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Ng CA, De Abreu Lourenco R, Viney R, Norman R, King MT, Kim N, Mulhern B. Valuing quality of life for economic evaluations in cancer: navigating multiple methods. Expert Rev Pharmacoecon Outcomes Res 2024:1-14. [PMID: 39158365 DOI: 10.1080/14737167.2024.2393332] [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: 06/19/2024] [Revised: 08/08/2024] [Accepted: 08/13/2024] [Indexed: 08/20/2024]
Abstract
INTRODUCTION Utility values offer a quantitative means to evaluate the impact of novel cancer treatments on patients' quality of life (QoL). However, the multiple methods available for valuing QoL present challenges in selecting the most appropriate method across different contexts. AREAS COVERED This review provides cancer clinicians and researchers with an overview of methods to value QoL for economic evaluations, including standalone and derived preference-based measures (PBMs) and direct preference elicitation methods. Recent developments are described, including the comparative performance of cancer-specific PBMs versus generic PBMs, measurement of outcomes beyond health-related QoL, and increased use of discrete choice experiments to elicit preferences. Recommendations and considerations are provided to guide the choice of method for cancer research. EXPERT OPINION We foresee continued adoption of the QLU-C10D and FACT-8D in cancer clinical trials given the extensive use of the EORTC QLQ-C30 and FACT-G in cancer research. While these cancer-specific PBMs offer the convenience of eliciting utility values without needing a standalone PBM, researchers should consider potential limitations if they intend to substitute them for generic PBMs. As the field advances, there is a greater need for consensus on the approach to selection and integration of various methods in cancer clinical trials.
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Affiliation(s)
- Carrie-Anne Ng
- Centre for Health Economics Research and Evaluation, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Richard De Abreu Lourenco
- Centre for Health Economics Research and Evaluation, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Rosalie Viney
- Centre for Health Economics Research and Evaluation, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Richard Norman
- School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Madeleine T King
- School of Psychology, University of Sydney, Sydney, New South Wales, Australia
| | - Nancy Kim
- Centre for Health Economics Research and Evaluation, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Brendan Mulhern
- Centre for Health Economics Research and Evaluation, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
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Padula WV, Kolchinsky P. Can Generalized Cost-Effectiveness Analysis Leverage Meaningful Use of Novel Value Elements in Pharmacoeconomics to Inform Medicare Drug Price Negotiation? VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:1100-1107. [PMID: 38677362 DOI: 10.1016/j.jval.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 03/08/2024] [Accepted: 04/09/2024] [Indexed: 04/29/2024]
Abstract
OBJECTIVES Decision makers considering using cost-effectiveness analysis (CEA) to inform health-technology assessment must contend with documented and controversial shortfalls of CEA, including its assumption of disease severity independence and static pricing. ISPOR has recently introduced novel value elements besides direct healthcare cost and effectiveness for the patient, and these should be captured in CEA. Although novel value elements advance our understanding of "what" should be measured (value of hope, severity of disease, health equity, etc), there is limited direction on "how" to measure them in conventional CEA. Furthermore, with Medicare empowered to set drug prices under the Inflation Reduction Act, it is not clear what role CEA might have on where prices are set, given objections to the quality-adjusted life year in conventional approaches. METHODS We critically reviewed the evidence for expanding conventional CEA methods to a more generalized approach of generalized CEA (GCEA). RESULTS GCEA accounts for methods that address objections to the quality-adjusted life year and incorporate novel value elements. Although GCEA offers advantages, it also requires further research to develop "off-the-shelf" resources to help inform, for example, maximum fair price in the context of Medicare drug price negotiation. CONCLUSIONS Should a shift toward GCEA reveal that the societal value of novel medicines exceeds their market-based costs, which will raise the key question of what market failure Medicare negotiation is meant to solve, if any, and therefore what the appropriate role of such negotiation might be to maximize the value society might garner from the development of novel medicines.
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Affiliation(s)
- William V Padula
- Department of Pharmaceutical and Health Economics, Alfred E. Mann School of Pharmacy & Pharmaceutical Sciences, University of Southern California, Los Angeles, CA, USA; Leonard D. Schaeffer Center for Health Policy and Economics, Los Angeles, CA, USA; Stage Analytics, Baltimore, MD, USA.
| | - Peter Kolchinsky
- RA Capital Management, Boston, MA, USA; No Patient Left Behind, Westland, MI, USA
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Ghabri S. Could or Should We Use Cost-Effectiveness Thresholds in the French Value-Based Pricing Process for New Drugs? PHARMACOECONOMICS 2024; 42:823-827. [PMID: 38733557 DOI: 10.1007/s40273-024-01393-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 05/13/2024]
Affiliation(s)
- Salah Ghabri
- Department of Medical Evaluation-Direction of Evaluation and Access to Innovation-French National Authority for Health, Haute Autorité de Santé, HAS, Saint-Denis, France.
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Basu A. Logical Inconsistencies With Expected Utility Theory May Align Better With Patient Preferences-A Response to Paulden et al. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:815-816. [PMID: 38484796 DOI: 10.1016/j.jval.2023.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 12/21/2023] [Indexed: 04/14/2024]
Affiliation(s)
- Anirban Basu
- The CHOICE Institute, University of Washington, Seattle, and the National Bureau of Economic Research, Cambridge, MA, USA.
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Willke RJ, Pizzi LT, Rand LZ, Neumann P. The Value of the Quality-Adjusted Life Years. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:702-705. [PMID: 38703994 DOI: 10.1016/j.jval.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/25/2024] [Accepted: 04/25/2024] [Indexed: 05/06/2024]
Affiliation(s)
- Richard J Willke
- Senior Scientific Advisor and CSO Emeritus, ISPOR, The Professional Society for Health Economics and Outcomes Research, Lawrenceville, NJ, USA.
| | - Laura T Pizzi
- Chief Science Officer, ISPOR, The Professional Society for Health Economics and Outcomes Research, Lawrenceville, NJ, USA; Research Professor, Ernest Mario School of Pharmacy, Rutgers University, Lawrenceville, NJ, USA
| | - Leah Z Rand
- Research Scientist, Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston MA Lecturer, Harvard Medical School, Boston, MA, USA
| | - Peter Neumann
- Director, Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center Professor, Tufts University School of Medicine, Boston, MA, USA
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Paulden M, Sampson C, O'Mahony JF, Spackman E, McCabe C, Round J, Snowsill T. Author Reply. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:817-819. [PMID: 38636696 DOI: 10.1016/j.jval.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/29/2024] [Accepted: 04/04/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Mike Paulden
- School of Public Health, University of Alberta, Edmonton, AB, Canada.
