Contribution of economic evaluations to public health decisions

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Contribution of economic evaluations to public health decisions Powered By Docstoc
					Contribution of economic 
evaluations to public health 
decisions 
decisions
About pathogen attenuation 
About pathogen attenuation
Pr Isabelle Durand‐Zaleski
         Economic evaluation

• What is it
  What it  means for physicians
• Wh i           f    h i i
  What it means for policy makers
• What it means for policy makers
             What is it?
• relate the costs of a diagnostic or
  therapeutic strategy to its results
• decide on the allocation of
  resources
    Costs and results
    Costs and results

• Always compared to a reference 
  strategy
  Begin with the analysis of the results: 
• Begin with the analysis of the results:
  what are the health gains?
• Cost analysis follows 
Misconceptions about economic evaluation


• Not cost–computations (accounting)
• Not a tool to reduce health  
  expenditures
• Needs 2 components:
– Medical outcome
  Value of resources used to obtain this outcome
– Value of resources used to obtain this outcome
What does ‘cost‐effective ‘ mean ?

    Laupacis et al. Can Med Assoc J, 1992                 3 to 5x per capita GDP or
•                                                t
                                              costs +     £30,000 per QALY
                                                              1x per capita GDP/
                                                              QALY
                 dominated

effectiveness -

                                                            effectiveness +
are we ready to give up
o e ect ve ess o owe
on effectiveness for lower                              dominant
costs?

                                            costs -
‘cost‐effective ‘  and individual decision

  injunction to rescue identifiable individuals in
  immediate peril, regardless of cost (the "Rule of
•
  Rescue").                                3 to 5x per capita GDP or
            dominated                         £30,000 per QALY



                                                 1x per capita GDP/
                                                 QALY



                                                effectiveness +
Ann Int Med 2009 vol. 151 no. 9 662-667
                                  Table
                           League Table*
   •   Driver automatic (vs. manual) belts in cars $ 0/LYS (cost-saving)
   •   Childhood immunizations                     $ 0/LYS (cost-saving)
   •   Enalapril in heart failure (in SOLVD)                    (cost-saving)
                                                        $ 0/LYS (cost saving)
   •   Pacemaker implant                           $ 1,600/LYS
   •   Mammography every 3 years (women 50-65)          $ 2,700/LYS
   •   PTCA (males age 55 with severe angina)           $ 7,400/LYS
   •   Simvastatin in CHD (in 4S)                       $ 8,000/LYS
   •   Cervical cancer screening (women age 20) $ 12,000/LYS
   •   CABG Surgery for 3 vessel disease                $ 12,000/LYS
   •   Antihypertensive drugs (age 40, > 105 mmHg) $ 16,000/LYS
   •   Airbags (vs. manual lap belts) in cars
       Ai b    (            l l b lt ) i                  120,000/LYS
                                                        $ 120 000/LYS
              Five-         life-                              cost-
*Tengs et al. Five-hundred life-saving interventions and their cost-effectiveness.
                 Jun;15(3):369-
                    ; ( )
Risk Anal 1995 Jun;15(3):369-90
• Kamper‐Jørgensen M, Hjalgrim H, Edgren G, Titlestad K, 
  Ullum H, Shanwell A, Reilly M, Melbye M, Nyrén O, 
  Ullum H Shanwell A Reilly M Melbye M Nyrén O
  Rostgaard K. Expensive blood safety initiatives may offer 
  less benefit than we think. Transfusion. 2010 Jan;50(1):240‐
  less benefit than we think. Transfusion. 0 0 Jan;50( ): 40
  2. 
                        g                             y
• Busch M, Walderhaug M, Custer B, Allain JP, Reddy R, 
  McDonough B. Risk assessment and cost‐
  effectiveness/utility analysis. Biologicals. 2009 Apr;37(2):78‐
  87. 
  87
• Grosse SD, Teutsch SM, Haddix AC. Lessons from cost‐
  effectiveness research for United States public health policy.
  effectiveness research for United States public health policy
  Annu Rev Public Health. 2007;28:365‐91.
          pp                       y
         Application to blood safety:
                          p    g
The cost‐effectiveness of pathogen 
 reduction technology (Canada)
             t bl d f t
    – current blood safety screens vs
    – interventions to riboflavin‐based whole blood PRT 
      (currently in development) 
                     p
    – Platelets ‐and‐plasma PRT

Custer B, Agapova M, Martinez RH. The cost-effectiveness of
pathogen reduction technology as assessed using a multiple risk
reduction model.
  Transfusion. 2010 Nov;50(11):2461-73.
                    Model
  costs and consequences of the 
• costs and consequences of the
  following:
  – HIV, HBV, HCV,HTLV, syphilis, West Nile virus, 
    bacteria Chikungunya virus, CMV, Trypanosoma 
    Cruzi,
    G      , feb e o e o yt c t a s us o eact o s
  – GVHD, febrile nonhemolytic transfusion reactions
  – transfusion‐related immunomodulation 
                 Results
  In a cohort of 100,000 transfusion 
• In a cohort of 100,000 transfusion
  recipients the gain is 9 QALYs. 

  The incremental cost‐effectiveness of
• The incremental cost effectiveness of
   o e b ood     co pa ed to cu e t
whole blood PRT compared to current 
  screens and interventions is 
$1,276,000/ QALY
Sensitivity analysis
                               y
       Politics and blood safety
  It is not because interventions have an 
• It is not because interventions have an
  ICER far in excess of usual thresholds that 
  they are not undertaken
  Example in 2001 : cost and effectiveness 
• Example in 2001 : cost and effectiveness
  of adding a system of PCR testing to the 
  current ELISA screening for HCV in blood 
  donations in France.
       MATERIAL AND METHODS: 
  cost‐effectiveness analysis of three HCV 
• cost‐effectiveness analysis of three HCV
  screening strategies : 
  – detection of antibodies against HCV by an ELISA on 
    blood donations (the current policy) vs. 
  – ELISA and PCR either on each blood donation 
    or on blood pools. 
  – or on blood pools
• Markov model for natural history of HCV 
  disease and its treatment.
                                      RESULTS
  PCR testing will potentially add less than 1 year 
• PCR t ti         ill t ti ll dd l     th 1
  of life for all French recipients compared to 
  ELISA screening alone. 
• The incremental costs per life year saved were,
  The incremental costs per life year saved were, 
  respectively, €84.6 million with ELISA and PCR 
  testing of blood pools, and €891.1 million with 
  testing of blood pools and €891 1 million with
  testing of individual blood donations.
•       bè          l
    Loubière S, Rotily M, Durand‐Zaleski I, Costagliola D. Including polymerase chain reaction in 
                                 d l k            l l         l d      l          h
    screening for hepatitis C virus RNA in blood donations is not cost‐effective. Vox Sang. 2001 
    May;80(4):199‐204.

				
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