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Qiu T, Aballéa S, Pochopień M, Toumi M, Dussart C, Yan D. A systematic review on the appropriate discounting rates for the economic evaluation of gene therapies: whether a specific approach is justified to tackle the challenges? Int J Technol Assess Health Care 2024; 40:e23. [PMID: 38725378 DOI: 10.1017/s0266462324000096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Abstract
OBJECTIVES Discounting the cost and effect for health intervention is a controversial topic over the last two decades. In particular, the cost-effectiveness of gene therapies is especially sensitive to the discount rate because of the substantial delay between the upfront cost incurred and long-lasing clinical benefits received. This study aims to investigate the influence of employing alternative discount rates on the incremental cost-effectiveness ratio (ICER) of gene therapies. METHODS A systematic review was conducted to include health economic evaluations of gene therapies that were published until April 2023. RESULTS Sensitivity or scenario analysis indicated that discount rate represented one of the most influential factors for the ICERs of gene therapies. Discount rate for cost and benefit was positively correlated with the cost-effectiveness of gene therapies, that is, a lower discount rate significantly improves the ICERs. The alternative discount rate employed in some cases could be powerful to alter the conclusion on whether gene therapies are cost-effective and acceptable for reimbursement. CONCLUSIONS Although discount rate will have substantial influence on the ICERs of gene therapies, there lacks solid evidence to justify a different discounting rule for gene therapies. However, it is proposed that the discount rate in the reference case should be updated to reflect the real-time preference, which in turn will affect the ICERs and reimbursement of gene therapies more profoundly than conventional therapies.
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Affiliation(s)
- Tingting Qiu
- Beijing Institute of Clinical Pharmacy, Beijing Friendship Hospital of Capital Medical University, Beijing, China
- Public Health Department, Aix-Marseille University, Marseille, France
| | - Samuel Aballéa
- Public Health Department, Aix-Marseille University, Marseille, France
| | - Michal Pochopień
- Public Health Department, Aix-Marseille University, Marseille, France
| | - Mondher Toumi
- Public Health Department, Aix-Marseille University, Marseille, France
| | - Claude Dussart
- Faculté de Pharmacie, Université Claude Bernard Lyon 1, Lyon, France
| | - Dan Yan
- Beijing Institute of Clinical Pharmacy, Beijing Friendship Hospital of Capital Medical University, Beijing, China
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Li F, Chen Y, Xiao D, Jiang S, Yang Y. Cost-Effectiveness Analysis of Sintilimab Plus Chemotherapy in Advanced Non-Squamous Non-Small Cell Lung Cancer: A Societal Perspective. Adv Ther 2024; 41:1436-1449. [PMID: 38356107 DOI: 10.1007/s12325-024-02808-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 01/30/2024] [Indexed: 02/16/2024]
Abstract
INTRODUCTION The updated ORIENT-11 study demonstrated that sintilimab, when combined with chemotherapy, had promising survival advantage compared to standard chemotherapy alone in the first-line treatment for previously untreated, locally advanced or metastatic non-squamous non-small cell lung cancer (nsNSCLC). This study aims to evaluate the cost-effectiveness of sintilimab plus chemotherapy for advanced nsNSCLC from a Chinese societal perspective. METHODS A partitioned survival model with a embedded decision tree was developed to assess the economic value of sintilimab plus chemotherapy over a lifetime horizon. Clinical data was captured from the updated ORIENT-11 study, while costs, health productivity losses, and utility values were collected from a nationwide cross-sectional survey in tertiary hospitals across multiple provinces in China. The primary outcomes were measured using the metrics of quality-adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICER). Costs and health outcomes were discounted at an annual rate of 5% per annum. Sensitivity analyses, including one-way and probabilistic sensitivity analyses, subgroup analyses, and scenario analyses, were performed. RESULTS Compared to standard chemotherapy, treatment with sintilimab plus chemotherapy incurred a mean total cost of $23,979 and gained 0.98 QALYs over the lifetime horizon, resulting in an ICER of $24,568 per QALY gained. The use of sintilimab accumulated direct non-medical costs of $9262 and indirect costs of $6780 over 16 years. Probabilistic sensitivity analyses showed an 84.2% probability of sintilimab plus chemotherapy being cost-effective at a threshold of three times China's per capita gross domestic product in 2022 ($38,201). The model was most sensitive to the discount rate of QALYs and costs, as well as the costs of pemetrexed, sintilimab, and subsequent therapy in progressive disease state. Subgroup analyses indicated favorable incremental net monetary benefits in all subgroups. CONCLUSION Sintilimab plus chemotherapy is a cost-effective first-line treatment therapy for advanced nsNSCLC in China when compared to standard chemotherapy. These findings, along with the improved progression-free survival and overall survival (OS) observed in ORIENT-11, support the use of this regimen in eligible candidates for advanced nsNSCLC.