| | | | | | - Eldon Spackman
- Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Christopher McCabe
- Centre for Public Health and Queens Management School, Queens University Belfast, Belfast, Northern Ireland, UK
| | - Jeff Round
- Institute of Health Economics, Edmonton, AB, Canada; Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Tristan Snowsill
- Health Economics Group, University of Exeter, Exeter, England, UK
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Herring WL, Gallagher ME, Shah N, Morse KC, Mladsi D, Dong OM, Chawla A, Leiding JW, Zhang L, Paramore C, Andemariam B. Cost-Effectiveness of Lovotibeglogene Autotemcel (Lovo-Cel) Gene Therapy for Patients with Sickle Cell Disease and Recurrent Vaso-Occlusive Events in the United States. PHARMACOECONOMICS 2024; 42:693-714. [PMID: 38684631 PMCID: PMC11126463 DOI: 10.1007/s40273-024-01385-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/20/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND AND OBJECTIVE Gene therapies for sickle cell disease (SCD) may offer meaningful benefits for patients and society. This study evaluated the cost-effectiveness of lovotibeglogene autotemcel (lovo-cel), a one-time gene therapy administered via autologous hematopoietic stem cell transplantation, compared with common care for patients in the United States (US) with SCD aged ≥ 12 years with ≥ 4 vaso-occlusive events (VOEs) in the past 24 months. METHODS We developed a patient-level simulation model accounting for lovo-cel and SCD-related events, complications, and mortality over a lifetime time horizon. The pivotal phase 1/2 HGB-206 clinical trial (NCT02140554) served as the basis for lovo-cel efficacy and safety. Cost, quality-of-life, and other clinical data were sourced from HGB-206 data and the literature. Analyses were conducted from US societal and third-party payer perspectives. Uncertainty was assessed through probabilistic sensitivity analysis and extensive scenario analyses. RESULTS Patients treated with lovo-cel were predicted to survive 23.84 years longer on average (standard deviation [SD], 12.80) versus common care (life expectancy, 62.24 versus 38.40 years), with associated discounted patient quality-adjusted life-year (QALY) gains of 10.20 (SD, 4.10) and direct costs avoided of $1,329,201 (SD, $1,346,446) per patient. Predicted societal benefits included discounted caregiver QALY losses avoided of 1.19 (SD, 1.38) and indirect costs avoided of $540,416 (SD, $262,353) per patient. Including lovo-cel costs ($3,282,009 [SD, $29,690] per patient) resulted in incremental cost-effectiveness ratios of $191,519 and $124,051 per QALY gained from third-party payer and societal perspectives, respectively. In scenario analyses, the predicted cost-effectiveness of lovo-cel also was sensitive to baseline age and VOE frequency and to the proportion of patients achieving and maintaining complete resolution of VOEs. CONCLUSIONS Our analysis of lovo-cel gene therapy compared with common care for patients in the US with SCD with recurrent VOEs estimated meaningful improvements in survival, quality of life, and other clinical outcomes accompanied by increased overall costs for the health care system and for broader society. The predicted economic value of lovo-cel gene therapy was influenced by uncertainty in long-term clinical effects and by positive spillover effects on patient productivity and caregiver burden.
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Affiliation(s)
- William L Herring
- Health Economics, RTI Health Solutions, Research Triangle Park, NC, USA.
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden.
| | | | - Nirmish Shah
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - K C Morse
- Theatre Management and Producing, Columbia University School of the Arts, New York, NY, USA
| | - Deirdre Mladsi
- Health Economics, RTI Health Solutions, Research Triangle Park, NC, USA
| | - Olivia M Dong
- Health Economics, RTI Health Solutions, Research Triangle Park, NC, USA
| | | | | | - Lixin Zhang
- Biostatistics, bluebird bio, Somerville, MA, USA
| | | | - Biree Andemariam
- New England Sickle Cell Institute, University of Connecticut Health, Farmington, CT, USA
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Xie F, Zhou T, Humphries B, Neumann PJ. Do Quality-Adjusted Life Years Discriminate Against the Elderly? An Empirical Analysis of Published Cost-Effectiveness Analyses. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:706-712. [PMID: 38548176 DOI: 10.1016/j.jval.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 03/17/2024] [Accepted: 03/19/2024] [Indexed: 04/17/2024]
Abstract
OBJECTIVES Critics of quality-adjusted life-years argue that it discriminates against older individuals. However, little empirical evidence has been produced to inform this debate. This study aimed to compare published cost-effectiveness analyses (CEAs) on patients aged ≥65 years and those aged <65 years. METHODS We used the Tufts Cost-Effectiveness Analysis Registry to identify CEAs published in MEDLINE between 1976 and 2021. Eligible CEAs were categorized according to age (≥65 years vs <65 years). The distributions of incremental cost-effectiveness ratios (ICERs) were compared between the age groups. We used logistic regression to assess the association between age groups and the cost-effectiveness conclusion adjusted for confounding factors. We conducted sensitivity analyses to explore the impact of mixed age and age-unknown groups and all ICERs from the same CEAs. Subgroup analyses were also conducted. RESULTS A total of 4445 CEAs categorized according to age <65 years (n = 3784) and age ≥65 years (n = 661) were included in the primary analysis. The distributions of ICERs and the likelihood of concluding that the intervention was cost-effective were similar between the 2 age groups. Adjusted odds ratios ranged from 1.132 (95% CI 0.930-1.377) to 1.248 (95% CI 0.970-1.606) (odds ratio >1 indicating that CEAs for age ≥65 years were more likely to conclude the intervention was cost-effective than those for age <65 years). Sensitivity and subgroup analyses found similar results. CONCLUSION Our analysis found no systematic differences in published ICERs using quality-adjusted life-years between CEAs for individuals aged ≥65 years and those for individuals aged <65 years.
