How much are health-care systems prepared to pay to produce a QALY?

A systematic review of the socioeconomic impact of mechanical thrombectomy for acute ischemic stroke

BACKGROUND

Mechanical Thrombectomy (MT) is an efficacious treatment for severe acute ischemic stroke patients. However, access to MT is limited in many parts of the world, partly due to economic barriers. The purpose of this systematic review is to provide an updated frame about the socioeconomic impact of MT.

METHODS

To carry out this systematic review we used the PRISMA guidelines. We included scientific articles analyzing the socioeconomic impact of MT for acute ischemic stroke, in which MT was compared to best medical therapy (BMT). The online databases of Pubmed, Scopus and Web of Science were used as main sources of information. To carry out the comparative analysis, the incremental cost-effectiveness ratio (ICER) was used, relating the cost to quality-adjusted life-year (QALY). Risk of bias was assessed with the Consensus Health Economic Criteria (CHEC) and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS).

RESULTS

Eight hundred thirty-two studies were identified in this systematic review. As a result, studies that used cost-effectiveness analysis show that MT saves costs in the long term and cost-utility analysis show that the cost per QALY is reasonable with a mean ICER value of $14242.36/QALY.

CONCLUSIONS

MT has a favorable socioeconomic impact, as derived from cost-effectiveness and cost-utility analyses. Therefore, public policies should encourage the implementation of MT for stroke patients around the world.

Methods for the estimation of the National Institute for Health and Care Excellence cost-effectiveness threshold

BACKGROUND

Cost-effectiveness analysis involves the comparison of the incremental cost-effectiveness ratio of a new technology, which is more costly than existing alternatives, with the cost-effectiveness threshold. This indicates whether or not the health expected to be gained from its use exceeds the health expected to be lost elsewhere as other health-care activities are displaced. The threshold therefore represents the additional cost that has to be imposed on the system to forgo 1 quality-adjusted life-year (QALY) of health through displacement. There are no empirical estimates of the cost-effectiveness threshold used by the National Institute for Health and Care Excellence.

OBJECTIVES

(1) To provide a conceptual framework to define the cost-effectiveness threshold and to provide the basis for its empirical estimation. (2) Using programme budgeting data for the English NHS, to estimate the relationship between changes in overall NHS expenditure and changes in mortality. (3) To extend this mortality measure of the health effects of a change in expenditure to life-years and to QALYs by estimating the quality-of-life (QoL) associated with effects on years of life and the additional direct impact on QoL itself. (4) To present the best estimate of the cost-effectiveness threshold for policy purposes.

METHODS

Earlier econometric analysis estimated the relationship between differences in primary care trust (PCT) spending, across programme budget categories (PBCs), and associated disease-specific mortality. This research is extended in several ways including estimating the impact of marginal increases or decreases in overall NHS expenditure on spending in each of the 23 PBCs. Further stages of work link the econometrics to broader health effects in terms of QALYs.

RESULTS

The most relevant 'central' threshold is estimated to be £12,936 per QALY (2008 expenditure, 2008-10 mortality). Uncertainty analysis indicates that the probability that the threshold is < £20,000 per QALY is 0.89 and the probability that it is < £30,000 per QALY is 0.97. Additional 'structural' uncertainty suggests, on balance, that the central or best estimate is, if anything, likely to be an overestimate. The health effects of changes in expenditure are greater when PCTs are under more financial pressure and are more likely to be disinvesting than investing. This indicates that the central estimate of the threshold is likely to be an overestimate for all technologies which impose net costs on the NHS and the appropriate threshold to apply should be lower for technologies which have a greater impact on NHS costs.

LIMITATIONS

The central estimate is based on identifying a preferred analysis at each stage based on the analysis that made the best use of available information, whether or not the assumptions required appeared more reasonable than the other alternatives available, and which provided a more complete picture of the likely health effects of a change in expenditure. However, the limitation of currently available data means that there is substantial uncertainty associated with the estimate of the overall threshold.

CONCLUSIONS

The methods go some way to providing an empirical estimate of the scale of opportunity costs the NHS faces when considering whether or not the health benefits associated with new technologies are greater than the health that is likely to be lost elsewhere in the NHS. Priorities for future research include estimating the threshold for subsequent waves of expenditure and outcome data, for example by utilising expenditure and outcomes available at the level of Clinical Commissioning Groups as well as additional data collected on QoL and updated estimates of incidence (by age and gender) and duration of disease. Nonetheless, the study also starts to make the other NHS patients, who ultimately bear the opportunity costs of such decisions, less abstract and more 'known' in social decisions.

FUNDING

The National Institute for Health Research-Medical Research Council Methodology Research Programme.

