1. Evaluating COPD Services
Insights from Economics
Dr. Andrew Walker

2. 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

3. The state we’re in …

4. 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

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

7. Is anything getting funded?
The case of new medicines

8. 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

9. Declare my conflicts of interest!!!

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

11. 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

12. 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

13. 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

15. 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

16. 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

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

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

19. 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)

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

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

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

23. 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

24. 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

25. 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

26. 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

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

28. “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?

29. Case Study 1 – Griffiths et al

30. 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

31. Case Study 2 – Hoogendoorn et al

32. 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”?

33. 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)

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

35. 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

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

37. What are the options for doing a local evaluation?

38. 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?

39. 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?

40. 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?

41. 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)

42. 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