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Affiliation(s)
- Feng Xie
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada; Centre for Health Economics and Policy Analysis, Faculty of Health Sciences, McMaster University, Hamilton, Canada.
| | - Ting Zhou
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada; Center for Pharmacoeconomics and Outcome Research, China Pharmaceutical University, Nanjing, China
| | - Brittany Humphries
- Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
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Devlin NJ, Drummond MF, Mullins CD. Quality-Adjusted Life Years, Quality-Adjusted Life-Year-Like Measures, or Neither? The Debate Continues. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:689-691. [PMID: 38705459 DOI: 10.1016/j.jval.2024.04.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 04/25/2024] [Indexed: 05/07/2024]
Affiliation(s)
- Nancy J Devlin
- School of Population and Global Health, University of Melbourne, Melbourne, Australia.
| | | | - C Daniel Mullins
- School of Pharmacy, University of Maryland Baltimore, Baltimore, MD, USA
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Paulden M, Sampson C, O'Mahony JF, Spackman E, McCabe C, Round J, Snowsill T. Logical Inconsistencies in the Health Years in Total and Equal Value of Life-Years Gained. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:356-366. [PMID: 38048985 DOI: 10.1016/j.jval.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 10/07/2023] [Accepted: 11/08/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVES This study aimed to assess whether recently proposed alternatives to the quality-adjusted life-year (QALY), intended to address concerns about discrimination, are suitable for informing resource allocation decisions. METHODS We consider 2 alternatives to the QALY: the health years in total (HYT), recently proposed by Basu et al, and the equal value of life-years gained (evLYG), currently used by the Institute for Clinical and Economic Review. For completeness we also consider unweighted life-years (LYs). Using a hypothetical example comparing 3 mutually exclusive treatment options, we consider how calculations are performed under each approach and whether the resulting rankings are logically consistent. We also explore some further challenges that arise from the unique properties of the HYT approach. RESULTS The HYT and evLYG approaches can result in logical inconsistencies that do not arise under the QALY or LY approaches. HYT can violate the independence of irrelevant alternatives axiom, whereas the evLYG can produce an unstable ranking of treatment options. HYT have additional issues, including an implausible assumption that the utilities associated with health-related quality of life and LYs are "separable," and a consideration of "counterfactual" health-related quality of life for patients who are dead. CONCLUSIONS The HYT and evLYG approaches can result in logically inconsistent decisions. We recommend that decision makers avoid these approaches and that the logical consistency of any approaches proposed in future be thoroughly explored before considering their use in practice.
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Affiliation(s)
- Mike Paulden
- School of Public Health, University of Alberta, Edmonton, AB, Canada.
| | | | | | - Eldon Spackman
- Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Christopher McCabe
- Centre for Public Health and Queens Management School, Queen's University Belfast, Belfast, Northern Ireland, UK
| | - Jeff Round
- Institute of Health Economics, Edmonton, AB, Canada; Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Tristan Snowsill
- Health Economics Group, University of Exeter, Exeter, England, UK
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Yin Y, Peng Q, Ma L, Dong Y, Sun Y, Xu S, Ding N, Liu X, Zhao M, Tang Y, Mei Z, Shao H, Yan D, Tang W. QALY-type preference and willingness-to-pay among end-of-life patients with cancer treatments: a pilot study using discrete choice experiment. Qual Life Res 2024; 33:753-765. [PMID: 38079024 DOI: 10.1007/s11136-023-03562-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2023] [Indexed: 02/26/2024]
Abstract
PURPOSE Quality-adjusted life-year (QALY) is a dominant measurement of health gain in economic evaluations for pricing drugs. However, end-of-life (EoL) patients' preference for QALY gains in life expectancy (LE) and quality of life (QoL) during different disease stages remains unknown and is seldom involved in decision-making. This study aims to measure preferences and willingness-to-pay (WTP) towards different types of QALY gain among EoL cancer patients. METHODS We attributed QALY gain to four types, gain in LE and QoL, respectively, and during both progression-free survival (PFS) and post-progression survival (PPS). A discrete choice experiment including five attributes (the four QALY attributes and one cost attribute) with three levels each was developed and conducted with 85 Chinese advanced non-small cell lung cancer patients in 2022. All levels were set with QALY gain/cost synthesised from research on anti-lung cancer drugs recently listed by Chinese National Healthcare Security Administration. Each respondent answered six choice tasks in a face-to-face interview. The data were analysed using mixed logit models. RESULTS Patients valued LE-related QALY gain in PFS most, with a relative importance of 81.8% and a WTP of $43,160 [95% CI 26,751 ~ 59,569] per QALY gain. Respondents consistently preferred LE-related to QoL-related QALY gain regardless of disease stage. Patients with higher income or lower education levels tended to pay more for QoL-related QALY gain. CONCLUSION Our findings suggest a prioritised resource allocation to EoL-prolonging health technologies. Given the small sample size and large individual heterogeneity, a full-scale study is needed to provide more robust results.
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Affiliation(s)
- Yue Yin
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, 211198, China
| | - Qian Peng
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, 211198, China
| | - Longhao Ma
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, China
| | - Yi Dong
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, China
| | - Yinan Sun
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, China
| | - Silu Xu
- Department of Pharmacy, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, 210009, China
| | - Nianyang Ding
- Department of Pharmacy, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, 210009, China
| | - Xiaolin Liu
- Department of Pharmacy, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, 210009, China
| | - Mingye Zhao
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, 211198, China
| | - Yaqian Tang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, 211198, China
| | - Zhiqing Mei
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, 211198, China
| | - Hanqiao Shao
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, China
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, 211198, China
| | - Dan Yan
- Department of Pharmacy, Jiangsu Cancer Hospital, Jiangsu Institute of Cancer Research, The Affiliated Cancer Hospital of Nanjing Medical University, Nanjing, 210009, China.
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, 211198, China.
| | - Wenxi Tang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, China.
- Center for Pharmacoeconomics and Outcomes Research, China Pharmaceutical University, Nanjing, 211198, China.
- Department of Public Management, School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, 211198, China.
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Lakdawalla DN, Doctor JN. A principled approach to non-discrimination in cost-effectiveness. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2024:10.1007/s10198-023-01659-7. [PMID: 38411845 DOI: 10.1007/s10198-023-01659-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 12/05/2023] [Indexed: 02/28/2024]
Abstract
The US Inflation Reduction Act (IRA) prohibits the Centers for Medicare and Medicaid Services (CMS) from using standard quality-adjusted life-years or other value assessment methods that discriminate against the aged, terminally ill, or disabled when setting maximum fair prices for prescription drugs. This policy has reignited interest in methods for assessing value without discrimination. Equal value of life-years gained (EVL), healthy years in total (HYT), and Generalized Risk-Adjusted Cost-Effectiveness (GRACE) have emerged as proposals. Neither EVL nor HYT rests on well-articulated microeconomic foundations. We show that they produce decisions that are inconsistent over time in a variety of ways, including: (1) failure to support additivity and indirect comparison in cases where the standard-of-care therapy changes over time; (2) strictly negative value of survival gains that accrue from a new, better standard-of-care, particularly for the disabled themselves; (3) unbounded average value of survival gains; and (4) non-convex survival preferences. We propose an alternative method that relies on GRACE and its microeconomic foundations.