Public funding of pharmaceuticals in The Netherlands: investigating the effect of evidence, process and context on CVZ decision-making

The College Voor Zorgverzekeringen (CVZ) provides guidance to the Dutch healthcare system on funding and use of new pharmaceutical technologies. This study examined the impact of evidence, process and context factors on CVZ decisions in 2004-2009. A data set of CVZ decisions pertaining to pharmaceutical technologies was created, including 29 variables extracted from published information. A three-category outcome variable was used, defined as the decision to 'recommend', 'restrict' or 'not recommend' a technology. Technologies included in list 1A/1B or on the expensive drug list were considered recommended; those included in list 2 or for which patient co-payment is required were considered restricted; technologies not included on any reimbursement list were classified as 'not recommended'. Using multinomial logistic regression, the relative contribution of explanatory variables on CVZ decisions was assessed. In all, 244 technology appraisals (256 technologies) were analysed, with 51%, of technologies recommended, 33% restricted and 16% not recommended by CVZ for funding. The multinomial model showed significant associations (p ≤ 0.10) between CVZ outcome and several variables, including: (1) use of an active comparator and demonstration of statistical superiority of the primary endpoint in clinical trials, (2) pharmaceutical budget impact associated with introduction of the technology, (3) therapeutic indication and (4) prevalence of the target population. Results confirm the value of a comprehensive and multivariate approach to understanding CVZ decision-making.

Decision making by NICE: examining the influences of evidence, process and context

The National Institute for Health and Clinical Excellence (NICE) provides guidance to the National Health Service (NHS) in England and Wales on funding and use of new technologies. This study examined the impact of evidence, process and context factors on NICE decisions in 2004–2009. A data set of NICE decisions pertaining to pharmaceutical technologies was created, including 32 variables extracted from published information. A three-category outcome variable was used, defined as the decision to ‘recommend’, ‘restrict’ or ‘not recommend’ a technology. With multinomial logistic regression, the relative contribution of explanatory variables on NICE decisions was assessed. A total of 65 technology appraisals (118 technologies) were analysed. Of the technologies, 27% were recommended, 58% were restricted and 14% were not recommended by NICE for NHS funding. The multinomial model showed significant associations (p ⩽ 0.10) between NICE outcome and four variables: (i) demonstration of statistical superiority of the primary endpoint in clinical trials by the appraised technology; (ii) the incremental cost-effectiveness ratio (ICER); (iii) the number of pharmaceuticals appraised within the same appraisal; and (iv) the appraisal year. Results confirm the value of a comprehensive and multivariate approach to understanding NICE decision making. New factors affecting NICE decision making were identified, including the effect of clinical superiority, and the effect of process and socio-economic factors.

Contingent valuation: what needs to be done?

Contingent valuation (CV) has been argued to have theoretical advantages over other approaches for benefit valuation used by health economists. Yet, in reality, the technique appears not to have realised these advantages when applied to health-care issues, such that its influence in decision-making at national levels has been non-existent within the health sector. This is not a result of a lack of methodological work in the area, which has continued to flourish. Rather, it is a result of such activities being undertaken in a rather uncoordinated and unsystematic fashion, leading CV to be akin to a 'ship without a sail'. This paper utilises a systematic review of the CV literature in health to illustrate some important points concerning the conduct of CV studies, before providing a comment on what the remaining policy and research priorities are for the technique, and proposing a guideline for such studies. It is hoped that this will initiate some wider and rigorous debate on the future of the CV technique in order to make it seaworthy, give it direction and provide the right momentum.

Economic evaluation of the decisions of the Israeli Public Committee for updating the National List of Health Services in 2006/2007

OBJECTIVE

The Public Committee (PC), which decides on the inclusion and ranking of new technologies in the Israeli List of Health Services facing a given budget, does not explicitly consider the results of economic evaluations of the technologies discussed. The present article includes an ex post economic examination of the PC's 2006/2007 decisions.

METHODS

The cost per quality-adjusted life-year (QALY) (CPQ) values of the technologies approved and rejected were retrieved from national health technologies assessments and the professional literature.

RESULTS

CPQ values were found for 40 technologies out of the 52 that were approved by the PC, and for 26 out of 42 randomly sampled among those rejected. The technologies approved for inclusion produce QALYs in a cheaper way, in general, than those rejected. A CPQ of about 50,000 new Israeli shekels (NIS) (15,500 USDPPP [purchasing power parity adjusted U.S. dollars]) is identified as the best discriminating value between approved and rejected technologies. The agreement between the PC's ranking of the approved technologies and the ranking by CPQ is low, and the only significant determinant of the Committee's ranking is the number of patients expected to benefit from the technology.

CONCLUSIONS

Although not considering CPQ data explicitly, the PC tends, in fact, to approve technologies with relatively low CPQ. In ranking the approved technologies, however, the PC tries to maximize the number of persons expected to benefit from the additional budget even at the expense of possibly giving up cheaper QALYs. The size of the budget should be determined in accordance with an Israeli value of QALY and Israeli values of the CPQ of the technologies submitted for inclusion.

