HOW TO INCLUDE ECONOMICS IN COCHRANE REVIEW PROTOCOLS

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HOW TO INCLUDE ECONOMICS IN COCHRANE REVIEW
PROTOCOLS
16th Cochrane Colloquium, Freiburg, Germany

• Part One Background, objectives, outcome
  measures and types of studies

PART TWO 2.15pm TOMORROW KG1 - 1108
Campbell Cochrane Economics Methods Group
www.c-cemg.org
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Learning objectives

• Incorporate economics perspectives into
  Background
• Formulate an Objective for a critical review of
  published and unpublished health economics
  studies
• Identify measures of resource use, costs and
  cost-effectiveness to be included in Types of
  outcome measures
• Identify types of health economics studies to be
  included in Types of studies

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Caveats

• No substitute for advisory support from an
  experienced health economist
• Check with CRG - designated health economist
  advisor?
• Contact Economics Methods Group
  research_at_c-cemg.org
• Focus is on how to prepare protocol for a
  critical review of published and unpublished
  health economics studies
• Brand new workshops comments and criticisms
  please!

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http//www.cochrane-handbook.org
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http//www.cochrane-handbook.org
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Overview

• Presentation
• Small group exercise
• Feedback and discussion

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Background Describe economic burden of condition

• Faecal incontinencecan be a debilitating problem
  with medical, social and economic implications...
  In the United States more than 400 million is
  spent each year on a range of both urinary and
  faecal incontinence products... During 1991 the
  direct costs of pads, appliances and other
  prescription items throughout hospitals and long
  term care settings in the UK for incontinence in
  general was estimated at 68 million... With the
  rise in numbers of elderly people in the world,
  this condition will be an increasing challenge to
  both healthcare services and home carers.

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Background Describe potential impacts of
intervention(s) on resource use (costs)

• Resource inputs (input costs)
• e.g. staff time and skills, equipment, devices,
  drugs, hospital care, patient out-of-pocket
  expenses
• Resource consequences (downstream costs)
• e.g. health care resources used to manage
  sequalae and complications of treatment, time off
  work

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Background Describe potential impacts of
intervention(s) on resource use (costs)

• The cost of palliative chemotherapy treatment for
  advanced colorectal cancer includes not only the
  costs associated with the administration of
  chemotherapy, but also the provision of support
  to manage chemotherapy related complications. If
  palliative chemotherapy improves symptom control
  and quality of life this may reduce patient
  dependency and need for other symptomatic and/or
  supportive care measures, offsetting the cost of
  this treatment. On the other hand, if the
  incidence of chemotherapy related toxicity is
  high and there is a decrease in quality of life
  as a result of treatment, then the cost of
  palliative chemotherapy will become much greater
  than that of supportive care alone.

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Background Highlight issue of cost-effectiveness

• There is considerable controversy as to whether
  any added benefit of combination chemotherapy
  outweighs increased toxic effects and
  inconvenience to patients, as well as the
  additional costs to health care systemsIn the
  setting of palliative chemotherapy, the costs of
  such strategiesmust be weighed against the
  expected benefits.

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Background Highlight issue of cost-effectiveness

• It is important to consider whether use of Bone
  Morphogenetic Protein is worthwhilegiven the
  incremental costs (resource use) and benefits
  (effects) which may be associated with the
  intervention.

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Objectives Clinical effects

• To assess the clinical effectiveness of Bone
  Morphogenetic Protein for fracture healing in
  skeletally mature adults, compared to current
  standard treatments

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Objectives Economics

• To assess the cost-effectiveness of intervention
  or comparison for health problem for/in types
  of people, disease or problem and setting if
  specified

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Objectives Economics

• To critically appraise and summarise current
  evidence on the resource use/ costs/ and
  cost-effectiveness associated with intervention
  or comparison for health problem for/in types
  of people, disease or problem and setting if
  specified

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Objectives Economics

• To critically appraise and summarise current
  evidence on the (incremental) resource use, costs
  and cost-effectiveness of Bone Morphogenetic
  Protein for fracture healing in skeletally mature
  adults, compared to current standard treatments