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Affiliation(s)
- Darius N Lakdawalla
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, USA.
| | - Jason N Doctor
- Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, USA
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DiStefano MJ, Zemplenyi A, Anderson KE, Mendola ND, Nair KV, McQueen RB. Alternative approaches to measuring value: an update on innovative methods in the context of the United States Medicare drug price negotiation program. Expert Rev Pharmacoecon Outcomes Res 2024; 24:171-180. [PMID: 37961908 DOI: 10.1080/14737167.2023.2283584] [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] [Received: 09/20/2023] [Accepted: 11/10/2023] [Indexed: 11/15/2023]
Abstract
INTRODUCTION The United States has begun assessing the value of pharmaceuticals to inform negotiated prices in the Medicare program. Given strong political objections in the United States to the use of QALYs, Medicare will need to adopt an alternative approach to measuring value. AREAS COVERED In this narrative review, we identified six alternative approaches to measuring value (equal value life-years, health years in total, generalized risk-adjusted cost-effectiveness, severity weighting based on absolute or proportional shortfall, comparative effectiveness based on conventional clinical endpoints, and comparative effectiveness based on both conventional endpoints and patient-centric value elements) and five criteria for assessing these approaches (responsiveness to concerns about discrimination, feasibility, transparency, flexibility, and the ability to incorporate factors beyond traditional value elements). EXPERT OPINION Four of the alternatives are broadly aligned with the cost-effectiveness framework, but none fully addresses all aspects of the stated concerns that QALYs may be used to unintentionally implement discrimination. We note, however, that the extent to which these concerns lead to discrimination in practice is unknown. Finally, we recommend an approach for measuring value in terms of comparative effectiveness that combines quantitative ranking and weighting of distinct criteria (including patient-centric value elements) with deliberation.
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Affiliation(s)
- Michael J DiStefano
- Center for Pharmaceutical Outcomes Research, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Antal Zemplenyi
- Center for Pharmaceutical Outcomes Research, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, USA
- Center for Health Technology Assessment and Pharmacoeconomics Research, Faculty of Pharmacy, University of Pécs, Pécs, Hungary
| | - Kelly E Anderson
- Center for Pharmaceutical Outcomes Research, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Nicholas D Mendola
- Center for Pharmaceutical Outcomes Research, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Kavita V Nair
- Department of Neurology, School of Medicine, University of Colorado Anschutz Medical Campus, Aurora, USA
| | - Robert Brett McQueen
- Center for Pharmaceutical Outcomes Research, Department of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of Colorado Anschutz Medical Campus, Aurora, USA
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Basu A, Winn AN, Johnson KM, Jiao B, Devine B, Hankins JS, Arnold SD, Bender MA, Ramsey SD. Gene Therapy Versus Common Care for Eligible Individuals With Sickle Cell Disease in the United States : A Cost-Effectiveness Analysis. Ann Intern Med 2024; 177:155-164. [PMID: 38252942 DOI: 10.7326/m23-1520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Sickle cell disease (SCD) and its complications contribute to high rates of morbidity and early mortality and high cost in the United States and African heritage community. OBJECTIVE To evaluate the cost-effectiveness of gene therapy for SCD and its value-based prices (VBPs). DESIGN Comparative modeling analysis across 2 independently developed simulation models (University of Washington Model for Economic Analysis of Sickle Cell Cure [UW-MEASURE] and Fred Hutchinson Institute Sickle Cell Disease Outcomes Research and Economics Model [FH-HISCORE]) using the same databases. DATA SOURCES Centers for Medicare & Medicaid Services claims data, 2008 to 2016; published literature. TARGET POPULATION Persons eligible for gene therapy. TIME HORIZON Lifetime. PERSPECTIVE U.S. health care sector and societal. INTERVENTION Gene therapy versus common care. OUTCOME MEASURES Incremental cost-effectiveness ratios (ICERs), equity-informed VBPs, and price acceptability curves. RESULTS OF BASE-CASE ANALYSIS At an assumed $2 million price for gene therapy, UW-MEASURE and FH-HISCORE estimated ICERs of $193 000 per QALY and $427 000 per QALY, respectively, under the health care sector perspective. Corresponding estimates from the societal perspective were $126 000 per QALY and $281 000 per QALY. The difference in results between models stemmed primarily from considering a slightly different target population and incorporating the quality-of-life (QOL) effects of splenic sequestration, priapism, and acute chest syndrome in the UW model. From a societal perspective, acceptable (>90% confidence) VBPs ranged from $1 million to $2.5 million depending on the use of alternative effective metrics or equity-informed threshold values. RESULTS OF SENSITIVITY ANALYSIS Results were sensitive to the costs of myeloablative conditioning before gene therapy, effect on caregiver QOL, and effect of gene therapy on long-term survival. LIMITATION The short-term effects of gene therapy on vaso-occlusive events were extrapolated from 1 study. CONCLUSION Gene therapy for SCD below a $2 million price tag is likely to be cost-effective when applying a societal perspective at an equity-informed threshold for cost-effectiveness analysis. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.
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Affiliation(s)
- Anirban Basu
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy; Department of Health Systems and Population Health; and Department of Economics, University of Washington, Seattle, Washington (A.B.)
| | - Aaron N Winn
- Pharmacy Administration, Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin (A.N.W.)
| | - Kate M Johnson
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, Washington, and Faculty of Pharmaceutical Sciences and Division of Respiratory Medicine, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada (K.M.J.)
| | - Boshen Jiao
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, Washington, and Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts (B.J.)
| | - Beth Devine
- The Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy, and Department of Health Systems and Population Health, University of Washington, Seattle, Washington (B.D.)
| | - Jane S Hankins
- Department of Global Pediatric Medicine and Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee (J.S.H.)
| | - Staci D Arnold
- Aflac Cancer and Blood Disorders Center at Children's Healthcare of Atlanta, Emory University, Atlanta, Georgia (S.D.A.)
| | - M A Bender
- Department of Pediatrics, University of Washington, and Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington (M.A.B.)
| | - Scott D Ramsey
- Division of Public Health Sciences and Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, and the Comparative Health Outcomes, Policy & Economics (CHOICE) Institute, Department of Pharmacy, University of Washington, Seattle, Washington, and Pharmacy Administration, Department of Clinical Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin (S.D.R.)
