There is no single value of a QALY – context matters - in terms of the

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                                                                                                       A conceptual model of factors
   There is no single value of a QALY –                                                               influencing the value of a QALY
    context matters - in terms of the                                                          Budget restrictions
        level of decision making!
                                                                                               Decision-making rules
                                                                                                                                                     The relative
                                                                                               L k of transparency
                                                                                               Lack f t                                              importance of
                                                                                                                                                     i     t      f
                                 Sandra Erntoft (PhD)                                          Internal institutions                                 cost per QALY
                            Research Director                                                                                                        information
                                                                                               External institutions
              The Swedish Institute for Health Economics (IHE)
                       P.O. Box 2127, 220 02 Lund                                              Prevailing templates
                             +46 46 32 91 21
                                www.ihe.se
                                                                                        Source: Erntoft S. 2010. The use of health economic evaluations in pharmaceutical
                                                                                        priority setting. Lund Studies in Economics and Management 116
ISPOR Prague 7th November 2010                                                         ISPOR Prague 7th November 2010




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                                                                                                 A DCE directed towards Swedish macro,
                                   Hypotheses
                                                                                                 meso and micro level decision makers

     H1: Budget restrictions decrease the value of a QALY.                                  Research group
     H2: Strong medical internal and external institutions (e.g.
       organisational culture,ethics, norms, expectations from                              Sandra Erntoft, IHE, Sweden
                             etc.)                         QALY.
       major stakeholders etc ) increase the value of a QALY                                Christian Asseburg, ESiOR Fi l d
                                                                                            Ch i ti A      b    ESiOR, Finland
     H3: A short distance to the patient (direct contact) increases                         Reed Johnson, RTI International, U.S.A
       the value of a QALY.
                                                                                            Anders Anell, Lund University, Sweden
     H4: the relative importance of cost per QALY information
       decreases the value of a QALY.                                                       Ulf Persson, IHE and Lund University, Sweden




ISPOR Prague 7th November 2010                                                         ISPOR Prague 7th November 2010




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                   The questionnaire – example TLV                                                                      Descriptive statistics
                                                                                                                              TLV           Form. Com.           Physicians
Criteria                            Treatment A             Treatment B
                                                                                            Age (mean)                        52,2               54,9                 47,3
The average health status in        High degree of          Low degree of
patient population                  pain/discomfort         pain/discomfort                 Sex ( % males)                     78                 62                   43
Type of medical effect              Increased QoL           Life-sustainment
                                                                                            Education:
                                                                                            Physician                          25                 86                  83
Expected size of medical effect     Avoid loss of 1 QALY    Avoid loss of 0.2               Economist
(effectiveness)                                             QALY
                                                                                                                               50                  0                  N/a
                                                                                            Lawyer                             0                   0                  N/a
Cost per QALY                       114.700 €               31.300 €                        Pharmacist
                                                                                                                               0                   2                  N/a
                                                                                            Other/no answer
Budget Impact                       312.800 € per 100 000   20.900 € per 100 000                                               25                 12                  17
                                    inhabitants             inhabitants
                                                                                            HE education
                                                                                            (% yes)                            58                 35                   12
 A) Which treatment is better? (A is better, B is better)
                                                                                            Budget/ Operational
                                                                                            responsibility (% yes)             N/a                22                   23
 B) Which treatment do You think TLV should reimburse? (A, B,
 both A and B, neither A or B)
                                                                                              Response rate: 21 % n= 214
ISPOR Prague 7th November 2010                                                         ISPOR Prague 7th November 2010




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       Relative importance when ranking pharmaceutical                                                                  The Swedish National Board of Health and Welfare
                          treatments                                                                                    (SoS): relative importance when making a decision

 3.5

   3                                                                                                                     1.2

 2.5                                                                    2.4               2.4                                          1,0
                                                                                                                           1
                                                                  2.1
   2                                                  1.8                           1.8                                  0.8
                                                                                                                         08
                                                                                                TLV
 1.5                                1.4
                                                                                                Form. Com.
                                                1.1                                                                      0.6
         1.0 1.0 1.0                                                                            Prescribers
   1                          0.9                                                                                                                                                          0,4
                                                                                                                         0.4                                                  0,3
                                                            0.4               0.5
 0.5                    0.3               0.3
                                                                                                                         0.2                                 0,1
   0
        Cost/QALY Budg. Imp. Type of med.                     Pain            QALY gain                                    0
                                 eff.                                                                                              Cost/QALY         Type of med.eff.   Clinical area   Pain



ISPOR Prague 7th November 2010                                                                                     ISPOR Prague 7th November 2010




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                                                                                                                                                      Consequences
                 Cost-effectiveness threshold values

                                                                                                                        H1: Budget restrictions decrease the value of a QALY.
       • 41 cases of statistically significant differences between                                                      H2: Strong medical internal and external institutions (e.g.
         decision makers (%).                                                                                             organisational culture,ethics, norms, expectations from
       • In 28 cases the cost-effectiveness threshold values were lower                                                   major stakeholders etc.) increase the value of a QALY.
         rated by the TLV, than by formulary committee members and                                                      H3: A short distance to the patient (direct contact) increases
         prescribing physicians.                                                                                                          QALY.
                                                                                                                          the value of a QALY
                                                                                                                        H4: the relative importance of cost per QALY information
       Cost per QALY                                                                                                      decreases the value of a QALY.
       • TLV: Lowest 48.900 € ; Highest 120.500€.
       • SoS: Lowest 28.700 €; Highest 93.900 €                                                                                    Both the relative importance of cost-effectiveness
       • Formulary committees: Lowest – 61.600 € ; Highest 341.000 €                                                               information and the threshold values of the cost/QALY
                                                                                                                                   varies between decision makers at national, regional and
       • Physicians: Lowest 5.500 € ; Highest 270.000 €.                                                                           local level.
                                                                                                                                   Decisions made at the national level may not be
       100€ = 959 SEK (October 14th 2010)                                                                                          implemented at meso and micro level.
 ISPOR Prague 7th November 2010                                                                                     ISPOR Prague 7th November 2010




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                               Possible solutions?                                                                               Thank you for your attention!
       Is it a problem?

       • No!
          • Decision-makers should have different threshold
                                                                                                                                                    Sandra Erntoft
             values
             values.
                                                                                                                                             Email: Sandra.Erntoft@ihe.se
       • Yes!                                                                                                                                  Phone: +46 46 32 91 21
          • Discussion among macro, meso and micro level
            decision makers regarding whether limited resources
            and QALYs should directly or indirectly influence
            decision-making.
          • Willingness to pay for a QALY from a general public
            perspective.
 ISPOR Prague 7th November 2010                                                                                    ISPOR Prague 7th November 2010




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