![ICUR
Incremental Cost Utility Ratio
• ICUR = [Cost A – Cost B] / [QALY A – QALY B]](https://image.slidesharecdn.com/catedral-costutilityanalysis-191202215200/75/Cost-Utility-Analysis-26-2048.jpg)
![ICER
• ICER = [Cost A – Cost B] / [QALY A – QALY B]
Incremental Cost Effectiveness Ratio](https://image.slidesharecdn.com/catedral-costutilityanalysis-191202215200/75/Cost-Utility-Analysis-35-2048.jpg)
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Cost Utility Analysis
- 1. Cost Utility Analysis Dr.Lance I. G. Catedral T: @lanceoncology E: [email protected]
- 2. Mark 8:36, KJV “Forwhat shall it profit a man, if he shall gain the whole world, and lose his own soul?” A new chemo drug? A new screening modality? A new surgical technique? Physicians
- 3. Cost Utility Analysis •special form of cost-effectiveness analysis • costs per unit of utility are calculated • compares cost and benefits, where benefits = number of life years saved, adjusted for loss of quality • anti-retrovirals vs polio vaccination • osimertinib vs afatinib as first line treatment for lung cancer • combines length and quality of life
- 4. When is CUAused? • quality of life is the important outcome • the program affects both morbidity and mortality • the programs being compared have a wide range of outcomes • one of the programs being compared has already been evaluated using CUA
- 5. • Useful forpolicy makers and reimbursement agencies • “Cost-effective if: • UK: £30K per QALY gained • USA: $50K per QALY gained • WHO: ICER < 3x per capita gross domestic product for a given country Adapted from: Mohammed, Pharmacoeconomics: Cost utility analysis. https://www.slideshare.net/mameclinical/ pharmacoeconomics-cost-utility-analysis?qid=082f5261-353f-4e89-8dcf-2b557e7719c1&v=&b=&from_search=1
- 6. When NOT touse CUA • Only have intermediate outcome data • Effectiveness data show outcomes are equivalent • Effectiveness data show dominance
- 7. Utility • “measure ofthe preference for, or desirability of, a specific level of health status or specific health outcome • not “usefulness” • also: “preference weights” • quantitative approach for describing preferences for quality of life • based on 0 to 1 scale • 0 = death • 1 = perfect health Measurable, quantifiable, and analyzable
- 8. Response method Question type Certainty (“value”) Uncertainty (“utility”) ScaleRating scale Choice Time trade-off Standard gamble
- 9. Standard gamble Example ofthe standard gamble Explanation As with the time trade-off method, utilities for states of health can be de- Complete healthAlternative 2: uncertain outcome Alternative 1: certain outcome Death Limited health 95% 5% 100% gamble on the alternatives, complete recovery or death. The probabilities between the two alternatives are varied until the patient is indifferent to both alternatives.
- 10. “Imagine you havebreast cancer stage III. Suppose there is a surgery that can potentially cure your cancer, but there is a risk for death. How low does the probability of death have to be for you to be indifferent between having breast cancer stage III and the gamble of taking the surgery which can lead to death or cure?”
- 11. Standard gamble Example ofthe standard gamble Explanation As with the time trade-off method, utilities for states of health can be de- Complete healthAlternative 2: uncertain outcome Alternative 1: certain outcome Death Limited health 95% 5% 100% gamble on the alternatives, complete recovery or death. The probabilities between the two alternatives are varied until the patient is indifferent to both alternatives. Alternative 1: Breast cancer Alternative 2: Breast cancer + surgery Limited health (living with cancer) 85% 15% Complete health (cancer remission or cure)
- 12. Standard gamble • Goldstandard in utility elicitation • respondent must choose between two options • living with below-optimal health • a lottery between two uncertain health states • Limitations • time-consuming • cognitively difficult for many people
- 13. Time trade-off The timetrade-off method Explanation Time trade-off is a method of deriving utility values that can be used in 1.0 Alternative 2 Time Alternative 1 hi 0 x t choose between a period that is spent in a specific state of health and a (shorter) period in perfect health, until they are indifferent to both peri- ods of time.
- 14. “Imagine you havebreast cancer stage III and you have a life expectancy of 10 years. How much of your remaining life expectancy would you give up to eliminate breast cancer so you have perfect health?”
