Cost-effectiveness analysis of implementing an integrated neonatal care kit to reduce neonatal infection in rural Pakistan

ObjectiveTo evaluate the cost-effectiveness of distribution of the integrated neonatal care kit (iNCK) by community health workers from the healthcare payer perspective in Rahimyar Khan, Pakistan.SettingRahimyar Khan, Pakistan.ParticipantsN/A.InterventionCost-utility analysis using a Markov model based on cluster randomised controlled trial (cRCT: NCT 02130856) data and a literature review. We compared distribution of the iNCK to pregnant mothers to local standard of care and followed infants over a lifetime horizon.Primary and secondary outcome measuresThe primary outcome was incremental net monetary benefit (INMB, at a cost-effectiveness threshold of US$15.50), discounted at 3%. Secondary outcomes were life years, disability-adjusted life years (DALYs) and costs.ResultsAt a cost-effectiveness threshold of US$15.50, distribution of the iNCK resulted in lower expected DALYs (28.7 vs 29.6 years) at lower expected cost (US$52.50 vs 55.20), translating to an INMB of US$10.22 per iNCK distributed. These results were sensitive to the baseline risk of infection, cost of the iNCK and the estimated effect of the iNCK on the relative risk of infection. At relative risks of infection below 0.79 and iNCK costs below US$25.90, the iNCK remained cost-effective compared with current local standard of care.ConclusionThe distribution of the iNCK dominated the current local standard of care (ie, the iNCK is less costly and more effective than current care standards). Most of the cost-effectiveness of the iNCK was attributable to a reduction in neonatal infection.

Estimating Cost-Effectiveness Thresholds Under a Managed Healthcare System: Experiences from Colombia

Like most of the world, low- and middle-income countries have faced a growing demand for new health technologies and higher budget constraints. It is necessary to have technical instruments to make decisions based on real-world evidence that allows maximization of the population’s health with a limited budget. We estimated the supply-based cost-effectiveness elasticity, which was then used to determine the cost-effectiveness threshold for the healthcare system of Colombia, a middle-income country where multiple insurers, paid under capitation rules, manage the compulsory contributions of the citizens and government subsidies. Using administrative data, we explored the variation of health expenditures and outcomes at the insurer, geographical region, diagnosis group, and year levels. To deal with endogeneity in a two-way fixed-effects model, we instrumented health expenditures using characteristics of the health system such as drug-price regulation. We estimated the threshold to be US$ 4487.5 per YLL avoided (14.7 million COP at 2019 prices) and US$ 5180.8 per QALY gained (17 million COP at 2019 prices), around one times the GDP per capita. To our knowledge, this is the first estimation of the cost-effectiveness threshold elasticity supply-based in a middle-income country with a managed care health system.

PP451 Does NICE Reimburse Oncology Treatments Meeting End-Of-Life Criteria More Often Than Treatments That Do Not?

IntroductionThe National Institute of Health and Care Excellence (NICE) issued a supplementary advice in 2009 stating that treatments for patients with short life expectancies (<24 months) can exceed the cost-effectiveness threshold of GBP30,000 (EUR34,668) per additional quality-adjusted life-year (QALY), as long as the treatment is indicated for small patient populations and there is sufficient evidence that it extends life (≥ three months), compared with current National Health Service (NHS) treatments. This study investigated how often NICE reimburses treatments that meet end-of-life (EOL) criteria.MethodsHealth technology assessments (HTAs) conducted by NICE from 2009 to 2020 were reviewed for approved oncology drugs. Terminated appraisals were excluded. Data regarding EOL criteria in these submissions were then gathered. The HTA decisions were divided into the following categories: EOL criteria met; EOL criteria not met; and EOL criteria not applicable. A chi-square analysis was performed.ResultsA total of 316 reviews were assessed in the final sample, of which 71 percent (n = 223) of decisions were positive. Out of the positive decisions, 43 percent (n = 96), 25 percent (n = 55), and 32 percent (n = 72) of decisions were in the EOL criteria met, EOL criteria not met, and EOL criteria not applicable groups, respectively. The chi-square analysis showed a significant correlation between HTA decisions and EOL criteria (p = 0.0008). These results were consistent when the “EOL criteria not applicable” group was excluded (p = 0.001). When the analysis was performed between the “EOL criteria met” and “EOL criteria not met”, along with “EOL criteria not applicable” groups, it showed a possible correlation (p = 0.05).ConclusionsThis study showed that in oncology, NICE reimburses treatments that meet EOL criteria more often than treatments that attempt, but fail, to meet the EOL criteria.

