ramipril.aventis

7/25/2019 ramipril.aventis

1/43

IImplication of Costmplication of Costeffectiveness in theeffectiveness in themanagement of Patients atmanagement of Patients at

high CV-riskhigh CV-riskRonnie RivanyRonnie Rivany

Pusat Kajian Ekonomi KesehatanPusat Kajian Ekonomi Kesehatan

FKMUIFKMUI


2/43

KARAKTERISTIK INDUSTRI KESEHATANKARAKTERISTIK INDUSTRI KESEHATAN


3/43

Ekonomi KesehatanEkonomi Kesehatan

EKONOMI KESEHATAN

Health EconomicsHosital Economics

Pha!macoeconomics

"ental Health Economics


4/43

PharmacoeconomicsPharmacoeconomics( Bootman et al, 1996)( Bootman et al, 1996)

The description andThe description andanalysis of the costsanalysis of the costsof drug therapy toof drug therapy tohealth care systemshealth care systems

and societyand society

Identies, measuresIdenties, measures

and compares theand compares thecosts andcosts andconsequences ofconsequences ofpharmaceuticalpharmaceuticalproducts andproducts andservicesservices


5/43

How to calculateHow to calculate??

TEHNIK EVA!A"ITEHNIK EVA!A"I

EK#N#$I KE"EHATANEK#N#$I KE"EHATAN


6/43


7/43

Distinguishing CharacteristicDistinguishing Characteristicof Health Care Evaluationof Health Care Evaluation

Scope of Examination: Both Cost and Consequences

NO YES

Examine onlyConsequences

Examine onlyCosts

OutcomeDescription

CostDescription

1A PARTIAL EVALUATION 1B

Efficacy orEffectienessEaluation

CostAnalysis

3A PARTIAL EVALUATION 3B

2 PARTIAL EVALUATION

4 F!! ECONO"#C

E$A!A%#ON

Cost!"inimi#ation Analysis

Cost!Effectieness Analysis

Cost!Utility Analysis

Cost!$enefit Analysis

N

O

Y

E

S

2o&mo&e

A't

e&nati(

es


8/43

easurement of Costs ! Conse"uenceseasurement of Costs ! Conse"uences

Type ofType of

"tudy"tudy

$easurement%$easurement%

valuation ofvaluation ofcost in &othcost in &oth

alternativesalternatives

Identication ofIdentication of

consequencesconsequences

$easurement%$easurement%

valuation ofvaluation ofconsequencesconsequences

'$A'$A (ollars(ollars Identical in allIdentical in allrelevant respectsrelevant respects

NoneNone

'EA'EA (ollars(ollars "ingle e)ect of"ingle e)ect ofinterest, commoninterest, commonto &othto &oth

alternatives, &utalternatives, &utachieved toachieved todi)erent degreedi)erent degree

Natural unitsNatural units*e+g+ life years*e+g+ life yearsgained, disa&ilitygained, disa&ility

days saved,days saved,

'A'A (ollars(ollars "ingle or multiple"ingle or multiplee)ecte)ect

(ollars(ollars

'!A'!A (ollars(ollars "ingle or multiple"ingle or multiplee)ecte)ect

Healthy days,Healthy days,-uality ad.usted-uality ad.usted

life yearslife years

*-A/0s1*-A/0s1


9/43

#ehnik Evaluasi#ehnik Evaluasi

Ekonomi KesehatanEkonomi Kesehatan

((Drummond,Drummond,

199$)199$)

ToolsTools

'ompone'omponentnt

CostCostMinimizatiMinimizati

onon

AnalysisAnalysis

CostCost

BeneftBeneft

AnalysisAnalysis

CostCostEectivenesEectivenes

ss

AnalysisAnalysis

CostCost

UtilityUtility

AnalysisAnalysis

INPUTINPUT iayaiayadalamdalammonetermoneter

iaya dalamiaya dalammonetermoneter

iayaiayadalamdalammonetermoneter

CONSEQUENCESCONSEQUENCES

( OUTPUT /( OUTPUT /

OUTCOME )OUTCOME )

