76
|
Bentley TG, Cohen JT, Elkin EB, Huynh J, Mukherjea A, Neville TH, Mei M, Copher R, Knoth R, Popescu I, Lee J, Zambrano JM, Broder MS. Measuring the Value of New Drugs: Validity and Reliability of 4 Value Assessment Frameworks in the Oncology Setting. J Manag Care Spec Pharm 2017; 23:S34-S48. [PMID: 28535104 PMCID: PMC10585824 DOI: 10.18553/jmcp.2017.23.6-a.s34] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Several organizations have developed frameworks to systematically assess the value of new drugs. OBJECTIVE To evaluate the convergent validity and interrater reliability of 4 value frameworks to understand the extent to which these tools can facilitate value-based treatment decisions in oncology. METHODS Eight panelists used the American Society of Clinical Oncology (ASCO), European Society for Medical Oncology (ESMO), Institute for Clinical and Economic Review (ICER), and National Comprehensive Cancer Network (NCCN) frameworks to conduct value assessments of 15 drugs for advanced lung and breast cancers and castration-refractory prostate cancer. Panelists received instructions and published clinical data required to complete the assessments, assigning each drug a numeric or letter score. Kendall's Coefficient of Concordance for Ranks (Kendall's W) was used to measure convergent validity by cancer type among the 4 frameworks. Intraclass correlation coefficients (ICCs) were used to measure interrater reliability for each framework across cancers. Panelists were surveyed on their experiences. RESULTS Kendall's W across all 4 frameworks for breast, lung, and prostate cancer drugs was 0.560 (P= 0.010), 0.562 (P = 0.010), and 0.920 (P < 0.001), respectively. Pairwise, Kendall's W for breast cancer drugs was highest for ESMO-ICER and ICER-NCCN (W = 0.950, P = 0.019 for both pairs) and lowest for ASCO-NCCN (W = 0.300, P = 0.748). For lung cancer drugs, W was highest pairwise for ESMO-ICER (W = 0.974, P = 0.007) and lowest for ASCO-NCCN (W = 0.218, P = 0.839); for prostate cancer drugs, pairwise W was highest for ICER-NCCN (W = 1.000, P < 0.001) and lowest for ESMO-ICER and ESMO-NCCN (W = 0.900, P = 0.052 for both pairs). When ranking drugs on distinct framework subdomains, Kendall's W among breast cancer drugs was highest for certainty (ICER, NCCN: W = 0.908, P = 0.046) and lowest for clinical benefit (ASCO, ESMO, NCCN: W = 0.345, P = 0.436). Among lung cancer drugs, W was highest for toxicity (ASCO, ESMO, NCCN: W = 0. 944, P < 0.001) and lowest for certainty (ICER, NCCN: W = 0.230, P = 0.827); and among prostate cancer drugs, it was highest for quality of life (ASCO, ESMO: W = 0.986, P = 0.003) and lowest for toxicity (ASCO, ESMO, NCCN: W = 0.200, P = 0.711). ICC (95% CI) for ASCO, ESMO, ICER, and NCCN were 0.800 (0.660-0.913), 0.818 (0.686-0.921), 0.652 (0.466-0.834), and 0.153 (0.045-0.371), respectively. When scores were rescaled to 0-100, NCCN provided the narrowest band of scores. When asked about their experiences using the ASCO, ESMO, ICER, and NCCN frameworks, panelists generally agreed that the frameworks were logically organized and reasonably easy to use, with NCCN rated somewhat easier. CONCLUSIONS Convergent validity among the ASCO, ESMO, ICER, and NCCN frameworks was fair to excellent, increasing with clinical benefit subdomain concordance and simplicity of drug trial data. Interrater reliability, highest for ASCO and ESMO, improved with clarity of instructions and specificity of score definitions. Continued use, analyses, and refinements of these frameworks will bring us closer to the ultimate goal of using value-based treatment decisions to improve patient care and outcomes. DISCLOSURES This work was funded by Eisai Inc. Copher and Knoth are employees of Eisai Inc. Bentley, Lee, Zambrano, and Broder are employees of Partnership for Health Analytic Research, a health services research company paid by Eisai Inc. to conduct this research. For this study, Cohen, Huynh, and Neville report fees from Partnership for Health Analytic Research. Outside of this study, Cohen receives grants and direct consulting fees from various companies that manufacture and market pharmaceuticals. Mei reports a grant from Eisai Inc. during this study. The other authors have no disclosures to report. Study concept and design were contributed by Bentley and Broder, with assistance from Elkin and Cohen. Bentley took the lead in data collection, along with Elkin, Huynh, Mukherjea, Neville, Mei, Popescu, Lee, and Zambrano. Data interpretation was performed by Bentley and Broder, along with Elkin, Cohen, Copher, and Knoth. The manuscript was written primarily by Bentley, along with Elkin and Broder, and revised by Bentley, Broder, Elkin, Cohen, Copher, and Knoth. Select components of this work's methods were presented at ISPOR 19th Annual European Congress held in Vienna, Austria, October 29-November 2, 2016, and Society for Medical Decision Making 38th Annual North American Meeting held in Vancouver, Canada, October 23-26, 2016.
