Changes in cost-effectiveness over time

Abstract

We analysed the factors influencing cost-effectiveness of a health care intervention over time using economic evaluations of erythropoietin as a case study. The analytical framework of a study conducted in 1990 was used to revisit the cost-effectiveness of erythropoietin. Study variables were updated to 2000 using meta-analysis, published sources, and expert opinion. After 10 years of further experience with the use of erythropoietin the cost-effectiveness ratio now falls within the range considered acceptable in the UK. The analysis shows that the vast proportion of the reduction in the cost-effectiveness ratio achieved since 1990 results from reductions in the dose and price of erythropoietin. True cost-effectiveness of a treatment can change over time, and early analysis can reach incorrect conclusions because of data deficiencies. The existence of a body such as NICE might have delayed the widespread adoption of erythropoietin in the UK, but the higher standards of clinical and economic evidence demanded by such a body might have expedited the appropriate pricing,dosage, and hence utilisation of the treatment.

The Cost Effectiveness of Erythropoietin-Stimulating Agents for Treating Anemia in Patients on Dialysis: A Systematic Review

“…One study found hospital stay to decrease with higher hemoglobin targets and found that strategy to be dominant [16], whereas a second study found higher targets to be associated with an increase in hospitalization risk and found the strategy to be dominated by lower targets [13]. A final study found that length of stay was greatly reduced with the use of ESAs (1.83 vs. 4.91 days) and found ESAs to be cost effective, given typical thresholds (USD <50,000/QALY) [17]. All of the studies assumed that the use of ESAs was associated with an increase in quality of life in comparison to no ESA or RBCT and that higher targets were associated with increased quality of life, with larger utility gains from low and medium targets in comparison to no ESA, having less incremental benefit to overall utility, as hemoglobin targets reached over 11-12 g/dl in studies that considered higher hemoglobin targets [13,15].…”

“…All seven studies follow a health-care payer perspective. Five studies compared ESA treatment to routine blood transfusion [13,15,17,18,19], and three compared to lower hemoglobin targets [13,14,17]. The characteristics of the included studies are summarized in table 1.…”

“…Two studies originated in Canada [13,14], two from the United States [15,16], one from the United Kingdom [17], one from Sweden [18] and one was a combined study from Germany, France, Italy, Spain, and the United Kingdom [19]. All seven studies follow a health-care payer perspective.…”

“…The reported cost per quality-adjusted life-year (QALY) ratios for ESA treatment compared to RBCTs in patients on dialysis ranged from USD 931 to 677,749 across five studies [13,15,17,18,19]. The two studies evaluating higher hemoglobin targets in comparison to lower targets ranged widely, with one study finding that higher targets where both less costly and more effective [16], and a second study finding higher hemoglobin targets to have ICERs ranging from USD 71,684 to 1,073,705 for intravenously administered EPO, and from USD 62,068 to 926,969 for subcutaneously administered EPO, with increasing ICERs for a rise in hemoglobin targets [14].…”

“…Six of the seven included studies assumed in the baseline case that treatment with ESAs would have no effect on mortality [15,16,17,18,19,20]. The seventh study, which found higher hemoglobin targets to be dominated by a lower target strategy, assumed that targeting higher hemoglobin ranges was associated with an increase in the odds of death (OR of mortality 1.12 in those with Hb >12 g/dl in comparison to Hb 9-10.9 g/dl) [13].…”