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RCT > economic evaluation > Flashcards

economic evaluation Flashcards

1
Q

Why economic evaluations?

A
  • mainly efficiency arguments: does it provide value for money to implement a certain intervention?
  • resources for healthcare are scarce, so we need to make choices!
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2
Q

definition economic evaluation

A
  • a systematic comparison of the costs and effects of two or more treatments –> do costs weigh up the extra benefits? –> Is intervention the best way to spend our money?
  • not necessarily the cheapest, but “best value” –> it is okay to pay more if additional benefits way up additional costs
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3
Q

what do we need to measure in an economic evaluation?

A
  1. costs

2. effects

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4
Q

what is the aim in economic evaluations?

A

informing resource allocation decisions/ healthcare policy makers, more interested in effectiveness (than efficacy)

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5
Q

4 types of economic evaluations

A
  1. cost-minimization analysis
  2. cost-effectiveness analysis
  3. cost-utility analysis
  4. cost-benefit analysis
    - -> determined by effect outcome that you look at
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6
Q

cost-minimization analysis

A
  • we assume that effects equal (but also clinical relevant equally?)
  • identification of intervention with lowest costs
  • strictly speaking not a full economic evaluation: because we don’t look at outcomes
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7
Q

cost-effectiveness analysis

A
  1. disease specific outcome measures
  2. life-years gained
  3. quality of life
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8
Q

cost-effectiveness analysis

1. disease specific outcome measures

A

e. g. severity of depressive symptoms
- no comparison possible with other disorders
- relevant for health care providers

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9
Q

cost-effectiveness analysis

2. life-years gained

A
  • hard to measure
  • follow-up is not until you die
  • we don’t expect that anxiety or a lot of other disorders contributes to life expectancy
  • possible to compare all interventions that aim to extend life
  • health has 2 aspects: duration and state
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10
Q

cost-effectiveness analysis

3. quality of life

A
  • functioning, wellbeing, mental and physical, vitality… –> includes multiple domains
  • when does a person improve? (some domains improved, some got worse, some stayed the same)
  • hard to say
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11
Q

cost-utility analysis

A
  • effects expressed in quality-adjusted life-years
  • QALY= number of years in perfect health
  • combination of quality and quantity of life
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12
Q

QALY graph

A

y-axis: QoL = death, 1 = perfect health

x-axis: duration of life (years)

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13
Q

QALY advantages

A
  • not disease specific
    • relevant for health care policy makers
    • comparisons possible between all kinds of disorders and treatments
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14
Q

QALY Formel

A

QALY = V(Q) * Y

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15
Q

QALY negative values

A
  • QoL is so bad, that you’d rather be dead
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16
Q

measuring utilities

A
  • profiles rated by society (large sample!) to determine coefficients
  • not by individuals themselves, because they may overestimate or underestimate the impact & whole society pays (we are all potential patients)
  • EQ-5D-5L questionnaire filled out by patient
  • -> compare baseline vs. after e.g., 3 mo with intervention
17
Q

EQ-5D-5L

A
  • often used questionnaire –> patients indicate their QoL
  • 5 domains:
    1. mobility
    2. self-care
    3. pain/ discomfort
    4. anxiety/ depression
    5. ability to do usual activities
  • -> how are the changes/decrements rated by society?
18
Q

cost-benefit analysis

A
  • effects expressed in monetary units
    • benefits > costs?
    • difficult to put a money value on health: how much money would you be willing to pay for 1 recovered patient extra?
19
Q

2 types of economic evaluations

A
  1. mathematical model

2. conducted alongside an RCT (“Piggyback” design)

20
Q

choice of comparator treatment

A
  • primarily aimed at informing health care decision makers
  • control should be an implemented treatment in actual current practice
  • usual care
  • standard care
  • most commonly used treatment (can be no treatment)
  • placebo is not a good comparator (you don’t use it in usual care and you might overestimate the effects of your treatment)
21
Q

choice of perspective

A
  • which cost categories should be included:
    1. society
    2. health care insurer
    3. health care provider
    4. patient
    5. company
    …
22
Q

choice of perspective: societal perspective

A
  • standard

- all costs and benefits are taken into account regardless of who pays or benefits

23
Q

more choices to make if you want to do economic evaluation alongside RCT

A
  1. time horizon should be long enough to capture full consequences of the intervention (end point of interest& consequences)
  2. patients typical of the normal caseload are enrolled (resemble patients that you see in practice)
  3. physicians and patients are not blinded (not done it practice)
  4. patients are followed under routine conditions (no extra blood tests etc.)
  5. effectiveness rather than efficacy
24
Q

cost categories

A
  1. health care costs –> costs within the formal healthcare sector
  2. patient costs –> costs paid by patients themselves
  3. lost productivity costs
  4. other costs
    - medical costs in life-years gained
    - costs of special schools
    - justice and police costs
    - … –> depending on situation and population
25
Q

healthcare costs

A
  • generally include costs that are reimbursed by the health care insurer, e.g. GP, laboratory tests, psychologist, medication …
26
Q

patient costs

A
  • costs that patients pay for themselves. e.g. complementary medicine, informal care, time and travel costs
27
Q

lost of productivity costs

A
  • days absence from paid work
  • being present at work but not fully productive
  • hours of being unable to perform daily activities, e.g. housekeeping, study or voluntary work
28
Q

other costs

A
  • medical costs in life-years gained, measurement impossible, so estimation necessary, only relevant in interventions that extent life or in prevention programs
29
Q

cost diary

A
  • often filled out retrospectively
  • -> not so accurate
    now: questionnaires: how many times did you visit the GP? etc.
    balance: number of questionnaires, length of recall periods
30
Q

how to value resource use

A
  • if available: standard costs
  • list of costs available in a lot of countries
  • cost price calculations are very time-consuming (only done for large impact items)
31
Q

ICER

A

= Incremental Cost-Effectiveness Ratio = incremental costs per incremental unit of effect

= Costs intervention- costs control/ effects interventions - effects control

32
Q

ICER be aware

A
  • only the ICER does not give enough information!
  • information needed on size and direction of cost and effect differences (can be more expensive and more effective but also less expensive and less effective)
33
Q

Interpretation ICER

A

… to gain 1 QALY in the intervention group …Euros needs to be invested in comparison with the medication group

34
Q

cost-effectiveness plane

A 
y-axis: incremental costs
x-axis: incremental effects
4 quadrants:
1. low right: dominant
2. up left: dominated
3 and 4. : Trade-off: Are the additional effects worth the extra costs? Are we willing to trade off some effects to save money? 
--> you plot ICER in the plane
35
Q

When is an intervention considered cost-effective in comparison with the control treatment? decision rule

A

ICER < maximum amount of money society is willing to pay per uni or effect extra (ceiling ratio)

36
Q

What should the ceiling ratio be?

A
  • as we increase the ceiling ratio, the proportion of dots in the cost-effectiveness area increases too –> probability of cost-effectiveness increases
37
Q

cost-effectiveness acceptability curve

A
  • shows the probability that an intervention is more cost-effective than its comparator for different ceiling ratios
  • represents the decision uncertainty in cost-effectiveness analysis by showing the decision-maker the probability they have made the wrong decision if they decide to adopt a particular intervention
  • -> the more value of ceiling ratios, the higher probability of cost-effectiveness

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