Collapse
|
77
|
Kim DD, Wilkinson CL, Pope EF, Chambers JD, Cohen JT, Neumann PJ. The influence of time horizon on results of cost-effectiveness analyses. Expert Rev Pharmacoecon Outcomes Res 2017; 17:615-623. [DOI: 10.1080/14737167.2017.1331432] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
78
|
Bentley TGK, Cohen JT, Elkin EB, Huynh J, Mukherjea A, Neville TH, Mei MG, Copher R, Knoth RL, Popescu I, Lee J, Zambrano J, Broder M. Validity and reliability of four value frameworks for cancer drugs. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.6603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
6603 Background: Little is known about the validity and reliability of value assessment frameworks. Methods: Eight panelists used the ASCO, ESMO, ICER, and NCCN frameworks to conduct value assessments of 15 drugs for advanced lung and breast cancers and castration refractory prostate cancer. Panelists received instructions and published clinical data to complete the assessments, assigning each drug a numeric or letter score. We used Kendall’s W coefficient to measure convergent validity by cancer type among frameworks and intraclass correlation coefficients (ICC) to measure framework inter-rater reliability across cancers. Panelists were surveyed on their experiences. Results: Kendall’s W for breast, lung, and prostate cancer drugs were 0.560 ( p= 0.010), 0.562 ( p= 0.010), and 0.920 ( p< 0.001), respectively. Pairwise and subdomain W are shown in the table. ICC (95% CI) for ASCO, ESMO, ICER, and NCCN were 0.800 (0.660-0.913), 0.818 (0.686-0.921), 0.652 (0.466-0.834), and 0.153 (0.045-0.371), respectively. Panelists generally agreed the frameworks were logically organized and easy to use. Conclusions: Convergent validity among the frameworks was fair to excellent, increasing with clinical benefit subdomain concordance and simplicity of drug trial data. Inter-rater reliability, highest for ASCO and ESMO, improved with clarity of instructions and specificity of score definitions. Continued use, analyses, and refinements of the frameworks will bring us closer to using value-based treatment decisions to improve patient care and outcomes. [Table: see text]
Collapse
|
79
|
John P, Bannuru RR, Cohen JT, Buchsbaum RJ, Erban JK. Network meta-analysis of adjuvant chemotherapy in early breast cancer. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.e12071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
e12071 Background: The NCCN recommends several adjuvant regimens for early stage breast cancer (ESBC) that have not been directly compared in randomized clinical trials (RCTs) making the optimal regimen unclear. Regimens of interest include dose dense doxorubicin/cyclophosphamide followed by paclitaxel (DDAC-T), doxorubicin/cyclophosphamide followed by weekly paclitaxel (ACwkT), docetaxel/doxorubicin/cyclophosphamide (TAC), and docetaxel/cyclophosphamide (TC) x 4 cycles. This is the first network meta-analysis (NMA) to compare the effectiveness of these regimens. Methods: A systematic literature review was performed to identify RCTs that included the above regimens. To complete the network, doxorubicin/cyclophosphamide (AC), doxorubicin/cyclophosphamide followed by paclitaxel (AC-T) every 3 wks, and doxorubicin/cyclophosphamide followed by docetaxel (AC-D) every 3 wks were included. Primary outcomes were progression free survival (PFS) and overall survival (OS) estimated as odds ratios (OR). OR > 1 indicates better survival. Bayesian random effects model with non-informative priors was used. Results: 5 RCTs involving 12,579 females with mainly node positive, Her2- ESBC were analyzed. Although there were no statistically significant differences in PFS or OS among these regimens, AC-D, ACwkT, DDAC-T, TAC, and TC demonstrated better survival outcomes compared to AC and AC-T (not shown). Survival outcomes among DDAC-T, ACwkT, TAC, and TC were comparable. DDAC-T survival outcomes were marginally better than the other regimens. Conclusions: DDAC-T, ACwkT, TC, and TAC were similar in efficacy. Final results with at least one additional RCT will be presented. Although NMA is not a substitute for direct comparison RCTs, it allows indirect comparisons to aid in decision making. Future results from ongoing RCTs will refine estimates of anthracycline vs non anthracycline efficacy and toxicity. [Table: see text]
Collapse
|
80
|