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Affiliation(s)
- Fuming Li
- School of Public Health, Fudan University, Shanghai, People's Republic of China
- National Health Commission Key Laboratory of Health Technology Assessment (Fudan University), Shanghai, People's Republic of China
| | - Yingyao Chen
- School of Public Health, Fudan University, Shanghai, People's Republic of China
- National Health Commission Key Laboratory of Health Technology Assessment (Fudan University), Shanghai, People's Republic of China
| | - Dunming Xiao
- School of Public Health, Fudan University, Shanghai, People's Republic of China
- National Health Commission Key Laboratory of Health Technology Assessment (Fudan University), Shanghai, People's Republic of China
| | - Shan Jiang
- Macquarie University Centre for the Health Economy, Macquarie Business School and Australian Institute of Health Innovation, Macquarie University, Sydney, NSW, Australia
| | - Yi Yang
- School of Public Health, Fudan University, Shanghai, People's Republic of China.
- National Health Commission Key Laboratory of Health Technology Assessment (Fudan University), Shanghai, People's Republic of China.
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Charlton V. The normative grounds for NICE decision-making: a narrative cross-disciplinary review of empirical studies. HEALTH ECONOMICS, POLICY, AND LAW 2022; 17:444-470. [PMID: 35293306 DOI: 10.1017/s1744133122000032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
The National Institute for Health and Care Excellence (NICE) is the UK's primary health care priority-setter, responsible for advising the National Health Service on its adoption of health technologies. The normative basis for NICE's advice has long been the subject of public and academic interest, but the existing literature does not include any comprehensive summary of the factors observed to have substantively shaped NICE's recommendations. The current review addresses this gap by bringing together 29 studies that have explored NICE decision-making from different disciplinary perspectives, using a range of quantitative and qualitative methods. It finds that although cost-effectiveness has historically played a central role in NICE decision-making, 10 other factors (uncertainty, budget impact, clinical need, innovation, rarity, age, cause of disease, wider societal impacts, stakeholder influence and process factors) are also demonstrably influential and interact with one another in ways that are not well understood. The review also highlights an over-representation in the literature of appraisals conducted prior to 2009, according to methods that have since been superseded. It suggests that this may present a misleading view of the importance of allocative efficiency to NICE's current approach and illustrates the need for further up-to-date research into the normative grounds for NICE's decisions.
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Affiliation(s)
- Victoria Charlton
- Department of Global Health & Social Medicine, King's College London, London, UK
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Michaels JA. Value assessment frameworks: who is valuing the care in healthcare? JOURNAL OF MEDICAL ETHICS 2022; 48:419-426. [PMID: 33687915 DOI: 10.1136/medethics-2020-106503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 10/27/2020] [Accepted: 02/08/2021] [Indexed: 06/12/2023]
Abstract
Many healthcare agencies are producing evidence-based guidance and policy that may determine the availability of particular healthcare products and procedures, effectively rationing aspects of healthcare. They claim legitimacy for their decisions through reference to evidence-based scientific method and the implementation of just decision-making procedures, often citing the criteria of 'accountability for reasonableness'; publicity, relevance, challenge and revision, and regulation. Central to most decision methods are estimates of gains in quality-adjusted life-years (QALY), a measure that combines the length and quality of survival. However, all agree that the QALY alone is not a sufficient measure of all relevant aspects of potential healthcare benefits, and a number of value assessment frameworks have been suggested. I argue that the practical implementation of these procedures has the potential to lead to a distorted assessment of value. Undue weight may be ascribed to certain attributes, particularly those that favour commercial or political interests, while other attributes that are highly valued by society, particularly those related to care processes, may be omitted or undervalued. This may be compounded by a lack of transparency to relevant stakeholders, resulting in an inability for them to participate in, or challenge, the decisions. The makes it likely that costly new technologies, for which inflated prices can be justified by the current value frameworks, are displacing aspects of healthcare that are highly valued by society.
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Affiliation(s)
- Jonathan Anthony Michaels
- Health Economics and Decision Science, University of Sheffield School of Health and Related Research, Sheffield, UK
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Charlton V. Justice, Transparency and the Guiding Principles of the UK's National Institute for Health and Care Excellence. HEALTH CARE ANALYSIS 2022; 30:115-145. [PMID: 34750743 PMCID: PMC8575159 DOI: 10.1007/s10728-021-00444-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 11/29/2022]
Abstract
The National Institute for Health and Care Excellence (NICE) is the UK's primary healthcare priority-setting body, responsible for advising the National Health Service in England on which technologies to fund and which to reject. Until recently, the normative approach underlying this advice was described in a 2008 document entitled 'Social value judgements: Principles for the development of NICE guidance' (SVJ). In January 2020, however, NICE replaced SVJ with a new articulation of its guiding principles. Given the significant evolution of NICE's methods between 2008 and 2020, this study examines whether this new document ('Principles') offers a transparent account of NICE's current normative approach. It finds that it does not, deriving much of its content directly from SVJ and failing to fully acknowledge or explain how and why NICE's approach has since changed. In particular, Principles is found to offer a largely procedural account of NICE decision-making, despite evidence of the increasing reliance of NICE's methods on substantive decision-rules and 'modifiers' that cannot be justified in purely procedural terms. Thus, while Principles tells NICE's stakeholders much about how the organisation goes about the process of decision-making, it tells them little about the substantive grounds on which its decisions are now based. It is therefore argued that Principles does not offer a transparent account of NICE's normative approach (either alone, or alongside other documents) and that, given NICE's reliance on transparency as a requirement of procedural justice, NICE does not in this respect satisfy its own specification of a just decision-maker.
