How to weight cost effectiveness in appraisal NVTAG / CVZ course: The appraisal process, work in...
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Transcript of How to weight cost effectiveness in appraisal NVTAG / CVZ course: The appraisal process, work in...
How to weight cost effectiveness in appraisal
NVTAG / CVZ course:The appraisal process, work in progress
22th of April 2009
Jan van Busschbach
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Context investigation CVZ
Cost effectiveness is considered in all new reimbursement application
Cost effectiveness is an important aspect in the appraisal
How to implement cost effectiveness in appraisal?
Two research questions:
1) What is a “good” and what a “bad” cost effectiveness? What is the threshold value? In terms of costs per QALY
2) How does one weight cost effectiveness with other considerations?
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What is the threshold value?
Should there be a threshold value? If there was one: what is the point in weighting with
other arguments? A threshold provokes strategic behavior Is there a normative paradigm (theory), that provides
such threshold? The need for a threshold is pragmatic
It helps to chose between good and bad Its value is historical determined
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Threshold most likely a range
A range like in England and Scotland £ 20.000 - £ 30.000 But higher values are possible
As defined by RvZ maximum € 80.000 per QALY In de media € 80.000 seem threshold But much lower values also possible
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Cost effectiveness in practice
Threshold might stand for average cost effectiveness in practice
Average cost per QALY Meerding et al, 2007 Cardiovascular diseases: € 2.000 to € 5.000 per QALY Oncology: €16.000 tot € 18.000 per QALY
In practice: A range Averages cost effectiveness is lower than used in most
debates about the threshold
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Conclusion research question 1
1. What is a “good” and what a “bad” cost effectiveness? What is the threshold value? In terms of costs per QALY
There is no empirically or theoretically fixed value
More likely: a range (of thresholds) Other variables determine good or bad cost
effectiveness
A variable threshold
Research question 2 How does one weight cost effectiveness with other
considerations? Same question as:
Is the threshold variable? If so: which variables have an influence?
For instance: does disease burden interacts with threshold value? CvZ models 2001, RvZ model 2006, 2007
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A variable thresholdThe RvZ model: interaction with
burden
Burden of Disease
Cos
ts p
er Q
ALY
Interaction with Burden
Burden of disease most often discussed As candidate to alter decision making To weight cost effectiveness
Know as the equity debate1) Maximize average population health…
Without looking at burden of disease2) Focus on the worse of….
Without looking at the average population health Interaction is intermediate position in debate
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Interaction with burden often suggested
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Methodology issues
How to measure burden? What should be the form of the curve?
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Cost per QALY
Burden of disease
But we do know…
The function is continuously ascending Burden can be measured
Next presentation: Elly Stolk We can deduct the curve from research
Population preferences The appraisal committee
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Next to burden….
Other argument than burden might be also be relevant
Examples are rarity (orphan drugs), budget impact, live style etc.
Some might increase the threshold, some might lower it…
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Increasing or lowering the threshold
Increasing Burden Rarity (orphan drugs) Relates to much informal care Risks for others
Lowering Limited relation to domain of health care High budget impact High future medical costs Unsuitable for insurance because of high incidence Unsuitable for insurance because of autonomy patient
Increasing threshold, and critics
Burden But lower population health…
Rarity (orphan drugs) Cause of disease becomes more important that burden and
effectiveness… Does not make much sense from epidemiology point of view
Relates to much informal care Could be include in the CE-ratio…
Risks for others Could be include in the CE-ratio…
Lowering the threshold, and critics
Limited relation to domain of health care What is the domain of health care...?
High budget impact Focus on costs, not on cost effectiveness
High future medical costs Could be include in the CE-ratio…
Unsuitable for insurance because of high incidence Might cause people to avoid health care
Unsuitable for insurance because of autonomy patient Might cause people to avoid health care
Conclusions
There does not seem to be a fixed threshold Many factors might alter threshold Burden of disease is best described Decisions of the appraisal committee will reveal trade-off
between cost effectiveness and other arguments