Meeting round-up: ISPOR Europe 2018 (part 2)

Have you missed ISPOR Europe 2018 but are eager to know all about it? Time to continue reading! In yesterday’s post, I wrote about ISPOR’s outstanding short-course on causal inference and the superb sessions I had attended on day 1. This blog post is about day 2, Tuesday 13th, which was another big day.

The second plenary session was on fairness in pharmaceutical pricing. It was moderated by Sarah Garner, with presentations by many key stakeholders. The thought-provoking discussion highlighted the importance of pharmaceutical pricing policy and the large role that HTA can have in shaping it.

Communicating cost-effectiveness analysis was the next session, where myself, together with Rob Hettle, Gabriel Rogers and Mike Drummond, discussed the pitfalls and approaches to explaining cost-effectiveness models to non-health economists. This was a hugely popular session! We were delighted by the incredibly positive feedback we received, which reassured us that we are clearly not alone in finding it difficult to communicate cost-effectiveness analysis to a lay audience. We certainly feel incentivised to continue working on this topic. The slides are available here, and for the audience’s feedback, search on twitter #communicateCEA.

The lunch was followed by the open meeting of ISPOR Women in HEOR Initiative with Shelby Reed, Olivia Wu and Louise Timlin. It is really encouraging to see ISPOR taking a proactive stance to gender balance!

The most popular session in the afternoon was Valuing a cure: Are new approaches needed, with Steve Pearson, Jens Grueger, Sarah Garner and Mark Sculpher. The panel showed the various perspectives on the pricing of curative therapies. Payers call for a sustainable pricing model, whilst pharma warns that pricing policy is necessarily linked to the incentives for investment in research. I agree with Mark in that these challenges are not unique to curative therapies. As pharmaceutical therapies have greater health benefits but at large costs, it is pressing that cost-effectiveness assessments are also able to consider the opportunity cost of funding more costly treatments. See here for a roundup of the estimates already available.

I then attended the excellent session on Drug disinvestment: is it needed and how could it work, moderated by Richard Macaulay. Andrew Walker explained that HTA agencies’ advice does not always go down well with local payers, highlighting this with an amusing imaginary dialogue between NICE and a hospital. Detlev Parow argued that payers find that prices are often unaffordable, hence payment schemes should consider other options, such as treatment success, risk-sharing agreements and payment by instalments. Bettina Ryll made an impressive case from the patients’ perspective, for whom these decisions have a real impact.

The conference continued late into the evening and, I suspect, long into the early hours of Wednesday, with the ever-popular conference dinner. Wednesday was another day full of fascinating sessions. The plenary was titled Budget Impact and Expenditure Caps: Potential or Pitfall, moderated by Guillem López-Casasnovas. It was followed by inspiring sessions that explored a wide range of topics, presented by the top experts in the relevant fields. These really delved into the nitty-gritty on subjects, such as using R to build decision models, the value of diagnostic information, and expert elicitation, just to name a few.

I don’t think I’m just speaking personally when I say that ISPOR Barcelona was an absolutely brilliant conference! I’ve mentioned here a few of the most outstanding sessions, but there were many, many more. There were so many sessions at the same time that it was physically impossible to attend all of those with a direct relevance to my research. But fortunately, we can access all the presentations by downloading them from the ISPOR website. I’ll leave the suggestion to ISPOR here, that they should think about filming some of the key sessions and broadcasting them as webinars after the conference. This could create a further key resource for our sector.

As in previous editions, ISPOR Barcelona truly confirms ISPOR Europe in the top HTA conferences in Europe, if not the world. It expertly combines cutting-edge methodological research with outstanding applied work, all with the view to better inform decision making. As I’m sure you can guess, I’m already looking forward to the next ISPOR Europe in Copenhagen on the 2nd-6th November 2019, and the amazing sessions which will indubitably be featured!

