The generalisability of pharmacoeconomic studies: issues and challenges ahead

Cost-Effectiveness and Cost-Utility of Palbociclib versus Ribociclib in Women with Stage IV Breast Cancer: A Real-World Data Evaluation

Palbociclib and ribociclib are indicated in the first-line treatment of hormonal-receptor-positive HER-2 negative (HR+/HER-2 negative) advanced breast cancer. Despite their clinical benefit, they can increase healthcare expenditure. Yet, there are no comparative pharmacoeconomic evaluations for them in developing countries, the Middle East, or Gulf countries. This study compared the cost-effectiveness of palbociclib and ribociclib in Qatar. A 10-year within-cycle-corrected Markov's model was developed using TreeAge Pro^® software. The model consisted of three main health states: progression-free (PFS), progressed-disease (PD), and death. Costs were obtained from the actual hospital settings, transition probabilities were calculated from individual-patient data, and utilities were summarized from the published literature. The incremental cost-effectiveness ratio (ICER) and the incremental cost-utility ratio (ICUR) were calculated and compared to three gross-domestic-products per capita. Deterministic and probabilistic sensitivity analyses were performed. Ribociclib dominated palbociclib in terms of costs, life-years gained, and quality-adjusted life-years gained. The conclusions remained robust in the different cases of the deterministic sensitivity analyses. Taking all combined uncertainties into account, the confidence in the base-case conclusion was approximately 60%. Therefore, in HR+/HER-2 negative stage IV breast cancer patients, the use of ribociclib is considered cost-saving compared to palbociclib.

Indirectness (transferability) is critical when considering existing economic evaluations for GRADE Clinical Practice Guidelines: A systematic review

OBJECTIVE

GRADE practice guideline developers often perform systematic reviews of potential economic evaluations to inform recommendation decision-making. We aimed to identify indirectness characteristics of economic evaluations, related to GRADE evidence-to-decision (EtD) theoretical frameworks, that influence selection of these articles.

STUDY DESIGN AND SETTING

MEDLINE, EMBASE, CINAHL and EconLit were systematically searched to May 2020 to identify indirectness characteristics relevant for economic evaluation transferability to GRADE evidence-to-decision (EtD) theoretical frameworks. Four reviewers screened citations to identify articles of any type that explored study characteristics most important or relevant to economic evaluation transferability, restricted to English language We generated frequencies of article features, used thematic analysis to summarize study characteristics and assessed certainty in the evidence using GRADE-CERQual.

RESULTS

We included 57 articles, with a dearth of empirical literature - some may have been missed. We identified 8 general themes and 28 sub-themes most important to transferability from 41% of articles. Moderate-to-high confidence evidence suggested that GRADE EtD domains of population, intervention and comparison research question elements, resource use estimation and methodology, and provider and decision-maker acceptability are most important indirectness study characteristics that economists consider when choosing economic evaluation outcomes for use in recommendation decision-making.

CONCLUSION

We have identified factors important for guideline developers to consider when selecting economic evaluations as research evidence. An economic competency on the development team facilitates these endeavors. This supports the GRADE Working Group's tenant of transparent reporting or availability of sufficient information elsewhere to assess indirectness.

Cost transferability problems in economic evaluation as a framework for an European health care and social costs database

This article presents part of the work within Work Package 3 (WP3) of Impact HTA (Improved methods and actionable tools for enhancing HTA), a H2020 EU-funded research project, intended to enhance and promote collaboration in HTA across EU MS. Amongst other objectives, and in close collaboration with WP4, WP3 addressed setting up a multi-country unit-cost database: the European health care and social costs database (EU HCSCD). The purpose of the database is to facilitate the transference of healthcare economic evaluation analyses across countries, jurisdictions and settings. WP3 concentrates on healthcare costs; WP4 on social costs. This paper discusses the state of the art on this topic, building an appropriate conceptual and theoretical framework for Database development. We conducted a broad, but not systematic, literature and gray-literature review (LR), identifying existing practices and problems, and their implications, described in the Results section. We discuss practical implications and draw important conclusions behind the construction, and future evolution, of this database.