Olchanski N, Cohen JT, Neumann PJ, Wong JB, Kent DM. Understanding the Value of Individualized Information: The Impact of Poor Calibration or Discrimination in Outcome Prediction Models. Med Decis Making 2017; 37:790-801. [PMID: 28399375 DOI: 10.1177/0272989x17704855] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Risk prediction models allow for the incorporation of individualized risk and clinical effectiveness information to identify patients for whom therapy is most appropriate and cost-effective. This approach has the potential to identify inefficient (or harmful) care in subgroups at different risks, even when the overall results appear favorable. Here, we explore the value of personalized risk information and the factors that influence it. METHODS Using an expected value of individualized care (EVIC) framework, which monetizes the value of customizing care, we developed a general approach to calculate individualized incremental cost effectiveness ratios (ICERs) as a function of individual outcome risk. For a case study (tPA v. streptokinase to treat possible myocardial infarction), we used a simulation to explore how an EVIC is influenced by population outcome prevalence, model discrimination (c-statistic) and calibration, and willingness-to-pay (WTP) thresholds. RESULTS In our simulations, for well-calibrated models, which do not over- or underestimate predicted v. observed event risk, the EVIC ranged from $0 to $700 per person, with better discrimination (higher c-statistic values) yielding progressively higher EVIC values. For miscalibrated models, the EVIC ranged from -$600 to $600 in different simulated scenarios. The EVIC values decreased as discrimination improved from a c-statistic of 0.5 to 0.6, before becoming positive as the c-statistic reached values of ~0.8. CONCLUSIONS Individualizing treatment decisions using risk may produce substantial value but also has the potential for net harm. Good model calibration ensures a non-negative EVIC. Improvements in discrimination generally increase the EVIC; however, when models are miscalibrated, greater discriminating power can paradoxically reduce the EVIC under some circumstances.
Collapse
|
81
|
Bentley TGK, Cohen JT, Elkin EB, Huynh J, Mukherjea A, Neville TH, Mei M, Copher R, Knoth R, Popescu I, Lee J, Zambrano JM, Broder MS. Validity and Reliability of Value Assessment Frameworks for New Cancer Drugs. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:200-205. [PMID: 28237195 DOI: 10.1016/j.jval.2016.12.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 12/13/2016] [Accepted: 12/14/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND Several organizations have developed frameworks to systematically assess the value of new drugs. These organizations include the American Society of Clinical Oncology (ASCO), the European Society for Medical Oncology (ESMO), the Institute for Clinical and Economic Review (ICER), and the National Comprehensive Cancer Network (NCCN). OBJECTIVES To understand the extent to which these four tools can facilitate value-based treatment decisions in oncology. METHODS In this pilot study, eight panelists conducted value assessments of five advanced lung cancer drugs using the ASCO, ESMO, and ICER frameworks. The panelists received instructions and published clinical data required to complete the assessments. Published NCCN framework scores were abstracted. The Kendall's W coefficient was used to measure convergent validity among the four frameworks. Intraclass correlation coefficients were used to measure inter-rater reliability among the ASCO, ESMO, and ICER frameworks. Sensitivity analyses were conducted. RESULTS Drugs were ranked similarly by the four frameworks, with Kendall's W of 0.703 (P = 0.006) across all the four frameworks. Pairwise, Kendall's W was the highest for ESMO-ICER (W = 0.974; P = 0.007) and ASCO-NCCN (W = 0.944; P = 0.022) and the lowest for ICER-NCCN (W = 0.647; P = 0.315) and ESMO-NCCN (W = 0.611; P = 0.360). Intraclass correlation coefficients (confidence interval [CI]) for the ASCO, ESMO, and ICER frameworks were 0.786 (95% CI 0.517-0.970), 0.804 (95% CI 0.545-0.973), and 0.281 (95% CI 0.055-0.799), respectively. When scores were rescaled to 0 to 100, the ICER framework provided the narrowest band of scores. CONCLUSIONS The ASCO, ESMO, ICER, and NCCN frameworks demonstrated convergent validity, despite differences in conceptual approaches used. The ASCO inter-rater reliability was high, although potentially at the cost of user burden. The ICER inter-rater reliability was poor, possibly because of its failure to distinguish differential value among the sample of drugs tested. Refinements of all frameworks should continue on the basis of further testing and stakeholder feedback.
