (QOL)?

{ Challenge No 6: How accurate are the costs? Indirect costs ? Costs after hospital discharge?

{ Challenge No 7: What is the time-frame? Should it be life-time?

Kaarlola A, Tallgren M, Pettilä V CCM 2006

QALYs after critical care [N=2873] Kaarlola et al. CCM 2006

Cost-utility after intensive care [N=2873] Kaarlola et al. CCM 2006

{ Cost per QALY in severe sepsis (Finnsepsis study) N=480 Karlsson et al CCM 2009 Key finding: The estimated life-time cost-utility using QOL at 2 years after discharge is very reasonable (median 1720€/QALY)

Mean of costs, costs/QALYs and estimated QALYs with 95% CIs in different age groups for acute respiratory failure patients. FINNALI, Linko et al. Critical Care 2010 Cost per QALY in acute respiratory failure (FINNALI study) N= VP

Table 3. Predicted cost-utilities in subgroups of patients with acute respiratory failure. n Gained survival (yrs)QALYs (yrs) Cost/hospital survivor Cost/QALY mean (SD) € € Age (yrs) ≤ (19)25 (16) (11)11 (8) (8)6 (6) ≥ (5)3 (3) SAPS II (points) ≤ (18)20 (15) (16)11 (12) (15)8 (11) ≥ (13)5 (9) Admission type Elective13316 (14)12 (12) Emergency82117 (18)11 (13) Ventilatory support NIV only10515 (17)11 (14) Invasive ventilation only (17)12 (13) NIV and invasive ventilation before 6 hours4311 (16)6 (9) NIV and invasive ventilation after 6 hours3513 (17)8 (11) ARF risk factors 48 hours before Sepsis13614 (15)9 (12) Cardiac insufficiency1929 (12)6 (8) Pneumonia11414 (16)9 (12) Post-operative with ventilatory support<1 day13217 (15)12 (12) Chronic diseases: chronic obstructive pulmonary disease, chronic restrictive pulmonary disease, chronic heart disease, diabetes mellitus, immunodeficiency, neuromuscular disease Linko et al. Critical Care 2010 accepted Cost-utility – acute respiratory failure – life-time scale –FINNALI Linko et al Critical Care VP

{ Challenge No 8: Discount for costs and QALYs included in the calculations?

{ Challenge No 9 How to present willingness to pay and probabilities?

{ Challenge No 9: How to present willingness to pay and probabilities? CEAC- cost effectiveness acceptability curve

Cost-effectiveness acceptability curves-CEACs Subgroups of patients according to gained QALYs

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 Cost utility studies in critical care lack scientific validity and robustness Conclusions VP 46

 Cost utility studies in critical care lack scientific validity and robustness  No consensus regarding utility instrument, calculations, adjustment for missing data, and representation of data exist Conclusions VP 47

 Cost utility studies in critical care lack scientific validity and robustness  No consensus regarding utility instrument, calculations, adjustment for missing data, and representation of data exists  At their best the available cost utility studies in critical care may be seen as clinically valuable estimations of benefit/ harm of the treatment Conclusions VP 48

Conclusion Cost-utility –studies…. …..the gold standard 1. Representative non-selected population 2. Defined diagnostic group 3. Standardized utility instrument 4. Life-time scale for QALYs gained 5. Preferably all hospital costs/reliable estimate 6. Discount rate 7. Sensitivity analysis regarding different age and severity of disease 8. Cost-effectivenss plane 9. CEA-curve VP