Model-based economic evaluations in smoking cessation and their transferability to new contexts: a systematic review

AIMS

To identify different types of models used in economic evaluations of smoking cessation, analyse the quality of the included models examining their attributes and ascertain their transferability to a new context.

METHODS

A systematic review of the literature on the economic evaluation of smoking cessation interventions published between 1996 and April 2015, identified via Medline, EMBASE, National Health Service (NHS) Economic Evaluation Database (NHS EED), Health Technology Assessment (HTA). The checklist-based quality of the included studies and transferability scores was based on the European Network of Health Economic Evaluation Databases (EURONHEED) criteria. Studies that were not in smoking cessation, not original research, not a model-based economic evaluation, that did not consider adult population and not from a high-income country were excluded.

FINDINGS

Among the 64 economic evaluations included in the review, the state-transition Markov model was the most frequently used method (n = 30/64), with quality adjusted life years (QALY) being the most frequently used outcome measure in a life-time horizon. A small number of the included studies (13 of 64) were eligible for EURONHEED transferability checklist. The overall transferability scores ranged from 0.50 to 0.97, with an average score of 0.75. The average score per section was 0.69 (range = 0.35-0.92). The relative transferability of the studies could not be established due to a limitation present in the EURONHEED method.

CONCLUSION

All existing economic evaluations in smoking cessation lack in one or more key study attributes necessary to be fully transferable to a new context.

Validation and calibration of structural models that combine information from multiple sources

INTRODUCTION

Mathematical models that attempt to capture structural relationships between their components and combine information from multiple sources are increasingly used in medicine. Areas covered: We provide an overview of methods for model validation and calibration and survey studies comparing alternative approaches. Expert commentary: Model validation entails a confrontation of models with data, background knowledge, and other models, and can inform judgments about model credibility. Calibration involves selecting parameter values to improve the agreement of model outputs with data. When the goal of modeling is quantitative inference on the effects of interventions or forecasting, calibration can be viewed as estimation. This view clarifies issues related to parameter identifiability and facilitates formal model validation and the examination of consistency among different sources of information. In contrast, when the goal of modeling is the generation of qualitative insights about the modeled phenomenon, calibration is a rather informal process for selecting inputs that result in model behavior that roughly reproduces select aspects of the modeled phenomenon and cannot be equated to an estimation procedure. Current empirical research on validation and calibration methods consists primarily of methodological appraisals or case-studies of alternative techniques and cannot address the numerous complex and multifaceted methodological decisions that modelers must make. Further research is needed on different approaches for developing and validating complex models that combine evidence from multiple sources.

Mental health economics: insights from Brazil

BACKGROUND

As the responsibility and demand on health care grows and resources do not increase at the same pace, the healthcare system has been forced to reconsider the benefits and costs of their actions, to ensure a rational and effective decision-making process regarding the adoption of interventions and allocation of resources. Cost-effectiveness (CE) studies represent one of the basic tools to achieve this goal.

AIMS

To present the current state of Health Technology Assessment (HTA) and health economics in mental health in Brazil and its importance to the decision-making process.

METHODOLOGY

Descriptive paper on HTA and health economics in Brazil. Databases from government and universities as well as some scientific databases to assess the information are presented.

RESULTS AND CONCLUSION

Economic analysis to evaluate interventions in mental health care is a relatively recent addition to the field of health economics; in Brazil, it is also considered a topic within Epidemiology research area. There have been an increased number of studies developed in high-income countries. However, there are fewer CE studies in low- and middle-income ones. Psychiatric disorders represent a significant burden in developing countries, where resources devoted to health care are even scarcer.

