Biomedical subjects

Ron Akehurst

Publications and source records attributed to Ron Akehurst.

7 recordsLinked to original sources

PubMed2006

Discounting and cost-effectiveness in NICE - stepping back to sort out a confusion.

Brouwer and colleagues [1] argue that the reasons for specifying an equal discount rate for health outcomes and costs in the recent guidance on methods of technology appraisal issued by the National Institute for Clinical Excellence (NICE) [2] is both opaque and wrong. They argue that a lower rate should apply to health outcomes like QALYs. It is also claimed that the guidance on discounting represents a step backwards, that is both inconsistent with current theoretical insights and will prejudice the outcome of cost-effectiveness studies of preventive interventions.The reasoning behind the use of equal discount rates for costs and health outcomes is indeed not well developed in the published guidance. Nor does it reflect the debate that underpinned the guidance. We therefore welcome the opportunity to explain more completely the rationale in the minds of the principal authors of the current guidance.

Academies and Institutes↗

PubMed2005

Probabilistic sensitivity analysis for NICE technology assessment: not an optional extra.

Recently the National Institute for Clinical Excellence (NICE) updated its methods guidance for technology assessment. One aspect of the new guidance is to require the use of probabilistic sensitivity analysis with all cost-effectiveness models submitted to the Institute. The purpose of this paper is to place the NICE guidance on dealing with uncertainty into a broader context of the requirements for decision making; to explain the general approach that was taken in its development; and to address each of the issues which have been raised in the debate about the role of probabilistic sensitivity analysis in general. The most appropriate starting point for developing guidance is to establish what is required for decision making. On the basis of these requirements, the methods and framework of analysis which can best meet these needs can then be identified. It will be argued that the guidance on dealing with uncertainty and, in particular, the requirement for probabilistic sensitivity analysis, is justified by the requirements of the type of decisions that NICE is asked to make. Given this foundation, the main issues and criticisms raised during and after the consultation process are reviewed. Finally, some of the methodological challenges posed by the need fully to characterise decision uncertainty and to inform the research agenda will be identified and discussed.

Cost-Benefit Analysis↗

PubMed2005

Modelling the long term cost effectiveness of clopidogrel for the secondary prevention of occlusive vascular events in the UK.

OBJECTIVE: To assess the long term cost effectiveness of clopidogrel monotherapy compared with acetylsalicylic acid (aspirin; ASA) monotherapy in patients at risk of secondary occlusive vascular events (OVEs) in the UK. DESIGN: Cost utility analysis based on clinical data from CAPRIE (a multicentre randomised controlled trial, involving 19185 patients); long-term effects were extrapolated beyond the trial period using a Markov model populated with data from UK observational studies. Health economic evaluation carried out from the perspective of the UK National Health Service. PARTICIPANTS: A representative cohort of 1000 UK patients aged 60 years (approximate mean age of the CAPRIE population), with the qualifying diagnoses of myocardial infarction, ischaemic stroke and peripheral arterial disease, who are at risk of secondary OVEs (non-fatal myocardial infarction, non-fatal stroke or vascular death). INTERVENTIONS: Patients were assumed to receive treatment with either clopidogrel (75 mg/day) for 2 years followed by ASA (325 mg/day, average) for their remaining lifetime, or ASA alone (325 mg/day, average) for life. MAIN OUTCOME MEASURES: Incremental cost per life year gained and incremental cost per quality-adjusted life year (QALY) gained. RESULTS: In the base case, the incremental cost effectiveness of clopidogrel versus ASA in this population is estimated at 18888 pounds per life year gained and 21 489 pounds per QALY gained. Multiple deterministic and probabilistic sensitivity analyses suggest the model is robust to variations in a wide range of input parameters. CONCLUSION: Two years of treatment with clopidogrel can be considered a cost effective intervention in patients at risk of secondary OVEs in the UK.

Aged↗

PubMed2005

Incorporation of uncertainty in health economic modelling studies.