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Affiliation(s)
- Victoria Charlton
- Department of Global Health and Social Medicine, King's College London, 40 Aldwych, London, WC2B 4BG, United Kingdom.
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Pinho-Gomes AC, Cairns J. Evaluation of Advanced Therapy Medicinal Products by the National Institute for Health and Care Excellence (NICE): An Updated Review. PHARMACOECONOMICS - OPEN 2022; 6:147-167. [PMID: 34415514 PMCID: PMC8864053 DOI: 10.1007/s41669-021-00295-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/02/2021] [Indexed: 06/04/2023]
Abstract
This review discusses the methodological challenges to the evaluation of advanced therapy medicinal products (ATMPs) by the UK National Institute for Health and Care Excellence (NICE). We analysed the health technology appraisals (both published and in development) of ATMPs conducted by NICE in England until July 2021. A total of 14 health technology appraisals of ATMPs were included, of which two were in development and 12 had been published. There were ten gene therapy products (talimogene laherparepvec [TA410], strimvelis [HST7], tisagenlecleucel [TA554 and TA567], axicabtagene ciloleucel [TA559], voretigene neparvovec [HST11], autologous anti-CD19-transduced CD3+ cells [TA677], betibeglogene autotemcel [ID968], onasemnogene abeparvovec [HST15] and OTL-200 [ID1666]), one tissue engineered product (holoclar [TA467]) and three somatic cell therapy products (darvadstrocel [TA556] and autologous chondrocyte implantation [ACI] [TA477 and TA508]). Only three of these technologies were not recommended by NICE, although four were only recommended within the Cancer Drugs Fund. There was large uncertainty in the assessment of clinical effectiveness, as evidence relied mostly on small, single-arm, open-label studies. There were also several concerns in the cost-effectiveness evaluations, such as limited information on health-related quality of life, immature survival data due to short follow-up, and unclear curative potential. Substantial risk may be incurred with ATMPs, which have high upfront and possibly irrecoverable costs but uncertain long-term benefits. In conclusion, the challenges raised by the economic appraisal of ATMPs, albeit not unique, may be exacerbated by the uncertainty related to the often scant evidence base. Adaptations of the conventional decision-making process rather than completely new methods may improve appraisals of ATMPs.
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Affiliation(s)
- Ana-Catarina Pinho-Gomes
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, SE1 1UL, UK.
- The George Institute for Global Health, London, UK.
| | - John Cairns
- London School of Hygiene and Tropical Medicine, London, UK
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On the timing and probability of Presurgical Teledermatology: how it becomes the dominant strategy. Health Care Manag Sci 2022; 25:389-405. [PMID: 35040019 DOI: 10.1007/s10729-021-09574-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 07/14/2021] [Indexed: 11/04/2022]
Abstract
Health level fluctuations make the outcome of any treatment option uncertain, so that decision-makers might have to wait for more information before optimally choosing treatments, especially when time spent in treatment cannot be fully recovered later in terms of health outcome. To examine whether or not, and when decision-makers should use presurgical teledermatology, a dynamic stochastic model is applied to patients waiting for dermatology surgical intervention. The theoretical model suggests that health uncertainty discourages using teledermatology. As teledermatology becomes less cost competitive, the uncertainty becomes more dominant. The results of the model were then tested empirically with the teledermatology network covering the area served by one Portuguese regional hospital, which links the primary care centers of 24 health districts with the hospital's dermatology department via the corporate intranet of the Portuguese healthcare system. Under uncertainty and irreversibility, presurgical teledermatology becomes the dominant strategy for younger patients and with lower probability of developing skin cancer.
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O'Mahony JF. Revision of Ireland's Cost-Effectiveness Threshold: New State-Industry Drug Pricing Deal Should Adequately Reflect Opportunity Costs. PHARMACOECONOMICS - OPEN 2021; 5:339-348. [PMID: 34318440 PMCID: PMC8315504 DOI: 10.1007/s41669-021-00289-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/11/2021] [Indexed: 05/25/2023]
Abstract
Ireland's cost-effectiveness threshold is currently €45,000 per quality-adjusted life-year (QALY). It has previously been determined by periodic agreements between the State and a pharma industry lobby body. A new deal is due in July 2021 and it is therefore timely to re-examine Ireland's threshold, how it is set and transparency around adherence to it. Previous research has noted a series of problems with the threshold, including that it is likely too high relative to the opportunity cost of unmet need within Ireland's health system. This means reimbursement at the threshold may do net harm to population health. The high threshold may also mean the Irish health system is failing to satisfy existing legislation on healthcare resource allocation. Recent COVID-19-related pressures on healthcare capacity and public spending appear to increase the urgency for an evidence-based revision of threshold to better reflect opportunity costs within the Irish healthcare system. Despite these problems, the prospects for reform of the threshold do not appear strong as the political and institutional incentives may favour the status quo. At the very least, the State should provide greater transparency regarding how the threshold is set and adhered to. A potential reform for consideration in the longer run could include a partial abandonment of thresholds in favour of an auction process to achieve the lowest cost per QALY from new drug interventions.