2erolehan2erolehan%penghind%penghind

aran hasilaran hasildalamdalam

nilainilaimonetermoneter

'a3upan'a3upanyangyang

diperolehdiperoleh

2erolehan2erolehanhasilhasil

dalamdalam3ualitas3ualitas

hidup yghidup ygter3aitter3ait


10/43

C%C%

(I4E'T '#"T(I4E'T '#"T IN(I4E'T '#"TIN(I4E'T '#"T

#rgani5ing and operating#rgani5ing and operatingcosts 6ithin the health sectorcosts 6ithin the health sector

*e+g+ health professional time,*e+g+ health professional time,

supplies, equipment, capitalsupplies, equipment, capital

costs1costs1

Time lost from 6or3Time lost from 6or3

'osts &orne &y patients and'osts &orne &y patients andtheir families *e+g+ out oftheir families *e+g+ out of

poc3et e7penses, patient andpoc3et e7penses, patient and

family input into treatment1family input into treatment1

2sychic cost2sychic cost


11/43

C%'&EE'CE&C%'&EE'CE&

( %#P# * %#C%E * E++EC# )( %#P# * %#C%E * E++EC# )

'hanges in physical, social and emotional'hanges in physical, social and emotional

functioning *e)ects1functioning *e)ects1

'hanges in resources use *&enets1'hanges in resources use *&enets1

'hanges in the quality of life of patients'hanges in the quality of life of patientsand their families *utility1and their families *utility1


12/43

C%'&EE'CE&C%'&EE'CE&

( %#P# * %#C%E * E++EC# )( %#P# * %#C%E * E++EC# )

(I4E'T ENE8IT(I4E'T ENE8IT IN(I4E'T ENE8ITIN(I4E'T ENE8IT

"avings in resources use"avings in resources use "avings in lost 6or3 time"avings in lost 6or3 time

"avings in e7penditure or"avings in e7penditure orleisure time inputleisure time input

"avings in 'ost of illness"avings in 'ost of illness


13/43

Ho to calculate - (1)Ho to calculate - (1)

'ost of'ost of

IllnessIllness

*a1*a1

'ost of'ost of

InterventioInterventionn

*&1*&1

'ost of'ost of

"avings"avings

*c1 9 *a1 : *&1*c1 9 *a1 : *&1

Drug # 1Drug # 1 dihitungdihitungdari &iayadari &iaya

yangyang

di&utuh3di&utuh3

an untu3an untu34a6at4a6at

Inap *;1Inap *;1

4a6at4a6at

.alan.alan

(ihitung dari(ihitung dari

&iaya program %&iaya program %intervensiintervensidengandengan Drug #Drug #

11 yang telahyang telahdila3u3an dalamdila3u3an dalam3urun 6a3tu3urun 6a3tutertentutertentu


&iaya&iayapenghematanpenghematanyang diperolehyang diperoleh

dari pengurangandari pengurangan&iaya 4I *;1 4


14/43

Clinical Pathway Cost of IllnessClinical Pathway Cost of Illness

"+#+2"+#+2 Hari+=Hari+= Hari+>Hari+> Hari+?Hari+? HariHari

@++@++

Tinda3an aTinda3an a

Tinda3an &Tinda3an &

Tinda3an cTinda3an c

Tinda3anTinda3an

@@


15/43


CraniotomyCraniotomy


@++@++

2era6atan2era6atan ;; ;; ;; ;;

2emeri3sa2emeri3sa

anan;; ;; ;; ;;

Tinda3anTinda3an

;;

;;

#perasi#perasi ;;


16/43

Kom.onen Bia/a Ce0era Ke.ala 0enganKom.onen Bia/a Ce0era Ke.ala 0engan

Craniotom/ 0i & 2 (3 14 th) 57Craniotom/ 0i & 2 (3 14 th) 57

DC81 D85DC81 D85

iayaiaya 4atarata *4p14atarata *4p1 BB2era6atan2era6atan =+=CC+DF=+=CC+DF =,G=,G

#&at Al3es#&at Al3es ?+?F+G=??+?F+G=? ??

