1. John Q. Wong, MD, MSc 30 September 2010

2. Quiz Ethics of health economics Quick guide to types of economic evaluation Critical appraisal of a CEA article Homework

3. 1. By how many months does bevacizumab (Avastin) extend the life of lung cancer patients when used at double the regular dose? 2. The claim that trastuzumab (Herceptin) increases survival by almost 50% is based on what measure of association? 3. In the economic evaluation study of Drummond et al, which two regimens are being compared? 4. Which of the two regimens in #3 was discovered to be more effective? 5. Which of the two regimens in #3 was discovered to be less costly?

5. What is the utilitarianism? Health care examples Counter-example

6. Belief: human life is priceless Implications Social worth Cost of treatment Moral obligation

7. Why a price has to be placed on human life Health care resources are limited Rationing decisions are being made whether we like it or not Sometimes, prolongation of life is marginal Without conscious rationing, health priorities can become skewed A just rationing process is explicit, rational, and democratic

8. Breast cancer recurrence Without trastuzumab (Herceptin) = 17% With = 11% Compute RR ARR NNT Which measure of association should be used when talking about populations (public health)?

10. Are both costs (inputs) and consequences (outputs) of the alternatives examined? Is there comparison of two or more alternatives? NoYes NoExamines only consequences Examines only costs Partial Evaluation Outcome description Partial Evaluation Cost description Partial Evaluation Cost-outcome description YesPartial Evaluation Efficacy or effectiveness evaluation Partial Evaluation Cost analysis Full Economic Evaluation Cost- minimization analysis Cost- effectiveness analysis Cost-utility analysis Cost-benefit analysis

11. Cost-minimization analysis Outcomes are the same in terms of volume and type Cheapest choice based on grounds of efficiency Branded vs generic drugs

12. Cost-effectiveness analysis Volume of outcomes are different Efficient choice Which option costs least to produce a unit of outcome Different interventions that prolong life for people with breast cancer

13. Cost-utility analysis Type of outcomes are different Use a common outcome currency QALY or DALY Choice Depend on the cost of producing a unit of the chosen currency Hip replacements vs. CABG vs. hemodialysis

14. Cost-benefit analysis Places monetary values on benefits To enable comparison with the monetary units used to measure costs Doing something vs doing nothing Instead of vs. doing something else Whether or not to invest in crash barriers along a road to avoid traffic deaths and injuries

16. Drummond, Becker, Hux, et al

17. Research question Description of alternatives Measurement of effectiveness Identification of costs and consequences Measurement of costs and consequences Valuation of costs Adjustment for differential timing Incremental analysis Sensitivity analysis Discussion included users’ concerns

18. Choices Yes No Can’t tell Support answer by paraphrasing and citing the appropriate portions of the article

19. Both costs and effects studied? Comparison of alternatives? Perspective Patient Provider Payor Society Yes Variables (abstract) Exposure Moxifloxacin vs. co- amoxiclav +/- clarithromycin Outcome Cure rate 5-7 days after treatment Costs Perspective (abstract) French and German health care system

20. Detailed description References for clinical protocols Identification of control arm Any important alternatives omitted? Nice to have Flow chart or decision tree of patients Yes Detailed description, references, and identification of control arm p. 527, column 1, par. 1 No alternatives omitted No flow chart

21. Randomized controlled trial done? Efficacy or effectiveness study? Meta-analysis or systematic review done? If observational studies used, what were the biases? Yes TARGET study

22. Costs Capital costs Operating costs Consequences Clinically relevant outcomes? All relevant viewpoints? Yes Costs P. 528, column 2, par. 2 Consequences P. 529, column 1, par. 1

23. Consequences Physical units Costs Quantities of all resources used Unit costs of each resource Total costs Any items omitted? Yes Consequences P. 529, column 1, par. 1 Costs P. 528, column 2, pars. 2 and 3

24. Source data for costs Market values used? If not used, what adjustments were made to approximate market values? Yes Adjustments P. 528, column 1, par. 6 P. 528, column 2, pars. 1- 4

26. Time preference An advantage to receive a benefit earlier and/or to incur a cost later It gives you more options Benefit in the future valued less highly than a benefit today

27. Why people have a positive time preference Short-term view of life The future is uncertain Individuals expect to be wealthier in the future Can obtain a positive rate of return from a riskless investment Give costs and benefits in the future a present-day value WHO = 3% discount per year

28. Future costs and consequences discount to present values? Any justification for discount rate? No, but not necessary since costs and consequences all occur within one year

30. = Cost A - Cost B Efficiency A - Efficiency B

31. Incremental effectiveness of treatment compared to control Incremental cost of treatment compared to control MoreSameLess More742 Same395 Less168

32. Strong dominance for decision 1 = accept treatment 2 = reject treatment Weak dominance for decision 3 = accept treatment 4 = reject treatment 5 = reject treatment 6 = accept treatment Non-dominance; no obvious decisions 7 = is added effect worth the added cost to adopt treatment? 8 = is reduced effect acceptable given reduced cost to adopt treatment? 9 = neutral on cost and effects. Other reasons to adopt treatment?

33. Incremental costs compared to incremental effects? Moxifloxacin dominant ICER not necessary P. 531, table 3

35. Data on costs and outcomes are seldom precise To check how much a range of estimates affect the final outcome

36. If real data, statistical tests performed? Sensitivity analysis Justification for Variables adjusted Range of values Were the study results sensitive? Yes P. 521, tables 3 and 4 P. 532, figures 1 and 2

37. Conclusion based on ICER? Interpreted correctly? Results compared with previous studies? External generalizability discussed? Other issues discussed: ethics, equity? Implementation issues? Feasibility Alternative use of freed resources Conclusion P. 533, column 1, par. 3 Comparion P. 533, column 2, par. 2 External generalizability P. 533, column 1, par. 3 Ethics P. 534, column 1, par. 1 Equity P. 534, column 2, par. 1 Feasibility P. 533, column 1, par. 1 Alternative use No

38. Critical appraisal of Schermer, Thoonen, Van den Boom, et al. Randomized Controlled Economic Evaluation of Asthma Self- Management in Primary Health Care. Amer J Resp and Crit Care Med, Vol 166, 2002. Group work Due: 6 Oct, 12 nn via email to Keshia