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Lindsay Hedden Priorities 2010, Boston, MA

An Application of Evidence-Based Marginal Analysis: Assessing the Incremental Cost Effectiveness of Eras of Metastatic Colorectal Cancer Therapy in British Columbia, Canada: Pre- and Post- Bevacizumab Introduction . Lindsay Hedden Priorities 2010, Boston, MA.

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Lindsay Hedden Priorities 2010, Boston, MA

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  1. An Application of Evidence-Based Marginal Analysis: Assessing the Incremental Cost Effectiveness of Eras of Metastatic Colorectal Cancer Therapy in British Columbia, Canada: Pre- and Post-Bevacizumab Introduction Lindsay Hedden Priorities 2010, Boston, MA

  2. Priority Setting and Resource Allocation at BCCA • This bevacizumab study is part of a larger program of research into Evidence Based Marginal Analysis • Goal: to develop and pilot novel evidence-based methods for priority setting and resource allocation within the context of cancer control and care in British Columbia • A key objective: evaluate the effectiveness of priority setting decisions using utilization, mortality, and quality of life data

  3. EMBA Study Structure STEERING COMMITTEE • Established and refined decision criteria • Identified three areas for potential resource reallocation • Reviewed results of cost-effectiveness analyses • Made recommendations for resource reallocation PROGRAM PANELS • Provide clinical and data expertise on model building • Validate results

  4. Bevacizumab (Avastin): Background • Bevacizumab (bev): given as a first- or second-line systemic therapy in combination with other regimens to treat metastatic colorectal cancer (mCRC) • 2.8 month average improvement in overall survival • 2.6 months average improvement in progression-free survival • National Institute for Health and Clinical Excellence (UK) • £62,857-£88,436 per QALY gained • Use of bev as first-line therapy is NOT recommended

  5. Goal To estimate the incremental cost-effectiveness of bevas a systemic therapy treatment for mCRC, accounting for the differences in costs and health outcomes associated with bevand standard of care treatments BUT: Cannot directly compare costs and outcomes for patients treated vs. not treated with bevacizumab because of selection bias

  6. Approach and Objectives • Compare eras of treatment for mCRC: • pre-bevacizumab introduction and post-bevacizumab introduction • secondary pseudo case-control comparison • Objectives • 1) To assess the cost-effectiveness of the era of bev protocols in the treatment of mCRC compared with the pre-bev era • 2)to evaluate the incremental cost-effectiveness of a first- and second-line bevamong the subset of patients receiving “doublet” chemotherapy (5-FU plus irinotecan or oxaliplatin)

  7. Markov Model Schema

  8. Sample • Complete cohort of patients presenting with mCRC at diagnosis, identified using BCCA’s Information Service (CAIS) • Pre-era: Diagnosed Jan 1, 2003-Dec 31, 2004; followed to death, censoring, or Oct 31, 2005 • Bev-era: Diagnosed Jan 1, 2006-Dec 31, 2006; followed to death, censoring, or Oct 31, 2008 • 611 cases in pre-era & 332 in the post-era

  9. Transition Probabilities Survival: derived based on Weibull models Chemotherapy: derived based on Exponential models

  10. Costs

  11. Utility Values *Source: Ness, R.M., et al., Outcome states of colorectal cancer: identification and description using patient focus groups. The American Journal of Gastroenterology, 1998. 93(9): p. 1491-1497

  12. Survival for individuals who initiated chemotherapy

  13. Era-Based Base-Case Results

  14. Sensitivity Analysis

  15. Restricted Analysis • Subset of era-based analysis: • 1) Diagnosed before age 70 • 2) Treated with first-line doublet chemotherapy • Intent: include only patients who wereorwould have been eligible for a bev-based protocol

  16. Restricted Cohort Base-Case Results

  17. Interpretation • Era-based: $62,468.68/QALY or $15,617/LYG 3.9 month/patient improvement in survival & $3,791/patient increase in cost • Not directly inferred as cost-effectiveness of bev • Other factors my have led to improvements in survival, increases in cost

  18. Interpretation (2) • Restricted Analysis: $43,058/QALY or $10,764/LYG  4.4 month/patient improvement in survival & $1,894/patient increase in cost • Closer to a true incremental cost-effectiveness comparing bev with standard of care, but not perfect • Both methods produced ICERs demonstrating better cost-effectiveness than estimated by NICE

  19. Implications • As a 1st or 2nd line treatment for mCRC, bev may be relatively cost-effective, considered as part of a suite of available treatments • the era-based ICER of $62,468 is well in-line with cost-effectiveness ratios reported for other therapies for metastatic cancer therapies

  20. Acknowledgements • Project team: • Dr. Stuart Peacock • Dr. Diego Villa • Dr. Hagen Kennecke • Funding sources: • CIHR Partnerships in Health Systems Improvement

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