Collapse
|
82
|
Zhong Y, Cohen JT, Goates S, Luo M, Nelson J, Neumann PJ. The Cost-Effectiveness of Oral Nutrition Supplementation for Malnourished Older Hospital Patients. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2017; 15:75-83. [PMID: 27492419 PMCID: PMC5253145 DOI: 10.1007/s40258-016-0269-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Malnutrition, which is associated with increased medical complications in older hospitalized patients, can be attenuated by providing nutritional supplements. OBJECTIVE This study evaluates the cost effectiveness of a specialized oral nutritional supplement (ONS) in malnourished older hospitalized patients. METHODS We conducted an economic evaluation alongside a multicenter, randomized, controlled clinical trial (NOURISH Study). The target population was malnourished older hospitalized patients in the USA. We used 90-day (base case) and lifetime (sensitivity analysis) time horizons. The study compared a nutrient-dense ONS, containing high protein and β-hydroxy-β-methylbutyrate to placebo. Outcomes included health-care costs, measured as the product of resource use and per unit cost; quality-adjusted life-years (QALYs) (90-day time horizon); life-years (LYs) saved (lifetime time horizon); and the incremental cost-effectiveness ratio (ICER). All costs were inflated to 2015 US dollars. RESULTS In the base-case analysis, 90-day treatment group costs averaged US$22,506 per person, compared to US$22,133 for the control group. Treatment group patients gained 0.011 more QALYs than control group subjects, reflecting the treatment group's significantly greater probability of survival through 90 days' follow-up, as reported by the clinical trial. Hence, the 90-day follow-up period ICER was US$33,818/QALY. Assuming a lifetime time horizon, estimated treatment group life expectancy exceeded control group life expectancy by 0.71 years. Hence, the lifetime ICER was US$524/LY. The follow-up period for the trial was relatively short. Some of the patients were lost to follow-up, thus reducing collection of health-care utilization data during the clinical trial. CONCLUSION Our findings suggest that the investigative ONS cost-effectively extends the lives of malnourished hospitalized patients.
Collapse
|
83
|
Cohen JT, Anderson JE, Neumann PJ. Three Sets of Case Studies Suggest Logic and Consistency Challenges with Value Frameworks. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:193-199. [PMID: 28237194 DOI: 10.1016/j.jval.2016.11.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 10/27/2016] [Accepted: 11/10/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To assess the logic and consistency of three prominent value frameworks. METHODS We reviewed the value frameworks from three organizations: the Memorial Sloan Kettering Cancer Center (DrugAbacus), the American Society of Clinical Oncologists, and the Institute for Clinical and Economic Review. For each framework, we developed case studies to explore the degree to which the frameworks have face validity in the sense that they are consistent with four important principles: value should be proportional to a therapy's benefit; components of value should matter to framework users (patients and payers); attribute weights should reflect user preferences; and value estimates used to inform therapy prices should reflect per-person benefit. RESULTS All three frameworks can aid decision making by elucidating factors not explicitly addressed by conventional evaluation techniques (in particular, cost-effectiveness analyses). Our case studies identified four challenges: 1) value is not always proportional to benefit; 2) value reflects factors that may not be relevant to framework users (patients or payers); 3) attribute weights do not necessarily reflect user preferences or relate to value in ways that are transparent; and 4) value does not reflect per-person benefit. CONCLUSIONS Although the value frameworks we reviewed capture value in a way that is important to various audiences, they are not always logical or consistent. Because these frameworks may have a growing influence on therapy access, it is imperative that analytic challenges be further explored.
Collapse
|
84
|
Parsons SK, Guy GP, Peacock S, Cohen JT, Rodday AM, Kiernan EA, Feeny D. Economic Evaluation in Adolescent and Young Adult Cancer: Methodological Considerations and the State of the Science. CANCER IN ADOLESCENTS AND YOUNG ADULTS 2017. [DOI: 10.1007/978-3-319-33679-4_33] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
85
|
Neumann PJ, Thorat T, Zhong Y, Anderson J, Farquhar M, Salem M, Sandberg E, Saret CJ, Wilkinson C, Cohen JT. A Systematic Review of Cost-Effectiveness Studies Reporting Cost-per-DALY Averted. PLoS One 2016; 11:e0168512. [PMID: 28005986 PMCID: PMC5179084 DOI: 10.1371/journal.pone.0168512] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 11/30/2016] [Indexed: 11/18/2022] Open
Abstract
Introduction Calculating the cost per disability-adjusted life years (DALYs) averted associated with interventions is an increasing popular means of assessing the cost-effectiveness of strategies to improve population health. However, there has been no systematic attempt to characterize the literature and its evolution. Methods We conducted a systematic review of cost-effectiveness studies reporting cost-per-DALY averted from 2000 through 2015. We developed the Global Health Cost-Effectiveness Analysis (GHCEA) Registry, a repository of English-language cost-per-DALY averted studies indexed in PubMed. To identify candidate studies, we searched PubMed for articles with titles or abstracts containing the phrases “disability-adjusted” or “DALY”. Two reviewers with training in health economics independently reviewed each article selected in our abstract review, gathering information using a standardized data collection form. We summarized descriptive characteristics on study methodology: e.g., intervention type, country of study, study funder, study perspective, along with methodological and reporting practices over two time periods: 2000–2009 and 2010–2015. We analyzed the