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Challenges in cost-utility analysis in the critical care setting

Challenges in cost-utility analysis in the critical care setting. Ville Pettilä MD, PhD , A/P Helsinki University Hospital. SFAI- veckan / Kalmar. CCM 2006. CCM 2006. - only 19 papers - max $958,423/ QALY $1,150 - $575,000 / life-year - many < $50,000 /QALY -.

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Challenges in cost-utility analysis in the critical care setting

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  1. Challenges in cost-utilityanalysisin the criticalcaresetting Ville Pettilä MD, PhD, A/P Helsinki UniversityHospital SFAI- veckan / Kalmar VP

  2. CCM 2006

  3. CCM 2006 • - only 19 papers • - max $958,423/ QALY • $1,150 - $575,000 / life-year • - many < $50,000 /QALY • -

  4. 41 studies in critical/intensive care • quality assessed as poor to moderate

  5. Boston- CEA Registry- Quality of cost-utility analyses

  6. .. In the idealworld VP

  7. Sintonen 1994

  8. VP

  9. ARDS N=200 Angus D AMJRCCM 2001

  10. Quality-adjusted survival Angus DC et al. CCM 2006

  11. Challenge No 1: Inter-patient variability

  12. Costs and QALYs – the real world in the ICU

  13. Cost-effectiveness planes for a treatment Räsänen P et al. HQLO 2006

  14. Crit Care Med 2003

  15. Challenge No 2: Inter-diagnoses variability

  16. Challenge No 3: How to adjust for non-survivors?

  17. Angus D et al. CCM 2006

  18. Challenge No 4: Which instrument to use for quality of life (QOL)?

  19. (1) What is an OPTIMAL QOL measure ? SF- (RAND- 36) EQ-5D Nottingham Health Profile (NPH) SIP etc.

  20. EQ-5D *simple *ESICM recommendation *one number between 0 and 1 * enables QALY calculations

  21. (2) QOL – target population ? selected vs. unselected defined vs. all trauma ?, sepsis? ARDS? timing of measurement 6(-12) months post/ICU ? a cohort or an RCT?

  22. (3) QOL- missing data Proportion of missing data - < 10%? How to handle missing data ? Comparison of patients with missing data to those with available data ! Adequate sample size !

  23. (4) QOL- follow-up and adjustment ? Wereallpatientsfollowed ? What is the optimaltime for QOL measurement ?

  24. Dowdy et al ICM 2006

  25. - 8894references • - 111 studies • 21differentpatientpopulations • 21 studiesincluded • Differentinstruments, patientpopulations Dowdy et al. ICM 2005

  26. VP

  27. Challenge No 5: How to calculate/ estimate quality of life (QOL)?

  28. Challenge No 6: How accurate are the costs? Indirect costs ? Costs after hospital discharge?

  29. Challenge No 7: What is the time-frame? Should it be life-time?

  30. Kaarlola A, Tallgren M, Pettilä V CCM 2006

  31. QALYs after critical care[N=2873] Kaarlola et al. CCM 2006

  32. Cost-utility after intensive care [N=2873] Kaarlola et al. CCM 2006

  33. Cost per QALY in severe sepsis (Finnsepsis study) N=480 Key finding: The estimatedlife-timecost-utilityusing QOL at 2 years afterdischarge is veryreasonable (median 1720€/QALY) Karlsson et al CCM 2009

  34. Cost per QALY in acute respiratory failure (FINNALI study) N=958 Mean of costs, costs/QALYs and estimated QALYs with 95% CIs in different age groups for acute respiratory failure patients. VP FINNALI, Linko et al. Critical Care 2010

  35. Table 3. Predicted cost-utilities in subgroups of patients with acute respiratory failure. Cost-utility – acute respiratory failure – life-time scale –FINNALI -2007 VP Linko et al Critical Care 2010 Chronic diseases: chronic obstructive pulmonary disease, chronic restrictive pulmonary disease, chronic heart disease, diabetes mellitus, immunodeficiency, neuromuscular disease Linko et al. Critical Care 2010 accepted

  36. Challenge No 8: Discount for costs and QALYs included in the calculations?

  37. Challenge No 9 How to present willingness to pay and probabilities?

  38. Challenge No 9: How to present willingness to pay and probabilities? CEAC- cost effectiveness acceptability curve

  39. Cost-effectiveness acceptability curves-CEACs Subgroups of patients according to gained QALYs

  40. VP

  41. VP

  42. Costutilitystudies in criticalcarelackscientificvalidity and robustness Conclusions VP

  43. Costutilitystudies in criticalcarelackscientificvalidity and robustness • No consensusregardingutilityinstrument , calculations, adjustment for missing data, and representation of data exist Conclusions VP

  44. Costutilitystudies in criticalcarelackscientificvalidity and robustness • No consensusregardingutilityinstrument , calculations, adjustment for missing data, and representation of data exists • At theirbest the availablecostutilitystudies in criticalcaremaybeseen as clinicallyvaluableestimations of benefit/ harm of the treatment Conclusions VP

  45. 1. Representativenon-selectedpopulation 2. Defineddiagnosticgroup 3. Standardizedutilityinstrument 4. Life-timescale for QALYsgained 5. Preferablyallhospitalcosts/reliableestimate 6. Discountrate 7. Sensitivityanalysisregardingdifferentage and severity of disease 8. Cost-effectivenssplane 9. CEA-curve ConclusionCost-utility –studies….…..the gold standard VP

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