Prioritising HTA funding: The benefits and challenges of using value of information in anger

1. CENTRE FOR HEALTH ECONOMICS Prioritising HTA funding: The benefits and challenges of using value of information in anger K Claxton, L Ginnelly, MJ Sculpher, Z Philips. Centre for Health Economics, University of York, UK

2. Overview • Overview of methods • Screening for age-related macular degeneration • Considered by NCCHTA diagnostic and screening panel • Manual chest physiotherapy techniques for asthma and chronic obstructive pulmonary disease • Considered by NCCHTA therapeutic procedures panel • long-term antibiotic treatment for preventing recurrent urinary tract infections (UTI) in children • Considered by Prioritisation Strategy Group (PSG)

3. An overview of methods Background • Other methods • Research as a means changing clinical practice • Statistical decision theory • Reduction in the costs of decision uncertainty • Value consistent with objective and constraints of service provision Methods • Constructions of decision analytic model • Probabilistic analysis to characterise decision uncertainty • Value of information analysis

4. Identifying research priorities • EVPI • Maximum return to research (decision problem) • Comparing the EVPI to the costs of research • Comparing EVPI across technologies • Partial EVPI • Maximum return to research (endpoint) • Comparing partial EVPIs • Considering the costs of research

5. Screening for age-related macular degeneration (AMD) Options • Weekly self screening with Amsler grid • No screen but self referral on decline in visual acuity • No PDT treatment and no screening Indications • 1st eye neovascular AMD • 20/40 and 20/80 visual acuity • Male and female (age 55-64) • Eligibility of PDT consistent with NICE guidance Time horizon of 10 years NHS Perspective

6. Model structure for AMD screening

7. Manual chest physiotherapy techniques for asthma Patient groups • Children treated in the community • Adults treated in the community • Children treated in hospital Options • Massage therapy • Chiropractic spinal manipulation (CSM) • Physical therapy • No manual therapy Time horizon of 30-days NHS perspective

8. Manual Chest Physiotherapy Techniques for adults with Chronic Obstructive Pulmonary Disease (COPD) Patient groups • Adults with stable COPD Options • Autogenic drainage • Active breathing, • Heat lamp • Chest percussion with drainage • No manual therapy Time horizon of 30-days NHS perspective

9. Structure of the asthma and COPD model

10. long-term antibiotic treatment for preventing recurrent urinary tract infections (UTI) in children Patient groups • Infants of 1 year and children age 3 • Girls and boys • Recurrent UTI (no abnormalities) • Mild VUR (grade I and II) Options • Long-term low dose antibiotics (Cochrane review) (Trimethoprim, Nitrofurantoin, Cotrimoxazole) • Intermittent treatment of UTIs Time horizon • 3 years of long-term antibiotics and follow-up to end stage renal disease NHS perspective

11. Model Structure for UTI

12. The evidence Effectiveness • Existing reviews (variable quality) • Meta analysis, Multiple parameter synthesis • Probabilistic trial based model Natural history • Epidemiological studies • Pooled trial baselines • Registry studies • Clinical judgement Quality of life • Published studies • Survey Costs • Published studies • Published unit costs and dosage (BNF, PSSRU, CIPFA)

13. Results: cost-effectiveness acceptability curve

14. Results: population EVPI (girls age 3 with no VUR)

15. Partial EVPI (girls age 3 with no VUR)

16. Results: EVPI

17. Conclusions Asthma • Children treated in the community • Massage therapy may be cost-effective • Further research is potentially cost-effective • Effect of massage therapy on FEV1 (no value in effect of CSM) • Manual physiotherapy for adults treated in the community • Manual therapy not cost effective • Further research not cost-effective • Children treated in hospital • Physical therapy may be cost-effective • Further research is potentially cost-effective • Effect of physical therapy on hospital length of stay and FEV1 COPD • Manual chest physiotherapy for stable COPD is not cost-effective. • Further research not cost-effective • Inpatient manual chest physiotherapy?

18. Conclusions AMD • Screening may be cost-effective • Further research appears to be potentially cost-effective • Evidence about the quality of life with and without PDT UTI Prophylaxis • Long-term antibiotics are cost-effective for all patient groups • Which of the antibiotics should be used is uncertain • Primary research maybe required for selected patient groups • girls age 3 with no VUR • Trials should include head to head comparisons • Cotrimoxazole and trimethoprim or all three antibiotics • Longer follow-up would be worthwhile • trials with 6 month follow-up are unlikely to be worthwhile

19. Feasibility and policy impact • Feasibility • Completed despite not meeting selection criteria • Analysis conducted and presented within NCCHTA time lines • Policy impact • Mixed responses from panel members • Potential (selective) role at PSG • Impact on commissioning decisions

20. Methods and implementation • Methods • More complex and resource intensive than anticipated • Comprehensive searching for model parameters • Methods of evidence synthesis • Quality of evidence (bias and exchangeability) • Sensitivity analysis (evidence, model structure) • Implementation • Communicating complex material • Requires an iterative process • Identifying topics where VoI should be conducted