In a recent leading article in PharmacoEconomics, Nuijten described some methods for incorporating uncertainty into health economic models and for utilising the information on uncertainty regarding the cost effectiveness of a therapy in resource allocation decision-making. His proposals are found to suffer from serious flaws in statistical and health economic reasoning.Nuijten's suggestions for incorporating uncertainty: (a) wrongly interpret the p-value as the probability that the null hypothesis is true; (b) represent this probability wrongly by truncating the input distribution; and (c) in the specific example of an antiparkinsonian drug uses a completely inappropriate p-value of 0.05 when the null hypothesis would, in reality, be emphatically disproved by the data.His suggestions regarding minimum important differences in cost effectiveness: (a) introduce areas of indifference that suggest inappropriate reliance on cost minimisation while failing to recognise that decisions should be based on expected costs versus benefits; and (b) offer no guidance on how the probabilities associated with these areas could be used in decision-making. Furthermore, Nuijten's model for Parkinson's disease is over-simplified to the point of providing a bad example of modelling practice, which may mislead the readers of PharmacoEconomics. The rationale for this paper is to ensure that readers do not apply inappropriate analyses as a result of following the proposals contained in Nuijten's paper. In addition to a detailed critique of Nuijten's proposals, we provide brief summaries of the currently accepted best practice in cost-effectiveness decision-making under uncertainty.

Antiparkinson Agents↗

PubMed2005

Should patients have a greater role in valuing health states?

Currently, health state values are usually obtained from members of the general public trying to imagine what the state would be like rather than by patients who are actually in the various states of health. Valuations of a health state by patients tend to vary from those of the general population, and this seems to be due to a range of factors including errors in the descriptive system, adaptation to the state and changes in internal standards. The question of whose values are used in cost-effectiveness analysis is ultimately a normative one, but the decision should be informed by evidence on the reasons for the differences. There is a case for obtaining better informed general population preferences by providing more information on what it is like for patients (including the process of adaptation).

Adaptation, Psychological↗

PubMed2004

Economic evaluation of everolimus versus mycophenolate mofetil in combination with cyclosporine and prednisolone in de novo renal transplant recipients.

An economic evaluation was undertaken alongside a multicentre, international, trial of everolimus (Certican). Resource usage within the trial was assessed, and the cost implications of the use of everolimus were evaluated. Recipients of a primary cadaveric kidney transplant were recruited into a double-blind trial and received either everolimus 1.5 mg (n=194); everolimus 3 mg (n=198) or mycophenolate mofetil (MMF) 2 g (n=196). Clinical outcomes and resource usage were monitored for 12 months following transplantation. Local costs were obtained, and global analysis using health sector PPP rates was undertaken. The mean overall cost of treatment was 33,715 dollars (95%CI 30,013 dollars-37,417 dollars) with everolimus 1.5 mg, 38,519 dollars (95%CI 34,094 dollars-42,943 dollars) with everolimus 3 mg and 36,509 dollars (95%CI 32,430 dollars-40,587 dollars) with MMF. Differences between the three groups did not reach statistical significance. In conclusion, the economic analysis showed statistical equivalence over the three arms of the trial. Further work is required to demonstrate the cost consequences of the use of everolimus compared with MMF in renal transplantation patients.

Adult↗

PubMedDate not supplied

Cost-effectiveness of sibutramine in the treatment of obesity.

BACKGROUND: This study reports incremental cost-utility of sibutramine compared to diet and lifestyle advice for the treatment of obesity. METHOD: The model estimates the costs and quality of life benefits associated with weight loss itself and the reduced incidence of coronary heart disease (CHD) and diabetes in the "healthy obese." The key source of effectiveness data is 2 randomized controlled trials over 12 months. Utility gain per kilogram lost is analyzed using Short Form-36 data from sibutramine trials. The impact on CHD is estimated using the Framingham risk equation, which relates age/sex/body mass index to risk of heart disease. The reduced incidence of diabetes due to weight loss is estimated from published literature. A life tables approach was used to calculate the cost per quality-adjusted life year (QALY) of 1 year's treatment with sibutramine compared to diet and lifestyle advice. RESULTS: The incremental cost per QALY of sibutramine is 4,780 UK pounds. Sensitivity analyses show that this result is sensitive to utility associated with weight loss and the frequency of monitoring. CONCLUSIONS: Sibutramine is a cost-effective treatment for obesity when combined with diet and lifestyle advice.

Adult↗