Dangerous Omissions the Cost of Ignoring Decision Uncertainty
- Slides: 19
Dangerous Omissions – the Cost of Ignoring Decision Uncertainty Mark Sculpher Susan Griffin Karl Claxton Steve Palmer Centre for Health Economics, University of York,
Background • • • Increasing demands to assess new drugs closer to launch Inevitable uncertainty in evidence Hence a series of linked questions – Should a technology be adopted? – How uncertain is this decision? – Is more evidence needed? • • But decisions may be fragmented Need a methods framework to handle these questions
What are the decisions? • Should a technology be adopted given existing information? – Which clinical strategies are worthwhile? – For which patient groups? • Is current evidence sufficient to support use in NHS? – Do we need more evidence? – What type of evidence is required? – What additional research should be conducted to provide this evidence?
What are the decisions? • Should a technology be adopted given existing information? – Which clinical strategies are worthwhile? – For which patient groups? • Is current evidence sufficient to support use in NHS? – Do we need more evidence? – What type of evidence is required? – What additional research should be conducted to provide this evidence?
Is it costeffective? Is it worthwhile? Is the ICER less than the cost-effectiveness threshold? ICER = Additional cost QALYs gained = £ 20, 000 2 QALYs = £ 10, 000 per QALY If the cost-effectiveness threshold is £ 20, 000 per QALY, B is cost-effective Is net benefit positive? Net health benefit = QALYs gained – QALYs lost £ 20, 000 = 2 – 1 = 1 QALY = 2 – £ 20, 000 Net money benefit = £ value of QALYs gained – additional costs = 2 x £ 20, 000 – £ 20, 000 = 1 QALY
Should a technology be adopted? Treatment A QAL Y 1 Cost £ 10, 000 0 £ 5, 000 2 £ 15, 000 1 £ 10, 000 ICER = Additional cost QALYs gained = £ 20, 000 2 QALYs = £ 10, 000 per QALY Is the ICER less than the cost-effectiveness threshold? £ 10, 000 per QALY < £ 20, 000 per QALY, B is cost-effective Is net benefit positive? Treatment B QAL Y 2 Cost £ 30, 000 3 £ 20, 000 4 £ 40, 000 3 £ 30, 000 Net health benefit = QALYs gained – QALYs lost £ 20, 000 = 2 – 1 = 1 QALY = 2– £ 20, 000 Net money benefit = £ value of QALYs gained – additional costs = 2 x £ 20, 000 – £ 20, 000 = 1 QALY
What are the decisions? • Should a technology be adopted given existing information? – Which clinical strategies are cost-effective? – For which patient groups? • Is current evidence sufficient to support use in NHS? – Do we need more evidence? – What type of evidence is required? – What additional research should be conducted to provide this evidence?
How uncertain is a decision? How things could turn out Net Health Benefit Treatment A Treatment B Treatment C Best choice Possibility 1 9 12 8 B Possibility 2 12 10 9 A Possibility 3 14 17 11 B Possibility 4 11 10 10 A Possibility 5 14 16 12 B Average 12 13 10 What’s the best we can do now? But we are not always right Choose B and expect 13 QALYs Chance that B is the best = 3/5 = 0. 6 Chance that A is the best = 2/5 = 0. 4 Chance that C is the best = 0/5 = 0 So if we adopt B the probability of error = 0. 4
How uncertain is the decision? Choose A Choose B B ICER = £ 25, 000 per QALY A C
Why does uncertainty matter? How things could turn out Net Health Benefit Treatment A Treatment B Best we Best choice could do if we knew What we could lose Possibility 1 9 12 B 12 0 Possibility 2 12 10 A 12 2 Possibility 3 14 17 B 17 0 Possibility 4 11 10 A 11 1 Possibility 5 14 16 B 16 0 Average 12 13 13. 6 0. 6 What’s the best we can do now? Could we do better? Choose B and expect 13 QALYs If we knew we get 13. 6 QALYs Maximum benefit of more evidence is 0. 6 QALYs But is it worth it?
Do we need more evidence? Cost of research Choose A Choose B
Do we need more evidence?
Decisions in a joined up world? • Adopt technologies if we expect them to be cost effective based on existing evidence • But only if we simultaneously address question: Is the evidence sufficient? • Demand or commission further research to inform this choice in the future
A fragmented world • Separation of adoption and research decisions – Adoption decisions without accountability for impact on future research – Research decisions without accountability for relevance to adoption decisions • Dangers – Adoption decisions undermine evidence base for practice • Incentives and ethics – Commissioned research does not inform decisions • Adoption becomes the only policy instrument
Account for the cost of uncertainty What we loose if we reject a technology What we loose if we accept technology
Clear signals and incentives Provide more evidence!
Clear signals and incentives Reduce price
Why say no (or only in research)? • Clear signals – No because it is not a cost-effective use of resources – No because there is currently insufficient evidence to justify NHS use – Spell out the key evidence needed (not the research) • Clear incentives – If and when additional evidence is made available then considered for early review – Incentives to sponsors (evidence and price) – Incentives for others stakeholders to lobby for publicly funded research – Clear signals to research commissioners
Conclusions • All decisions about new technologies involve uncertainty • Is uncertainty being used in decision making? • Need to address adoption decision and need for further research simultaneously • But adoption decision may be only policy lever
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