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Meeting round-up: ISPOR Europe 2018 (part 1)

ISPOR Europe 2018, which took place in Barcelona on the 10th-14th November, was an exceptional conference. It had a jam-packed programme on the latest developments and most pressing challenges in health technology assessment (HTA), economic evaluation and outcomes research. In two blog posts, I’ll tell you about the outstanding sessions and thought-provoking discussions in this always superb conference.

For me, proceedings started on Sunday, with the excellent short-course Adjusting for Time-Dependent Confounding and Treatment Switching Bias in Observational Studies and Clinical Trials: Purpose, Methods, Good Practices and Acceptance in HTA, by Uwe Siebert, Felicitas Kühne and Nick Latimer. Felicitas Kühne explained that causal inference methods aim to estimate the effect of a treatment, risk factor etc. on our outcome of interest, controlling for other exposures that may affect it and hence bias our estimate. Uwe Siebert and Nick Latimer provided a really useful overview of the methods to overcome this challenge in observational studies and RCTs with treatment switching. This was an absolutely brilliant course. Highly recommended to any health economist!

ISPOR conferences usually start early and finish late with loads of exceptional sessions. On Monday, I started the conference proper with the plenary Joint Assessment of Relative Effectiveness: “Trick or Treat” for Decision Makers in EU Member States, moderated by Finn Børlum Kristensen. There were presentations from representatives of payers, HTA agencies, EUnetHTA, pharmaceutical industry and patients. The prevailing mood seemed to be of cautious anticipation. Avoiding duplication of efforts in the clinical assessment was greatly welcomed, but there were some concerns voiced about the practicalities of implementation. The proposal was due to be discussed soon by the European Commission, so undoubtedly we can look forward to knowing more in the near future.

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My next session was the fascinating panel on the perils and opportunities of advanced computing techniques with the tongue-in-cheek title Will machines soon make health economists obsolete?, by David Thompson, Bill Marder, Gerry Oster and Mike Drummond. Don’t panic yet as, despite the promises of artificial intelligence, I’d wager that our jobs are quite safe. For example, Gerry Oster predicted that demand for health economic models is actually likely to increase, as computers make our models quicker and cheaper to build. Mike Drummond finished with the sensible suggestion to simply keep calm and carry on modelling, as computing advances will liberate our time to explore other areas, such as the interface with decision-makers. This session left us all in a very positive mood as we headed for a well-earned lunch!

There were many interesting sessions in the afternoon. I chose to pop over to the ISPOR Medical Device and Diagnostic Special Interest Group Open Meeting, the ISPOR Portugal chapter meeting, along with taking in the podium presentations on conceptual papers. Many of the presentations will be made available in the ISPOR database, which I recommend exploring. I had a wonderful experience moderating the engaging podium session on cancer models, with outstanding presentations delivered by Hedwig Blommestein, Ash Bullement, and Isle van Oostrum.

The workshop Adjusting for post-randomisation confounding and switching in phase 3 and pragmatic trials to get the estimands right: needs, methods, sub-optimal use, and acceptance in HTA by Uwe Siebert, Felicitas Kühne, Nick Latimer and Amanda Adler is one worth highlighting. The panellists showed that some HTAs do not include any adjustments for treatment switching, whilst adjustments can sometimes be incorrectly applied. It reinforced the idea that we need to learn more about these methods, to be able to apply them in practice and critically appraise them.

The afternoon finished with the second session of the day on posters. Alessandro Grosso, Laura Bojke and I had a poster on the impact of structural uncertainty in the expected value of perfect information. Alessandro did an amazing job encapsulating the poster and presenting it live to camera, which you can watch here.

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In tomorrow’s blog post, I’ll tell you about day 2 of ISPOR Europe 2018 in Barcelona. Tuesday was another big day, with loads of outstanding sessions on the key topics in HTA. It featured my very own workshop, with Rob Hettle, Gabriel Rogers and Mike Drummond on communicating cost-effectiveness analysis. I hope you will stay tuned for the ISPOR meeting round-up part 2!