2emeri3saan2emeri3saan2enun.ang2enun.ang

C+G?C+G? ,G,G

"e6a Kamar"e6a Kamar#perasi#perasi

>+G??+?CG>+G??+?CG >=,F>=,F


17/43

Ho to calculate - (5)Ho to calculate - (5)

#ost#ostTotal &iayaTotal &iaya

yangyang

di&utuh3andi&utuh3an

untu3untu3

mela3sana3amela3sana3a

n programn program

$ene%t$ene%tiaya sa3itiaya sa3it

yang dapatyang dapat

dihindari olehdihindari oleh

3arena3arena

intervensiintervensi

programprogram

RasioRasio' % ' %

* L = 1* L = 1

(rug M =(rug M =&& && &&

(rug M >(rug M >&& && &&


18/43

Cost ModelingCost Modeling (1)(1)

K# B:;

&&


19/43


K# B:;


20/43


;';=:&:& B:;


21/43

Cost ModelingCost Modeling (7)(7);&:%;&:%

AlternatAlternat

ifif

CostCost

MinimizatiMinimizationon

AnalysisAnalysis

CostCost

BeneftBeneftAnalysisAnalysis

CostCost

EectivenesEectivenesss

AnalysisAnalysis

CostCost

UtilityUtilityAnalysisAnalysis

(rug M =(rug M =

(rug M >(rug M >


22/43

CE; ofCE; of

;lternatives :mmuni>ations81;lternatives :mmuni>ations81

NoNo AlternativeAlternative

ss'ost'ost E)ectivenesE)ectivenes

ss

== 'ampaign'ampaign F,F,

=+=+

>> $'$$'$

'linics'linics

G,G,=+=+

?? $o&ile$o&ile

!nits!nits

C,C,=+=+


23/43

CE; ofCE; of


NoNo AlternativeAlternative


ss'E'E

4atio4atio

== 'ampaign'ampaign F,F,

=+=+ + +

% imm% imm

>> $'$$'$

'linics'linics

G,G,=+=+ ?+ ?+

% imm% imm

?? $o&ile$o&ile

!nits!nits

C,C,=+=+ G+?? G+??

% imm% imm


24/43

CE; ofCE; of


NoNo 2rogram2rogram


ssNo+ of lives savedNo+ of lives saved

'E 4atio'E 4atio per life per lifesavedsaved

== "" =,=, ==

>> TT =,=,

=>=>

?? !! >,>,

==


25/43


26/43

)am*a& #$+1

Pola pi%ir Cost Utility Analysis

Direct

Cost

Total Cost

Indirect

Cost

Cost

EQ-5D QALYs

INA-HRQol Utility

HUI-3 QALY's

Tie !re"erence


27/43

#he Benefits of#he Benefits of RamiprilRamipril

;ortic arter/

Pulmonar/veins

=eft atrium

=eft coronar/arter/

;nterior

interventricular arter/

reat car0iac

vein

Descen0ing aorta

;nterior

car0iac veins

:nferior

vena cava

ight ventricle

ight coronar/

arter/

ight atrium

Pulmonar/veins

&u.erior

vena cava

Pulmonar/arter/

+at

HE;#

Ramiprilsignificantl/

re0uces the rates of

0eath, m/ocar0ial

infarction, an0 strokein a @roa0 range of

highArisk .atients ho

are not knon to

have a lo eectionfraction or heart

failure ( ' Engl e0

57?51?$A$7 )


28/43

Definisi %.erasionalDefinisi %.erasional

4amipril4amipril 2lace&o2lace&o

Stan4a!4Stan4a!4 *;1*;1

4amipril4amipril

#&at>an yang#&at>an yang

di&eri3andi&eri3ansecarasecara

Stan4a!4Stan4a!4

(ari "#2(ari "#2'ardiovascula'ardiovascularr


29/43

Effects of an ;ngiostensinAConvertingAEn>/meEffects of an ;ngiostensinAConvertingAEn>/me

:nhi@itor, ami.ril,on Car0iovasculer events in:nhi@itor, ami.ril,on Car0iovasculer events in

HighAisk .atients ( H%PE :nvestigator,5)HighAisk .atients ( H%PE :nvestigator,5)