- 15. The time trade-offmethod Explanation Time trade-off is a method of deriving utility values that can be used in 1.0 Alternative 2 Time Alternative 1 hi 0 x t choose between a period that is spent in a specific state of health and a (shorter) period in perfect health, until they are indifferent to both peri- ods of time. Cured of breast cancer stage III Breast cancer stage III 10 y
- 16. Rating scale 0 Best possible state 50100 Worst possible state
- 17. Rating scale • Doesnot involve trade offs • Simple, easy to administer • Ordinal, not an interval scale
- 18. QALY weights Source ExamplesDisadvantages Literature Individual studies CUA databases Lack of comparability Indirect measures EQ-5D-5L EORTC QLQ-C30 FACT-G Only common diseases Direct measures Expert panel Special sample survey Expense Time Representation
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- 20. QALY • Quality-Adjusted Life-Years •number of years of perfect health • calculated by estimating the total life-years gained from a treatment and weighing each year with a quality-of-life score (from 0, representing worst health, to 1 or 100, representing best health) to reflect the quality of life in that year. •
- 21. QALY’s advantage overCEA • combines more than one measure of effectiveness • mortality + morbidity in one single measure
- 22. Determining QALYs usingthe example of dialysis and kidney transplants Explanation Initial situation Death Dialysis Kidney transplant Full health 1 0 Life expectancy (years) Qualityoflife(standardised) Area A: QALYs lost Area B: QALYs gained A B Surgery Lumpectomy + RT
- 23. QALY • Dapat angyears of life, may quality! • Example: If a treatment prolongs the remainder of the patient’s life by an average of 3 years and the quality of life is 0.5 on a scale of 0 (= poorest state of health) to 1 (= best state of health) • The number of QALYs is 3 × 0.5 = 1.5, without discounting. Photo credit: Dr. RE King
- 24. Exercise • In yourhospital in Cavite, you have been using chemo A as standard of care. Chemo A prolongs life by 1 year but reduces the quality of life of your patients due to its side effects. The new chemo B prolongs life by 1.5 years at estimated utility value of 0.5. Calculate the QALY for chemo A and chemo B. • Chemo B (standard) • Life expectancy = 1. 5 y • Utility = 0.5 • QALY = 1.5 x 0.5 = 0.6=5 years • Chemo A adds 0.75 QALY to the patient’s life • Chemo A (standard) • Life expectancy = 1 y • Utility = 1–0.35=0.65 • QALY = 1 x 0.65 = 0.65 years • Chemo A adds 0.65 QALY to the patient’s life
- 25. League tables Extract froma league table Explanation Measures Current cost of an additional QALY (pounds sterling; 1985 prices) Fitting a pacemaker 700 Hip replacement 750 Heart transplant 5000 Haemodialysis in hospital 14000 Source: Briggs A, Gray A. Using cost effectiveness information. BMJ 2000; 320: 246. Brief definition League tables rank medical treatments according to their relative cost:utility ratios as a guide to resource-allocation decisions. In this way, conclusions can be drawn about which healthcare services should be given preference if resources are tight (or which procedures should be removed from the programme of services). l • Cost:utility ratios (CUR) • Used for allocating health resources with a limited budget
- 26. ICUR Incremental Cost UtilityRatio • ICUR = [Cost A – Cost B] / [QALY A – QALY B]
- 27. Exercise • In yourhospital in Cavite, you have been using chemo A as standard of care. Chemo A prolongs life by 1 year but reduces the quality of life of your patients due to its side effects. The new chemo B prolongs life by 1.5 years at estimated utility value of 0.5. Calculate the QALY for chemo A and chemo B. • Suppose a full course of treatment costs are as follows: • $1,200 for chemo A • $1,500 for chemo B • Calculate ICUR.
- 28. • ICUR = 1500– 1200 0.75 – 0.65 cost of chemo B – cost of chemo A QALY chemo B – QALY chemo A • ICUR = = 3000 per QALY On the average, it costs $3000 to add one year of perfect health onto the life of the patient if chemo B is used
- 29. DALY • Disability-Adjusted Life-Years •indicator developed to quantify the global burden of disease • calculated by adjusting a standard life expectancy for loss of healthy life resulting from disability and premature death • scale: 0 = perfect health, 1 = death • adjusts for time and age preferences
- 30. DALY YLL (years of lifelost)= N x L where N is number of deaths, L is standard life expectancy at age of death YLD (years of life lived with disability)= I x DW x L where I is incidence, DW is disease weight (0 = perfect health, 1= dead), L is average disease duration +
- 31. DALY • Useful in: •defining burden of disease • evaluating interventions and programs • setting health service and research priorities
- 32. Murthy et al.Disability Adjusted Life Years for Cancer Patients in India. Asian Paci c Journal of Cancer Prevention, Vol 11, 2010 .
- 33. DALY: criticisms • Dataused to estimate DALY are inadequate • DALYs used standardized maximum life expectancies • may not be true for the developing countries • Preferential treatment: young adults > infants or elderly; present generations > future ones • Obscures too much information for resource allocation
- 34. Cost Utility AnalysisTheadditional quality of life and years of life gained with two alternative treatments Explanation Time QALYs lost through B QALYs won through B Treatment A Treatment B Utility(e.g.QALYs) being) are calculated. The most commonly used unit of utility is quality- adjusted life-years (QALYs). The additional costs of a treatment are compared with the utility gained as a result of the treatment (e.g. cost per QALY).
- 35. ICER • ICER =[Cost A – Cost B] / [QALY A – QALY B] Incremental Cost Effectiveness Ratio
- 36. Cost-effectiveness of Osimertinibin the First-Line Treatment of Patients With EGFR-Mutated Advanced Non–Small Cell Lung Cancer Pedro N. Aguiar Jr, MD, MSc; Benjamin Haaland, PhD; Wungki Park, MD; Pui San Tan, MPharm, PhD; Auro del Giglio, MD, PhD; Gilberto de Lima Lopes Jr, MD, FAMS, MBA IMPORTANCE The survival of patients with advanced non–small cell lung cancer (NSCLC) with epidermal growth factor receptor (EGFR) gene mutations has improved substantially in the last decade with the development of targeted tyrosine kinase inhibitors (TKIs). Osimertinib, a third-generation TKI that is approved by the US Food and Drug Administration for the treatment of patients who develop EGFR T790M mutations, has recently shown improved clinical outcomes compared with gefitinib and erlotinib for treatment-naive patients. Supplemental content Research JAMA Oncology | Original Investigation JAMA Oncology, 4(8), 1080. doi:10.1001/jamaoncol.2018.1395
- 37. Summary of resultsand findings • Is osimertinib a cost-effective first-line therapy for treatment-naive, epidermal growth factor receptor gene (EGFR)-mutated, non–small cell lung cancer? • Results: • Incremental QALY gained with osimertinib versus 1st and 2nd generation TKIs: 0.594 • US: Incremental cost per QALY → $225,000; in Brazil, $172,000. • Not cost-effective either in the US or Brazil • cost-effective if cost is $12,5000 in US and %3000 in Brazil
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