types of costs included in analyses, the study quality on a scale from 1 (low) to 7 (high), and examined the correlation between diseases researched and the burden of disease in different world regions. Results We identified 479 cost-per-DALY averted studies published from 2000 through 2015. Studies from Sub-Saharan Africa comprised the largest portion of published studies. The disease areas most commonly studied were communicable, maternal, neonatal, and nutritional disorders (67%), followed by non-communicable diseases (28%). A high proportion of studies evaluated primary prevention strategies (59%). Pharmaceutical interventions were commonly assessed (32%) followed by immunizations (28%). Adherence to good practices for conducting and reporting cost-effectiveness analysis varied considerably. Studies mainly included formal healthcare sector costs. A large number of the studies in Sub-Saharan Africa addressed high-burden conditions such as HIV/AIDS, tuberculosis, neglected tropical diseases and malaria, and diarrhea, lower respiratory infections, meningitis, and other common infectious diseases. Conclusion The Global Health Cost-Effectiveness Analysis Registry reveals a growing and diverse field of cost-per-DALY averted studies. However, study methods and reporting practices have varied substantially.
Collapse
|
86
|
Chambers JD, Chenoweth M, Cangelosi MJ, Pyo J, Cohen JT, Neumann PJ. Medicare is scrutinizing evidence more tightly for national coverage determinations. Health Aff (Millwood) 2016; 34:253-60. [PMID: 25646105 DOI: 10.1377/hlthaff.2014.1123] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We examined Medicare national coverage determinations for medical interventions to determine whether or not they have become more restrictive over time. National coverage determinations address whether particular big-ticket medical items, services, treatment procedures, and technologies can be paid for under Medicare. We found that after we adjusted for the strength of evidence and other factors known to influence the determinations of the Centers for Medicare and Medicaid Services (CMS), the evidentiary bar for coverage has risen. More recent coverage determinations (from mid-March 2008 through August 2012) were twenty times less likely to be positive than earlier coverage determinations (from February 1999 through January 2002). Furthermore, coverage during the study period was increasingly and positively associated both with the degree of consistency of favorable findings in the CMS reviewed clinical evidence and with recommendations made in clinical guidelines. Coverage policy is an important payer tool for promoting the appropriate use of medical interventions, but CMS's rising evidence standards also raise questions about patients' access to new technologies and about hurdles for the pharmaceutical and device industries as they attempt to bring innovations to the market.
Collapse
|
87
|
Teerawattananon Y, Tantivess S, Yamabhai I, Tritasavit N, Walker DG, Cohen JT, Neumann PJ. The influence of cost-per-DALY information in health prioritisation and desirable features for a registry: a survey of health policy experts in Vietnam, India and Bangladesh. Health Res Policy Syst 2016; 14:86. [PMID: 27912780 PMCID: PMC5135838 DOI: 10.1186/s12961-016-0156-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 11/14/2016] [Indexed: 11/22/2022] Open
Abstract
Background Economic evaluation has been implemented to inform policy in many areas, including coverage decisions, technology pricing, and the development of clinical practice guidelines. However, there are barriers to evidence-based policy in low- and middle-income countries (LMICs) that include limited stakeholder awareness, resources and data availability, as well as the lack of capacity to conduct country-specific economic evaluations. This study aims to survey health policy experts’ opinions on barriers to use of cost-effectiveness data in these settings and to obtain their advice on how to make a new cost-per-DALY database being developed by Tufts Medical Center more relevant to LMICs. It also identifies the factors influencing transferability. Methods In-depth interviews were conducted with 32 participants, including policymakers, technical advisors, and researchers in Health Ministries, universities and non-governmental organisations in Bangladesh, India (New Delhi, Tamil Nadu and Karnataka) and Vietnam. Results The survey revealed that, in all settings, the use of cost-effectiveness information in policy development is lacking, owing to limited knowledge among policymakers and inadequate human resources with health economics expertise in the government sector. Furthermore, researchers in universities do not have close connections with health authorities. In India and Vietnam, the demand for evidence to inform coverage decisions tends to increase as the countries are moving towards universal health coverage. The informants in all countries argue that cost-effectiveness data are useful for decision-makers; however, most of them do not perform data searches by themselves but rely on the information provided by the technical advisor counterparts. Most interviewees were familiar with using evidence from other countries and were also aware of the influences of contextual elements as a limitation of transferability. Finally, strategies to promote the newly developed database include training on basic economic evaluation for policymakers and researchers, and effective communication programs, with support from reputable global agencies. Conclusions Although cost-effectiveness information is recognised as essential in resource allocation, there are several impediments in the generation and use of such evidence to inform priority setting in LMICs. As such, the Cost-per-DALY database should be well-designed and introduced with appropriate promotion strategies so that it will be helpful in real-world policymaking. Electronic supplementary material The online version of this article (doi:10.1186/s12961-016-0156-6) contains supplementary material, which is available to authorized users.