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15
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Mott DJ, Schirrmacher H, Al-Janabi H, Guest S, Pennington B, Scheuer N, Shah KK, Skedgel C. Modelling Spillover Effects on Informal Carers: The Carer QALY Trap. PHARMACOECONOMICS 2023; 41:1557-1561. [PMID: 37659032 PMCID: PMC10635951 DOI: 10.1007/s40273-023-01316-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/21/2023] [Indexed: 09/05/2023]
Abstract
The provision of informal (unpaid) care can impose significant 'spillover effects' on carers, and accounting for these effects is consistent with the efficiency and equity objectives of health technology assessment (HTA). Inclusion of these effects in health economic models, particularly carer health-related quality of life (QOL), can have a substantial impact on net quality-adjusted life year (QALY) gains and the relative cost effectiveness of new technologies. Typically, consideration of spillover effects improves the value of a technology, but in some circumstances, consideration of spillover effects can lead to situations whereby life-extending treatments for patients may be considered cost ineffective due to their impact on carer QOL. In this piece we revisit the classic 'QALY trap' and introduce an analogous 'carer QALY trap' which may have practical implications for economic evaluations where the inclusion of carer QOL reduces incremental QALY gains. Such results may align with a strict QALY-maximisation rule, however we consider the extent to which this principle may be at odds with the preferences of carers themselves (and possibly society more broadly), potentially leading decision makers into the carer QALY trap as a result. We subsequently reflect on potential solutions, highlighting the important (albeit limited) role that deliberation has to play in HTA.
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Affiliation(s)
- David J Mott
- Office of Health Economics, 2nd Floor, Goldings House, Hay's Galleria, 2 Hay's Lane, London, SE1 2HB, UK.
| | - Hannah Schirrmacher
- Office of Health Economics, 2nd Floor, Goldings House, Hay's Galleria, 2 Hay's Lane, London, SE1 2HB, UK
| | - Hareth Al-Janabi
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | - Becky Pennington
- Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Koonal K Shah
- National Institute for Health and Care Excellence, London, UK
| | - Chris Skedgel
- Office of Health Economics, 2nd Floor, Goldings House, Hay's Galleria, 2 Hay's Lane, London, SE1 2HB, UK
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16
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Campbell JD, Whittington MD, Pearson SD. An Alternative Measure of Health for Value Assessment: The Equal Value Life-Year. PHARMACOECONOMICS 2023; 41:1175-1182. [PMID: 37458912 DOI: 10.1007/s40273-023-01302-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/29/2023] [Indexed: 09/10/2023]
Abstract
The quality-adjusted life-year (QALY) is an international standard in cost-effectiveness analysis. A known concern arises from the relatively lower QALY gains attributed to treatments that extend the life of individuals with chronic disability. We analyze here the advantages and disadvantages of the equal value life-year (evLY) as an alternative or a complementary measure to the QALY, and share learned experiences from using this measure in health technology assessments. We present the conceptual rationale for the evLY, describe how it is estimated, and assess the differences in results between analyses based on the evLY and the QALY. We share a how-to guide in estimating the evLY using a downloadable tool and summarize our empirical experience using this measure. Incremental evLYs are feasible and address concerns regarding the risk for a cost-effectiveness analysis to undervalue treatments for people with chronic disabilities. Based on our set of analyses using the evLY, a threshold of $84,000 per evLY gained would be needed to maintain alignment with a threshold of $100,000 per added QALY. The evLY is a measure of health gain that can be used as an alternative or a complement to the QALY to address concerns related to undervaluing treatments that extend the life of individuals with serious illness or chronic disability. We recommend that it be reported within all cost-effectiveness analyses but may have special relevance in the current political environment in the USA, where use of the QALY is often challenged or prohibited.
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Affiliation(s)
- Jonathan D Campbell
- Institute for Clinical and Economic Review, 14 Beacon Street, 8th Floor, Boston, MA, 02108, USA.
| | - Melanie D Whittington
- Institute for Clinical and Economic Review, 14 Beacon Street, 8th Floor, Boston, MA, 02108, USA
| | - Steven D Pearson
- Institute for Clinical and Economic Review, 14 Beacon Street, 8th Floor, Boston, MA, 02108, USA
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17
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Rand LZ, Melendez‐Torres GJ, Kesselheim AS. Alternatives to the quality-adjusted life year: How well do they address common criticisms? Health Serv Res 2023; 58:433-444. [PMID: 36537647 PMCID: PMC10012222 DOI: 10.1111/1475-6773.14116] [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] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To analyze whether other outcome measures used in health technology assessment (HTA) address the criticisms of quality-adjusted life years (QALYs). DATA SOURCES AND STUDY SETTING HTA methods guidance from 11 US comparator countries (the G10 and Australia) and six value frameworks from US organizations were reviewed to identify health outcome measures currently used to evaluate the benefits of a drug. STUDY DESIGN The study involved a documentary analysis of guidelines to identify outcome measures used by the sampled HTA organizations. Similar outcomes were grouped together into outcome types. Each type was analyzed to determine the extent to which it replicates key advantages and responds to criticisms of QALYs extracted from the literature. EXTRACTION METHODS Outcomes were included if guidance from at least one HTA organization identified the outcome as acceptable for HTA. Outcomes measuring or evaluating the benefit, clinical effect, or impact of a drug or health technology was included; methods of calculating costs were excluded. PRINCIPAL FINDINGS Seven types of outcome measures were identified falling into three groups: preference-based, single-dimension outcomes, and outcomes using non-health perspectives. Among the seven QALY alternative outcome measures currently used for HTA by the sampled countries, no one outcome measure addresses all the QALY criticisms while retaining the advantageous features of the QALY. CONCLUSIONS Proposals to adopt health technology assessment (HTA) to support value-based pricing of prescription drugs in the US have faced pushback over the use of the QALY. There is no single "right" outcome measure, and the criticisms of QALYs apply to other outcome measures used to evaluate health. The measures identified have different features and strengths, which may be appropriate for specific decision making goals, but the QALY remains the best option for decision making that requires comparisons of the overall societal value of health gains.