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Objectives Economics

• To critically appraise and summarise current
  evidence on the (incremental) resource use, costs
  and cost-effectiveness of Bone Morphogenetic
  Protein for fracture healing in skeletally mature
  adults, compared to current standard treatments

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Use of Clinical event pathway description

• Systematic, explicit method of representing
  health care processes and outcomes
• Describes main pathways of events with distinct
  resource implications or outcome values

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Use of Clinical event pathway descriptions
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Types of outcome measures economic outcomes

• Resource use
• Costs
• Cost-effectiveness
• Magnitude
• Analytic perspective
• Time horizon

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Types of outcome measures economic outcomes

• Resource use
• Specific items of resource use
• Length of hospital stay (days)
• Duration of operation (minutes)
• Outpatient visits (number)
• Pharmaceuticals (treatment duration and dosage)
• Time to return to work (days)

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Types of outcome measures economic outcomes

• Resource use
• Exceptions
• Direct health care resource use associated with
  complications of treatment
• OR
• Duration of revisional surgery (minutes)
• Duration of rehospitalisation (days)
• Other direct health care resource use associated
  with complications of treatment

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Types of outcome measures economic outcomes

• Resource use
• Specify natural units
• Length of hospital stay (days)
• Duration of operation (minutes)
• Outpatient visits (number)
• Pharmaceuticals (treatment duration and dosage)
• Time to return to work (days)

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Types of outcome measures economic outcomes

• Costs
• Specific cost items?
• Cost of hospital stay
• Cost of operation
• Cost of outpatient visits
• Cost of pharmaceuticals (treatment duration and
  dosage)
• Lost wages due to time off work
• Patient out-of-pocket expenses

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Types of outcome measures economic outcomes

• Costs
• Specific cost categories
• Direct medical/ health care costs
• Indirect non-medical costs

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Types of outcome measures economic outcomes

• Costs
• Level
• Cost of X per patient (specific cost items)
• - Average (mean) cost of X per patient
• Total direct medical/ healthcare costs per
  patient
• - Average (mean) total direct medical costs per
  patient
• Total indirect non-medical costs per patient
• - Average (mean) total indirect non-medical
  costs per patient

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Types of outcome measures economic outcomes

• Cost-effectiveness
• Incremental cost-effectiveness ratios (ICERs)
• Incremental cost per quality-adjusted life year
  (QALY)
• Incremental cost per disability-adjusted life
  year (DALY)
• Incremental cost-benefit ratios
• Net benefits

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Types of studies health economics studies

• Resource utilisation studies
• Type I - Specific medical condition
• Type II - Single treatment

X
?
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Bone Morphogenetic Protein

• Objectives
• To critically appraise and summarise current
  evidence on the (incremental) resource use, costs
  and cost-effectiveness of Bone Morphogenetic
  Protein for fracture healing in skeletally mature
  adults, compared to current standard treatments
• Types of intervention
• BMP versus surgery alone
• BMP versus surgery with or without bone graft
• BMP and bone substitutes versus surgery and bone
  substitutes

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Types of studies health economics studies

• Resource utilisation studies
• Type I - Specific medical condition
• Type II - Single treatment

X
?
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Types of studies health economics studies

• Resource utilisation studies
• Type I - Specific medical condition
• Type II - Single treatment
• Type III - Alternative treatments

X
?
?
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Types of studies Comparative resource
utilisation studies (Type III)
Treatment A
Treatment B
Measure of each item of resource use in natural
units
R1
R2
R3
R4
R1
R2
R3
R4
R1
-
R1

?R1
R2
-
R2

?R2
R3
-
R3

?R3
R3
-
R3

?R3
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Types of studies Economic evaluation studies
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Types of studies Partial economic evaluations
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Types of studies Partial economic evaluations
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Types of studies Partial economic evaluations
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Types of studies Cost analysis
Treatment A
Treatment B
Measure of each item of resource use in natural
units
R1
R2
R3
R4
R1
R2
R3
R4
Valuation of each item of resource use using
health care pay and prices (unit costs) C1 R1 x
UCR1
C1
C2
C3
C4
C1
C2
C3
C4
Sum of cost of each item of resource use total
cost (per patient) CA C1 C2 C3 C4
CA
CB
C1
-
C1

