Economic Evaluation.pptx

Ppt on Full Economic Evaluation - CMA, CBA, CUA, CEA

1. ECONOMIC EVALUATION

2. TYPES OF FULL EVALUATIONS Cost Benefit Analysis Cost Utility Analysis Cost Minimization Analysis Cost Effectiveness Analysis

3. Cost Minimization Analysis Outcomes measured in monetary terms Outcomes measured in QALYs Yes Yes No No Cost Benefit Analysis Cost Utility Analysis Interventions Equally effective Yes No Cost Effectiveness Analysis Other units

4. Cost-Minimization Analysis

5. Example Cost- minimisation Analysis of Laparoscopic and Open Appendicectomy ( Kald A et al. 1999) Conclusion: Laparoscopic appendicectomy has higher direct costs than open operation

6. Limitations In practice, it is difficult to find interventions or services with the same outcomes What perspective should be chosen?

7. Cost-Effectiveness Analysis

8. Purposes of Cost Effectiveness Analysis To identify most cost-effective intervention from group of alternatives To identify and exclude programs wasting resources To provide general information on relative costs and health benefits of different alternatives

9. Measurements of cost-effectiveness     Cost spent for each unit of health gained

10. Cost-effectiveness Plane Increasing cost Decreasing cost Decreasing effectiveness Increasing effectiveness Poor value! Poor value? Good value! Good value? ICER Threshold WHO CHOICE: ICER threshold 1 to 3x GDP  NICE: £20,000 per QALY

11. Cost-effectiveness acceptability curve Shows the probability that an intervention is cost-effective Compared with the alternative for a range of ceiling ratios or thresholds That a decision-maker might be willing to pay For a particular unit of outcomes

12. Cost-effectiveness acceptability curve Shows the probability that an intervention is cost-effective Compared with the alternative for a range of ceiling ratios or thresholds That a decision-maker might be willing to pay For a particular unit of outcomes

13. Example Parenting programme for parents of children at risk of developing conduct disorder (Edwards et al. 2007) The Webster-Stratton Incredible Years basic parenting programme versus six month waiting list control Main outcome measure: Incremental cost per unit of improvement on the intensity score of the Eyberg child behaviour inventory ICER = ₤73 per 1 point change in Eyberg intensity score

14. Example Parenting programme for parents of children at risk of developing conduct disorder (Edwards et al. 2007) The Webster-Stratton Incredible Years basic parenting programme versus six month waiting list control Main outcome measure: Incremental cost per unit of improvement on the intensity score of the Eyberg child behaviour inventory ICER = ₤73 per 1 point change in Eyberg intensity score

15. Example Parenting programme for parents of children at risk of developing conduct disorder (Edwards et al. 2007) The Webster-Stratton Incredible Years basic parenting programme versus six month waiting list control Main outcome measure: Incremental cost per unit of improvement on the intensity score of the Eyberg child behaviour inventory ICER = ₤73 per 1 point change in Eyberg intensity score

16. Cost-Utility Analysis Extension of cost-effectiveness analysis Health benefits measured in preference-based non-monetary units Health utility scores typically range between 0 and 1 CUA weighs costs and quality adjusted health outcomes of each intervention

17. Cost-Utility Analysis Ideal method when Interventions affect both morbidity and mortality Treatments have a wide range of different outcomes A common unit is required Measures of CUA: DALY, QALY

18. Disability Adjusted Life Years 1 DALY = 1 year of healthy life lost

19. Quality Adjusted Life Years Measure both quality & quantity of life lived, based on no. of life added by intervention Measures person’s length of life weighted by a valuation of their health-related quality of life QALY = Length of life X Quality of life 1 QALY = 1 year of life lived in perfect health

20. QALY’s gained from an intervention Without treatment Life length=40yrs QOL=0.9 QALY=40x0.9=36 40 years 53 years 0.9 With treatment Life extended=13yrs QOL= 0.9 QALY=53x0.9=47.7 QALY gained =(47.7-36) = 11.7

21. QOL measurement methodologies Direct Indirect Visual analogue scale EuroQol-5 Dimension (EQ-5D) Time trade-off scale Health utilities index Standard gamble Short form-6 dimension (SF-6D) WHOQOL

22. Limitations of CUA Equity issues (young gain more QALYs) Doesn't capture non-health effects QALY approach may be too narrow to capture the full range of benefits Doesn't incorporate a patient's willingness to pay when deciding to finance new treatments

