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Sandra Erntoft (PhD) Project Manager The Swedish Institute for Health Economics (IHE)

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.

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Sandra Erntoft (PhD) Project Manager The Swedish Institute for Health Economics (IHE)

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  1. 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

  2. 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?

  3. 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?

  4. 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.

  5. Example of a D C question directed towards the TLV 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)

  6. Formulas 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

  7. Descriptive statistics Response rate: 21 %

  8. Result 1: Relative importance when ranking pharmaceutical treatments

  9. Result 2: Relative importance when making a decision

  10. 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. $

  11. 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.

  12. 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.

  13. Thank you for your attention! • Sandra Erntoft • Email: Sandra.Erntoft@ihe.se • Phone: +46 46 32 91 21

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