Evaluating COPD Services Insights from Economics Dr. Andrew Walker

Structure How are we taking account of costs just now? Assessment of new medicines at national level Case studies of economic evaluation of pulmonary rehabilitation Using economic evaluation locally

The state we’re in …

Health Committee Report Financial state of NHS, May 2010 Spending growing by 4-5% per annum Funding for NHS boards grew by 2% this year Gap covered by “efficiency savings” Creates problem for investment that will not go away for several years

For discussion: How do we take account of costs, affordability and value for money just now?

Is anything getting funded? The case of new medicines

Scottish Medicines Consortium Since 2002 advised on all new medicines Effectiveness, cost-effectiveness and other criteria (as appropriate) Manufacturer assembles evidence base, which is critically appraised Still subject to local formulary listing www.scottishmedicines.org

Declare my conflicts of interest!!!

How does SMC do it? And what can we learn?

SMC system Submission from manufacturer Appraised by pharmacist and economist Access to clinician experts Report on strengths and weaknesses of the case made Consider written submission from patient interest group Decision: accepted for use or not recommended

Cost-effectiveness Balance between added cost and added benefit (in terms of improved health) Broad view of costs, long-term Savings Change in survival Change in quality-of-life Latter factors captured in the QALY

COPD at SMC Accepted for use: Not recommended Seretide, Symbicort, Spiriva But we haven’t said which is best Not recommended Erdosteine, Seretide for moderate COPD Next decision due in ten days: roflumilast

Calculating an ICER Total cost QALYs ICER Existing medicine £6,000 1.3 New medicine £10,000 1.5 Difference £4,000 0.2 £20,000/QALY

Contrast New Medicine Randomised controlled trial design Adequate sample size so stats tests can be used Final/proxy outcomes Adequate follow-up (time) Service Development “Before and after” trial design Sample: whoever turns up Pre-existing data collection only Follow-up of a few weeks

Useful Concepts? Utilities Costs of events Speed of progression Incremental analysis Savings Sensitivity analysis

Question: where full health = 1 and “as bad as dead” = 0, where would you rate the average COPD patient?

Examples of utilities Daily quality of life Mild COPD 0.81 Moderate COPD 0.72 Severe COPD 0.67 Severe exacerbation Halves the figures above, or 0.52 (if mild COPD), 0.45 (if moderate COPD) or 0.41 (if severe COPD)

Question: what do you think it costs the NHS per severe exacerbation?

Costs Gani et al – Delphi Panel of Scottish clinicians estimated resource use Of pts suffering a severe exacerbation: 65% require admission @ £3,564 each 23% managed in community @ £566 each 5% self-managed @ £0 (to NHS) Average £2,516 Duration of 1 month (NOT all in hospital)

Question: how quickly does COPD progress e.g. from moderate to severe?

Natural history Economists construct models of the natural history of disease Each year a patient with COPD that is mild has 3% risk of developing moderate moderate has 10% risk of severe COPD Increasing risk of severe exacerbation (5% in mild, 8.5% moderate, 15% severe) 11-15% chance of mortality

Thinking Need to compare to what we do now, what does new treatment ADD? What are we trying to achieve: Patient satisfaction Clinical outcome Patient outcome

Savings NHS costs = staff + buildings & equipment + medicines When we avoid an exacerbation do we need: Less staff? Less buildings? Less medicines? Freeing up time, not making cash savings

Sensitivity analysis Lack of evidence is a barrier to evaluation e.g. before-and-after design Sensitivity analysis explores uncertainty “What if…?” Effectiveness is only half efficacy Hospital length-of-stay fell anyway There is a longer-term mortality benefit In terms of impact on costs and benefits

What do we know about cost-effectiveness beyond new medicines?

“The literature” Cost per QALY studies in COPD: Lots on smoking cessation Lots on prescribing Two evaluations of pulmonary rehabilitation What do they show and can we rely on it?

Case Study 1 – Griffiths et al

Additional data (Lanect) Rehab Control Admitted to hospital 40/99 41/101 Average stay 10 days 21 days Visits to GP 8.6 7.3 GP home visits 1.5 2.8

Case Study 2 – Hoogendoorn et al

Some issues Definition of rehab and ‘usual care’ Timescale and perspective (breadth) Shelf-life, when practice is changing Efficacy trial vs day-to-day practice Different result in less severe disease? Nature of savings – cash versus time Does the NHS understand QALYs? What is “good value”?

Savings on hospital time 400 bed-days in a year 24-bed ward has 8742 potential bed-days 80% occupancy means 6994 used Reduced by 400, brings occupancy down to 75% occupancy Roughly equivalent to 1.5 beds (1.5*365*0.8 = 438)

Can you use these studies to make a case for funding locally?

Types of decision Nationally QIS standard SMC SIGN Targets (HEAT) May or may not include economic evaluation already Locally Things that that have not been evaluated nationally Policy or target set nationally, local challenge is how to achieve the goal Savings required

National evaluation Examples New medicines through SMC Case-finding: screening smokers for COPD DOTS through Scottish Government initiative Pulmonary rehabilitation – established in QIS standard

What are the options for doing a local evaluation?

Cost-minimisation analysis Use when: you expect outcomes to be the same Choose the cheapest But how will you define costs NHS or beyond? Financial or economic? And do you know outcomes are the same?

Cost-effectiveness analysis Use: when there are different ways of achieving an objective E.g. admissions avoided Compare options in terms of added cost per admission avoided But how will you know admissions are avoided? And what are we willing to pay?

Cost-consequence analysis Use: when service has multiple benefits, some not easily measured Evaluation is in terms of costs versus benefits as “bullet point list” But how do you come to a decision? And, again, how do you know what the benefits are?

Hypothetical GPwSI Costs Added staff costs Prescribe more Higher paid Slower Prescribe more Less overheads Overall £100 more per patient per yera Consequences Shorter waiting time by 6 weeks Greater patient satisfaction (85% versus 70%) Slightly better outcomes (5% better FEV1)

Programme budgeting Use: when reviewing the whole service in an area e.g. COPD in a CHP Establish total spend Could it be spent to better effect, to get more total benefit? Raises questions, options for change Apply evaluation techniques to the options