Cost-effectiveness evidence on approved cancer drugs in Ireland: the limits of data availability and implications for public accountability

Abstract Background We surveyed evidence published by Ireland’s National Centre for Pharmacoeconomics (NCPE) on the cost-effectiveness of cancer drugs approved for funding within the Irish public healthcare system. The purpose is threefold: to assess the completeness and clarity of publicly available cost-effectiveness data of such therapies; to provide summary estimates of that data; to consider the implications of constraints on data availability for accountability regarding healthcare resource allocation. Methods The National Cancer Control Programme lists 91 drug-indication pairs approved between June 2012 and July 2020. Records were retrieved from the NCPE website for each drug-indication pair, including, where available, health technology assessment (HTA) summary reports. We assessed what cost-effectiveness data regarding approved interventions is available, aggregated it and considered the consequences of reporting constraints. Results Among the 91 drug-indication pairs 61 were reimbursed following full HTA, 22 after a rapid review process and 8 have no corresponding NCPE record. Of the 61 where an HTA report was available, 41 presented costs and quality-adjusted life-year (QALY) estimates of the interventions compared. Cost estimates and corresponding incremental cost-effectiveness ratios (ICERs) are based on prices on application for reimbursement. Reimbursed prices are not published. Aggregating over the drug-indication pairs for which data is available, we find a mean incremental health gain of 0.85 QALY and an aggregate ICER of €100,295/QALY, which exceeds Ireland’s cost-effectiveness threshold of €45,000/QALY. Conclusion Reimbursement applications by pharmaceutical manufacturers for cancer drugs typically exceed Ireland’s cost-effectiveness threshold, often by a considerable margin. On aggregate, the additional total net cost of new drugs relative to current treatments needs to be more than halved for the prices sought on application to be justified for reimbursement. Commercial confidentiality regarding prices and cost-effectiveness upon reimbursement compromises accountability regarding the fair and efficient allocation of scarce healthcare resources.

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The cost-effectiveness threshold for medical interventions may depend on the context of the circumstances

PsycEXTRA Dataset ◽

10.1037/e556142006-025 ◽

2006 ◽

Keyword(s):

Cost Effectiveness ◽

Medical Interventions ◽

The Cost ◽

Cost Effectiveness Threshold ◽

Effectiveness Threshold

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Does NICE have a cost-effectiveness threshold and what other factors influence its decisions? A binary choice analysis

Health Economics ◽

10.1002/hec.864 ◽

2004 ◽

Vol 13 (5) ◽

pp. 437-452 ◽

Cited By ~ 447

Author(s):

Nancy Devlin ◽

David Parkin

Keyword(s):

Cost Effectiveness ◽

Binary Choice ◽

Choice Analysis ◽

Cost Effectiveness Threshold ◽

Effectiveness Threshold

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Cost Needed to Treat (CNT) and Number Needed to Treat (NNT) analysis of drugs for treatment of heart failure in India

European Heart Journal ◽

10.1093/ehjci/ehaa946.3539 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

K Mullavelil ◽

V George ◽

A Thannikkal ◽

R Aravindakshan ◽

D John ◽

...

Keyword(s):

Heart Failure ◽

Cost Effectiveness ◽

Treatment Strategies ◽

Future Research ◽

Number Needed To Treat ◽

Neprilysin Inhibitor ◽

Long Term Treatment ◽

The Cost ◽

Cost Effectiveness Threshold ◽

Effectiveness Threshold

Abstract Background Only little attention has been paid to treatment strategies of chronic disease conditions that require long term treatment and repeated hospitalizations Purpose Our aim was to review cost-effectiveness of guideline directed medical therapy of heart failure in India and identify drugs that can be made available free of cost or at subsidized rates to the patient population. Methods Data extracted from ten landmark trials in heart failure was used to compute Number Needed to Treat (NNT) and Cost Needed to Treat (CNT) of drugs used in heart failure, to prevent cardiovascular mortality and heart failure re-hospitalization using HDS Plotter- Incremental Cost Effectiveness Calculator. Since various brands (i.e. trade names) with wide cost range are available in Indian market, the average retail price in Indian Rupees for year 2019 was considered and converted to US dollars and used for the analysis.NNT and CNT of each drug was computed and the cost-effectiveness was analyzed. WHO recommendation of three times per capita GDP was used as the cost effectiveness threshold. Results Medications that were labeled as class I for the treatment of heart failure, were included in our analysis. Ivabradine, Valsartan and Angiotensin Receptor Neprilysin inhibitor (ARNi) did not meet the cost effectiveness criteria for preventing cardio-vascular mortality. For prevention of heart failure re-hospitalization, all drugs except ARNi, met the cost effectiveness threshold. Conclusion Any future research would need to consider compliance factor along with Willingness to Pay (WTP) to understand the real acceptance of these drugs on the ground in India. Log prices (in US$) of various HF drugs Funding Acknowledgement Type of funding source: None

