Cost-effectiveness of noninvasive liver fibrosis tests for treatment decisions in patients with chronic hepatitis B in the UK: systematic review and economic evaluation

We compared the cost-effectiveness of various noninvasive tests (NITs) in patients with chronic hepatitis B and elevated transaminases and/or viral load who would normally undergo liver biopsy to inform treatment decisions. We searched various databases until April 2012. We conducted a systematic review and meta-analysis to calculate the diagnostic accuracy of various NITs using a bivariate random-effects model. We constructed a probabilistic decision analytical model to estimate health care costs and outcomes quality-adjusted-life-years (QALYs) using data from the meta-analysis, literature, and national UK data. We compared the cost-effectiveness of four decision-making strategies: testing with NITs and treating patients with fibrosis stage ≥F2, testing with liver biopsy and treating patients with ≥F2, treat none (watchful waiting) and treat all irrespective of fibrosis. Treating all patients without prior fibrosis assessment had an incremental cost-effectiveness ratio (ICER) of £28,137 per additional QALY gained for HBeAg-negative patients. For HBeAg-positive patients, using Fibroscan was the most cost-effective option with an ICER of £23,345. The base case results remained robust in the majority of sensitivity analyses, but were sensitive to changes in the ≥ F2 prevalence and the benefit of treatment in patients with F0-F1. For HBeAg-negative patients, strategies excluding NITs were the most cost-effective: treating all patients regardless of fibrosis level if the high cost-effectiveness threshold of £30,000 is accepted; watchful waiting if not. For HBeAg-positive patients, using Fibroscan to identify and treat those with ≥F2 was the most cost-effective option.

Does convenience matter in health care delivery? A systematic review of convenience-based aspects of process utility

OBJECTIVES

To systematically review the existing literature on the value associated with convenience in health care delivery, independent of health outcomes, and to try to estimate the likely magnitude of any value found.

METHODS

A systematic search was conducted for previously published studies that reported preferences for convenience-related aspects of health care delivery in a manner that was consistent with either cost-utility analysis or cost-benefit analysis. Data were analyzed in terms of the methodologies used, the aspects of convenience considered, and the values reported.

RESULTS

Literature searches generated 4715 records. Following a review of abstracts or full-text articles, 27 were selected for inclusion. Twenty-six studies reported some evidence of convenience-related process utility, in the form of either a positive utility or a positive willingness to pay. The aspects of convenience valued most often were mode of administration (n = 11) and location of treatment (n = 6). The most common valuation methodology was a discrete-choice experiment containing a cost component (n = 15).

CONCLUSIONS

A preference for convenience-related process utility exists, independent of health outcomes. Given the diverse methodologies used to calculate it, and the range of aspects being valued, however, it is difficult to assess how large such a preference might be, or how it may be effectively incorporated into an economic evaluation. Increased consistency in reporting these preferences is required to assess these issues more accurately.

Informing a decision framework for when NICE should recommend the use of health technologies only in the context of an appropriately designed programme of evidence development

BACKGROUND

The general issue of balancing the value of evidence about the performance of a technology and the value of access to a technology can be seen as central to a number of policy questions. Establishing the key principles of what assessments are needed, as well as how they should be made, will enable them to be addressed in an explicit and transparent manner.

OBJECTIVES

The aims of this research are to (1) establish the key principles of what assessments are needed to inform an 'only in research' (OIR) or 'approval with research' (AWR) recommendation, (2) evaluate previous National Institute for Health and Clinical Evidence (NICE) guidance in which OIR or AWR recommendations were made or considered and (3) evaluate a range of alternative options to establish criteria, additional information and/or analysis that could be made available to inform the assessments needed.

DATA SOURCES

All NICE draft and final guidance up to January 2010 was considered in the review of NICE technology appraisal guidance. Four case studies were used to evaluate the range of options of what information and analysis could be made available to inform the assessment required. These were based on a reanalysis of existing health technology appraisals for NICE or the Health Technology Assessment programme.

REVIEW METHODS

A critical review of policies, practice and literature was undertaken using traditional systematic searching based on initial search terms informed by key publications. An iterative approach was adopted using 'pearl growing' evaluated through capture-recapture methods. In addition, grey literature, policy documents and other sources, such as special interest groups and the expertise of the Advisory Group for the project, were used to contribute to this process.

RESULTS

A series of recommendations, or options, for NICE to consider were developed with the involvement of key stakeholders. These establish the key principles and associated criteria that might guide OIR and AWR recommendations and identify what, if any, additional information or analysis might be included in the technology appraisal process, including how such recommendations might be more likely to be implemented through publically funded and sponsored research. To meet these aims the research is broadly structured as follows. A critical review of policy, practice and literature in this area informs the development of a coherent conceptual framework to establish the key principles and the sequence of assessment and judgements required. This sequence of assessment and judgement is represented as an algorithm, which can also be summarised as a simple set of explicit criteria or a 7-point checklist of assessments. A review of previous NICE guidance in which OIR or AWR recommendations were either made or considered was undertaken to examine the extent to which the key principles are evident. The application of the checklist of assessment to a series of four case studies informs considerations of whether or not such assessments can be made based on existing information and analysis in current NICE appraisal and in what circumstances could additional information and/or analysis be useful. Finally, some of the implications that this more explicit assessment of OIR and AWR might have for policy (e.g. NICE guidance and drug pricing), the process of appraisal (e.g. greater involvement of research commissioners) and methods of appraisal (e.g. should additional information, evidence and analysis be required) are drawn together. At each stage this research has been informed by a diverse and international Advisory Group and the feedback from participants at two workshops involving a wide range of key stakeholders, which included members of NICE and its Advisory Committees (including lay members and other NICE programmes), patient advocates, manufacturers, and research and NHS commissioners, as well as relevant academics.