Cost-outcome analysis of joint replacement: evidence from a Spanish public hospital

BACKGROUND AND OBJECTIVES

Efficiency-based healthcare decision-making has been widely accepted for some time, with cost per quality-adjusted life year (QALY) as the main outcome measure. Nevertheless, for numerous medical procedures, little data are available on the cost per QALY gained. The aim of the present study was to calculate the cost per QALY gained with primary hip and knee replacement and to compare the result with the cost per QALY for other medical procedures, as well as with the maximum threshold cost considered acceptable in Spain.

METHODS

We performed a prospective cohort pre-test/post-test study of patients undergoing primary hip or knee arthroplasty. Age, sex, and clinical variables were recorded. Functional status and quality of life were measured by means of the WOMAC and EuroQol instruments, respectively, before the intervention and 6 months later. The direct costs of the intervention were calculated, with length of hospital stay and the prosthesis as the main cost drivers.

RESULTS

A total of 80 patients, 40 from each intervention, were included in this study. Both functional and perceived health status improved after the intervention. The number of QALYs gained in the knee cohort was 4.64, while that in the hip cohort was 0.86. The total cost of knee replacement was lower (6,865.52 euro) than that of hip replacement (7,891.21 euro). The cost per QALY gained was 1,275.84 euro and 7,936.12 euro for knee and hip interventions, respectively. The calculations performed included a 6% discount rate for health outcomes, a 3% inflation rate for costs, and a success rate of 95% at 15 years.

CONCLUSIONS

The costs of both knee and hip replacement were lower than the threshold of 30,000 euro per QALY considered acceptable in Spain, and compared favorably with other medical and surgical procedures.

Modeling the impact of genetic screening technologies on healthcare: theoretical model for asthma in children

BACKGROUND AND OBJECTIVE

This study focuses on the potential impact of genetic screening technologies on healthcare. Genetic screening for asthma in children was chosen as a case study to explore the cost effectiveness of applying early genetic screening to infants, and preventive treatment to the population at risk. Early intervention could prevent progression and facilitate clinical management of the disease. From the elite group of genetic markers that have been associated with asthma-related phenotypes, ADAM33 was the first published candidate gene detected by a positional cloning approach, marking the entry of asthma research into the genomic era. The model was, therefore, initially set for an ex ante analysis of the cost effectiveness of applying the preventive program to an infant population at risk, i.e. infants presenting wheezing episodes during the first year of life, and the ADAM33 ST+7 genetic marker, with the idea of expanding to further markers and their combinations lat a later date.

METHODS

In accordance with the US National Heart, Lung, and Blood Institute, four categories of asthma were considered. A Markov model was constructed, consisting of six mutually exclusive disease states (including healthy and dead states) with a simulation horizon of 100 years and a cycle length of 1 year. We define a scenario where early genetic screening was applied to infants presenting wheezing episodes during the first year of life and a preventive treatment to those children within this group who tested positive for selected ADAM33 polymorphism (ST+7). The cost-effectiveness analysis was performed from the third-party payer and patient perspective after year 6. We applied our model to a hypothetical cohort of 100 European infants.

RESULTS

The number of quality-adjusted life-years (QALYs) gained during the 6 years was 1.483, and the incremental cost-effectiveness ratio per QALY gained was euro 10,100/QALY. A sensitivity analysis was carried out that varied the discount rate and cost of genetic testing, and considered two different transition matrices for the preventive program. Three main conclusions were drawn from the sensitivity analysis. Firstly, if the discount rate for both cost and health outcomes is increased by 2%, the cost effectiveness of the preventive program does not vary significantly. Discounting costs and benefits at 5%, the preventive program appears cost effective (euro 11,100/QALY). Secondly, if the cost of genetic testing is increased to euro 100, the cost effectiveness of the preventive program remains within the limits of cost effectiveness. Thirdly, the cost of genetic screening, together with transition probabilities between health states, will determine the cost effectiveness of applying a preventive program based on genetic information.

CONCLUSIONS

Preventive treatment based on an early genetic screening of those children who present wheezing episodes during the first year of life, with treatment applied to those who test positive for the asthma-associated genetic marker ADAM33 ST+7, is theoretically cost effective. The model is a valuable tool for the ex ante assessment of the cost effectiveness of preventive schemes based on genetic screening. The value of modeling prior to clinical trials lies in informing study design and setting priorities for future research.

Cost-effectiveness of neonatal screening for medium chain acyl-CoA dehydrogenase deficiency: the homogeneous population of The Netherlands

OBJECTIVE

To assess the cost-effectiveness of neonatal screening on medium chain acyl-CoA dehydrogenase (MCAD) deficiency in a homogeneous population.

