Cost effectiveness

							City University notes


      AJ Fischer




     October 2003
              Nancy’s Questions
Q1 Different people present material with
   different cost perspectives?

A      With all such conundrums, one hopes the
       different ways are not material to the
       decision to be made. If not, NICE muddles
       through. Wouldn’t you?
    Proper answer: NICE subjects data to
    Bayesian analysis, contributions being
    weighted by beliefs about the relative merits
    of each component. (Wish it were true!)
               Nancy’s Questions
Q2   What does NICE do when faced with CE ratios
     using different output measures?

A    In terms of cost per QALY, the CE ratio should
     contain all relevant output measures. If benefits are not
     in terms of QALYs, the decision becomes difficult.
     Answers will be made on a case-by-case basis. Depends
     how clear-cut things are: if very high or very low cost
     per QALY, the correct decision will not be in doubt. If
     the case is near the threshold, then the extra uncertainty
     will not result in a great efficiency loss if the wrong
     decision is made.
          Nancy’s Questions
Q3 What does NICE do when faced with
   QALYs measured in two different
   ways in a particular appraisal?

A   Again, one hopes firstly that the
    decision to be made does not depend
    on the measurement method. If the
    method matters, then probably even
    God doesn’t know the right answer.
        Nancy’s Naughty Question
Q4   How would NICE assess the costs and benefits
     of IVF?
A    The costs do not pose much of a problem. The
     benefits, as ever, are more difficult. How many
     life years are to be given to a live embryo
     compared with a dead one or the absence of one?
     At 39 weeks? At 30 weeks? At 12 weeks? At 3
     weeks? Who knows the answer? The Committee
     will make a decision, but will not really like
     doing so. They do so in the absence of any
     scientific or research guidance about what the
     answer should be. Further, is this about health or
     about lifestyle? Who should judge? Should the
           Nancy’s Questions
Q5 How does NICE weigh up “scientific”
   evidence with patient evidence?

A   If patient evidence is “scientific”, it
    will become part of the scientific
    evidence. Therefore, what is left is not
    “scientific” and should be disregarded.
    Fortunately, that is not the end of the
    question: (1) we are all humans
               (2) X-inefficiency
           Nancy’s Questions
Q6 How does NICE weigh up RCT
   evidence with evidence of poorer
   quality?
A If sufficient RCT evidence is available,
   then there will be no need to go to
   other, potentially biased, sources of
   evidence, such as case series or case
   studies. If no RCT evidence is
   available, or is sparse or of poor
   quality, then it makes sense to look
   towards other evidence.
          Nancy’s Questions
Q7 NICE provides guidance at national
   level which must be followed locally.
   What if some local projects have lower
   cost per QALY?
A This is in part an equity-efficiency
   trade-off. It is not equitable to have
   postcode prescribing, so it has been
   made mandatory to follow NICE
   guidance. But there are limits.
   Currently, we just don’t know the
   worth of projects forgone.