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Affiliation(s)
- James F O'Mahony
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland.
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O'Mahony JF, Paulden M, McCabe C. NICE's Discounting Review: Clear Thinking on Rational Revision Meets Obstacle of Industrial Interests. PHARMACOECONOMICS 2021; 39:139-146. [PMID: 33462758 DOI: 10.1007/s40273-020-00990-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/18/2020] [Indexed: 06/12/2023]
Abstract
The National Institute of Health and Care Excellence (NICE) recently published a review of discounting practice and theory as part of a consultation on its current methods guidelines. The review examines the case for revision or retention of current methods. The changes considered include eliminating favourable rates in certain special cases and the reduction of the base-case rate for costs and health effects from 3.5 to 1.5%. The review also notes the potential need to reduce the cost-effectiveness threshold to accommodate a discount rate reduction, explaining that an agreement between the UK government and the pharmaceutical industry proscribes changing NICE's threshold range until the end of 2023. We believe NICE should be commended for a useful overview of the existing literature and relevant issues. We firmly endorse NICE's view that favourable discount rates are not a good way to apply a preference for certain interventions. Similarly, we support the option of reducing the discount rate to 1.5%, which better accords with real government borrowing costs. We suggest further work to clarify the appropriate theoretical basis for the NICE's social discount rate and the sensitivity of the threshold to changes in discounting. The prospects of a necessary discount rate reduction appear to depend on whether a threshold reduction can be achieved within NICE's current range or if the range itself must be revised downwards. NICE has usefully informed the debate around discount rates. Ultimately, the path to a methodologically consistent and evidence-based revision of discounting depends on whether NICE needs to adjust the threshold too and if it is free to do so.
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Affiliation(s)
- James F O'Mahony
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland.
| | - Mike Paulden
- School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Chris McCabe
- Institute of Health Economics, Edmonton, AB, Canada
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
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10
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AlMukdad S, Elewa H, Arafa S, Al-Badriyeh D. Short- and long-term cost-effectiveness analysis of CYP2C19 genotype-guided therapy, universal clopidogrel, versus universal ticagrelor in post-percutaneous coronary intervention patients in Qatar. Int J Cardiol 2021; 331:27-34. [PMID: 33535078 DOI: 10.1016/j.ijcard.2021.01.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/16/2020] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Patients having CYP2C19 loss-of-function alleles and receiving clopidogrel are at higher risk of adverse cardiovascular outcomes. Ticagrelor is an effective antiplatelet that is unaffected by the CYP2C19 polymorphism. The main aim of the current research is to evaluate the cost-effectiveness among CYP2C19 genotype-guided therapy, universal ticagrelor, and universal clopidogrel after a percutaneous coronary intervention (PCI). METHODS A two-part decision-analytic model, including a one-year model and a 20-year follow-up Markov model, was created to follow the use of (i) universal clopidogrel, (ii) universal ticagrelor, and (iii) genotype-guided antiplatelet therapy. Outcome measures were the incremental cost-effectiveness ratio (ICER, cost/success) and incremental cost-utility ratio (ICUR, cost/quality-adjusted life years [QALY]). Therapy success was defined as survival without myocardial infarction, stroke, cardiovascular death, stent thrombosis, and no therapy discontinuation because of adverse events, i.e. major bleeding and dyspnea. The model was based on a multivariate analysis, and a sensitivity analysis confirmed the robustness of the model outcomes, including against variations in drug acquisition costs. RESULTS Against universal clopidogrel, genotype-guided therapy was cost-effective over the one-year duration (ICER, USD 6102 /success), and dominant over the long-term. Genotype-guided therapy was dominant against universal ticagrelor over the one-year duration, and cost-effective over the long term (ICUR, USD 1383 /QALY). Universal clopidogrel was dominant over ticagrelor for the short term, and cost-effective over the long-term (ICUR, USD 10,616 /QALY). CONCLUSION CYP2C19 genotype-guided therapy appears to be the preferred antiplatelet strategy, followed by universal clopidogrel, and then universal ticagrelor for post-PCI patients in Qatar.
