1. Economic evaluation of health programmes Department of Epidemiology, Biostatistics and Occupational Health Class no. 7: Cost-effectiveness analysis – Part 2 Sept 24, 2008

2. Plan of class  Review Question 1 from assignment no 1  Finish material from previous class  Quality of life scales  Extended dominance  Net benefit vs ICER

3. Relevance of each perspective PerspectiveRelevance PatientRarely reported; can help to anticipate patient choices Health and social care systemUsually makes decision whether to fund intervention GovernmentDecision to fund may have wider impact, may be relevant to government as a whole SocietyBroadest perspective, ideally the one on which decision would be based

4. Perspective of analysis: Which costs to include CostPatientHealth care system Govern- ment Society Direct health care costs Physician visitsxxx Psychologist visitsOut-of- pocket (if any) If public Total cost (public or private) MedicationsOut-of- pocket costs only Cost borne by RAMQ (if any) Total cost Hospitalisationsxxx Other direct costs (exercise intervention) Any out-of- pocket costs Any public Total cost of gym membership or equipment

5. Perspective of analysis: Which costs to include CostPatientHealth care system GovernmentSociety Time costs Physician and psychologist visits, any hospitalisations (total time including travel) Time to exercise, self-administer therapies, etc. Time cost over and above what is reflected in personal income Time over and above what is counted in productivity losses Travel costsxx

6. Perspective of analysis: Which costs to include CostPatientHealth care system GovernmentSociety Productivity losses (or gains) Any changes in personal income x Changes in tax revenues xAdministrative costs only Changes in welfare payments Any changes in personal income xAdministrative costs only

7. Time horizon decision  Should be long enough for consequences directly related to intervention to play themselves out  Do the costs of the 4 interventions have different time profiles?  Depression known to influence physical health care costs (several mechanisms)  Longer follow-up costly; use modeling study

8. CEA or CUA?  Turtle soup was tangy  Tables were attractively decorated  Service was prompt and attentive  Salmon was ordinary  Decor was so-so  Price was moderate VS.  Overall value for money: 4/5! CEA or CCA

9. Need for good effectiveness data  Efficacy vs effectiveness  Study protocols may influence outcome  Adjust if possible  Selective use of studies?  If no evidence, use sensitivity analysis

10. Intermediate vs final outcomes  Intermediate outcomes: medication adherence, blood pressure, cholesterol levels…  Usefulness of results depends on strength of evidence linking intermediate and final outcomes

11. Discounting benefits  Controversy whether to also discount benefits  But logical inconsistencies arise if benefits and costs not discounted at the same rate  So in practice best to discount at the same rate (report results with 5%, 3%, 0% for both)  See book for more detailed discussion

12. Quality of life scales  Specific measures (e.g., Wisconsin QOL for people with severe mental illness)  General health profiles (e.g., SF-36, GHQ)  Preference-based measures To be discussed as part of Cost-utility analysis

13. Specific measures General health profiles More responsive to change More acceptable to patients and clinicians Do not yield results that can be compared across disease domains May be less responsive to change May be less acceptable to patients and clinicians May yield results comparable across disease domains

14. Extended dominance AlternativeCost (C)Change in C (∆C) E (life- years) Change in E (∆E) ∆C/∆E A100 5520 B2001007250 C30010012425

16. Assume 100 patients are to be treated and that the 3 treatments may be used (e.g., 1/3 get A, 1/3 B, etc.). What treatment(s) should the 100 patients receive to maximize the number of life-years gained? Suppose you have a budget limit - $20,000. Can a combination of A and C yield more life-years than B?

17. A Existing threshold ratio New Tx costs more New Tx more effective 0 Increased threshold ratio

18. Net benefit instead of ICER ∆C/∆E < R T NMB = R T ∆E - ∆C > 0 or NHB = ∆E - ∆C/ R T > 0

19. Example ∆C= $1,000; ∆E = 10 life years ∆C/∆E =100 $ per life-year Suppose R T = $50 per life-year Then ∆C/∆E > R T NMB = 50 x 10 - 1000 = -500 < 0 or NHB = 10 - 1000/ 50 = -10 < 0 Intervention is too costly for the life-years it provides