23. Cost-Benefit Analysis

24. Valuation of benefits

25. Decision tools

26. Example Intervention Total cost (C) Outcome (No of case averted) A (Vaccine) 10000 200 B (Vaccine & handwashing) 15000 650 C (Vaccine, hand washing & Water treatment) 18000 900 Suppose COI $40 for societal perspective

27. Example Intervention Total cost (C) Outcome (No of case averted) Total Benefit (B) A (Vaccine) 10000 200 8,000 B (Vaccine & handwashing) 15000 650 26,000 C (Vaccine, hand washing & Water treatment) 18000 900 36,000 Suppose COI $40 for societal perspective

28. Example Intervention Total cost (C) Outcome (No of case averted) Total Benefit (B) Net Social Benefit (NSB = B-C) A (Vaccine) 10000 200 8,000 -2,000 B (Vaccine & handwashing) 15000 650 26,000 11000 C (Vaccine, hand washing & Water treatment) 18000 900 36,000 18000 If we consider intervention A, B – C < 0 (NSB < 0), Reject A In intervention B, here, B – C > 0 (NSB>0), Accept B In intervention C, here, B – C > 0 (NSB>0), Accept C Suppose COI $40 for societal perspective

29. Importance of CBA

30. Cost-Consequent Analysis Collects, categorizes and lists the cost components of a chosen intervention Lists the components of an intervention in a disaggregated format Verdict is left to the decision maker

31. Example Gage et al. 2006 Evaluating rehabilitation using cost-consequences analysis: an example in Parkinson’s disease

32. Example (Gage et al. 2006) Cost, ₤ (1999-2000) Health service Participants Total (%) Per patient Total Per patient a) Treatment (1 x 6 week programme for 6 people with PD & their carers) Human resources 2160 (34) 360 Consumables 144 (2) 24 Space & overheads 4110 (64) 685 Total 6414 (100) 1069 b) Transport Hospital provided for 41 people (35%) 18655 455 Private car for 73 people (62%) 3358 46 Taxi for 4 people (3%) NA NA

33. Example (Gage et al. 2006) Consequences Baseline-immediate post-treatment, Mean±SD Baseline-4 months post-treatment, Mean±SD a) Patient outcomes Mobility - 10-min walk with turn - Stand-walk-sit-test at 4 months 14.7(7.2) - 13.7(5.7) P = 0.02 Treated: 20.1(8.7) - 19.4(6.9) Control: 21.5(8.0) - 23.2(10.3) P = 0.09 Speech & language 6.2(4.9) - 4.6(4.3) P < 0.001 Brown PD disability scale - No significant change Anxiety No significant change No significant change Depression (0-21) 6.1(2.9) - 5.6(2.8) P = 0.03 No significant change HRQoL (generic) 67.4(17.8) - 71.6 (15.8) P = 0.001 No significant change HRQoL (PD specific) No significant change

34. Example (Gage et al. 2006) Consequences Baseline-immediate post-treatment, Mean±SD Baseline-4 months post-treatment, Mean±SD b) Carer outcomes Anxiety No significant change No significant change Depression No significant change No significant change HRQoL (generic) No significant change No significant change Carer strain No significant change c) Social services High/medium unmet need N=29 (31%), N=35(38%) Carer in danger of being unable to cope N=7(10%)

35. Example (Gage et al. 2006) Consequences Baseline-immediate post-treatment, Mean±SD Baseline-4 months post-treatment, Mean±SD d) Receipt of home care services Local authority services N=17 (20%), N=28 (30%) Not significant Private/voluntary services N=41 (48%), N=28 (33%) Not significant e) Perceptions of the programme Would like programme repeated at least once per year People with PD, N=104(94%) Carers, N=65(92%)

36. Limitations No weighting system to appraise the results Costs and consequences are presented disaggregated Decisions made at an individual level may not always be in the best interest of the patients or society

37. Steps in Economic Evaluation

38. 1. Deciding upon the study question Identifying the problem and aims of evaluation What is the problem? Why is this problem important? What aspects of the problem need to be explained? Choosing the alternative options Describing the interventions accurately

39. Defining the audience Defining the info needs of the audience Considering how the audience will use the study results Defining the perspective of the study Society / Providers / Patient / Payers Choosing a perspective depends on the audience

40. 2. Assessment of costs and consequences Identification of costs Resources within the health care sector Resources by patients and families Resources from other sectors