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Affiliation(s)
- Sawsan AlMukdad
- Weill Cornell Medicine-Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar; College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Hazem Elewa
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | - Salaheddin Arafa
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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Charlton V. NICE and Fair? Health Technology Assessment Policy Under the UK's National Institute for Health and Care Excellence, 1999-2018. HEALTH CARE ANALYSIS 2020; 28:193-227. [PMID: 31325000 PMCID: PMC7387327 DOI: 10.1007/s10728-019-00381-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The UK's National Institute for Health and Care Excellence (NICE) is responsible for conducting health technology assessment (HTA) on behalf of the National Health Service (NHS). In seeking to justify its recommendations to the NHS about which technologies to fund, NICE claims to adopt two complementary ethical frameworks, one procedural-accountability for reasonableness (AfR)-and one substantive-an 'ethics of opportunity costs' (EOC) that rests primarily on the notion of allocative efficiency. This study is the first to empirically examine normative changes to NICE's approach and to analyse whether these enhance or diminish the fairness of its decision-making, as judged against these frameworks. It finds that increasing formalisation of NICE's approach and a weakening of the burden of proof laid on technologies undergoing HTA have together undermined its commitment to EOC. This implies a loss of allocative efficiency and a shift in the balance of how the interests of different NHS users are served, in favour of those who benefit directly from NICE's recommendations. These changes also weaken NICE's commitment to AfR by diminishing the publicity of its decision-making and by encouraging the adoption of rationales that cannot easily be shown to meet the relevance condition. This signals a need for either substantial reform of NICE's approach, or more accurate communication of the ethical reasoning on which it is based. The study also highlights the need for further empirical work to explore the impact of these policy changes on NICE's practice of HTA and to better understand how and why they have come about.
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Affiliation(s)
- Victoria Charlton
- Department of Global Health and Social Medicine, King's College London, 40 Aldwych, London, WC2B 4BG, UK.
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Devlin N, Scuffham P. Health today versus health tomorrow: does Australia really care less about its future health than other countries do? AUST HEALTH REV 2020; 44:337-339. [PMID: 32475385 DOI: 10.1071/ah20057] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/19/2020] [Indexed: 11/23/2022]
Abstract
Economic evaluation provides important evidence on value for money in health care and is routinely used in health technology assessment processes. The relevant costs and benefits of health care that are considered may arise now and/or in the future, and the relative importance placed on costs and benefits in the future is reflected in the discount rate applied to them. In this paper we note that Australia appears to apply one of the highest discount rates in the world to the assessment of future healthcare benefits. At a time when healthcare systems worldwide are calling for a rebalance of effort towards prevention, Australia's discount rate risks pulling resource allocation in precisely the opposite direction, locking in institutional short-sightedness to funding decisions.
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Affiliation(s)
- Nancy Devlin
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, 207 Bouverie Street, Melbourne, Vic. 3010, Australia; and Corresponding author.
| | - Paul Scuffham
- Centre for Applied Health Economics, Menzies Health Institute Queensland, Griffith University, G40_8.83, Gold Coast Campus, Southport, Qld 4222, Australia.
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13
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O'Mahony JF, Paulden M. The Joint Committee on Vaccination and Immunisation's Advice on Extending Human Papillomavirus Vaccination to Boys: Were Cost-Effectiveness Analysis Guidelines Bent to Achieve a Politically Acceptable Decision? VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2019; 22:1227-1230. [PMID: 31708058 DOI: 10.1016/j.jval.2019.07.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 07/17/2019] [Accepted: 07/19/2019] [Indexed: 06/10/2023]
Abstract
In July 2018, the UK Minister of Public Health announced that human papillomavirus vaccination would be extended to 12-year-old boys. This decision was informed by updated evidence from the Joint Committee on Vaccination and Immunisation (JCVI) published earlier that month. Vaccination of boys had been found not to be cost-effective in a series of analyses conducted for the JCVI, including the most recent assessment prior to the minister's announcement. These analyses were conducted under the standard methods for cost-effectiveness analysis recommended by the JCVI, which are primarily based on guidelines from the National Institute of Health and Care Excellence. Although the JCVI concluded they were unable to advise extending vaccination on the basis of standard appraisal methods, their most recent round of assessment also considered analyses using nonstandard appraisal methods. In particular, the JCVI noted that vaccination of boys was likely to be cost-effective when a lower discount rate of 1.5% is applied to costs and health effects, as opposed to the 3.5% rate usually employed. The JCVI stated that they were supportive of applying such alternative methods, and on this basis, they would advise extending vaccination to boys. This commentary explains the JCVI's application of nonstandard appraisal methods and considers whether it was justified. We conclude that the JCVI was not justified in applying the lower discount rate. We voice concerns that a willingness to endorse a politically popular intervention may have driven the JCVI to depart from a fair and consistent application of healthcare rationing.
