Why Its Time to Abandon the ICER Dr Mike Paulden, Assistant - PowerPoint PPT Presentation

Why It’s Time to Abandon the ICER Dr Mike Paulden, Assistant Professor, School of Public Health, University of Alberta @mikepaulden paulden@ualberta.ca Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 1 mikepaulden.com +1 (844) PAULDEN

Introduction ● The incremental cost-effectiveness ratio (ICER) is widely used to report the results of economic analyses of health technologies ● Yet reporting ICERs is unnecessary - alternative measures exist, based on the concepts of net health benefit (NHB) or net monetary benefit (NMB) ● Yet ICERs remain popular with decision makers, and there is a common perception that there are advantages to using ICERs, particularly if the cost- effectiveness threshold (λ) is unknown ● This paper argues that this common perception is false - there are no advantages to using ICERs and many important limitations Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 2

Calculating ICERs where there are only two strategies Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 3

ICER = ∆Cost / ∆QALYs Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 4

Result: ICERs are easy to calculate with only two strategies Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 5

Interpreting the ICER where there are only two strategies Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 6

Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 7

Question: Is strategy B cost-effective ? Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 8

Question: Would a different strategy with an ICER of $25,000 per QALY be cost-effective? Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 10

Question: Would a different strategy with a negative ICER be cost-effective? Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 12

Question: Does a lower ICER imply that a strategy is necessarily more cost-effective ? Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 15

Limitations of ICERs in comparisons of two strategies 1. A threshold is required to determine whether a strategy is cost-effective , unless it is dominated/dominating (in which case an ICER is not required) 2. An ICER cannot be interpreted without also knowing the quadrant of the CE plane in which the strategy lies 3. Change in an ICER during a sensitivity analysis does not necessarily imply that the strategy is more or less cost-effective Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 19

Result: ICERs are difficult to interpret with only two strategies and any interpretation is limited Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 20

Calculating ICERs where there are multiple strategies Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 21

Strategy Cost QALYs A $600,000 24 B $1,300,000 34 C $400,000 16 D $500,000 26 E $700,000 20 F $100,000 6 G $1,000,000 30 H $350,000 8 Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 22

Step 1: Rank strategies by cost Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 23

Strategy Cost QALYs F $100,000 6 H $350,000 8 C $400,000 16 D $500,000 26 A $600,000 24 E $700,000 20 G $1,000,000 30 B 34 $1,300,000 Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 24

Step 2: Rule out ‘dominated’ strategies Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 25

Strategy Cost QALYs F $100,000 6 H $350,000 8 C $400,000 16 D $500,000 26 A $600,000 24 E $700,000 20 G $1,000,000 30 B $1,300,000 34 Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 26

Strategy Cost QALYs F $100,000 6 H $350,000 8 C $400,000 16 D $500,000 26 A $600,000 24 E $700,000 20 G $1,000,000 30 B $1,300,000 34 Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 27

Step 3: Calculate initial estimates of incremental values Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 28

ΔCost ΔQALYs Strategy Cost QALYs ICER F $100,000 6 H $350,000 8 C $400,000 16 D $500,000 26 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 B $1,300,000 34 Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 29

ΔCost ΔQALYs Strategy Cost QALYs ICER F $100,000 6 N/A N/A N/A H $350,000 8 C $400,000 16 D $500,000 26 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 B $1,300,000 34 Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 30

ΔCost ΔQALYs Strategy Cost QALYs ICER F $100,000 6 N/A N/A N/A H $350,000 8 $250,000 2 $125,000 C $400,000 16 $50,000 8 $6,250 D $500,000 26 $100,000 10 $10,000 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 $500,000 4 $125,000 B $1,300,000 34 $300,000 4 $75,000 Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 31

Step 4: Rule out initial ‘extendedly dominated’ strategies Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 32

ΔCost ΔQALYs Strategy Cost QALYs ICER F $100,000 6 N/A N/A N/A H $350,000 8 $250,000 2 $125,000 C $400,000 16 $50,000 8 $6,250 D $500,000 26 $100,000 10 $10,000 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 $500,000 4 $125,000 B $1,300,000 34 $300,000 4 $75,000 Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 33

ΔCost ΔQALYs Strategy Cost QALYs ICER F $100,000 6 N/A N/A N/A H $350,000 8 ED ED ED C $400,000 16 $50,000 8 $6,250 D $500,000 26 $100,000 10 $10,000 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 ED ED ED B $1,300,000 34 $300,000 4 $75,000 Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 34

Step 5: Recalculate incremental values Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 35

Why Its Time to Abandon the ICER Dr Mike Paulden, Assistant - PowerPoint PPT Presentation

Why Its Time to Abandon the ICER Dr Mike Paulden, Assistant Professor, School of Public Health, University of Alberta @mikepaulden paulden@ualberta.ca Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca

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