[A proposed guideline for economic evaluation of health technologies]

Over the last few years, economic evaluation of health technologies has become a major tool used by European health policy decision-makers to create strategies for prioritizing the allocation of health resources and the approval of new technologies. Spain was a pioneer in proposing the standardization of methodology applicable to economic evaluation studies. However, because health policy decision-makers refused to support the initiative, the methodology was never put into practice. In the medium term, evidence of the economic value of new health technologies financed by the national health system will probably be increasingly required. At that time, stakeholders and decision-makers will have to agree upon a clear and concise set of rules on the technical and methodological issues that must be followed by economic evaluations of health technologies. Consequently, we have provided guidelines and recommendations for producing first-rate economic evaluations. The recommendations appear under seventeen headings or sections. In each case, the recommended requirements to be satisfied by an economic evaluation of health technologies are provided and each recommendation is followed by a commentary, providing a justification and comparing and contrasting the proposal with other available alternatives.

Assessment of transparency of cost estimates in economic evaluations of patient safety programmes

OBJECTIVES

Transparency of costing is essential for decision-makers who require information on the efficiency of a health care programme, because effective decisions depend largely on applicability to their settings. The main objectives of this study were to assess published studies for transparency of cost estimates.

METHODS

We first developed criteria with two axes by reviewing publications dealing with economic evaluations and cost accounting studies: clarification of the scope of costing and accuracy of method evaluating costs. We then performed systematic searches of the literature for studies which estimated prevention costs and assessed the transparency and accuracy of costing based on our criteria.

RESULTS

Forty studies met the inclusion criteria. Half of the studies reported data for both the quantity and unit price of programmes in regard to prevention costs. Although 30 studies estimated costs of adverse events, 19 of these described the scope of costing only, and just five studies used a micro-costing method. Among 30 studies that estimated 'gross cost savings' and 'net cost savings', there was a huge discrepancy in labels.

CONCLUSIONS

Even if a cost study was conducted in accordance with existing techniques of economic evaluation which mostly paid attention to internal validity of cost estimates, without adequate explanation of the process of costing, reproducibility cannot be assured and the study may lose its value as scientific information. This study found that there is tremendous room for improvement.

Transferability indices for health economic evaluations: methods and applications

In this paper, we have elaborated an index in two phases to measure the degree of transferability of the results of the economic evaluation of health technologies. In the first phase, we have considered the objective factors (critical and non-critical) to derive a general transferability index, which can be used to measure this internal property of the studies of economic evaluation applied to health technologies. In the second phase, with a more specific index, we have measured the degree of applicability of the results of a given study to a different setting. Both indices have been combined (arithmetic and geometric mean) to obtain a global transferability index. We have applied the global index to a sample of 27 Spanish studies on infectious diseases. We have obtained an average value for the index of 0.54, quite far from the maximum theoretical value of 1. We also found that 11 studies lacked some critical factor and were directly deemed as not transferable.

Transferability of economic evaluations of medical technologies: a new technology for orthopedic surgery

Transferring results of economic evaluations across countries or jurisdictions can potentially save scarce evaluation resources while helping to make market access and reimbursement decisions in a timely fashion. This article points out why transferring results of economic evaluations is particularly important in the field of medical technologies. It then provides an overview of factors that are previously identified in the literature as affecting transferability of economic evaluations, as well as methods for transferring results in a scientifically sound way. As the current literature almost exclusively relates to transferability of pharmacoeconomic evaluations, this article highlights those factors and methodologies that are of particular relevance to transferring medical technology assessments. Considering the state-of-the-art literature and a worked, real life, example of transferring an economic evaluation of a product used in orthopedic surgery, we provide recommendations for future work in this important area of medical technology assessment.

How to improve pharmacoeconomic data generalisability between different countries

Pharmacoeconomics arises out of a response to the increasing need for accountability of healthcare money in an international environment, when escalating healthcare costs exert an unsustainable burden on the healthcare system. At present, it is difficult to convince any decision makers, whether at the national or institutional level, to list any new drugs into a formulary for subsidy purpose without providing some sort of 'cost-effectiveness' data. This paper discusses the need for having a consensus on what would make pharmacoeconomic data universally acceptable and deals with the issue of improving pharmacoeconomic data generalisability between different countries.