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Affiliation(s)
- James F O'Mahony
- Centre for Health Policy & Management, School of Medicine, Trinity College, Dublin, Ireland.
| | - Mike Paulden
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
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Wisløff T, Mundal LJ, Retterstøl K, Igland J, Kristiansen IS. Economic evaluation of lipid lowering with PCSK9 inhibitors in patients with familial hypercholesterolemia: Methodological aspects. Atherosclerosis 2019; 287:140-146. [PMID: 31280039 DOI: 10.1016/j.atherosclerosis.2019.06.900] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 06/10/2019] [Accepted: 06/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors have proved to reduce low density lipoprotein cholesterol levels in numerous clinical trials. In two large clinical trials, PCSK9 inhibitor treatment reduced the risk of cardiovascular disease. Our aim was to explore the impact of varying assumptions about clinical effectiveness on health and economic outcomes for patients with familial hypercholesterolemia. METHODS We used a previously published and validated Norwegian model for cardiovascular disease. The model was updated with recent data from the world's second largest registry of patients with genetically confirmed familial hypercholesterolemia. We performed analyses for 24 different subgroups of patients based on age, gender, statin tolerance and previous history of cardiovascular disease. RESULTS In 1 out of 24 subgroups, PCSK9 inhibitors were cost-effective when effectiveness was modelled using direct relative efficacy as reported in the FOURIER trial. When using assumptions, as suggested in a recent consensus statement from the European Atherosclerosis Society, 14 subgroups were cost-effective. CONCLUSIONS Cost-effectiveness of PCSK9 inhibitors depends highly on assumptions regarding effectiveness. Basing assumptions only on randomised controlled trials, and not taking into account varying effects based on baseline cholesterol level, results in much fewer groups being cost-effective.
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Affiliation(s)
- Torbjørn Wisløff
- Department of Health Management and Health Economics, University of Oslo, Oslo, Norway; Department of Infectious Disease Epidemiology and Modelling, Norwegian Institute of Public Health, Oslo, Norway.
| | - Liv J Mundal
- The Lipid Clinic, Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Oslo, Norway; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Kjetil Retterstøl
- The Lipid Clinic, Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Oslo, Norway; Department of Nutrition, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Jannicke Igland
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
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15
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O'Mahony JF, Paulden M. Appraising the cost-effectiveness of vaccines in the UK: Insights from the Department of Health Consultation on the revision of methods guidelines. Vaccine 2019; 37:2831-2837. [DOI: 10.1016/j.vaccine.2019.03.072] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/19/2019] [Accepted: 03/28/2019] [Indexed: 11/16/2022]
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16
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Whittington MD, McQueen RB, Ollendorf DA, Kumar VM, Chapman RH, Tice JA, Pearson SD, Campbell JD. Long-term Survival and Value of Chimeric Antigen Receptor T-Cell Therapy for Pediatric Patients With Relapsed or Refractory Leukemia. JAMA Pediatr 2018; 172:1161-1168. [PMID: 30304407 PMCID: PMC6583018 DOI: 10.1001/jamapediatrics.2018.2530] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Among children and young adults with relapsed or refractory B-cell acute lymphoblastic leukemia, the rate of 5-year disease-free survival is 10% to 20%. Approval of tisagenlecleucel, a chimeric antigen receptor T-cell therapy, represents a new and potentially curative treatment option. However, tisagenlecleucel is expensive, with a current list price of $475 000 per one-time administration. OBJECTIVE To estimate the long-term survival and value of tisagenlecleucel for children and young adults with B-cell acute lymphoblastic leukemia. DESIGN, SETTING, AND PARTICIPANTS In this cost-effectiveness analysis, a decision analytic model was designed to extrapolate trial evidence to a patient lifetime horizon. The survival evidence for the model was extracted from 3 studies: B2202 (enrolled patients from April 8, 2015, to November 23, 2016), B2205J (enrolled patients from August 14, 2014, to February 1, 2016), and B2101J (enrolled patients from March 15, 2012, to November 30, 2015). Long-term survival and outcomes of patients younger than 25 years with B-cell acute lymphoblastic leukemia that is refractory or in second or later relapse were derived using flexible parametric modeling from the direct extrapolation of event-free survival and overall survival curves. The published Kaplan-Meier curves were digitized from November 1, 2017, to November 30, 2017, using an algorithm to impute patient-level time-to-event data. Sensitivity and scenario analyses assessed uncertainty in the evidence and model assumptions to further bound the range of cost-effectiveness. Data were analyzed from December 1, 2017, to March 31, 2018. INTERVENTIONS The primary intervention of interest was tisagenlecleucel. The comparator of interest was the chemoimmunotherapeutic agent clofarabine. MAIN OUTCOMES AND MEASURES Model outcomes included life-years gained, quality-adjusted life-years (QALYs) gained, and incremental costs per life-year and QALY gained. RESULTS Forty percent of patients initiating treatment with tisagenlecleucel are expected to be long-term survivors, or alive and responding to treatment after 5 years. Tisagenlecleucel had a total discounted cost of $667 000, with discounted life-years gained of 10.34 years and 9.28 QALYs gained. The clofarabine comparator had a total discounted cost of approximately $337 000, with discounted life-years gained of 2.43 years and 2.10 QALYs gained. This difference resulted in an incremental cost-effectiveness ratio of approximately $42 000 per life-year gained and approximately $46 000 per QALY gained for tisagenlecleucel vs clofarabine. These results were robust to probabilistic sensitivity analyses. Across scenario analyses that included more conservative assumptions regarding long-term relapse and survival, the incremental cost-effectiveness ratio ranged from $37 000 to $78 000 per QALY gained. CONCLUSIONS AND RELEVANCE Tisagenlecleucel likely provides gains in survival and seems to be priced in alignment with these benefits. This study suggests that payers and innovators should develop novel payment models that reduce the risk and uncertainty around long-term value and provide safeguards to ensure high-value care.