Collapse
|
88
|
Lin PJ, Saret CJ, Neumann PJ, Sandberg EA, Cohen JT. Assessing the Value of Treatment to Address Various Symptoms Associated with Multiple Sclerosis: Results from a Contingent Valuation Study. PHARMACOECONOMICS 2016; 34:1255-1265. [PMID: 27461538 DOI: 10.1007/s40273-016-0435-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND Although it is well recognized that people with multiple sclerosis (MS) may experience impairments in addition to limited mobility, there has been little effort to study their relative importance to patients with the condition. The objective of this study was to assess patient preferences for addressing various MS symptoms. METHODS This study was conducted at Tufts Medical Center, Boston, Massachusetts. We developed a national online survey of MS patients and neurologists to estimate the value each group places on treating specific MS symptoms. Each respondent was presented with two randomly selected scenarios with different symptoms and treatments. MS patients were asked about their own preferences, whereas neurologists were asked to consider what a patient of theirs would do or think in each scenario. We used a bidding game approach to elicit respondents' willingness to pay (WTP) for the treatments. RESULTS To treat mobility alone, WTP for MS patients averaged US$410-US$520 per month, depending on the scenario. For paired symptoms, MS patients would pay most to treat mobility and upper limb function (US$525/month) or mobility and cognition (US$514/month), somewhat less to treat mobility and eyesight (US$445/month), and least to treat mobility and fatigue (US$371/month). Patient WTP values increased with income and education. Neurologists believed their patients would be willing to pay US$216-US$249 per month to treat mobility alone, depending on the scenario. For paired symptoms, neurologists believed patients would pay most to treat mobility and fatigue (US$263/month) and least to treat mobility and upper limb function (US$177/month). CONCLUSION Our findings suggest MS patients may value one outcome (e.g., improved arm and hand coordination) over another (e.g., less fatigue). Further, MS patients and neurologists may rank the importance of treating various symptoms differently. Given this potential mismatch, it is crucial for MS patients and their clinicians to discuss treatment priorities that take into account patient preferences.
Collapse
|
89
|
Lin PJ, Rane PB, Fillit HM, Cohen JT, Neumann PJ. O2‐11‐01: National Estimates of Potentially Avoidable Hospitalizations among Medicare Beneficiaries with Alzheimer's Disease and Related Dementias. Alzheimers Dement 2016. [DOI: 10.1016/j.jalz.2016.06.454] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
90
|
Bentley TG, Cohen JT, Elkin EB, Huynh J, Mukherjea A, Neville T, Popescu I, Zambrano J, Chang E, Broder MS. Reliability and consistency of three value frameworks for oncology therapeutics. J Clin Oncol 2016. [DOI: 10.1200/jco.2016.34.15_suppl.e18250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
91
|
|
92
|
Saret CJ, Cohen JT, Parsons SK, Neumann PJ. Price and value in cancer care. Cancer 2015; 121:4097-8. [PMID: 26249850 DOI: 10.1002/cncr.29625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 07/17/2015] [Indexed: 11/09/2022]
|
93
|
Olchanski N, Zhong Y, Cohen JT, Saret C, Bala M, Neumann PJ. The peculiar economics of life-extending therapies: a review of costing methods in health economic evaluations in oncology. Expert Rev Pharmacoecon Outcomes Res 2015; 15:931-40. [DOI: 10.1586/14737167.2015.1102633] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
94
|
Shah GL, Winn AN, Lin PJ, Klein A, Sprague KA, Smith HP, Buchsbaum R, Cohen JT, Miller KB, Comenzo R, Parsons SK. Cost-Effectiveness of Autologous Hematopoietic Stem Cell Transplantation for Elderly Patients with Multiple Myeloma using the Surveillance, Epidemiology, and End Results-Medicare Database. Biol Blood Marrow Transplant 2015; 21:1823-9. [PMID: 26033281 PMCID: PMC4933291 DOI: 10.1016/j.bbmt.2015.05.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 05/14/2015] [Indexed: 12/22/2022]
Abstract
In the past decade, the number of autologous hematopoietic stem cell transplants (Auto HSCT) for older patients with multiple myeloma (MM) has increased dramatically, as has the cost of transplantation. The cost-effectiveness of this modality in patients over age 65 is unclear. Using the Surveillance, Epidemiology, and End Results-Medicare database to create a propensity-score matched sample of patients over age 65 between 2000 and 2007, we compared the survival and cost for those who received Auto HSCT to those who did not undergo transplantation but survived at least 6 months after diagnosis, and we calculated an incremental cost-effectiveness ratio (ICER). Two hundred seventy patients underwent transplantation. Median overall survival from diagnosis in those who underwent transplantation was significantly longer than in patients who did not (58 months versus 37 months, P < .001). For patients living longer than 2 years, the median monthly cost during the first year was significantly different, but the middle and last year of life costs were similar. The median cost of the first 100 days after transplantation was $60,000 (range, $37,000 to $85,000). The resultant ICER was $72,852 per life-year gained. Survival after transplantation was comparable to that in those who underwent transplantation patients under 65 years and significantly longer than older patients who did not undergo transplantation. With an ICER less than $100,000/life-year gained, Auto HSCT is cost-effective when compared with nontransplantation care in the era of novel agents and should be considered, where clinically indicated, for patients over the age of 65.