?C1
CA
-
CB

?C
R1
-
R1

?R1
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Types of studies Full economic evaluation studies
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Types of studies Cost-effectiveness analysis
(CEA)
Treatment A
Treatment B
Measure of each item of resource use in natural
units
R1
R2
R3
R4
R1
R2
R3
R4
Valuation of each item of resource use using
health care pay and prices (unit costs) C1 R1 x
UCR1
C1
C2
C3
C4
C1
C2
C3
C4
Sum of cost of each item of resource use total
cost (per patient) CA C1 C2 C3 C4
CA
CB
Measure of each outcome
O1
O2
O1
O2
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Types of studies Full economic evaluation studies
CA
-
CB

?C

• Cost-effectiveness analysis

ICER

O1
-
O1

?O1
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Types of studies Cost-consequences analysis (CCA)
Treatment A
Treatment B
Measure of each item of resource use in natural
units
R1
R2
R3
R4
R1
R2
R3
R4
Valuation of each item of resource use using
health care pay and prices (unit costs) C1 R1 x
UCR1
C1
C2
C3
C4
C1
C2
C3
C4
Sum of cost of each item of resource use total
cost (per patient) CA C1 C2 C3 C4
CA
CB
Measure of each outcome
O1
O2
O1
O2
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Types of studies Full economic evaluation studies
CA
-
CB

?C

• Cost-effectiveness analysis(CEA)
• Cost-consequences analysis (CCA)

ICER

O1
-
O1

?O1
CA
-
CB

?C
O1
-
O1

?O1
O2
-
O2

?O2
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Types of studies Cost-utility analysis (CUA)
Treatment A
Treatment B
Measure of each item of resource use in natural
units
R1
R2
R3
R4
R1
R2
R3
R4
Valuation of each item of resource use using
health care pay and prices (unit costs) C1 R1 x
UCR1
C1
C2
C3
C4
C1
C2
C3
C4
Sum of cost of each item of resource use total
cost (per patient) CA C1 C2 C3 C4
CA
CB
Measure of each outcome
O1
O2
O1
O2
Valuation of outcomes using QALYs
QA
QB
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Types of studies Cost-utility analysis (CUA)
Treatment A
Treatment B
Measure of each item of resource use in natural
units
R1
R2
R3
R4
R1
R2
R3
R4
Valuation of each item of resource use using
health care pay and prices (unit costs) C1 R1 x
UCR1
C1
C2
C3
C4
C1
C2
C3
C4
Sum of cost of each item of resource use total
cost (per patient) CA C1 C2 C3 C4
CA
CB
Valuation of outcomes using QALYs
QA
QB
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Types of studies Full economic evaluation studies
CA
-
CB

?C

• Cost-effectiveness analysis(CEA)
• Cost-consequences analysis (CCA)
• Cost-utility analysis (CUA)

ICER

O1
-
O1

?O1
CA
-
CB

?C
O1
-
O1

?O1
O2
-
O2

?O2
CA
-
CB

?C
IC/Q

QA
-
QB

?Q
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Types of studies Cost-benefit analysis (CBA)
Treatment A
Treatment B
Measure of each item of resource use in natural
units
R1
R2
R3
R4
R1
R2
R3
R4
Valuation of each item of resource use using
health care pay and prices (unit costs) C1 R1 x
UCR1
C1
C2
C3
C4
C1
C2
C3
C4
Sum of cost of each item of resource use total
cost (per patient) CA C1 C2 C3 C4
CA
CB
Measure of each outcome
O1
O2
O1
O2
Monetisation of outcomes using contingent
valuation
BA
BB
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Types of studies Cost-benefit analysis (CBA)
Treatment A
Treatment B
Measure of each item of resource use in natural
units
R1
R2
R3
R4
R1
R2
R3
R4
Valuation of each item of resource use using
health care pay and prices (unit costs) C1 R1 x
UCR1
C1
C2
C3
C4
C1
C2
C3
C4
Sum of cost of each item of resource use total
cost (per patient) CA C1 C2 C3 C4
CA
CB
Monetisation of outcomes using contingent
valuation
BA
BB
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Types of studies Full economic evaluation studies
CA
-
CB

