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Aantekeningen alle lectures Economic Evaluation

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Economic Evaluation

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Vrije Universiteit Amsterdam (VU)

Aantekeningen van alle lectures van Economic Evaluation jaar . Alle powerpoints en overige aantekeningen zijn hierin verwerkt en soms ook nog wat literatuur. Met deze aantekeningen een 8.1 gehaald voor het tentamen.

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Tentamen economic evaluation
28 oktober 2022
Lectures – Gray (Applied Methods of Cost-effectiveness Analysis in Healthcare) – articles
_________________________________________________________________________
Lecture 1 – General principles of economic evaluation
Learning objectives:
- The student is able to describe the role of economic evaluations in healthcare decision
making.
- The student is able to define the various kinds of economic evaluations and to choose the
appropriate kind of economic evaluation to answer a certain research question.
- The student is able to formulate an appropriate research question for an economic
evaluation.
- The student is able to choose between a trial-based or model-based economic evaluation.
- The student is able to explain why it is important to perform a pragmatic trial when
evaluating the cost-effectiveness of an intervention.
- The student is able to describe and explain important design aspects of economic
evaluations.

Common used terminology
CEA = cost-effectiveness analysis
CUA = cost-utility analysis
CMA = cost- minimization analysis

Why economic evaluation?
1. Scarcity (available resources are never sufficient to allow all available health interventions to
be provided)
2. Choices (how can scarce health recourses best be used in order to maximise the health gain
obtained from them?)

Choices need to be made
- The health care market is not equal to the competitive market
- There are three fundamental sources of inefficiency
1. Lack of price discipline on the side of consumers
2. Information asymmetry between privders and consumers
3. Health is not a choice (when in need, you cant choose to have health or not)
- The prices in healthcare are no reflection on scarcity of money
- Decision making based on cost relative to benefits = economic evaluation

The basic question of economic evaluation
Is the service or programme worth doing compared with other things we could do with the same
resources?
OR
Do the extra costs weigh up to the extra benefits?

,Economic evaluation is a comparison of alternative options in terms of their costs and consequences
(NOT: what is the cheapest option)
- Two or more options can be compared and two dimensions along which to compare them
(cost and consequenses)
- Is interested in joint distribution of costs and effect differences

With an economic evaluation two quantities are used: costs and effects. With these two quantities an
ICER (incremental cost-effectiveness ratio) can be calculated:

There are 4 types of different economic evaluations
1. Cost-minimization analysis effects considered equal
2. Cost-effectiveness analysis disease-specific effects
3. Cost-utility analysis quality adjusted life years
4. Cost-benefit analysis effects expressed in monetary value

The aim of economic evaluations in health policy is to maximize health from available recourses.
Most decisions are based on coverage or reimbursement of treatments.

An intervention is accepted is the ICER is beneath the threshold. Examples are:
- UK: £20.000 - £30.000 per QALY gained
- US: $20.000 per lifeyear gained, $50.000 per QALY gained
- NL: €10.000 - €80.000 per QALY gained

BUT, an ICER is a poor predictor of decision making. Examples of inconsistencies are:
- Viagra: cost-effective but not reimbursed
- Lung transplantation: reimbursed but not cost-effective

Economic evaluation in clinical trials
Used as a ‘’piggyback’’ study (adding collection of economic data to a clinical trial)
Advantages are:
- Experimental design
- Prospective, patient level data
- Efficient use of resources available for scientific studies
Differences:
Aim of clinical trial: demonstrate safety/efficacy in a highly controlled environment
Aim of economic evaluation: informing recourse allocation decision (outcomes/cost in actual clinical
practice)

,Pragmatic trial (Pragmatic trials are designed to evaluate the effectiveness of interventions in real-life
routine practice conditions)
- Clinical trial vs economic evaluation (pragmatic/naturalistic trial design to improve the
generalisability of the results)
- Pragmatic trial: description of the costs and outcomes of an intervention when prescribed by
practicing physicians to real patients in actual clinical practice

Study design issues in a pragmatic trial are:
- Protocol-driven care
o Resource consumed for trial purposes that would not typically be consumed in
standard clinical practice
 Increased recourse consumption (recourse consumption in trials deviates
from that in clinical practice  more frequent and intensive physician visits,
tests and treatment AND to monitor clinical outcomes and side effects)
 Case finding (discovery of a previously undetected condition during a
protocol-mandated visit or diagnostic test (frequent monitoring and use of
gold standard measurement of outcomes)
 Patient compliance (therapietrouw)
- Blinding (how do you blind GP’s?): patients and providers do not have knowledge of the
treatment group to which patients have assigned (all study subjects receive the same tests
and services)
- Study population (patients carefully selected to minimize biological variation and highlight
the treatment effect)
o With economic evaluation: patients representative of the target population including
those with severe symptoms, comorbidity or risk factors effect
- Study sites (institutions and physicians should be representative of the totality)
- Comparator (the choice of comparator treatment, for example: usual care, standard care,
most commonly used treatment)
- Time horizon: should be long to capture the full consequences of the intervention
o Health effects and costs
o Often lifetime
o Intermediate versus final outcomes (blood pressure vs heart attack)
Follow up often terminated when the participant reaches a predetermined endpoint,
however, there may be important costs associated with reaching such an endpoint.
Follow up until the end of the follow-up period.

Summary
- Resources available for health care are scarce
- Prices do not reflect scarcity on a health care market
- Economic evaluations can inform resource allocation decisions
- But this has important consequences for the design of these studies

Addition (Gray chapter 2)
Economic evaluation can be defined as a comparison of alternative options in terms of their costs
and consequences. There are two (or more) options to compare and two dimensions (costs and
consequences) along which to compare them.

Methods of economic evaluation
1. Cost-consequence analysis (report the cost and consequences of two interventions and
calculate them disaggregated and leave the interpretation to decision-makers)

, Cost consequence analysis shifts the burden of interpretation and synthesis onto the
decision-maker and assume that users can reliably and consistently process such information
2. Cost-minimization analysis
Both costs and health outcomes or consequences are of interest, but in this case it is
assumed that the health outcomes of two or more options are identical, and so the option
that has the lowest costs will be preferred: the objective has become minimization of cost.
3. Cost-effectiveness analysis
First the costs and effects of an intervention and one or more alternatives will be calculated,
then calculate the differences in cost and differences in effect and finally present these
differences in the form of a ratio (ICER).
4. Cost-utility analysis
The QALY attempts to capture in one metric the two most important features of a health
intervention: its effect on survival measured in terms of life-years, and its effect on quality of
life.
5. Cost-benefit analysis
Attempt to place some monetary valuation on health outcomes as well as on health care
resources. However, a cost-effectiveness analysis is preferred. Firstly because there is a
aversion to the concept of placing explicit monetary values on health or on life and secondly
because of the human capital approach and the willingness to pay approach,

Incremental means grow  incremental costs-effectiveness ratio is defined as the difference in costs
between two alternatives divided by the difference in effects.

Interventions can be measured on averages, which is compared to basic care or no care OR
Interventions can be measured incremental, which is compared to the next best alternative

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