41. Individual items measured in appropriate units (natural units, unit costs or prices) Example: Radiotherapy- no. of treatment sessions, length of session & time of day like normal working hours Bed days- no. of bed days recorded differentiating by type of hospital ward Measuring health in a common unit: Quality of life measures (e.g. SF-36, EQ-5D) Measures health in monetary unit e.g. US $ Valuing health into monetary terms: Willingness-to-pay (WTP) Human capital Utility or preference assessment: Quality adjusted life years (QALYs) Measurement of costs (measuring health)

42. Individual items measured in appropriate units (natural units, unit costs or prices) Example: Radiotherapy- no. of treatment sessions, length of session & time of day like normal working hours Bed days- no. of bed days recorded differentiating by type of hospital ward Measuring health in a common unit: Quality of life measures (e.g. SF-36, EQ-5D) Measures health in monetary unit e.g. US $ Valuing health into monetary terms: Willingness-to-pay (WTP) Human capital Utility or preference assessment: Quality adjusted life years (QALYs) Measurement of costs (measuring health)

43. Valuation: Market prices (e.g. wage rates) used unless strong belief they do not reflect opportunity cost (e.g. volunteers) Local currencies vs. international currencies Adjustments for price inflation Calculation: Multiply unit of measurement by unit cost (e.g. 2 hours of time at $5 per hour = $10 labour cost) Measurement of consequences: Valuation if appropriate, either in terms of: Utility (e.g. QALY, DALY) Money (e.g. WTP)

44. Valuation: Market prices (e.g. wage rates) used unless strong belief they do not reflect opportunity cost (e.g. volunteers) Local currencies vs. international currencies Adjustments for price inflation Calculation: Multiply unit of measurement by unit cost (e.g. 2 hours of time at $5 per hour = $10 labour cost) Measurement of consequences: Valuation if appropriate, either in terms of: Utility (e.g. QALY, DALY) Money (e.g. WTP)

45. 3. Adjusting costs & consequences for differential timing Comparison of programs or services must be made at one point in time (usually the present) Timing of programme costs and consequences must be taken into account Prefer to have benefits now and bear costs in the future – ‘time preference’ ‘Rate’ of time preference is termed ‘Discount rate’ To allow for differential timing of costs (and benefits) between programmes all future costs (and benefits) should be stated in terms of their present value using discount rate

46. 3. Adjusting costs & consequences for differential timing Comparison of programs or services must be made at one point in time (usually the present) Timing of programme costs and consequences must be taken into account Prefer to have benefits now and bear costs in the future – ‘time preference’ ‘Rate’ of time preference is termed ‘Discount rate’ To allow for differential timing of costs (and benefits) between programmes all future costs (and benefits) should be stated in terms of their present value using discount rate

47. 4. Adjustments for uncertainty The measurement of key cost and benefit variables is crucial to the result of an economic evaluation A change in the value of any of the variables might in fact reverse the result Results are sensitive to the deterministic variables in the analysis

48. Sensitivity analysis Process of assessing the robustness of an economic evaluation by considering the effects of uncertainty Values recorded for important parameters are varied, usually one at a time to determine whether the results are sensitive to the assumptions made Health planners can then judge the options and decide which is more appropriate to the local situations

49. 5. Making a Decision Endpoint – when a decision is taken on the basis of the appraisal Usually taken by someone who has the responsibility to make a decision Appraisers often do recommend a decision

50. Decision making tier Who makes decisions? Different outcomes Similar health-related outcomes Programmes which will affect same health outcomes National-level decision Health sector level Programme level

51. Critical appraisal of economic evaluations Consolidated Health Economic Evaluation Reporting Standards (CHEERS) Developed in 2013 by Husereau et al. To provide consistency in the reporting of economic evaluations E vidence-based, minimum set of recommendations T o create standardization in reporting, to facilitate transparency and aid critical appraisal and interpretation Initially 24 item checklist, updated in 2022 (28 items) Describes key recommendations of the information that should be included

52. Critical appraisal of economic evaluations Consolidated Health Economic Evaluation Reporting Standards (CHEERS) Developed in 2013 by Husereau et al. To provide consistency in the reporting of economic evaluations E vidence-based, minimum set of recommendations T o create standardization in reporting, to facilitate transparency and aid critical appraisal and interpretation Initially 24 item checklist, updated in 2022 (28 items) Describes key recommendations of the information that should be included

