hta training - prof cathal walsh - march 27th 2015
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Intro to Health
Technology
Assessment
Cathal Walsh
Centre for Health Decision Science (HRB)
@CHeDS_ie
Biostatistician (NCPE) - Chair of Statistics (UL)
Health Technology
Assessment
• In theory, HTA provides a structured
framework for decision making.
• The framework used in Ireland is similar
to that employed in the UK and uses the
QALY and cost tradeoff.
Decision Making … the QALY
• The quality adjusted life year (QALY) is a
function of quality and duration of life.
This is best illustrated by a sketch …
• Note that it explicitly trades side effects,
disability and inconvenience of treatment
(etc!) against outcomes.
Notes on the QALY
• In theory we can compare in an
equitable fashion across disease areas.
• This allows consideration of the impact
of interventions in a fair way and in a
univariate fashion.
• Thus a perfect ranking of interventions
can be obtained.
Decision Making - the C/E
plane
• The cost effectiveness plane is a core
aspect of how outcomes are
communicated and interpreted. It trades
off gains in health outcomes (on the x-
axis) and costs (on the y-axis).
The Threshold … Estimation in Practice
• What is the cost per QALY of the things
we stop doing to afford the new things?
• What is the cost per QALY of the things
we should stop doing to afford the new
things?
• On average, what is the marginal cost
per QALY in our health system?
The Threshold … Estimation in Practice
• What is the cost per QALY of the things
we stop doing to afford the new things?
• What is the cost per QALY of the things
we should stop doing to afford the new
things?
• On average, what is the marginal cost
per QALY in our health system?
Inefficiencies
Disinvestment
Practical Assessment
(Data?!)
Other considerations
• The Value set we use.
• The Uncertainty associated with the
parameters.
• The comparators used in the models.
• Indications for treatment.
• Structural uncertainty in models.
• Societal vs healthcare payer perspective.
Workarounds (Fudges)
• QALY loadings.
• Disease specific threshold.
• Selective alternative perspectives.
• Ring fenced budgets for selected
conditions.
• Differential discounting.
• MCDA (perhaps?).
Multi Criteria Decision
Analysis
• Affects the Value side alone.
• Allows explicit incorporation of other
factors into the value function.
• Strictly speaking cost per QALY is a form
of MCDA.
• Cannot change the budget available –
just the ordering of the interventions we
fund.
What do we do now?
• An ‘informal’ MCDA approach.
• A 45,000 / QALY ‘initial’ threshold.
• Reimbursement occurs for some
interventions above this level.
• A process for broader consideration of
the decision exists.
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