Clarifying health gains and losses when communicating cost-effectiveness analysis

1. Clarifying health gains and losses when communicating cost-effectiveness analysis Rita Faria, MSc Centre for Health Economics University of York, UK @RitaINdeFaria #communicateCEA #iHEA2019

2. Acknowledgements Thank you to Jessica Ochalek and James Lomas for insightful discussions on their work on the marginal productivity of the health care service and how to explain cost-effectiveness thresholds to wide audiences. For more details on the work on the estimation of the marginal productivity of the health care service, see https://www.york.ac.uk/che/research/teehta/health-opportunity-costs/ The PREVAIL project is a collaboration between the University College London, University of Liverpool, University of York among others. It is funded by the National Institute for Health Research (NIHR) HTA Programme 12/167/02. The views expressed here are mine and not necessarily those of the NIHR or the Department of Health and Social Care. For more details on the PREVAIL project, see http://prevailtrial.org.uk/

3. How to decide on SW interventions?The rational economist approach • Cost-effectiveness decision rule: approve if gains > losses • Application to south-west quadrant: • Losses: health (or other) lost directly from the new intervention. • Gains: health (or other outcomes) gained indirectly from using the cost savings to invest in other intervention/services/technology. • How to convert from cost to health? • Marginal productivity of health care (or other) systems • Consumption value of health (willingness to pay)

4. If it is so obvious…Why is there a problem? Could we explain our findings in a better way?

5. We’re used toadditional cost per unit of benefit gained CEA started with drugs Drugs approved only if evidence of benefit Decision rule always in NE/SE quadrant

6. The scope of CEA has expanded…well beyond new & better drugs

7. Framing effect on the specific choice X compared to Y results in $$$ saved per unit of health lost in people with Z Framing effect on loss of health Framing effect the target population What about the gains?

8. We now know what are the gains from the cost savings

9. Interactive tool https://www.york.ac.uk/che/research/teehta/health-opportunity-costs/estimating-health-opportunity-costs-for-lmics/

10. Saying the same… in a different wayCPT vs no CPT*  0.14 DALYs avoided • Net health benefit = 0.11 DALYs avoided Communication is essential for stakeholders to engage with the policy *Illustrative calculations based on published results. • ICER of No CPT vs CPT = $631/DALY per person • Cost saving=$20 • Health lost=0.03 DALY added • Marginal productivity of Ugandan HC = $133/DALY averted

11. For the UK NHS,we can predict on whom the health losses fall* *Illustrative calculations based on published results. http://www.eepru.org.uk/wp-content/uploads/2017/11/eepru-report-implementation-of-hep-c-drugs-scoping-study-may-2015-046.pdf https://www.york.ac.uk/che/research/teehta/health-opportunity-costs/

12. and health gains from cost savings • 8 weeks vs 12 weeks treatment* • Saves £8,090 per patient • Reduces health by 0.02 QALYs per patient • NHB=0.6 QALYs per patient • At the population level, NHB=25,000 QALYs in the population *Illustrative calculations based on published results. http://www.eepru.org.uk/wp-content/uploads/2017/11/eepru-report-implementation-of-hep-c-drugs-scoping-study-may-2015-046.pdf https://www.york.ac.uk/che/research/teehta/health-opportunity-costs/ https://doi.org/10.1016/j.jval.2018.12.011

13. Can we explain CE results better?Some ideas The new treatment is cost-effective if it improves health per dollar spent to a greater extent compared to what we already have. Conversely The new treatment is cost-effective if it releases funds that we can use for other treatments and the health benefits from these treatments more than offset any losses. Tell me your ideas! #communicateCEA

14. Is it not as obvious as we may think? Do stakeholders understand our methods?

15. CEA to inform resource allocation decisions • A CEA needs to consider • Direct and indirect effects on outcomes and costs • Intervention and relevant comparators • Target population • How? • Evidence • Uncertainty • Opportunity cost

16. Pitfalls in CEAPrevention of infection in preterm babies (the PREVAIL project) Within-trial analysis? Added cost per infection averted? Cost saving per additional infection? What would that mean?

17. The PREVAIL CEAModel conceptualisation Other causal paths Observed +infection with PICC? Necrotising enterocolitis Infection Baby Uncertainty +Impairment? +Impairment? Observational evidence Neurodevelopment impairment Uncertainty Poorer outcomes in the long-term Higher costs Modelled Manuscript under revision; for more information see: https://tools.ispor.org/research_pdfs/60/pdffiles/PMD96.pdf

18. Our mission, if we choose to accept it Traditional focus Our new challenge To conduct CEAthat can inform resource allocation decisions To communicate CEAin a way that is clear, lay-friendly and intuitive

19. Thank you! For more on my thoughts about communication of CEA: Rita Faria, MSc Centre for Health Economics University of York, UK @RitaINdeFaria #communicateCEA //aheblog.com/2019/06/12/how-to-explain-cost-effectiveness-models-for-diagnostic-tests-to-a-lay-audience/