STUDY DESIGN

For the scenario without neonatal screening, medical chart review and interviews were performed with physicians and families of 116 Dutch patients born between 1985 and July 2003 with clinically ascertained MCAD deficiency. For the scenario with neonatal screening, 66,205 unaffected and 11 affected newborns identified by prospective neonatal screening for MCAD deficiency in the northern part of the Netherlands were evaluated. The incremental cost-effectiveness ratio (ICER) used life years (LYs) as the outcome measure by combining both scenarios in a decision model with second-order Monte Carlo simulation.

RESULTS

For the scenarios with and without neonatal screening for MCAD deficiency, costs were $6.10 and $4.22 per newborn, respectively. The main cost categories were institutionalization (64%), admissions (17%), special education (8%), laboratory testing (4%), and (para)medical contact (4%). The resulting ICER was $1653 per LY gained. Sensitivity analysis generated an ICER between $14,839 and $4345 per LY gained.

CONCLUSIONS

Screening for MCAD deficiency in a well-defined population generates an ICER well within accepted boundaries for cost-effective interventions, even after sensitivity analysis.

The time for cost-effectiveness in the new European Union member states: the development and role of health economics and technology assessment in the mirror of the Hungarian experience

Sophisticated methodology and research centres of health economics and health technology assessment were established in the developed countries over the past 30 years, releasing more and more studies of better and better quality every year. A crucial factor in health policy and reimbursement decisions in these countries is cost-effectiveness results. Due to methodological diversification, results of locally performed health economics studies are constrained in international utility. This fact encourages us to set the current goal of greatest importance, i.e. to standardise country-specific methods, thereby promoting transferability and adaptability of results, being backed by each important health care organisation all over Europe. The situation in the new member states [European Union (EU)12] is profoundly different compared with EU15. In these countries, neither the necessary research institutions nor professionals are in place in sufficient numbers; even in most EU12 countries, the importance of cost-effectiveness has not yet been realised. The present study focuses mainly on the EU12. These countries are absolutely dependent on cost-effectiveness results from abroad, and this seems to persist in the long-term. Transferability and adaptability of the results of health economics studies carried out elsewhere through European collaboration is vital for these countries.

Handling value added tax (VAT) in economic evaluations: should prices include VAT?

In health economic evaluations, value added tax is commonly treated as a transfer payment. Following this argument, resources are valued equal to their net-of-tax prices in economic evaluations applying a societal perspective. In this article we argue that if there is the possibility that a new healthcare intervention may expand the healthcare budget, the social cost of input factors should be the gross-of-tax prices and not the net-of-tax prices. The rising interest in cost-benefit analysis and the use of absolute thresholds, net benefit estimates and acceptability curves in cost-effectiveness analysis makes this argument highly relevant for an appropriate use of these tools in prioritisation.

Economic evaluation and decision making in the UK

This article reviews the development of economic evaluation of health technologies in the UK and its impact on decision making. After a long period of limited impact from studies mainly carried out as academic exercises, the advent of the National Institute for Health and Clinical Excellence (NICE) in 1999 provided a transparent decision-making context where economic evaluation plays a central role. This article reviews some of the key characteristics about the way NICE works, for example, the way NICE has defined the form of analysis that it requires, reflecting its objective of maximising health gain (QALYs) from the predetermined and limited UK NHS budget. Two broad areas of widespread concern are noted. The first relates to the cost-effectiveness thresholds that NICE uses and the basis for them. The second is the patchy implementation of NICE guidance and the possible reasons for this. But even within the UK, NICE is the exception in making extensive and explicit use of economic evaluation and this article goes on to suggest that if there is to be a more widespread and consistent use of economic evaluation at both central and local levels, then health economists and others need to address three issues. The first is to be clear about what is the correct conceptual basis for determining the cost-effectiveness threshold and then to ensure that NICE has the empirical evidence to set it appropriately. The second is to recognise that even using the limited view of costs adopted by NICE, economic evaluations imply temporal and cross-service budgetary flexibility that the NHS locally does not in practice enjoy. The third issue is that with academic pressures for ever-increasing sophistication of 'state of the art' economic evaluation analysis, the NHS has more and more precise understanding of the cost effectiveness of just a few new technologies and little or no analysis of most. This limits the value of the former by reducing further the scope for appropriately disinvesting from cost-ineffective technologies to meet the additional costs of investing in cost-effective new ones. Whilst NICE stands out as an example of a context where high-quality economic evaluation plays a major role in decision making, the process is far from perfect and certainly is not representative of the use made of economic evaluation by the NHS as a whole. Health economists need to engage with the public and the health service to better understand their perspectives, rather than focusing on academic concerns relating to details of theory and analytical method.