Use of Value of Information in Healthcare Decision Making: Exploring Multiple Perspectives.

BACKGROUND: Value of information (VOI) is a tool that can be used to inform decisions concerning additional research in healthcare. VOI estimates the value of obtaining additional information and indicates the optimal design for additional research. Although it is recognized as good practice in handling uncertainty, it is still hardly used in decision making in the Netherlands. OBJECTIVE: This paper aims to examine the potential value of VOI, barriers and facilitators and the way forward with the use of VOI in the decision-making process for reimbursement of pharmaceuticals in the Netherlands. METHODS: Three focus group interviews were conducted with researchers, policy makers, and representatives of pharmaceutical companies. RESULTS: The results revealed that although all stakeholders recognize the relevance of VOI, it is hardly used and many barriers to the performance and use of VOI were identified. One of these barriers is that not all uncertainties are easily incorporated in VOI, and the results may be biased if structural uncertainties are ignored. Furthermore, not all research designs indicated by VOI may be feasible in practice. CONCLUSIONS: To fully embed VOI into current decision-making processes, a threshold incremental cost-effectiveness ratio and guidelines that clarify when and how VOI should be performed are needed. In addition, it should be clear to all stakeholders how the results of VOI are used in decision making.

Evaluation of patient registries supporting reimbursement decisions: the case of oxaliplatin for treatment of stage III colon cancer.

BACKGROUND: Access with evidence development has been established for expensive intramural drugs in The Netherlands. The procedure involves a 4-year period of conditional reimbursement. During this period, additional evidence has to be gathered usually through a patient registry. Given the costs and time involved in gathering the data, it is important to carefully evaluate the registry. OBJECTIVES: This study aimed to develop a model for the regular evaluation of patient registries during an access with evidence development process and find the optimal length of the registry period. METHODS: We used data from a recent registry in The Netherlands on oxaliplatin as a treatment option for stage III colon cancer. We added simulated follow-up data to the empirical data available and applied value of information analysis to balance the gains of extending the period and amount of data gathering against the costs of registering patients. RESULTS: We show that given the assumptions on cohort size, follow-up time, and purpose of the registry, the current (partly simulated) registry was not very efficient. Notably, the observation period could have been stopped to make a definite reimbursement decision after a maximum of 2 years rather than the fixed 4-year period. CONCLUSIONS: Patient registries may be an efficient way to gather data on new medical treatments, but they need to be carefully designed and evaluated, in particular regarding their follow-up time. For each purpose, data gathering can be tailored to make sure decisions are taken at the moment that sufficient data are available.

Value of information analysis from a societal perspective: a case study in prevention of major depression.

OBJECTIVES: Productivity losses usually have a considerable impact on cost-effectiveness estimates while their estimated values are often relatively uncertain. Therefore, parameters related to these indirect costs play a role in setting priorities for future research from a societal perspective. Until now, however, value of information analyses have usually applied a health care perspective for economic evaluations. Hence, the effect of productivity losses has rarely been investigated in such analyses. The aim of the current study therefore was to investigate the effects of including or excluding productivity costs in value of information analyses. METHODS: Expected value of information analysis (EVPI) was performed in cost-effectiveness evaluation of prevention from both societal and health care perspectives, to give us the opportunity to compare different perspectives. Priorities for future research were determined by partial EVPI. The program to prevent major depression in patients with subthreshold depression was opportunistic screening followed by minimal contact psychotherapy. RESULTS: The EVPI indicated that regardless of perspective, further research is potentially worthwhile. Partial EVPI results underlined the importance of productivity losses when a societal perspective was considered. Furthermore, priority setting for future research differed according to perspective. CONCLUSIONS: The results illustrated that advise for future research will differ for a health care versus a societal perspective and hence the value of information analysis should be adjusted to the perspective that is relevant for the decision makers involved. The outcomes underlined the need for carefully choosing the suitable perspective for the decision problem at hand.

Targeted screening for Coeliac Disease among irritable bowel syndrome patients: analysis of cost-effectiveness and value of information.

OBJECTIVES: A high prevalence of Coeliac Disease (CD) is found among patients with a clinical diagnosis of irritable bowel syndrome (IBS) compared to the general population. Symptoms of CD are quite similar to IBS, but its treatment is different. The aim of this study was to evaluate the cost-effectiveness of screening for CD in patients with diarrhoea/mixed type IBS (IBS-D/mix) in terms of cost per quality adjusted life year (QALY) in the Netherlands. METHODS: A decision model was constructed to evaluate the costs and health benefits of serological testing followed by confirmatory endoscopy with biopsy. Probabilistic sensitivity analysis (PSA) was performed to examine the effect of parameter uncertainty. Finally, the budget impact of implementing the screening process was also computed for implementation over a 10-year time horizon. RESULTS: Screening resulted in an increase of about 0.07 quality life years (QALYs) per patient over a lifetime horizon. The incremental cost effectiveness ratio was about 6,200 euro/QALY compared to no screening. The PSA showed that the uncertainty in cost effectiveness results is not considerable. The value of information analysis confirmed the robustness of the results. Screening all current patients with diarrhea/mixed type IBS would require a total budget of about 25 million Euros over a 10 year time period. CONCLUSION: Screening patients with IBS-D or IBS-mix for CD is almost certainly cost-effective. The screening program would improve the quality of life of those patients with IBS symptoms who actually have CD at a relatively low cost.