Rita Faria’s journal round-up for 18th June 2018

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

Objectives, budgets, thresholds, and opportunity costs—a health economics approach: an ISPOR Special Task Force report. Value in Health [PubMedPublished 21st February 2018

The economic evaluation world has been discussing cost-effectiveness thresholds for a while. This paper has been out for a few months, but it slipped under my radar. It explains the relationship between the cost-effectiveness threshold, the budget, opportunity costs and willingness to pay for health. My take-home messages are that we should use cost-effectiveness analysis to inform decisions both for publicly funded and privately funded health care systems. Each system has a budget and a way of raising funds for that budget. The cost-effectiveness threshold should be specific for each health care system, in order to reflect its specific opportunity cost. The budget can change for many reasons. The cost-effectiveness threshold should be adjusted to reflect these changes and hence reflect the opportunity cost. For example, taxpayers can increase their willingness to pay for health through increased taxes for the health care system. We are starting to see this in the UK with the calls to raise taxes to increase the NHS budget. It is worth noting that the NICE threshold may not warrant adjustment upwards since research suggests that it does not reflect the opportunity cost. This is a welcome paper on the topic and a must read, particularly if you’re arguing for the use of cost-effectiveness analysis in settings that traditionally were reluctant to embrace it, such as the US.

Basic versus supplementary health insurance: access to care and the role of cost effectiveness. Journal of Health Economics [RePEc] Published 31st May 2018

Using cost-effectiveness analysis to inform coverage decisions not only for the public but also for the privately funded health care is also a feature of this study by Jan Boone. I’ll admit that the equations are well beyond my level of microeconomics, but the text is good at explaining the insights and the intuition. Boone grapples with the question about how the public and private health care systems should choose which technologies to cover. Boone concludes that, when choosing which technologies to cover, the most cost-effective technologies should be prioritised for funding. That the theory matches the practice is reassuring to an economic evaluator like myself! One of the findings is that cost-effective technologies which are very cheap should not be covered. The rationale being that everyone can afford them. The issue for me is that people may decide not to purchase a highly cost-effective technology which is very cheap. As we know from behaviour economics, people are not rational all the time! Boone also concludes that the inclusion of technologies in the universal basic package should consider the prevalence of the conditions in those people at high risk and with low income. The way that I interpreted this is that it is more cost-effective to include technologies for high-risk low-income people in the universal basic package who would not be able to afford these technologies otherwise, than technologies for high-income people who can afford supplementary insurance. I can’t cover here all the findings and the nuances of the theoretical model. Suffice to say that it is an interesting read, even if you avoid the equations like myself.

Surveying the cost effectiveness of the 20 procedures with the largest public health services waiting lists in Ireland: implications for Ireland’s cost-effectiveness threshold. Value in Health Published 11th June 2018

As we are on the topic of cost-effectiveness thresholds, this is a study on the threshold in Ireland. This study sets out to find out if the current cost-effectiveness threshold is too high given the ICERs of the 20 procedures with the largest waiting lists. The idea is that, if the current cost-effectiveness threshold is correct, the procedures with large and long waiting lists would have an ICER of above the cost-effectiveness threshold. If the procedures have a low ICER, the cost-effectiveness threshold may be set too high. I thought that Figure 1 is excellent in conveying the discordance between ICERs and waiting lists. For example, the ICER for extracapsular extraction of crystalline lens is €10,139/QALY and the waiting list has 10,056 people; the ICER for surgical tooth removal is €195,155/QALY and the waiting list is smaller at 833. This study suggests that, similar to many other countries, there are inefficiencies in the way that the Irish health care system prioritises technologies for funding. The limitation of the study is in the ICERs. Ideally, the relevant ICER compares the procedure with the standard care in Ireland whilst on the waiting list (“no procedure” option). But it is nigh impossible to find ICERs that meet this condition for all procedures. The alternative is to assume that the difference in costs and QALYs is generalisable from the source study to Ireland. It was great to see another study on empirical cost-effectiveness thresholds. Looking forward to knowing what the cost-effectiveness threshold should be to accurately reflect opportunity costs.

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