4educes of4educes of 4amipril4amipril 2lace&o2lace&o

The rate o eathThe rate o eath C,= BC,= B J,= BJ,= B

MyocarialMyocarial

inarctioninarctionD,D BD,D B =>,? B=>,? B

!tro"e!tro"e ?,G B?,G B G,D BG,D B

Death rom anyDeath rom any

causecause=,G B=,G B =>,> B=>,> B

evascularizationevascularization

$roceure$roceure

=C, B=C, B =J,? B=J,? B

Cariac arrestCariac arrest ,J B,J B =,? B=,? B

%eart ailure%eart ailure D, BD, B ==, B==, B

Com&licationCom&lication

relaterelateto Dia'etesto Dia'etes

C,G BC,G B F,C BF,C B


30/43

#he costAeffectiveness of#he costAeffectiveness of RamiprilRamipril in thein the

treatment of .atients at high risk oftreatment of .atients at high risk of

car0iovascular eventscar0iovascular events(B%H%=# et al,55)(B%H%=# et al,55)



All (cause mortalityAll (cause mortality =,G B=,G B =>,> B=>,> B


31/43

#he costAeffectiveness of#he costAeffectiveness of RamiprilRamipril in the treatmentin the treatment

of .atients at high risk of car0iovascular eventsof .atients at high risk of car0iovascular events

(B%H%=# et al,55)(B%H%=# et al,55)

'ost'ost 'ost%/'ost%/

"EK"EK

'ost%'VE avoided'ost%'VE avoided

"EK"EK

'ardiovascular only'ardiovascular only

(irect medical(irect medical =C C=C C FC =FC =

(irect medical(irect medical

;direct non;direct non

medical ; indirectmedical ; indirect

=C ==C = F? JF? J

All diseaseAll disease(irect medical(irect medical G GG G >F ?>F ?

(irect medical(irect medical;direct non;direct non

medical ; indirectmedical ; indirect

G CG C >GD C>GD C


32/43

Cost :m.lications of the se ofCost :m.lications of the se of RamiprilRamipril in HighAin HighA

isk Patients Base0 on the Heart %utcomesisk Patients Base0 on the Heart %utcomes

Prevention Evaluation (H%PE) &tu0/Prevention Evaluation (H%PE) &tu0/

(=am/ et al, 57)(=am/ et al, 57)

P!ima!yP!ima!youtcomesoutcomes


CariovascularCariovascular

eatheathC,= BC,= B J,= BJ,= B

MyocarialMyocarial


!tro"e!tro"e ?,G B?,G B G,D BG,D BDeath rom anyDeath rom any


&ummar/ of the :m.act of ami.ril in the H%PE &tu0/


33/43

Cost :m.lications of the se ofCost :m.lications of the se of RamiprilRamipril in HighAin HighA

isk Patients Base0 on the Heart %utcomesisk Patients Base0 on the Heart %utcomes

Prevention Evaluation (H%PE) &tu0/Prevention Evaluation (H%PE) &tu0/

(=am/ et al, 57)(=am/ et al, 57)

Secon4a!ySecon4a!youtcomesoutcomes


evascularizationevascularization =C, B=C, B =J,G B=J,G B

%os&italization or%os&italization or

unsta'le Anginaunsta'le Angina

==,D B==,D B =>,> B=>,> B

Com&lications oCom&lications o

Dia'etesDia'etes

C, BC, B F,F BF,F B


Congestive %eartCongestive %eart

ailureailure

?, B?, B ?, B?, B


Cost :m.lications of the se ofCost :m.lications of the se of RamiprilRamipril in High iskin High isk


34/43

Cost :m.lications of the se ofCost :m.lications of the se of RamiprilRamipril in HighAiskin HighAisk

Patients Base0 on the Heart %utcomes PreventionPatients Base0 on the Heart %utcomes Prevention

Evaluation (H%PE) &tu0/Evaluation (H%PE) &tu0/

(=am/ et al, 57)(=am/ et al, 57)


Othe! outcomesOthe! outcomes 4amipril4amipril 2lace&o2lace&o


)orsening angina)orsening angina >?,J B>?,J B >C,? B>C,? B

*e+ ia'etes*e+ ia'etes ?,C B?,C B ,G B,G B

,vert ne&hro&athy,vert ne&hro&athy ?,= B?,= B G, BG, B

*onatal cariac*onatal cariac

arrestarrest,? B,? B ,C B,C B


ventricularventriculararrhythmiaarrhythmia

,> B,> B , B, B

Transient ischemiaTransient ischemia

attac"attac"=, B=, B =,G B=,G B

Unsta'le angina -Unsta'le angina -

EC. changesEC. changes

?,J B?,J B ?,D B?,D B


35/43

Effects of an ;ngiostensinAConvertingAEn>/meEffects of an ;ngiostensinAConvertingAEn>/me

