Session 1.3 – Translating National HTA for Local Decision-Making
Wednesday October 29 9:00-10:30
The Measurement of Benefits and Misuse of Costs by Economic Evaluation in the Context of an NHS
(Abstract 0103)Jeff Richardson
Monash University, Australia
This paper argues that there are theoretical and empirical errors in the measurement of both benefits and costs in the cost effectiveness ratio used in economic evaluation.
From amongst the smorgasbord of problems with Welfare Theory (the orthodox basis for economic evaluation) one stands out. Virtually all policies distribute benefits. To overcome this obstacle the concepts of Pareto efficiency and potential compensation are employed to justify policy. In the context of an NHS these concepts are midway between problematical and foolish. Nevertheless they probably explain the overwhelming emphasis upon efficiency and almost total neglect of fairness in evaluation studies.
The paper argues that economics has adopted a paradigm which focuses attention upon what is described as efficiency (but is not) to the neglect of fairness. It is argued that to maximise social welfare it is necessary to appreciate social values and that these must be obtained empirically (‘Empirical Ethics’) and not by assumption. Empirical results are reported suggesting that the economist’s emphasis upon utility as an endpoint neglects values associated with duty to others and community (values that are unsurprising for a race that evolved from herd to clan/community existence). These values are culturally formalised under the title ‘fairness’. Empirical results suggest a range of quantitatively important fairness based benefits presently omitted from evaluation studies. Other results from a recent web-based survey of fairness and efficiency are reported which indicate a new universal rejection of the C-E ratio as a decision algorithm.
HTA Directed Resource Allocation – is it Fit for Purpose?
(Abstract 0121)Daphne Austin
West Midlands Specialised Services Team, United Kingdom
Prioritisation is a particular form of decision making which requires the decision maker to choose between two or more options and, in doing so, be fully aware of the impact of that decision. NICE's technology appraisal programme does not do this because cannot take opportunity costs into account (and so does not undertake prioritisation). in addition, because it has no budgetary responsibilities is does not have to consider affordability. This programme is therefore not designed to answer one of the key questions facing those whose responsibility it is to commission healthcare and that is: amongst the many competing demands is this next most important investment for this population and can we afford it?
What NICE's technology appraisal programme is designed to to is eradicate postcode variation for high profile and politically difficult issues. However, to promote the idea that it is about prioritisation and the fair allocation of resources is both misleading and harmful.
This presentation will argue the case that NICE's technology appraisal programme is not an appropriate model for committing resources and provides some possible solutions to easing the ethical problem this presents.
Priority Setting in Practice: What is the Best Way to Compare Costs and Benefits?
(Abstract 0009)Ed Wilson1, Stuart Peacock2, Danny Ruta4
1University of East Anglia, United Kingdom, 2British Colombia Cancer Agency, Canada, 3University of British Colombia, Canada, 4Newcastle Primary Care Trust, United Kingdom
Prioritising candidates for health care expenditure using cost per QALY is a helpful but insufficient means of ranking alternative uses for scarce health care funds at the local level. This is because QALYs do not by themselves capture all criteria decision makers need to take into account. Other criteria such as reducing inequalities, meeting national and local priorities, and public acceptability also feature in the decision maker’s utility function.
Programme budgeting and marginal analysis (PBMA) is an established framework for systematic priority setting in which a ‘weighted benefit score’ for each option is calculated based on all relevant decision making criteria. Ranking options as a ratio of cost to benefit is desirable and necessary to ensure efficiency.
We present here a review of number of approaches in the literature to scoring costs and benefits of options in a PBMA context. Several approaches rank by benefit score alone, rather than efficiency (cost per unit of benefit). Of those that do rank by efficiency, we discuss their benefits and drawbacks. The optimal approach is far from clear, with each technique having its own strengths and weaknesses. A deliberative approach using summaries of costs and benefits of options as a basis for discussion may be preferable.
The Importance of Budgetary Impact
(Abstract 0045)Jennifer Field
National Institute for Health and Clinical Excellence, United Kingdom
One of the key information requirements to achieve change in practice is how much it will cost; for new technologies this is often called the budget impact. Assessing which technologies are appropriate to use is usually based on the relative cost effectiveness of the technology compared with its comparators. Assessing cost effectiveness combines treatment effect and cost of treatment to arrive at a cost per quality adjusted life year (QALY). However, the cost per QALY is not directly related to the budget impact, and does not provide the answer to ‘how much will it cost?’ This talk explores the importance of estimating budget impact and the data required. Using two high profile examples of technologies considered cost effective (statins for coronary heart disease prevention and alteplase for ischaemic stroke) the key differences between cost effectiveness and budget impact will be demonstrated. One key finding of undertaking the comparison is the identification of the common data elements required for both perspectives.