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Affiliation(s)
- Leah Z. Rand
- The Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Center for BioethicsHarvard Medical SchoolBostonMassachusettsUSA
| | - G. J. Melendez‐Torres
- Peninsula Technology Assessment Group (PenTAG), Faculty of Health and Life SciencesUniversity of ExeterExeterUK
| | - Aaron S. Kesselheim
- The Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Center for BioethicsHarvard Medical SchoolBostonMassachusettsUSA
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18
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COVID-19 Reveals Longstanding Health Inequities and Discrimination Against Americans With Disabilities. Med Care 2023; 61:55-57. [PMID: 36630556 PMCID: PMC9830958 DOI: 10.1097/mlr.0000000000001810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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19
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Diaz MI, Medford RJ, Lehmann CU, Petersen C. The lived experience of people with disabilities during the COVID-19 pandemic on Twitter: Content analysis. Digit Health 2023; 9:20552076231182794. [PMID: 37361433 PMCID: PMC10286555 DOI: 10.1177/20552076231182794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 06/01/2023] [Indexed: 06/28/2023] Open
Abstract
Objective People with disabilities (PWDs) are at greater risk of COVID-19 infection, complications, and death, and experience more difficulty accessing care. We analyzed Twitter tweets to identify important topics and investigate health policies' effects on PWDs. Methods Twitter's application programming interface was used to access its public COVID-19 stream. English-language tweets from January 2020 to January 2022 containing a combination of keywords related to COVID-19, disability, discrimination, and inequity were collected and refined to exclude duplicates, replies, and retweets. The remaining tweets were analyzed for user demographics, content, and long-term availability. Results The collection yielded 94,814 tweets from 43,296 accounts. During the observation period, 1068 (2.5%) accounts were suspended and 1088 (2.5%) accounts were deleted. Account suspension and deletion among verified users tweeting about COVID-19 and disability were 0.13% and 0.3%, respectively. Emotions were similar among active, suspended, and deleted users, with general negative and positive emotions most common followed by sadness, trust, anticipation, and anger. The overall average sentiment for the tweets was negative. Ten of the 12 topics identified (96.8%) related to pandemic effects on PWDs; "politics that rejects and leaves the disabled, elderly, and children behind" (48.3%) and "efforts to support PWDs in the COVID crisis" (31.8%) were most common. The sample of tweets by organizations (43.9%) was higher for this topic than for other COVID-19-related topics the authors have investigated. Conclusions The primary discussion addressed how pandemic politics and policies disadvantage PWDs, older adults, and children, and secondarily expressed support for these populations. The increased level of Twitter use by organizations suggests a higher level of organization and advocacy within the disability community than in other groups. Twitter may facilitate recognition of increased harm to or discrimination against specific populations such as people living with disability during national health events.
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Affiliation(s)
- Marlon I. Diaz
- Clinical Informatics Center, UT Southwestern Medical Center, Dallas, TX, USA
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Richard J. Medford
- Clinical Informatics Center, UT Southwestern Medical Center, Dallas, TX, USA
| | | | - Carolyn Petersen
- Department of Artificial Intelligence and Informatics, Mayo Clinic, Rochester, MN, USA
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20
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Keller E, Chambers GM. Valuing infertility treatment: Why QALYs are inadequate, and an alternative approach to cost-effectiveness thresholds. FRONTIERS IN MEDICAL TECHNOLOGY 2022; 4:1053719. [PMID: 36619344 PMCID: PMC9822722 DOI: 10.3389/fmedt.2022.1053719] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
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21
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Schneider P. The QALY is ableist: on the unethical implications of health states worse than dead. Qual Life Res 2022; 31:1545-1552. [PMID: 34882282 PMCID: PMC9023412 DOI: 10.1007/s11136-021-03052-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION A long-standing criticism of the QALY has been that it would discriminate against people in poor health: extending the lives of individuals with underlying health conditions gains fewer QALYs than extending the lives of 'more healthy' individuals. Proponents of the QALY counter that this only reflects the general public's preferences and constitutes an efficient allocation of resources. A pivotal issue that has thus far been overlooked is that there can also be negative QALYs. METHODS AND RESULTS Negative QALYs are assigned to the times spent in any health state that is considered to be worse than dead. In a health economic evaluation, extending the lives of people who live in such states reduces the overall population health; it counts as a loss. The problem with this assessment is that the QALY is not based on the perspectives of individual patients-who usually consider their lives to be well worth living-but it reflects the preferences of the general public. While it may be generally legitimate to use those preferences to inform decisions about the allocation of health care resources, when it comes to states worse than dead, the implications are deeply problematic. In this paper, I discuss the (un)ethical aspects of states worse than dead and demonstrate how their use in economic evaluation leads to a systematic underestimation of the value of life-extending treatments. CONCLUSION States worse than dead should thus no longer be used, and a non-negative value should be placed on all human lives.
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Affiliation(s)
- Paul Schneider
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, 30 Regent St, Sheffield, S1 4DA, UK.
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22
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Lakdawalla DN, Phelps CE. A guide to extending and implementing generalized risk-adjusted cost-effectiveness (GRACE). THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:433-451. [PMID: 34495445 PMCID: PMC8964662 DOI: 10.1007/s10198-021-01367-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 07/29/2021] [Indexed: 06/13/2023]
Abstract
The generalized risk-adjusted cost-effectiveness (GRACE) model generalizes conventional cost-effectiveness analysis (CEA) by introducing diminishing returns to Health-Related Quality of Life (QoL). This changes CEA practice in three ways: (1) Willingness to pay (WTP) increases exponentially with untreated illness severity or pre-existing permanent disability, and WTP ends up lower for mild diseases but higher for severe diseases compared with conventional CEA; (2) Average treatment effectiveness should be adjusted for uncertainty in outcomes; and (3) The marginal rate of substitution between life expectancy and QoL varies with health state. Implementing GRACE requires new parameters describing risk preferences over QoL, the marginal rate of substitution between life expectancy (LE) and QoL, and the variance and skewness of treatment outcomes distributions. In this paper, we provide: (1) a generalized WTP threshold incorporating the possibility of permanent disability; (2) a simpler method to estimate the tradeoff rate between QoL and LE, eliminating the need to carry out treatment-by-treatment estimates; (3) a more-general method to adjust WTP for illness severity that permits non-constant relative risk-aversion in QoL; (4) a new approach to estimating risk-preferences over QoL, leveraging established empirical methods from "happiness" economics; and (5) a step-by-step guide for practitioners wishing to implement multi-period GRACE analyses.