?C

• Cost effectiveness analysis(CEA)
• Cost consequences analysis (CCA)
• Cost utility analysis (CUA)
• Cost benefit analysis (CBA)

ICER

O1
-
O1

?O1
CA
-
CB

?C
O1
-
O1

?O1
O2
-
O2

?O2
CA
-
CB

?C
IC/Q

QA
-
QB

?Q
CA
-
CB

?C
ICBR

BA
-
BB

?B
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Types of studies Full economic evaluation studies
Treatment A
Treatment B
Measure of each item of resource use in natural
units
R1
R2
R3
R4
R1
R2
R3
R4
Valuation of each item of resource use using
health care pay and prices (unit costs) C1 R1 x
UCR1
C1
C2
C3
C4
C1
C2
C3
C4
Sum of cost of each item of resource use total
cost (per patient) CA C1 C2 C3 C4
CA
CB
Measure of each outcome
O1
O2
O1
O2
Monetisation of outcomes using contingent
valuation
BA
BB
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Types of studies health economics studies

• Potential types of health economics studies
• Resource utilisation studies
• Single treatment resource utilisation studies
  ???
• Comparative resource utilisation studies
• Partial economic evaluations
• Cost descriptions ???
• Cost-outcome descriptions ???
• Cost analyses
• Full economic evaluations
• Cost-effectiveness analyses (inc.cost-consequences
  analyses)
• Cost-utility analyses
• Cost-benefit analyses

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Types of studies health economics studies

• Types of studies
• Randomised controlled trials. Full economic
  evaluations (cost-effectiveness analyses,
  cost-utility analyses and cost-benefit analyses),
  cost analyses and comparative resource
  utilisation studies.

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Types of studies the issue of scope

• Full economic evaluations, partial economic
  evaluations and resource utilisation studies can
  all be conducted alongside an RCT
• Full economic evaluations, partial economic
  evaluations and resource utilisation studies can
  also be conducted alongside non-randomised
  studies comparing effects of alternative
  interventions
• Full economic evaluations can also be conducted
  as model-based economic evaluations
• Partial economic evaluations and resource
  utilisation studies can also be conducted as
  stand-alone studies

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Types of studies the issue of scope

• Option 1
• Include only empirical health economics studies
  conducted alongside single, primary studies of
  effects which meet eligibility criteria for the
  reviewof intervention effects

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Types of studies the issue of scope

• Option 2
• Include empirical health economics studies
  conducted alongside single, primary studies of
  effects which meet eligibility criteria for the
  review of intervention effects
• AND
• Health economics studies utilising effects data
  sourced from one or more single, primary studies
  meeting eligibility criteria for the review of
  intervention effects

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Types of studies the issue of scope

• Option 3
• Include all health economics studies meeting
  eligibility criteria re. populations and
  comparisons, whether or not conducted alongside
  or utilising effects data sourced from studies
  which meet eligibility criteria for the review of
  intervention effects

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Types of studies health economics studies

• Types of studies (Option 1)
• Randomised controlled trials. Full economic
  evaluations (cost-effectiveness analyses,
  cost-utility analyses and cost-benefit analyses),
  cost analyses and comparative resource
  utilisation studies conducted alongside
  randomised controlled trials.

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Types of studies health economics studies

• Types of studies (Option 2)
• Randomised controlled trials. Full economic
  evaluations (cost-effectiveness analyses,
  cost-utility analyses and cost-benefit analyses)
  conducted alongside randomised controlled trials
  or utilising effects data generated using either
  a meta-analysis of randomised controlled trials
  or a single randomised controlled trial. Cost
  analyses and comparative resource utilisation
  studies conducted alongside randomised controlled
  trials.

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Types of studies health economics studies

• Types of studies (Option 3)
• Randomised controlled trials. Full economic
  evaluations (cost-effectiveness analyses,
  cost-utility analyses and cost-benefit analyses),
  cost analyses and comparative resource
  utilisation studies any study design.

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HOW TO INCLUDE ECONOMICS IN COCHRANE REVIEW
PROTOCOLS
16th Cochrane Colloquium, Freiburg, Germany

• Part One Background, objectives, outcome
  measures and types of studies

Campbell Cochrane Economics Methods Group
www.c-cemg.org