The cost-effectiveness of different chemotherapy strategies for patients with poor prognosis advanced colorectal cancer (MRC FOCUS).

OBJECTIVES: To assess the value for money of alternative chemotherapy strategies for managing advanced colorectal cancer using irinotecan or oxaliplatin, either in sequence or in combination with fluorouracil. METHODS: A cost-effectiveness model was developed using data from the U.K. fluorouracil, oxaliplatin, and CPT11 (irinotecan)--use and sequencing (FOCUS) trial. The analysis adopted the perspective of the U.K. National Health Service. Input parameters were derived using a system of risk equations (for probabilities), count data regression models (for resource use), and generalized linear models (for utilities). Parameter estimates were obtained using Markov chain Monte Carlo methods, propagating the simulation values through the state-transition model to characterize appropriately the joint distributions of expected cost, survival and quality-adjusted life years for each treatment strategy. An acceptability frontier was used to represent the probability that the optimal option is cost-effective at different values of the cost-effectiveness threshold. RESULTS: The base-case analysis used drug unit costs provided by a typical English hospital. First-line doublet therapy combination therapy fluorouracil (5FU) plus irinotecan was the most cost-effective strategy at standard thresholds, with an incremental cost-effectiveness ratio (ICER) of £14,877 (pound sterling) compared with first-line 5FU until treatment failure followed by single agent irinotecan. Other strategies were all subject to extended dominance. A sensitivity analysis using published drug (list) prices found the most cost-effective strategy would be first-line fluorouracil until failure followed by 5FU plus irinotecan (ICER: £19,753). CONCLUSIONS: The combination of 5FU and irinotecan (whether used first or second line) appears to be more cost-effective than the single agent sequential therapies used in the FOCUS trial, or 5FU plus oxaliplatin.

Eliciting distributions to populate decision analytic models.

BACKGROUND: Elicitation can be used to characterize structural uncertainty within a decision analytic model. This allows the value of acquiring further evidence to resolve these uncertainties to be established. AIM: This article demonstrated the use of expert elicitation for this purpose and also compared the elicited results with the results from alternative assumptions previously used to characterize the uncertainties. MATERIALS AND METHODS: Distributions for two unknown parameters were elicited. These were used within a model developed to assess the cost-effectiveness of infliximab and etanercept for the treatment of active psoriatic arthritis (PsA), compared with palliative care. The experts' distributions were synthesized using two approaches: linear pooling and random effects meta-analysis. Weighting of experts is also explored. RESULTS: The four methods produce broadly similar results, and in each, the choice of optimum strategy is between etanercept and palliative care (incremental cost-effective ratio for etanercept is between pound29,021 and pound39,259 per costs and quality adjusted life years). Decision uncertainty, at a pound30,000 threshold, is high in all of the synthesis models thus generating high values of further research at between pound141 and pound634 million. In each model, the greatest value of further research was for the short-term effectiveness of treatment ( pound47- pound406 million). DISCUSSION: Although the cost-effectiveness results do not differ substantially between the models using the elicited values and the original scenarios, there are some stark contrasts in terms of the values of further research generated. CONCLUSION: Elicitation offers a feasible method to generate evidence for the missing information but there are a number of key issues for which further research is required.

Quality-adjusted life years.

Many health systems now use cost-effectiveness analysis to decide which interventions and programmes to fund. A key issue for such decision making is how to measure health outcomes from interventions to reflect changes in both health-related quality of life and life expectancy. For some decision makers, including the National Institute for Health and Clinical Excellence in the UK, the quality-adjusted life-year (QALY) is central to health measurement. This article describes the concept of the QALY, its derivation, and its strengths and weaknesses.

Is primary angioplasty cost effective in the UK? Results of a comprehensive decision analysis.

OBJECTIVE: To assess the cost effectiveness of primary angioplasty, compared with medical management with thrombolytic drugs, to achieve reperfusion after acute myocardial infarction (AMI) from the perspective of the UK NHS. DESIGN: Bayesian evidence synthesis and decision analytic model. METHODS: A systematic review was conducted and Bayesian statistical methods used to synthesise evidence from 22 randomised control trials. Resource utilisation was based on UK registry data, published literature and national databases, with unit costs taken from routine NHS sources and published literature. MAIN OUTCOME MEASURE: Costs from a health service perspective and outcomes measured as quality-adjusted life years (QALYs). RESULTS: For the base case, the incremental cost-effectiveness ratio of primary angioplasty was 9241 pounds sterling for each additional QALY, with a probability of being cost effective of 0.90 for a cost-effectiveness threshold of 20,000 pounds sterling. Results were sensitive to variations in the additional time required to initiate treatment with primary angioplasty. CONCLUSIONS: Primary angioplasty is cost effective for the treatment of AMI on the basis of threshold cost-effectiveness values used in the NHS and subject to a delay of up to about 80 minutes. These findings are mainly explained by the superior mortality benefit and the prevention of non-fatal outcomes associated with primary angioplasty for delays of up to this length.

Difficult commissioning choices: lessons from English primary care trusts.

OBJECTIVE: In England, primary care organizations (primary care trusts, PCTs) have scope to influence the provision of health care at the margin. However, when faced with difficult commissioning choices, restriction of services potentially leaves them vulnerable to legal challenge. PCTs are developing different approaches to priority setting but there is a need to develop processes that lead to more consistent, accountable and fair decision-making. Our objective was to describe recent local developments on prioritization decision-making. METHODS: Rationing policies in PCTs in West Yorkshire and North & East Yorkshire and North Lincolnshire (NEYNL) Strategic Health Authority areas in 2003 were examined. To evaluate priority setting, we compared the descriptive findings with an internationally recognized ethical framework for priority setting, 'accountability for reasonableness' (AFR). RESULTS: PCTs varied as regards the stage of policy development they had reached. Rationing by exclusion was the most common approach to prioritization, but in general PCTs failed to make the rationale for their decisions explicit and accessible. The importance of an appeals process was recognized by the majority of PCTs. Those that had developed a formal process to address difficult commissioning decisions were an exception. CONCLUSIONS: Adopting AFR as a prioritization framework can serve to improve the fairness and consistency of the decision-making process, reducing the vulnerability of PCTs to legal challenge. Characteristics of rationing policies already in place fulfil some of the AFR conditions but there remains scope for further improvements in their design and dissemination.