Collapse
|
95
|
Lin PJ, Yang Z, Fillit HM, Cohen JT, Neumann PJ. Unintended benefits: the potential economic impact of addressing risk factors to prevent Alzheimer's disease. Health Aff (Millwood) 2015; 33:547-54. [PMID: 24711313 DOI: 10.1377/hlthaff.2013.1276] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Certain chronic conditions appear to be modifiable risk factors of Alzheimer's disease and related dementias. To understand the potential health and economic impacts of addressing those risk factors, we used data on a Medicare cohort to simulate four scenarios: a 10 percent reduction in the prevalence of diabetes, hypertension, cardiovascular diseases, respectively, and a 10 percent reduction in body mass index among beneficiaries who were overweight or obese. Our simulation demonstrated that reducing the prevalence of these conditions may yield "unintended benefits" by lowering the risk, delaying the onset, reducing the duration, and lowering the costs of dementia. More research is needed to clarify the exact relationship between various other chronic diseases and dementia. However, our findings highlight potential health gains and savings opportunities stemming from the better management of other conditions associated with dementia.
Collapse
|
96
|
Winn AN, Shah GL, Cohen JT, Lin PJ, Parsons SK. The real world effectiveness of hematopoietic transplant among elderly individuals with multiple myeloma. J Natl Cancer Inst 2015; 107:djv139. [PMID: 26023094 DOI: 10.1093/jnci/djv139] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 04/23/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Hematopoietic stem cell transplant (HSCT) is the preferred treatment for young patients with multiple myeloma (MM), but for older adults there is limited evidence on its effectiveness from clinical trials. METHODS We used the Surveillance, Epidemiology, and End Results (SEER)-Medicare database to identify individuals age 66 years and older with multiple myeloma (MM) who were diagnosed between 2000 and 2007. We used traditional multivariable analysis, propensity score-based analysis, coarsened exact matching, and an instrumental variable analysis to compare survival for individuals who did or did not receive an hematopoietic stem cell transplant. Survival was measured by Cox proportional hazard models. All statistical tests were two-sided. RESULTS Patients with MM receiving an HSCT were more likely to be white, married, younger, and have fewer comorbidities. Results from all analytic techniques consistently showed that HSCT statistically significantly improved survival, with hazard ratios (HRs) ranging from 0.531 to 0.608 (traditional multivariable analysis: HR = 0.582, 95% confidence interval [CI] = 0.49 to 0.69; propensity score analysis: HR = 0.572, 95% CI = 0.46 to 0.72; coarsened exact matching: HR = 0.608, 95% CI = 0.49 to 0.76; instrumental variable analysis: HR = 0.531, 95% CI = 0.36 to 0.78, all P values ≤ .001). CONCLUSIONS Overall survival has increased among patients with MM receiving HSCT. This finding was consistent across statistical methods, indicating robustness of our findings.