:nhi@itor, ami.ril,on Car0iovasculer events in:nhi@itor, ami.ril,on Car0iovasculer events in

HighAisk .atients ( H%PE :nvestigator,5)HighAisk .atients ( H%PE :nvestigator,5)



MyocarialMyocarial


!tro"e!tro"e ?,G B?,G B G,D BG,D B

Death rom anyDeath rom any


evascularizationevascularization

$roceure$roceure

=C, B=C, B =J,? B=J,? B

Cariac arrestCariac arrest ,J B,J B =,? B=,? B


Com&licationCom&lication

relaterelate

to Dia'etesto Dia'etes

C,G BC,G B F,C BF,C B


36/43

Ho to calculate the @enefit ofHo to calculate the @enefit of

ami.rilami.ril'ost of'ost ofIllnessIllness

*a1*a1

'ost of'ost ofInterventioInterventionn

*&1*&1

'ost of'ost of"avings"avings

*c1 9 *a1 : *&1*c1 9 *a1 : *&1

ami&rilami&ril dihitungdihitungdari &iayadari &iaya

yangyang

di&utuh3di&utuh3

an untu3an untu34a6at4a6at

Inap *;1Inap *;1

4a6at4a6at

.alan.alan


&iaya program %&iaya program %intervensiintervensidengandengan ami&rilami&rilyang telahyang telah

dila3u3an dalamdila3u3an dalam3urun 6a3tu3urun 6a3tutertentutertentu


&iaya&iayapenghematanpenghematanyang diperolehyang diperoleh

dari pengurangandari pengurangan

&iaya 4I *;1 4


37/43


Cardio Vascular DiseaseCardio Vascular Disease


@++@++

Tinda3an aTinda3an a

Tinda3an &Tinda3an &

Tinda3an cTinda3an c

Tinda3anTinda3an

@@


38/43

Cost .er hos.itali>ation CFD @/ DCost .er hos.itali>ation CFD @/ D

(B%H%=# et al, 55)(B%H%=# et al, 55)

(4(4 (4(4

'ode'ode'ost%hos'ost%hos

p *"EK1p *"EK1

$yocardial Infarction$yocardial Infarction =>>=>> >+GG>+GG

"tro3e"tro3e =G=G >+>DJ>+>DJ

!nsta&le angina pectoris!nsta&le angina pectoris =G=G =+CD==+CD=

'ongestive heart failure'ongestive heart failure =>F=>F =F+GFD=F+GFD

"upraventricullar arrhytmia"upraventricullar arrhytmia =?D=?D C+=F?C+=F?


39/43


"+#+2"+#+2 Semeste!Semeste!**

+ , - .ln+ , - .ln

Semeste!Semeste!//

- , */ .ln- , */ .ln

Semeste!Semeste!00

*/ , *1*/ , *1.ln.ln

Semeste!Semeste!22

*1 , /2*1 , /2.ln.ln

ami&rilami&ril ;;

2lace&o2lace&o ;; ;;

Cost Effectiveness ;nal/sis of ami.rilCost Effectiveness ;nal/sis of ami.ril


40/43

Cost Effectiveness ;nal/sis of ami.rilCost Effectiveness ;nal/sis of ami.ril

#ost#ostTotal &iayaTotal &iaya

yangyang

di&utuh3andi&utuh3an

untu3untu3

mela3sana3mela3sana3

an programan program

E5ectivitaE5ectivitassHasil yangHasil yang

diperolehdiperoleh

3arena3arena

intervensiintervensi

programprogram

RasioRasio' % E' % E

* L = 1* L = 1

4amipril4amipril && && &&

2lace&o2lace&o && && &&



41/43


K# B:;


42/43


;';=:&:& B:;


43/43

Cost ModelingCost Modeling (?)(?);&:%;&:%

"+#+2"+#+2 CostCost

MinimizatiMinimizationon

AnalysisAnalysis

CostCost

BeneftBeneftAnalysisAnalysis

CostCost

EectivenesEectivenesss

AnalysisAnalysis

CostCost

UtilityUtilityAnalysisAnalysis

4amipril4amipril

&&

2lace&o2lace&o &&

ramipril.aventis

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