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Methods for the estimation of the National Institute for Health and Care Excellence cost-effectiveness threshold

Health Technology Assessment ◽

10.3310/hta19140 ◽

2015 ◽

Vol 19 (14) ◽

pp. 1-504 ◽

Cited By ~ 311

Author(s):

Karl Claxton ◽

Steve Martin ◽

Marta Soares ◽

Nigel Rice ◽

Eldon Spackman ◽

...

Keyword(s):

Cost Effectiveness ◽

Health Effects ◽

The Other ◽

Opportunity Costs ◽

Best Estimate ◽

The Cost ◽

The Impact ◽

The Relationship ◽

Cost Effectiveness Threshold ◽

Effectiveness Threshold

BackgroundCost-effectiveness analysis involves the comparison of the incremental cost-effectiveness ratio of a new technology, which is more costly than existing alternatives, with the cost-effectiveness threshold. This indicates whether or not the health expected to be gained from its use exceeds the health expected to be lost elsewhere as other health-care activities are displaced. The threshold therefore represents the additional cost that has to be imposed on the system to forgo 1 quality-adjusted life-year (QALY) of health through displacement. There are no empirical estimates of the cost-effectiveness threshold used by the National Institute for Health and Care Excellence.Objectives(1) To provide a conceptual framework to define the cost-effectiveness threshold and to provide the basis for its empirical estimation. (2) Using programme budgeting data for the English NHS, to estimate the relationship between changes in overall NHS expenditure and changes in mortality. (3) To extend this mortality measure of the health effects of a change in expenditure to life-years and to QALYs by estimating the quality-of-life (QoL) associated with effects on years of life and the additional direct impact on QoL itself. (4) To present the best estimate of the cost-effectiveness threshold for policy purposes.MethodsEarlier econometric analysis estimated the relationship between differences in primary care trust (PCT) spending, across programme budget categories (PBCs), and associated disease-specific mortality. This research is extended in several ways including estimating the impact of marginal increases or decreases in overall NHS expenditure on spending in each of the 23 PBCs. Further stages of work link the econometrics to broader health effects in terms of QALYs.ResultsThe most relevant ‘central’ threshold is estimated to be £12,936 per QALY (2008 expenditure, 2008–10 mortality). Uncertainty analysis indicates that the probability that the threshold is < £20,000 per QALY is 0.89 and the probability that it is < £30,000 per QALY is 0.97. Additional ‘structural’ uncertainty suggests, on balance, that the central or best estimate is, if anything, likely to be an overestimate. The health effects of changes in expenditure are greater when PCTs are under more financial pressure and are more likely to be disinvesting than investing. This indicates that the central estimate of the threshold is likely to be an overestimate for all technologies which impose net costs on the NHS and the appropriate threshold to apply should be lower for technologies which have a greater impact on NHS costs.LimitationsThe central estimate is based on identifying a preferred analysis at each stage based on the analysis that made the best use of available information, whether or not the assumptions required appeared more reasonable than the other alternatives available, and which provided a more complete picture of the likely health effects of a change in expenditure. However, the limitation of currently available data means that there is substantial uncertainty associated with the estimate of the overall threshold.ConclusionsThe methods go some way to providing an empirical estimate of the scale of opportunity costs the NHS faces when considering whether or not the health benefits associated with new technologies are greater than the health that is likely to be lost elsewhere in the NHS. Priorities for future research include estimating the threshold for subsequent waves of expenditure and outcome data, for example by utilising expenditure and outcomes available at the level of Clinical Commissioning Groups as well as additional data collected on QoL and updated estimates of incidence (by age and gender) and duration of disease. Nonetheless, the study also starts to make the other NHS patients, who ultimately bear the opportunity costs of such decisions, less abstract and more ‘known’ in social decisions.FundingThe National Institute for Health Research-Medical Research Council Methodology Research Programme.

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