Prioritising HTA funding:

The benefits and challenges of using value

of information in anger

K Claxton, L Ginnelly, MJ Sculpher, Z Philips.

Centre for Health Economics,
University of York, UK

CENTRE FOR HEALTH ECONOMICS

Overview
Overview of methods
Screening for age-related macular degeneration
Considered by NCCHTA diagnostic and screening panel

Manual chest physiotherapy techniques for asthma and chronic

obstructive pulmonary disease
Considered by NCCHTA therapeutic procedures panel

long-term antibiotic treatment for preventing recurrent urinary

tract infections (UTI) in children
Considered by Prioritisation Strategy Group (PSG)

An overview of methods
Background
Other methods
Research as a means changing clinical practice

Statistical decision theory

Reduction in the costs of decision uncertainty
Value consistent with objective and constraints of service provision

Methods
Constructions of decision analytic model
Probabilistic analysis to characterise decision uncertainty
Value of information analysis

Identifying research priorities

EVPI
Maximum return to research (decision problem)
Comparing the EVPI to the costs of research
Comparing EVPI across technologies

Partial EVPI
Maximum return to research (endpoint)
Comparing partial EVPIs
Considering the costs of research

Screening for age-related macular degeneration (AMD)

Options
Weekly self screening with Amsler grid
No screen but self referral on decline in visual acuity
No PDT treatment and no screening

Indications

1st eye neovascular AMD

20/40 and 20/80 visual acuity
Male and female (age 55-64)
Eligibility of PDT consistent with NICE guidance

Time horizon of 10 years

NHS Perspective

Model structure for AMD screening

No AMD
(starting Visual
accuity)

p(T+|no AMD)

Eye
examination

1-p(Sub|classic)
p(AMD)
p(Classic|NV AMD)

AMD
Visual Accuity
(0)

p(T+|AMD)

Eye
examination

p(NV AMD|AMD)=1

p(Sub|classic)

Angiography
1- p(Classic|NV AMD)

p(VA loss)

1-p(Sub|classic)
p(refer|VA-1)
)

AMD
Visual Accuity
(-1)

Net Benefit of
PDT| VA (0)

p(T+|AMD)

p(Classic|NV AMD)

Eye
examination

p(Sub|classic)

p(NV AMD|AMD)=1

Angiography

Net Benefit of
PDT| VA (-1)

1- p(Classic|NV AMD)

1-p(Sub|classic)

p(VA loss)
p(refer|VA-2)
p(Classic|NV AMD)

AMD
Visual Accuity
(-2)

p(T+|AMD)

Eye
examination

p(Sub|classic)

p(NV AMD|AMD)=1

Angiography

Net Benefit of
PDT| VA (-2)

1- p(Classic|NV AMD)

1-p(Sub|classic)

p(VA loss)
p(refer|VA-3)
p(Classic|NV AMD)

AMD
Visual Accuity
(-3)

p(T+|AMD)

Eye
examination

p(Sub|classic)

p(NV AMD|AMD)=1

Angiography
1- p(Classic|NV AMD)

Net Benefit of
PDT| VA (-3)

Manual chest physiotherapy techniques for asthma

Patient groups

Children treated in the community

Adults treated in the community
Children treated in hospital

Options

Massage therapy
Chiropractic spinal manipulation (CSM)
Physical therapy
No manual therapy

Time horizon of 30-days

NHS perspective

Manual Chest Physiotherapy Techniques for adults with

Chronic Obstructive Pulmonary Disease (COPD)
Patient groups

Adults with stable COPD

Options

Autogenic drainage
Active breathing,
Heat lamp
Chest percussion with drainage
No manual therapy

Time horizon of 30-days

NHS perspective

Structure of the asthma and COPD model

Predicted
Quality of Life
Predicted
hospital cost*

Baseline FEV
Predicted drug
cost

proportional change
from trials

Predicted
Quality of Life
Predicted
hospital cost*

Intervention
FEV
Predicted drug
cost

* physical therapy in children with severe asthma only

Intervention
cost

long-term antibiotic treatment for preventing recurrent

urinary tract infections (UTI) in children
Patient groups

Infants of 1 year and children age 3

Girls and boys
Recurrent UTI (no abnormalities)
Mild VUR (grade I and II)

Options

Long-term low dose antibiotics (Cochrane review)

(Trimethoprim, Nitrofurantoin, Cotrimoxazole)