LIMITATIONS

Further research is required to establish how these considerations could be integrated within a practical value-based pricing scheme. In addition, irrecoverable opportunity costs are commonly associated with many health technologies that offer future benefits following treatment. The significance of these types of irrecoverable costs is not widely recognised and further research to demonstrate their potential impact more generally is needed.

CONCLUSIONS

The categories of guidance available to NICE have a wider application than is reflected in the review of previous guidance. Importantly, determining which category of guidance will be appropriate depends only partly on an assessment of expected cost-effectiveness. As well as AWR for technologies expected to be cost-effective and OIR for those not expected to be cost-effective, there are other important circumstances when OIR should be considered. In particular, for technologies expected to be cost-effective, OIR rather than approve may be appropriate when research is not possible with approval and OIR or even reject, rather than AWR or approve, may be appropriate even if research is possible with approval when there are significant irrecoverable costs.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A randomised controlled trial to compare the cost-effectiveness of tricyclic antidepressants, selective serotonin reuptake inhibitors and lofepramine

OBJECTIVE

To determine the relative cost-effectiveness of three classes of antidepressants: tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and the modified TCA lofepramine, as first choice treatments for depression in primary care.

DESIGN

Open, pragmatic, controlled trial with three randomised arms and one preference arm. Patients were followed up for 12 months.

SETTING

UK primary care: 73 practices in urban and rural areas in England.

PARTICIPANTS

Patients with a new episode of depressive illness according to GP diagnosis.

INTERVENTIONS

Patients were randomised to receive a TCA (amitriptyline, dothiepin or imipramine), an SSRI (fluoxetine, sertraline or paroxetine) or lofepramine. Patients or GPs were able to choose an alternative treatment if preferred.

MAIN OUTCOME MEASURES

At baseline the Clinical Interview Schedule, Revised (CIS-R PROQSY computerised version) was administered to establish symptom profiles. Outcome measures over the 12-month follow-up included the Hospital Anxiety and Depression Scale self-rating of depression (HAD-D), CIS-R, EuroQol (EQ-5D) for quality of life, Short Form (SF-36) for generic health status, and patient and practice records of use of health and social services. The primary effectiveness outcome was the number of depression-free weeks (HAD-D less than 8, with interpolation of intervening values) and the primary cost outcome total direct NHS costs. Quality-adjusted life-years (QALYs) were used as the outcome measure in a secondary analysis. Incremental cost-effectiveness ratios and cost-effectiveness acceptability curves were computed. Estimates were bootstrapped with 5000 replications.

RESULTS

In total, 327 patients were randomised. Follow-up rates were 68% at 3 months and 52% at 1 year. Linear regression analysis revealed no significant differences between groups in number of depression-free weeks when adjusted for baseline HAD-D. A higher proportion of patients randomised to TCAs entered the preference arm than those allocated to the other choices. Switching to another class of antidepressant in the first few weeks of treatment occurred significantly more often in the lofepramine arm and less in the preference arm. There were no significant differences between arms in mean cost per depression-free week. For values placed on an additional QALY of over 5000 pounds, treatment with SSRIs was likely to be the most cost-effective strategy. TCAs were the least likely to be cost-effective as first choice of antidepressant for most values of a depression-free week or QALY respectively, but these differences were relatively modest.

CONCLUSIONS

When comparing the different treatment options, no significant differences were found in outcomes or costs within the sample, but when outcomes and costs were analysed together, the resulting cost-effectiveness acceptability curves suggested that SSRIs were likely to be the most cost-effective option, although the probability of this did not rise above 0.6. Choosing lofepramine is likely to lead to a greater proportion of patients switching treatment in the first few weeks. Further research is still needed on the management of depressive illness in primary care. This should address areas such as the optimum severity threshold at which medication should be used; the feasibility and effectiveness of adopting structured depression management programmes in the UK context; the importance of factors such as physical co-morbidity and recent life events in GPs' prescribing decisions; alternative ways of collecting data; and the factors that give rise to many patients being reluctant to accept medication and discontinue treatment early.

Investigating women's preferences for intrapartum care: home versus hospital births

There is an increasing amount of evidence to suggest that the clinical outcomes associated with a home birth for low risk women are at least as good, if not better than, the clinical outcomes associated with giving birth in hospital. If it is the case that there is little or no difference in clinical outcomes between the two modes of delivery, then traditional measures of benefit used in health economics, e.g. quality adjusted life years (QALYs), would detect little or no difference between the alternative modes of delivery. From this, the conclusion would be that the utility values associated with each mode of delivery are similar. However, women may still have clearly defined preferences relating to the way in which maternity care is provided. This paper uses the economic technique of conjoint analysis to assess the relative value attached to several main characteristics associated with the process of maternity care during the intrapartum stage for women who have actively chosen to give birth at home relative to women who have given birth in hospital. It was found that respondents who had chosen a home birth valued continuity of carer, a homely environment and the ability to make their own decisions about what happens during labour and delivery. In contrast, hospital birth respondents placed a relatively high value on access to an epidural for pain relief and not needing to be transferred to another location during labour if a problem arose. The results of the study suggest that women have clearly defined preferences for characteristics associated with the process of intrapartum care that would be unlikely to be detected by traditional benefit measures used in health economics. This finding is important where policy issues relating to aspects of maternity care service delivery are being considered.