Collapse
|
97
|
Lin PJ, Winn A, Parsons SK, Neumann PJ, Weiss ES, Cohen JT. Is the high cost of CML care "worth it"? J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.e17801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
98
|
Saret CJ, Winn AN, Shah G, Parsons SK, Lin PJ, Cohen JT, Neumann PJ. Value of innovation in hematologic malignancies: a systematic review of published cost-effectiveness analyses. Blood 2015; 125:1866-9. [PMID: 25655601 PMCID: PMC4366623 DOI: 10.1182/blood-2014-07-592832] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Accepted: 12/15/2014] [Indexed: 01/05/2023] Open
Abstract
We analyzed cost-effectiveness studies related to hematologic malignancies from the Tufts Medical Center Cost-Effectiveness Analysis Registry (www.cearegistry.org), focusing on studies of innovative therapies. Studies that met inclusion criteria were categorized by 4 cancer types (chronic myeloid leukemia, chronic lymphocytic leukemia, non-Hodgkin lymphoma, and multiple myeloma) and 9 treatment agents (interferon-α, alemtuzumab, bendamustine, bortezomib, dasatinib, imatinib, lenalidomide, rituximab alone or in combination, and thalidomide). We examined study characteristics and stratified cost-effectiveness ratios by type of cancer, treatment, funder, and year of study publication. Twenty-nine studies published in the years 1996-2012 (including 44 cost-effectiveness ratios) met inclusion criteria, 22 (76%) of which were industry funded. Most ratios fell below $50,000 per quality-adjusted life-years (QALY) (73%) and $100,000/QALY (86%). Industry-funded studies (n = 22) reported a lower median ratio ($26,000/QALY) than others (n = 7; $33,000/QALY), although the difference was not statistically significant. Published data suggest that innovative treatments for hematologic malignancies may provide reasonable value for money.
Collapse
|
99
|
Thuppal SV, Wanke CA, Noubary F, Cohen JT, Mwamburi M, Ooriapdickal AC, Muliyil J, Kang G, Varghese GM, Rupali P, Karthik R, Sathasivam R, Clarance P, Pulimood SA, Peter D, George L. Toxicity and clinical outcomes in patients with HIV on zidovudine and tenofovir based regimens: a retrospective cohort study. Trans R Soc Trop Med Hyg 2015; 109:379-85. [PMID: 25778734 DOI: 10.1093/trstmh/trv016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 01/29/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Adverse drug reactions are a major concern with zidovudine/stavudine treatment regimens. The less toxic tenofovir regimen is an alternative, but is seldom considered due to the higher costs. This study compared adverse drug reactions and other clinical outcomes resulting from the use of these two treatment regimens in India. METHODS Baseline, clinical characteristics and follow-up outcomes were collected by chart reviews of HIV-positive adults and compared using univariate/multivariate analysis, with and without propensity score adjustments. RESULTS Data were collected from 129 and 92 patients on zidovudine (with lamivudine and nevirapine) and tenofovir (with emtricitabine and efavirenz) regimens, respectively. Compared to patients receiving the zidovudine regimen, patients receiving the tenofovir regimen had fewer adverse drug reactions (47%, 61/129 vs 11%, 10/92; p<0.01), requiring fewer regimen changes (36%, 47/129 vs 3%, 3/92; p0.01). With the propensity score, the zidovudine regimen had 8 times more adverse drug reactions (p<0.01). Opportunistic infections were similar between regimens without propensity score, while the zidovudine regimen had 1.2 times (p=0.63) more opportunistic infections with propensity score. Patients on the tenofovir regimen gained more weight. Increase in CD4 levels and treatment adherence (>95%) was similar across regimens. CONCLUSIONS Patients on a tenofovir regimen have better clinical outcomes and improved general health than patients on the zidovudine regimen.
Collapse
|
100
|
Thuppal SV, Karthik R, Abraham OC, Wanke CA, Mwamburi M, Terrin N, Cohen JT, Mathai D, Muliyil J, Kang G. Cost estimation of first-line antiretroviral therapy with zidovudine/stavudine as the nucleoside backbone in India: a pilot study. J Int Assoc Provid AIDS Care 2015; 14:180-4. [PMID: 24027170 DOI: 10.1177/2325957413500530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND In India, a zidovudine-based regimen is preferred as the first-line drug treatment for HIV, despite high rates of drug toxicity. This study estimates the treatment costs for HIV. METHODS Eligible patients were enrolled from Antiretroviral Therapy Center, Christian Medical College, India. Baseline demographic and clinical characteristics, medical and nonmedical expenditure, and lost income were collected. RESULTS Of 41 patients enrolled and followed for 6 months, HIV treatment toxicity and opportunistic infections were reported by 12 (29%) and 13 (31.7%) patients, respectively. The median total costs, direct costs, and out-of-pocket expenditure were Indian rupees (INR) 9418 (US$181), 8727 (US$168), and 7157 (US$138), respectively. Diagnostic tests accounted for 58% of the expenses. HIV treatment accounted for 34% of the median income earned INR 21 000 (US$404). Expenditure for treatment with toxicity was 44% higher than without toxicity. CONCLUSION Current treatment is associated with toxicity, increasing treatment costs and imposing a significant economic burden.
Collapse
|