Seeingthe NICE side of costeffectiveness analysis

1
Seeing the NICE side of cost-effectiveness
analysis

• Stirling Bryan
• Center for Health Policy, Stanford University
• Health Services Management Centre, University of
  Birmingham

2
What am I drawing on?

• Member of an academic team (WMHTAC) that conducts
  analyses for NICE (1999-date)
• Member of NICE Appraisals Committee (2004-2005)
• Researcher of the use of CEA by NICE
• Qualitative case study research
• Interviews with 28 committee members
• Observation of 7 appraisal topics
• Documentary analyses

3
NICE Appraisal Committee membership (n28)
4
Use of CEA by Committee

• Some accessibility issues overcome
• CEA is commissioned and available for each
  decision
• CEA is a key driver of NICE technology coverage
  decisions
• How should CEA be used?
• An ordinal approach, whereby cost-effectiveness
  is only considered if the technology has passed a
  clinical effectiveness hurdle
• A framework approach, whereby the economic
  evaluation and model provide a structure for
  considering the decision problem and the evidence

5
Accessibility understanding and roles

• Range of levels of understanding of CEA
• I think my knowledge is poor and I know quite a
  number of other people on the Committee feel
  theirs is poor as well, so I think the people
  representing nursing, general practice and even
  quite a number of the medics would feel their
  understanding is poor.
• Criticism of overly technical CEA presentation
  styles
• How serious?
• This depends on the role of Committee members
  experts/advocates or representatives?

6
Acceptability concerns

• The decision problem
• The thing that worries me most is the fact that
  advice is, well its not advice anymore, its
  compulsory and it worries me because the
  opportunity cost notion thats supposed to
  underlie economics doesnt really bite at the
  NICE level.
• My biggest criticism is basically we are
  recommending things at a level that actually the
  NHS cannot afford that the cost per QALY
  figure is far too high, it should be much lower.
• Problems with methods
• QALYs failure to capture all important benefits
• Predominant focus on efficiency issues in CEA

7
In summary

• The decision making process
• The training of those involved in the process
• The methods of analysis and its presentation