Updating the Guidelines for the Economic Evaluation of Health Technologies: Canada

Welcome

• Project update

• Feedback from stakeholders

• Supporting work

• How to stay informed

• What’s next

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Updating the Guidelines

• Who?• What?• Why?• How?• When?

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Who?

• CADTH• Health Economics Working Group• Health Economic researchers

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Health Economics Working Group• Karen M. Lee (Chair), CADTH; University of Ottawa• Dr. Stirling Bryan, University of British Columbia;

Vancouver Coastal Health Research Institute• Dr. Doug Coyle, University of Ottawa; Brunel University• Dr. Murray Krahn, University of Toronto; Toronto Health

Economics and Technology Assessment Collaborative; University Health Network

• Dr. Carlo Marra, Memorial University• Dr. Chris McCabe, University of Alberta, University

of Leeds

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• Developments in methodologies in 2006

• Areas identified where clarity needed

• Assist “doers” and “users” of economic evaluations with the production of credible and standardized economic information

• Provide a set of standards for the conduct and reporting of economic evaluations

Why?

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Purpose

• To determine areas of most interest to stakeholders• To ensure all areas of interest have been identified

• Survey period: December 2015 to January 2016

Survey

• Four main questions• Seeking feedback on:

• What respondents feel is useful• What should/should not be updated• Other items of interest to stakeholders

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Survey ResponsesTotal of 20 responses

Academics (5)

Pharmaceutical industry/Consultants

(8)

HTA orga-nizations

(3)

Decision makers (2)

Patient groups (2)

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What do you find most useful?

• Clear and definitive guidance • Appropriately structured • Comprehensive in scope

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What topics should be updated? • Responses ranged from general topic areas to be

considered to specific items for consideration within topics

• Effectiveness• Discounting • Measurement and Valuation of Health• Resource Use and Costs• Equity• Generalizability• Uncertainty

All areas should be open to review

What topics should be clarified?

• Types of Evaluations• Perspective• Comparators

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Additional Suggestions

• Guidance on reviews of drugs for rare diseases• Incorporate oncology guidance within the updated 4th

edition• Update Guidelines more frequently• Educate lay community on concepts of health economic

evaluation

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Linking with the Update

• Aligned with CADTH thoughts for update • Validation of topics where more effort has been spent

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Network Meta-

analysis

Why Network Meta-Analysis?

• Network Meta-analysis (NMA) is an evolving area of research

• Details on its applicability and use in economic evaluations are limited

• Guidance required on the topic to help inform Guideline update

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What is Network Meta-Analysis?

• A key element of evidence-based health care evaluation is to assess the effectiveness and cost-effectiveness of all relevant alternative interventions based on the available evidence

• Evidence synthesis technique for summarising the effectiveness data by quantitatively combining the data in order to obtain overall pooled estimates of effectiveness

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What Distinguishes Network Meta-Analysis from Meta-Analysis?

Overall Pooled Estimates of Effectiveness

A vs. B

Meta-analysis (MA)Network Meta-analysis (NMA)

A vs. B

A vs. B

A vs. C

B vs. C

A vs. B

Allows for the simultaneous estimation of comparative effectiveness of multiple interventions using studies that individually may not compare all interventions

Allows for the estimation of comparative effectiveness of two interventions using studies that individually compare both interventions

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How to Incorporate Network Meta-Analysis into Economic Evaluations?

• The report focuses on how to use the results from NMA to inform parameters in an economic evaluation:

STEP 1: Define network of studies

STEP 2: Estimate relative treatment effects

STEP 3: Estimate absolute effects (e.g., probabilities)

STEP 4: Evaluate the decision problem based on the estimated effects and the associated uncertainty

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Other Topics • Using estimates from published NMAs to inform clinical

parameters in an economic evaluation

• Using NMA to synthesise information on adverse events or where data are sparse

• Advanced and emerging topics related to NMA and its use in economic evaluation

• Case studies illustrating the application of standard and advanced NMA methodology to inform clinical parameters

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Informing the Guidelines

Modelling

Effectiveness

Uncertainty

Discounting: Perspective on Social Choice

Welfarist Extra Welfarist

Social Decision Maker

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Discounting: Constrained or Unconstrained budgets

Constrained Budget

Opportunity costs fall on health care

budget

Unconstrained Budget

Opportunity costs fall other

budgets or taxpayer

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Choice of Discount rate: Welfarist/ Extra-welfarist

Constrained Budget

Discount Costs ($s) at: SRTP for consumption minus the expected growth rate in the consumption value of health plus expected growth rate in the cost effectiveness threshold

Discount Health at: SRTP for Consumption minus expected growth rate in the consumption value of health

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Choice of Discount rate: Social Decision Maker

Constrained Budget

Discount costs at: the real rate interest faced by the higher authority which finances the health system

Discount Health at: the real rate of interest faced by the higher authority minus the expected growth rate of the cost effectiveness threshold

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Social Rate of Time PreferenceRamsey Equation for the Social Rate of Time Preference

μg + L + δ

μg = Elasticity of utility of consumption*marginal consumptionL = Catastrophic riskδ = Pure time preference

μg = 2.65% (Evans et al, IFS, 2005)L = < 1% (Stern et al, 2006)δ = 0%

2.65%<SRTP<2.75%

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3 Y 5 Y 7 Y 10 Y 20 Y 30 Y

-1.000

-0.500

0.000

0.500

1.000

1.500

2.000

Dec 2014 Real Yield Curve (BofC Target)

ONPQNSBCABSKPEINFLNBMN

Yiel

d %

Discounting: Real rate of interest

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Choice of Discount rate: Social Decision Maker

Constrained Budget

Discount costs at: the real rate interest faced by the higher authority which finances the health system

Discount Health at: the real rate of interest faced by the higher authority minus the expected growth rate of the cost effectiveness threshold

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Discounting: Growth in the cost effectiveness threshold & Lambda

Budget Efficiency Demand Lambda

= =

= =

= == == == =

Discounting Issues

• What is the relevant perspective on Social Choice?

• Is the budget constrained or unconstrained?

• Will the cost effectiveness threshold increase, decrease or remain stable over time?

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Discounting: Real rate of interest

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How to stay informed?

• Website updateso Posting of commissioned reportso Alerts for feedback

• Subscribe to CADTH health economic updates

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What’s next?

• Technical Peer Review Summer 2016

• Stakeholder Review Fall 2016

• Finalize 4th Edition of the Guidelines Winter 2017

Stay tuned for planned workshops & information sessions

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Subscribe to ourHealth Economics Update

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