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Affiliation(s)
- Darius N. Lakdawalla
- School of Pharmacy, Sol Price School of Public Policy, The Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA USA
- The National Bureau of Economic Research (NBER), Cambridge, MA USA
| | - Charles E. Phelps
- University of Rochester, Rochester, NY USA
- Departments of Economics and Public Health Sciences, University Professor and Provost Emeritus, University of Rochester, Rochester, NY USA
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23
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Avanceña AL, Prosser LA. Innovations in cost-effectiveness analysis that advance equity can expand its use in health policy. BMJ Glob Health 2022; 7:bmjgh-2021-008140. [PMID: 35173023 PMCID: PMC8852660 DOI: 10.1136/bmjgh-2021-008140] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/29/2022] [Indexed: 11/16/2022] Open
Affiliation(s)
- Anton L.V. Avanceña
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan, USA
| | - Lisa A Prosser
- Department of Health Management and Policy, University of Michigan, Ann Arbor, Michigan, USA,Department of Pediatrics, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, Michigan, USA
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Neumann PJ. Toward Better Data Dashboards for US Drug Value Assessments. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1484-1489. [PMID: 34593172 DOI: 10.1016/j.jval.2021.04.1287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/19/2021] [Accepted: 04/23/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To explore the use of data dashboards to convey information about a drug's value, and reduce the need to collapse dimensions of value to a single measure. METHODS Review of the literature on US Drug Value Assessment Frameworks, and discussion of the value of data dashboards to improve the manner in which information on value is displayed. RESULTS The incremental cost per quality-adjusted life-year ratio is a useful starting point for conversation about a drug's value, but it cannot reflect all of the elements of value about which different audiences care deeply. Data dashboards for drug value assessments can draw from other contexts. Decision makers should be presented with well-designed value dashboards containing various metrics, including conventional cost per quality-adjusted life-year ratios as well as measures of a drug's impact on clinical and patient-centric outcomes, and on budgetary and distributional consequences, to convey a drug's value along different dimensions. CONCLUSIONS The advent of US drug value frameworks in health care has forced a concomitant effort to develop appropriate information displays. Researchers should formally test different formats and elements.
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Affiliation(s)
- Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Tufts Medical Center, Boston, MA, USA.
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25
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Rand LZ, Kesselheim AS. Controversy Over Using Quality-Adjusted Life-Years In Cost-Effectiveness Analyses: A Systematic Literature Review. Health Aff (Millwood) 2021; 40:1402-1410. [PMID: 34495724 DOI: 10.1377/hlthaff.2021.00343] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Researchers and policy makers in the US are exploring the implementation of health technology assessment and value-based pricing to negotiate drug prices and limit spending. Objections made to the quality-adjusted life-year (QALY), the most frequently used health economic outcome for such assessments, are a barrier to the adoption of these tools. This literature review identifies and addresses the range of criticisms made against QALYs. Methods-based criticisms require attention from stakeholders to address well-known shortcomings of the QALY and ensure consistency. Ethical criticisms, however, do not apply only to the QALY and require political decisions about societal values. Understanding and overcoming criticisms of the QALY to enable its use as part of health technology assessment and value-based pricing will be crucial as US policy makers seek to address high drug costs and health care spending.
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Affiliation(s)
- Leah Z Rand
- Leah Z. Rand is a postdoctoral fellow in the Program on Regulation, Therapeutics, and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, in Boston, Massachusetts
| | - Aaron S Kesselheim
- Aaron S. Kesselheim is a professor of medicine at Harvard Medical School, in Boston, Massachusetts, and the director of the Program on Regulation, Therapeutics, and Law, Brigham and Women's Hospital
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26
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Lakdawalla DN, Phelps CE. Health Technology Assessment With Diminishing Returns to Health: The Generalized Risk-Adjusted Cost-Effectiveness (GRACE) Approach. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:244-249. [PMID: 33518031 DOI: 10.1016/j.jval.2020.10.003] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/24/2020] [Accepted: 10/03/2020] [Indexed: 05/27/2023]
Abstract
OBJECTIVES Cost-effectiveness analysis (CEA) embeds an assumption at odds with most economic analysis-that of constant returns to health in the creation of happiness (utility). We aim to reconcile it with the bulk of economic theory. METHODS We generalize the traditional CEA approach, allow diminishing returns to health, and align CEA with the rest of the health economics literature. RESULTS This simple change has far-reaching implications for the practice of CEA. First, optimal cost-effectiveness thresholds should systematically rise for more severe diseases and fall for milder ones. We provide formulae for estimating how these thresholds vary with health-related quality of life (QoL) in the sick state. Practitioners can also use our approach to account for treatment outcome uncertainty. Holding average benefits fixed, risk-averse consumers value interventions more when they reduce outcome uncertainty ('insurance value') and/or when they provide a chance at positively skewed outcomes ('value of hope'). Finally, we provide a coherent way to combine improvements in QoL and life expectancy (LE) when people have diminishing returns to QoL. CONCLUSION This new approach obviates the need for increasingly prevalent and ad hoc exceptions to CEA for end-of-life care, rare disease, and very severe disease (eg, cancer). Our methods also show that the value of improving QoL for disabled people is greater than for comparable non-disabled people, thus resolving an ongoing and mathematically legitimate objection to CEA raised by advocates for disabled people. Our Generalized Risk-Adjusted Cost-Effectiveness (GRACE) approach helps align HTA practice with realistic preferences for health and risk.
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Affiliation(s)
- Darius N Lakdawalla
- Quintiles Professor of Pharmaceutical Development and Regulatory Innovation, School of Pharmacy, Price School of Public Policy, Leonard Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, USA; National Bureau of Economic Research, Cambridge, MA, USA.
| | - Charles E Phelps
- University Professor and Provost Emeritus, University of Rochester, Rochester, NY, USA
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27
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Padula WV, Sculpher MJ. Ideas About Resourcing Health Care in the United States: Can Economic Evaluation Achieve Meaningful Use? Ann Intern Med 2021; 174:80-85. [PMID: 32986487 DOI: 10.7326/m20-1234] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The United States is one of the few high-income countries not to apply economic evaluation routinely to health care decision making on a national level, yet it excels at spending least efficiently on health care. In the interest of continuing to develop new solutions to curb spending on health care and reduce waste in the United States, perhaps now is an important moment to reconsider the benefits of economic evaluation and the barriers that must be overcome to have it emerge as a solution for health care institutions and the patients they serve. This article offers several distinct considerations to make economic evaluation methods (such as cost-effectiveness analysis) an effective component of value-based decision making in the United States. These considerations include overcoming the barriers presented by opportunity costs, spending on health care services versus biomedical technologies, phasing out low-value care, using value of information to prioritize resources, and determining what to do with the quality-adjusted life-year. These issues need to be addressed to achieve a collective purpose for economic evaluation at state and national levels.