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Affiliation(s)
| | - R. Brett McQueen
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
| | | | - Varun M. Kumar
- The Institute for Clinical and Economic Review, Boston, Massachusetts
| | | | - Jeffrey A. Tice
- Department of Medicine, University of California, San Francisco
| | - Steven D. Pearson
- The Institute for Clinical and Economic Review, Boston, Massachusetts
| | - Jonathan D. Campbell
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus, Aurora
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17
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Mauskopf J, Standaert B, Connolly MP, Culyer AJ, Garrison LP, Hutubessy R, Jit M, Pitman R, Revill P, Severens JL. Economic Analysis of Vaccination Programs: An ISPOR Good Practices for Outcomes Research Task Force Report. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:1133-1149. [PMID: 30314613 DOI: 10.1016/j.jval.2018.08.005] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 08/16/2018] [Indexed: 05/21/2023]
Abstract
This report provides recommendations for budget holders and decision makers in high-, middle, and low-income countries requiring economic analyses of new vaccination programs to allocate scarce resources given budget constraints. ISPOR's Economic Evaluation of Vaccines Designed to Prevent Infectious Disease: Good Practices Task Force wrote guidelines for three analytic methods and solicited comments on them from external reviewers. Cost-effectiveness analyses use decision-analytic models to estimate cumulative changes in resource use, costs, and changes in quality- or disability-adjusted life-years attributable to changes in disease outcomes. Constrained optimization modeling uses a mathematical objective function to be optimized (e.g. disease cases avoided) for a target population for a set of interventions including vaccination programs within established constraints. Fiscal health modeling estimates changes in net present value of government revenues and expenditures attributable to changes in disease outcomes. The task force recommends that those designing economic analyses for new vaccination programs take into account the decision maker's policy objectives and country-specific decision context when estimating: uptake rate in the target population; vaccination program's impact on disease cases in the population over time using a dynamic transmission epidemiologic model; vaccination program implementation and operating costs; and the changes in costs and health outcomes of the target disease(s). The three approaches to economic analysis are complementary and can be used alone or together to estimate a vaccination program's economic value for national, regional, or subregional decision makers in high-, middle-, and low-income countries.
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Affiliation(s)
| | | | - Mark P Connolly
- University of Groningen, Groningen, The Netherlands; Global Market Access Solutions LLC, Geneva, Switzerland
| | | | - Louis P Garrison
- Department of Pharmacy, The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle, WA, USA
| | | | - Mark Jit
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine and Public Health, London, UK
| | | | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Johan L Severens
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands; Institute of Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
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18
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Abstract
Appropriate discounting rules in economic evaluations have received considerable attention in the literature and in national guidelines for economic evaluations. Rightfully so, as discounting can be quite influential on the outcomes of economic evaluations. The most prominent controversies regarding discounting involve the basis for and height of the discount rate, whether costs and effects should be discounted at the same rate, and whether discount rates should decline or stay constant over time. Moreover, the choice for discount rules depends on the decision context one adopts as the most relevant. In this article, we review these issues and debates, and describe and discuss the current discounting recommendations of the countries publishing their national guidelines. We finish the article by proposing a research agenda.
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Affiliation(s)
- Arthur E Attema
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands.
| | - Werner B F Brouwer
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, P.O. Box 1738, 3000 DR, Rotterdam, The Netherlands
| | - Karl Claxton
- Centre for Health Economics, University of York, York, UK
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19
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Timmis JK, Black S, Rappuoli R. Improving accountability in vaccine decision-making. Expert Rev Vaccines 2017; 16:1057-1066. [DOI: 10.1080/14760584.2017.1382358] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- James Kenneth Timmis
- Student MSc Health Policy, St Mary’s Campus, Imperial College London, London, UK
| | - Steven Black
- UC Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH, USA
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20
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Irresponsible and responsible resource management in obstetrics. Best Pract Res Clin Obstet Gynaecol 2017; 43:87-106. [PMID: 28268060 DOI: 10.1016/j.bpobgyn.2016.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 12/16/2016] [Accepted: 12/19/2016] [Indexed: 01/02/2023]
Abstract
Low budgets constrain and high budgets stimulate choices. In high-income countries, this economic reality may lead to overuse of healthcare services and pose unnecessary risks for mothers and infants. Options for improvement can be created at different levels of healthcare systems. Pregnancy provides an effective opportunity to profile maternal risks and represents a vulnerable but potentially modifiable period from prenatal life to adulthood. In response to system-inherent false incentives, professional responsibility requires obstetricians to strive to improve the future health of families and their offspring despite disincentives for doing so. This chapter addresses professionally responsible resource management in obstetrics and identifies implications for patients, care givers, communities, policy makers, and academic faculties.