53. Items in the CHEERS checklist 2022 Title Abstract Background and objectives Health economic analysis plan Study population Setting and location Comparators Perspective Time horizon Discount rate Selection of outcomes Measurement of outcomes Valuation of outcomes Measurement and valuation of resources and costs Currency, price date, and conversion Rationale and description of model Analytics and assumptions Characterizing heterogeneity Characterizing distributional effects Characterizing uncertainty Approach to engagement with patients and others affected by the study Study parameters Summary of main results Effect of uncertainty Effect of engagement with patients and others affected by the study Study findings, limitations, generalizability, and current knowledge Source of funding Conflicts of interest

54. Items in the CHEERS checklist 2022 Title Abstract Background and objectives Health economic analysis plan Study population Setting and location Comparators Perspective Time horizon Discount rate Selection of outcomes Measurement of outcomes Valuation of outcomes Measurement and valuation of resources and costs Currency, price date, and conversion Rationale and description of model Analytics and assumptions Characterizing heterogeneity Characterizing distributional effects Characterizing uncertainty Approach to engagement with patients and others affected by the study Study parameters Summary of main results Effect of uncertainty Effect of engagement with patients and others affected by the study Study findings, limitations, generalizability, and current knowledge Source of funding Conflicts of interest

55. Items in the CHEERS checklist 2022 Title Abstract Background and objectives Health economic analysis plan Study population Setting and location Comparators Perspective Time horizon Discount rate Selection of outcomes Measurement of outcomes Valuation of outcomes Measurement and valuation of resources and costs Currency, price date, and conversion Rationale and description of model Analytics and assumptions Characterizing heterogeneity Characterizing distributional effects Characterizing uncertainty Approach to engagement with patients and others affected by the study Study parameters Summary of main results Effect of uncertainty Effect of engagement with patients and others affected by the study Study findings, limitations, generalizability, and current knowledge Source of funding Conflicts of interest

56. Items in the CHEERS checklist 2022 Title Abstract Background and objectives Health economic analysis plan Study population Setting and location Comparators Perspective Time horizon Discount rate Selection of outcomes Measurement of outcomes Valuation of outcomes Measurement and valuation of resources and costs Currency, price date, and conversion Rationale and description of model Analytics and assumptions Characterizing heterogeneity Characterizing distributional effects Characterizing uncertainty Approach to engagement with patients and others affected by the study Study parameters Summary of main results Effect of uncertainty Effect of engagement with patients and others affected by the study Study findings, limitations, generalizability, and current knowledge Source of funding Conflicts of interest

57. OneHealth Tool What does it do? How much will my health plan cost? Costing as part of the planning process How many lives could be saved? Improving population health How many doctors and nurses will I need to implement my plan? Links programme plans to a health systems platform Ensures comparability A standardized costing approach across programmes /systems

58. OneHealth Tool What does it do? How much will my health plan cost? Costing as part of the planning process How many lives could be saved? Improving population health How many doctors and nurses will I need to implement my plan? Links programme plans to a health systems platform Ensures comparability A standardized costing approach across programmes /systems

59. Software Tool

60. To summarize... Unlimited needs, Limited resources, Multiple options Compare cost and benefits: choosing best value for money Measuring costs & benefits Perspective, discounting Partial & full evaluations Full evaluations: CMA, CEA, CUA, CBA Critical appraisal: CHEERS checklist

61. Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programmes . 4th ed. Oxford (UK): Oxford university press; 2015. 461p. Charles J, Edwards RT. A guide to health economics for those working in public health. Wales (UK): Centre for Health Economics and Medicines Evaluation, Bangor University; 2016. 32p. Goodacre S, McCabe C. An introduction to economic evaluation. Emerg Med J. 2002;19(3):198. Limwattananon S. Handling uncertainty of the economic evaluation result: sensitivity analysis. J Med Assoc Thai. 2011;91(6):59. Kald A, Kullman E, Anderberg B, Wirén M, Carlsson P, Ringqvist I, Rudberg C. Cost- minimisation analysis of laparoscopic and open appendicectomy. Eur J Surg. 1999;165(6):579-82. Edwards RT, Céilleachair A, Bywater T, Hughes DA, Hutchings J. Parenting programme for parents of children at risk of developing conduct disorder: cost effectiveness analysis. BMJ. 2007;334(7595):682. Gage H, Kaye J, Owen C, Trend P, Wade D. Evaluating rehabilitation using cost-consequences analysis: an example in Parkinson's disease. Clin Rehabil . 2006;20(3):232-8. World Health Organization. Workbook 8: economic evaluations—evaluation of psychoactive substance use disorder treatment. WHO/MSD/MSB 00.2i. 2008. 38p. Available from: https://www.unodc.org/documents/drug-prevention-and-treatment/Workbook_8_economic_evaluations.pdf Husereau D, Drummond M, Augustovski F, de Bekker-Grob E, Briggs AH, Carswell C, et al. Consolidated health economic evaluation reporting standards (CHEERS) 2022 explanation and elaboration: a report of the ISPOR CHEERS II good practices task force. Value health. 2022;25(1):10-31. References

62. Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programmes . 4th ed. Oxford (UK): Oxford university press; 2015. 461p. Charles J, Edwards RT. A guide to health economics for those working in public health. Wales (UK): Centre for Health Economics and Medicines Evaluation, Bangor University; 2016. 32p. Goodacre S, McCabe C. An introduction to economic evaluation. Emerg Med J. 2002;19(3):198. Limwattananon S. Handling uncertainty of the economic evaluation result: sensitivity analysis. J Med Assoc Thai. 2011;91(6):59. Kald A, Kullman E, Anderberg B, Wirén M, Carlsson P, Ringqvist I, Rudberg C. Cost- minimisation analysis of laparoscopic and open appendicectomy. Eur J Surg. 1999;165(6):579-82. Edwards RT, Céilleachair A, Bywater T, Hughes DA, Hutchings J. Parenting programme for parents of children at risk of developing conduct disorder: cost effectiveness analysis. BMJ. 2007;334(7595):682. Gage H, Kaye J, Owen C, Trend P, Wade D. Evaluating rehabilitation using cost-consequences analysis: an example in Parkinson's disease. Clin Rehabil . 2006;20(3):232-8. World Health Organization. Workbook 8: economic evaluations—evaluation of psychoactive substance use disorder treatment. WHO/MSD/MSB 00.2i. 2008. 38p. Available from: https://www.unodc.org/documents/drug-prevention-and-treatment/Workbook_8_economic_evaluations.pdf Husereau D, Drummond M, Augustovski F, de Bekker-Grob E, Briggs AH, Carswell C, et al. Consolidated health economic evaluation reporting standards (CHEERS) 2022 explanation and elaboration: a report of the ISPOR CHEERS II good practices task force. Value health. 2022;25(1):10-31. References

63. Drummond MF, Sculpher MJ, Claxton K, Stoddart GL, Torrance GW. Methods for the economic evaluation of health care programmes . 4th ed. Oxford (UK): Oxford university press; 2015. 461p. Charles J, Edwards RT. A guide to health economics for those working in public health. Wales (UK): Centre for Health Economics and Medicines Evaluation, Bangor University; 2016. 32p. Goodacre S, McCabe C. An introduction to economic evaluation. Emerg Med J. 2002;19(3):198. Limwattananon S. Handling uncertainty of the economic evaluation result: sensitivity analysis. J Med Assoc Thai. 2011;91(6):59. Kald A, Kullman E, Anderberg B, Wirén M, Carlsson P, Ringqvist I, Rudberg C. Cost- minimisation analysis of laparoscopic and open appendicectomy. Eur J Surg. 1999;165(6):579-82. Edwards RT, Céilleachair A, Bywater T, Hughes DA, Hutchings J. Parenting programme for parents of children at risk of developing conduct disorder: cost effectiveness analysis. BMJ. 2007;334(7595):682. Gage H, Kaye J, Owen C, Trend P, Wade D. Evaluating rehabilitation using cost-consequences analysis: an example in Parkinson's disease. Clin Rehabil . 2006;20(3):232-8. World Health Organization. Workbook 8: economic evaluations—evaluation of psychoactive substance use disorder treatment. WHO/MSD/MSB 00.2i. 2008. 38p. Available from: https://www.unodc.org/documents/drug-prevention-and-treatment/Workbook_8_economic_evaluations.pdf Husereau D, Drummond M, Augustovski F, de Bekker-Grob E, Briggs AH, Carswell C, et al. Consolidated health economic evaluation reporting standards (CHEERS) 2022 explanation and elaboration: a report of the ISPOR CHEERS II good practices task force. Value health. 2022;25(1):10-31. References

64. Thank you