what is the relative importance of cost-effectiveness information? results from a discrete choice...
TRANSCRIPT
What is the relative importance of cost-effectiveness information?
Results from a Discrete Choice Experiment among Swedish medical decision makers.
Sandra Erntoft (PhD)Project Manager
The Swedish Institute for Health Economics (IHE)
P.O. Box 2127, 220 02 Lund
+46 46 32 91 21
www.ihe.se
Background
• Previous research suggests that the relative importance of cost-effectiveness information varies between reimbursement-, formulary-, and prescribing - decisions.
• Little research has, however, investigated all three priority setting context simultanously…
• …and often used different methodologies and methods to investigate this question.
• Does the potential differences in the importance influence the threshold values of cost per QALY?
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Purpose
The purpose of the experiment was to investigate the relative importance of cost-effectiveness information (cost/QALY) compared with four other criteria;
• health status,• expected size of medical effect,• type of medical effect,• budget impact,
AND
which values of a QALY are acceptable to the TLV, formulary committees and prescribing physicians?
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Methods
• A sample of 996 questionnaires (TLV 53; formulary committee members 362; physicians 581).
• Previous study (Johnson & Backhouse 2006) and focus group consisting of 5 senior experts).
• 5 criteria – three reflecting need and two economics - 3 levels each.
• Two questions; A (ranking – ”forced choice”) and B (decision) in order to identify threshold values.
• 243 possible combinations or approx. 29 000 questions – main effects only + division into three blocks.
• Orthogonal design – iterative computer search algorithms in order to maximize D-efficiency.
• Conditional logit models.
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Example of a D C question directed towards the TLV
Criteria Treatment A Treatment B
The average health status in patient population
High degree of pain/discomfort
Low degree of pain/discomfort
Type of medical effect Increased QoL Life-sustainment
Expected size of medical effect (effectiveness)
Avoid loss of 1 QALY Avoid loss of 0.2 QALY
Cost per QALY 102 000 € 28 000 €
Budget Impact 280 000 € per 100 000 inhabitants
18 600 € per 100 000 inhabitants
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A) Which treatment is better? (A is better, B is better)
B) Which treatment do You think TLV should reimburse? (A, B, both A and B, neither A or B)
Formulas
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A question (ranking):
Uij=αpain*PAIN+αtype_eff*TYPE_EFF+αQALYgain*QALY_GAIN+αcost/QALY*COST_QALY+αbudg.imp.*BUDG_IMP
B question (decision):
Vij=βpain*PAIN+βtype eff* TYPE_EFF+ β QALYgain*QALY_GAIN+ β cost/QALY*COST_QALY+ β budg.imp.*BUDG_IMP
Descriptive statistics
TLV Form. Com. Physicians
Age (mean) 52,2 54,9 47,3
Sex ( % males) 78 62 43
Education:PhysicianEconomistLawyerPharmacistOther/no answer
255000
25
86002
12
83N/aN/aN/a17
HE education (% yes) 58 35 12
Budget/ Operational responsibility (% yes) N/a 22 23
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Response rate: 21 %
Result 1: Relative importance when ranking pharmaceutical treatments
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Result 2: Relative importance when making a decision
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Result 3: Cost-effectiveness threshold values
• 41 cases of statistically significant differences between decision makers.
• In 28 cases the cost-effectiveness threshold values were lower rated by the TLV, than by formulary committee members and prescribing physicians.
Cost per QALY• TLV: Lowest 43 600 € ; Highest 107 500 €.• Formulary committees: Lowest - 5 400 € ; Highest 304 200 €• Physicians: Lowest 4 900 € ; Highest 240 800 €.
1€ = 10,75 SEK (December 2009) ~ 1.3 U.S. $
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Discussion
• Cost-effectiveness information more important in reimbursement- than in formulary- and prescribing- decisions. Confirms results from previous research.
• Threshold values are lower in reimbursment- than in formulary- and prescribing decisions. Can this be explained by differences in educational backgrounds?
• Higher threshold values in Sweden than in for instance the Netherlands.
• Willingness to reimburse (WTR) rather than willingness to pay (WTP) – social utilities rather than individual utilities.
• The WTR is based on the relative value of the public program (the treatment option rejected) foregone.
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Conclusions
• Both the relative importance of cost-effectiveness information and the threshold values of the cost/QALY varies between decision makers at national, regional and local level.
• The relatively high threshold values among formulary committee members and prescribing physicians may be a sign of a lack of social learning regarding the necessity of setting priorities due to scarce resources….
• …or a result of the fact that priority setting is more difficult the closer the decision maker is to the patient.
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