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21
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Posso M, Carles M, Rué M, Puig T, Bonfill X. Cost-Effectiveness of Double Reading versus Single Reading of Mammograms in a Breast Cancer Screening Programme. PLoS One 2016; 11:e0159806. [PMID: 27459663 PMCID: PMC4961365 DOI: 10.1371/journal.pone.0159806] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 07/10/2016] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES The usual practice in breast cancer screening programmes for mammogram interpretation is to perform double reading. However, little is known about its cost-effectiveness in the context of digital mammography. Our purpose was to evaluate the cost-effectiveness of double reading versus single reading of digital mammograms in a population-based breast cancer screening programme. METHODS Data from 28,636 screened women was used to establish a decision-tree model and to compare three strategies: 1) double reading; 2) double reading for women in their first participation and single reading for women in their subsequent participations; and 3) single reading. We calculated the incremental cost-effectiveness ratio (ICER), which was defined as the expected cost per one additionally detected cancer. We performed a deterministic sensitivity analysis to test the robustness of the ICER. RESULTS The detection rate of double reading (5.17‰) was similar to that of single reading (4.78‰; P = .768). The mean cost of each detected cancer was €8,912 for double reading and €8,287 for single reading. The ICER of double reading versus single reading was €16,684. The sensitivity analysis showed variations in the ICER according to the sensitivity of reading strategies. The strategy that combines double reading in first participation with single reading in subsequent participations was ruled out due to extended dominance. CONCLUSIONS From our results, double reading appears not to be a cost-effective strategy in the context of digital mammography. Double reading would eventually be challenged in screening programmes, as single reading might entail important net savings without significantly changing the cancer detection rate. These results are not conclusive and should be confirmed in prospective studies that investigate long-term outcomes like quality adjusted life years (QALYs).
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Affiliation(s)
- Margarita Posso
- Service of Clinical Epidemiology and Public Health, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | | | - Montserrat Rué
- Basic Medical Sciences Department, Biomedical Research Institut of Lleida (IRBLLEIDA), Universitat de Lleida, Lleida, Spain
| | - Teresa Puig
- Service of Clinical Epidemiology and Public Health, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
| | - Xavier Bonfill
- Service of Clinical Epidemiology and Public Health, Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
- Universitat Autònoma de Barcelona (UAB), Barcelona, Spain
- CIBER of Epidemiology and Public Health (CIBERESP), Barcelona, Spain
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22
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Discounting in the evaluation of the cost-effectiveness of a vaccination programme: A critical review. Vaccine 2015; 33:3788-94. [DOI: 10.1016/j.vaccine.2015.06.084] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 06/21/2015] [Accepted: 06/22/2015] [Indexed: 12/24/2022]
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23
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Hill SR, Olson LG. NICE, social values, and balancing objectivity and equity. PHARMACOECONOMICS 2014; 32:1039-1041. [PMID: 25249201 DOI: 10.1007/s40273-014-0220-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Suzanne R Hill
- University of Melbourne Medical School, University of Melbourne, Parkville, VIC, 3010, Australia,
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24
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Raftery J. Health economic evaluation in England. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2014; 108:367-74. [PMID: 25444294 DOI: 10.1016/j.zefq.2014.08.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 08/05/2014] [Accepted: 08/28/2014] [Indexed: 11/16/2022]
Abstract
The 2010 National Health Service Constitution for England specified rights and responsibilities, including health economic evaluation for the National Institute for Health and Care Excellence (NICE) and the Joint Committee on Vaccinations and Immunisations. The National Screening Committee and the Health Protection Agency also provide advice to the Government based on health economic evaluation. Each agency largely follows the methods specified by NICE. To distinguish the methods from neoclassical economics they have been termed "extra-welfarist". Key differences include measurement and valuation of both benefits (QALYs) and costs (healthcare related). Policy on discounting has also changed over time and by agency. The debate over having NICE's methods align more closely with neoclassical economics has been prominent in the ongoing development of "value based pricing". The political unacceptability of some decisions has led to special funding for technologies not recommended by NICE. These include the 2002 Multiple Sclerosis Risk Sharing Scheme and the 2010 Cancer Drugs Fund as well as special arrangements for technologies linked to the end of life and for innovation. Since 2009 Patient Access Schemes have made price reductions possible which sometimes enables drugs to meet NICE's cost-effectiveness thresholds. As a result, the National Health Service in England has denied few technologies on grounds of cost-effectiveness.
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Affiliation(s)
- James Raftery
- University of Southampton, Southampton, United Kingdom.
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25
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Raftery J. How should we value future health? Was NICE right to change? VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2013; 16:699-700. [PMID: 23947961 DOI: 10.1016/j.jval.2013.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 03/02/2013] [Indexed: 06/02/2023]
Affiliation(s)
- James Raftery
- Wessex Institute, University of Southampton Southampton, UK
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