Intermittent treatment of UTIs

Time horizon

3 years of long-term antibiotics and follow-up to end stage renal disease

NHS perspective

Model Structure for UTI

Frequency of
recurrent UTIs

Number of
pyelonephritic attacks

Progressive
renal scaring

End-stage renal disease

No UTI

1 UTI

Pyelonephritic
attack

2 UTIs

Pyelonephritic
attack

3 UTIs

Pyelonephritic
attack

4 UTIs

Pyelonephritic
attack

Transplant

Number of
attacks

Progressive
renal
scaring

Development
of ESRD

Age at
ESRD onset

Dialysis

The evidence
Effectiveness
Existing reviews (variable quality)
Meta analysis, Multiple parameter synthesis
Probabilistic trial based model
Natural history
Epidemiological studies
Pooled trial baselines
Registry studies
Clinical judgement
Quality of life
Published studies
Survey
Costs
Published studies
Published unit costs and dosage (BNF, PSSRU, CIPFA)

Results: cost-effectiveness acceptability curve

1

Intermittent

0.9

Cotrimoxazole
Nitrofurantoin

0.8

Trimethoprim
Probability cost-effective

0.7

Frontier

0.6

0.5

0.4

0.3

0.2

0.1

0
0

10,000

20,000

30,000

40,000

Threshold for cost-effectiveness

50,000

60,000

Results: population EVPI

(girls
Population
EVPI age 3 with no VUR)
4,000,000

3,500,000

Populaion EVPI

3,000,000

2,500,000

2,000,000

1,500,000

1,000,000

500,000

0
0

10,000

20,000

30,000

40,000

Cost-effectiveness threshold

50,000

60,000

Partial EVPI (girls age 3 with no VUR)

Expected Value of Perfect Information

2,500,000

2,000,000

1,500,000

1,000,000

500,000

Results: EVPI
Topic

Patient Group

AMD Screening

20/40
20/80

6,950,000 Quality of life with and

18,220,000 without PDT

Asthma Physiotherapy

Children in Community
Adults in Community
Children in Hospital
Adults in Community

14,500,000
0
1,200,000
0

COPD Physiotherapy
UTI prophylaxis

Girls 3, no VUR
Girls 3, VUR
Girls 1, no VUR
Girls 1, VUR
Boys 3, no VUR
Boys 3, VUR
Boys 1, no VUR
Boys 1, VUR

Population EVPI

Partial EVPI

Effect of massage
Effect on LOS and FEV
-

2,240,000 Effect of prophylaxis on UTI

613,000 Effect < 6 months
690,000 Effect of:
544,000
Trimethoprim
41,000
Cotrimoxazole
23,000
Nitrofurantoin
267,000
176,000

Conclusions
Asthma

Children treated in the community

Massage therapy may be cost-effective
Further research is potentially cost-effective
Effect of massage therapy on FEV1 (no value in effect of CSM)

Manual physiotherapy for adults treated in the community

Manual therapy not cost effective
Further research not cost-effective

Children treated in hospital

Physical therapy may be cost-effective

Further research is potentially cost-effective
Effect of physical therapy on hospital length of stay and FEV1

COPD
Manual chest physiotherapy for stable COPD is not cost-effective.
Further research not cost-effective
Inpatient manual chest physiotherapy?

Conclusions
AMD
Screening may be cost-effective
Further research appears to be potentially cost-effective
Evidence about the quality of life with and without PDT

UTI Prophylaxis
Long-term antibiotics are cost-effective for all patient groups
Which of the antibiotics should be used is uncertain

Primary research maybe required for selected patient groups

girls age 3 with no VUR

Trials should include head to head comparisons

Cotrimoxazole and trimethoprim or all three antibiotics

Longer follow-up would be worthwhile

trials with 6 month follow-up are unlikely to be worthwhile

Feasibility and policy impact

Feasibility
Completed despite not meeting selection criteria
Analysis conducted and presented within NCCHTA time
lines

Policy impact
Mixed responses from panel members
Potential (selective) role at PSG
Impact on commissioning decisions

Methods and implementation

Methods

More complex and resource intensive than anticipated

Comprehensive searching for model parameters
Methods of evidence synthesis
Quality of evidence (bias and exchangeability)
Sensitivity analysis (evidence, model structure)

Implementation
Communicating complex material
Requires an iterative process
Identifying topics where VoI should be conducted