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Affiliation(s)
- William V Padula
- University of Southern California, Los Angeles, California, and University of York, York, United Kingdom (W.V.P.)
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28
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Carlson JJ, Brouwer ED, Kim E, Wright P, McQueen RB. Alternative Approaches to Quality-Adjusted Life-Year Estimation Within Standard Cost-Effectiveness Models: Literature Review, Feasibility Assessment, and Impact Evaluation. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2020; 23:1523-1533. [PMID: 33248507 DOI: 10.1016/j.jval.2020.08.2092] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 08/06/2020] [Accepted: 08/06/2020] [Indexed: 05/25/2023]
Abstract
OBJECTIVES The quality-adjusted life-year (QALY) has been long debated, but alternative estimation approaches have not been comprehensively evaluated. Our objective was to identify alternatives, characterize them by implementation feasibility, and evaluate the impact of implementing feasible options in cost-effectiveness models developed for the Institute for Clinical and Economic Review reports. METHODS We conducted a literature review combining keywords relating to QALYs, methodology alternatives, and cost-effectiveness in PubMed, EconLit, Web of Science, and MEDLINE. Articles that discussed alternatives to the conventional QALY were included. Alternatives were characterized by type, data availability, calculation burden, and overall implementation feasibility. The subset of feasible alternatives, that is, sufficient data and methodology compatible with incorporation into common modeling approaches, were evaluated according to impact on incremental QALYs, incremental net monetary benefit (iNMB), intervention rankings, and proportion of interventions with a positive iNMB. RESULTS We identified 28 articles discussing 9 alternatives. Feasible alternatives were using patient preference (PP) data; equity weighting according to baseline utility, fair innings, or proportional QALY shortfall; and the equal value of life-years-gained approach. All alternatives affected the incremental QALY and iNMB outcomes, rankings, and proportion of interventions with a positive iNMB. The PP alternative had the largest and most consistent impact. The PP impact on the proportion of interventions with a positive iNMB, was in the negative direction. CONCLUSIONS Our work is the first comprehensive evaluation of proposed alternatives to the conventional QALY. We found robust literature but few options that were feasible to be implemented in current healthcare decision-making processes.
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Affiliation(s)
- Josh J Carlson
- Department of Pharmacy, University of Washington, Seattle, WA, USA.
| | | | - Eunice Kim
- Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - Phoebe Wright
- Department of Pharmacy, University of Washington, Seattle, WA, USA
| | - R Brett McQueen
- Department of Clinical Pharmacy, University of Colorado, CO, USA
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Triantaphyllou E, Yanase J. Treatment selection for life-critical shared decision making under ranges of health-state utility scenarios. J Biomed Inform 2020; 115:103604. [PMID: 33217541 DOI: 10.1016/j.jbi.2020.103604] [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: 05/17/2020] [Revised: 10/06/2020] [Accepted: 10/15/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Selecting the best treatment for life-critical conditions via a shared decision making approach is a uniquely important challenge. Besides data from the healthcare physicians, other data that need to be considered are the personal values and perceptions of the patient. Usually, these data come in the form of health-state utility values. They are subjective and often times are elicited from the patient under emotional and stressful conditions. This paper examines an approach for selecting the best treatment under a life-critical shared decision making (SDM) framework. METHODS Health-state utility values are used in practice to quantify what is known as quality-adjusted life years (QALYs) and quality-adjusted life expectancy (QALE). The QALEs from different treatments are used to select the best treatment. This paper describes methods for determining QALEs under a range of scenarios defined by the way some key assumptions on the health-state utility values are satisfied. Approaches for comparing different treatments are described along with some counter-intuitive results. These approaches are based on some optimization formulations. The proposed approaches are demonstrated in terms of a real example taken from the literature. RESULTS Having results that are robust under a spectrum of different scenarios can provide more confidence that the most suitable treatment has been selected in a given case. On the other hand, having non-robust results can be useful information too as they may provide evidence that a more thorough assessment of the benefits and harms of the treatments may be needed to select a treatment with higher confidence. Finally, this study demonstrates that under certain mathematical conditions among the data it is possible to decide which treatment is better among two treatments without having to use health-state utility values. CONCLUSION The significance of this study is that it provides valuable and actionable insights for the important question of how health-state utilities can be used in treatment selection.
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Affiliation(s)
- Evangelos Triantaphyllou
- Division of Computer Science & Engin, College of Engineering, Louisiana State University, Baton Rouge, LA 70803, USA; Department of Medicine, Section of Hematology & Med Oncology, School of Medicine, Tulane University, New Orleans, LA 70112, USA.
| | - Juri Yanase
- Complete Decisions, LLC, Baton Rouge, LA 70810, USA. http://www.completedecisions.com
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Lakdawalla DN, Phelps CE. Health technology assessment with risk aversion in health. JOURNAL OF HEALTH ECONOMICS 2020; 72:102346. [PMID: 32592923 PMCID: PMC7402585 DOI: 10.1016/j.jhealeco.2020.102346] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 05/28/2020] [Accepted: 05/30/2020] [Indexed: 05/08/2023]
Abstract
Standard cost-effectiveness models compare incremental cost increases to incremental average gains in health, commonly expressed in Quality-Adjusted Life Years (QALYs). Our research generalizes earlier models in several ways. We introduce risk aversion in Quality of Life (QoL), which leads to "willingness-to-pay" thresholds that rise with illness severity, potentially by an order of magnitude. Unlike traditional CEA analyses, which discriminate against persons with disabilities, our analysis implies that the marginal value of improving QoL rises for disabled individuals. Our model can also value the uncertain benefits of medical interventions by employing well-established analytic methods from finance. Finally, we show that traditional QALYs no longer serve as a single index of health, when consumers are risk-averse. To address this problem, we derive a generalized single-index of health outcomes-the Generalized Risk-Adjusted QALY (GRA-QALY). Earlier models of CEA that abstract from risk-aversion nest as special cases of our more general model.
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Affiliation(s)
- Darius N Lakdawalla
- Quintiles Professor of Pharmaceutical Development and Regulatory Innovation, School of Pharmacy, Price School of Public Policy, Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA. 635 Downey Way, VPD 414K, Los Angeles, CA 90089-3333, USA; National Bureau of Economic Research, Cambridge, MA, USA.
| | - Charles E Phelps
- University Professor and Provost Emeritus, University of Rochester, Rochester, NY, 30250 South Highway One, Gualala, CA 95445, USA.
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