Risk Stratification in Cost-Effectiveness Analyses of Cancer Screening: Intervention Eligibility, Strategy Choice, and Optimality

Introduction There is increasing interest in risk-stratified approaches to cancer screening in cost-effectiveness analysis (CEA). Current CEA practice regarding risk stratification is heterogeneous and guidance on the best approach is lacking. This article suggests how stratification in CEA can be improved. Methods I use a simple example of a hypothetical screening intervention with 3 potential recipient risk strata. The screening intervention has 6 alternative intensities, each with different costs and effects, all of which vary between strata. I consider a series of alternative stratification approaches, demonstrating the consequences for estimated costs, effects, and the choice of optimal strategy. I supplement this analysis with applied examples from the literature. Results Adopting the same screening policy for all strata yields the least efficient strategies, where efficiency is understood as the volume of net health benefit generated across a range of cost-effectiveness threshold values. Basic stratification that withholds screening from lower-risk strata while adopting a common strategy for those screened increases efficiency. Greatest efficiency is achieved when different strata receive separate strategies. While complete optimization can be achieved within a single analysis by considering all possible policy combinations, the resulting number of strategy combinations may be inconveniently large. Optimization with separate strata-specific analyses is simpler and more transparent. Despite this, there can be good reasons to simulate all strata together in a single analysis. Conclusions If the benefits of risk stratification are to be fully realized, policy makers need to consider the extent to which stratification is feasible, and modelers need to simulate those choices adequately. It is hoped this analysis will clarify those policy and modeling choices and therefore lead to improved population health outcomes.

Cost-effectiveness evidence on approved cancer drugs in Ireland: the limits of data availability and implications for public accountability

Background We surveyed evidence published by Ireland’s National Centre for Pharmacoeconomics (NCPE) on the cost-effectiveness of cancer drugs approved for funding within the Irish public healthcare system. The purpose is threefold: to assess the completeness and clarity of publicly available cost-effectiveness data of such therapies; to provide summary estimates of that data; to consider the implications of constraints on data availability for accountability regarding healthcare resource allocation. Methods The National Cancer Control Programme lists 91 drug-indication pairs approved between June 2012 and July 2020. Records were retrieved from the NCPE website for each drug-indication pair, including, where available, health technology assessment (HTA) summary reports. We assessed what cost-effectiveness data regarding approved interventions is available, aggregated it and considered the consequences of reporting constraints. Results Among the 91 drug-indication pairs 61 were reimbursed following full HTA, 22 after a rapid review process and 8 have no corresponding NCPE record. Of the 61 where an HTA report was available, 41 presented costs and quality-adjusted life-year (QALY) estimates of the interventions compared. Cost estimates and corresponding incremental cost-effectiveness ratios (ICERs) are based on prices on application for reimbursement. Reimbursed prices are not published. Aggregating over the drug-indication pairs for which data is available, we find a mean incremental health gain of 0.85 QALY and an aggregate ICER of €100,295/QALY, which exceeds Ireland’s cost-effectiveness threshold of €45,000/QALY. Conclusion Reimbursement applications by pharmaceutical manufacturers for cancer drugs typically exceed Ireland’s cost-effectiveness threshold, often by a considerable margin. On aggregate, the additional total net cost of new drugs relative to current treatments needs to be more than halved for the prices sought on application to be justified for reimbursement. Commercial confidentiality regarding prices and cost-effectiveness upon reimbursement compromises accountability regarding the fair and efficient allocation of scarce healthcare resources.

Revision of Ireland’s Cost-Effectiveness Threshold: New State-Industry Drug Pricing Deal Should Adequately Reflect Opportunity Costs

Ireland’s cost-effectiveness threshold is currently €45,000 per quality-adjusted life-year (QALY). It has previously been determined by periodic agreements between the State and a pharma industry lobby body. A new deal is now due and it is therefore timely to re-examine Ireland’s threshold, how it is set and transparency around adherence to it. Previous research has noted a series of problems with the threshold, including that it is likely too high relative to the opportunity cost of unmet need in Ireland’s health system. This means reimbursement at the threshold may do net harm to population health. The high threshold may also mean the Irish health system is failing to satisfy existing legislation on healthcare resource allocation. Recent COVID-19 related pressures on healthcare capacity and public spending appear to increase the urgency for an evidence-based revision of threshold to better reflect opportunity costs within the Irish healthcare system. Despite these problems, the prospects for reform of the threshold do not appear strong as the political and institutional incentives may favour the status quo. At the very least, the State should provide greater transparency regarding how the threshold is set and adhered to. In the longer run, there may be good arguments for partially abandoning thresholds in favour of an auction process to achieve the lowest cost per QALY from new drug interventions.