c3 stuart peacock
TRANSCRIPT
Advancing Health Economics, Services, Policy and Ethics
REAL WORLD EVIDENCE:RESEARCH APPROACHES TO HEALTH TECHNOLOGY MANAGEMENT
Stuart PeacockCancer Control Research, BC Cancer AgencyCanadian Centre for Applied Research in Cancer Control (ARCC)Simon Fraser University
• Single shot policy questions• Ongoing priority setting frameworks• Some points for discussion
Real world evidence and priority setting
• Prostate Cancer Screening policy: funded and led by ARCC• Collaboration with ARCC, BCCA, Vancouver Prostate Centre (VPC),
and the Fred Hutchinson Cancer Research Centre • We found that regular screening resulted in a loss of quality-
adjusted life years, regardless of screening intensity, when quality of life was factored into the model
• BCCA/VPC updated their 2012 provincial recommendation on PSA screening to explicitly state that they did not support unselected, population-based screening
Prostate Cancer Screening
“The incremental cost-effectiveness of regular screening ranged from $36,300/LYG, for screening every four years from ages 55 to 69 years, to $588,300/LYG, for screening every two years from ages 40 to 74 years. After utility adjustment, all screening strategies resulted in a loss of quality-adjusted life years (QALYs)”
• PBMA is a practical framework to aid decision-makers seeking to maximize benefits from scarce resources
• Limitations of PBMA– reliance on simple models – perceived dependence on content expert’s subjective
estimates of effectiveness and/or benefits– lack of comparability between measures of
effectiveness
Program Budgeting and Marginal Analysis (PBMA)
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Real World Evidence and PBMADefine aim and
scope
Form Steering Committee
Determine current program budget
Establish decision-making criteria
Identify areas for resource
release
Identify areas for new
resource use
Make allocation recommendations
Validity check and final decisions
For each area identified:
Form Advisory Panel
Collect local costs/outcomes
Build Markov model - CUA
MCDA Models
5 areas identified:• Adjuvant trastuzumab in
breast cancer• Bevacizumab in metastatic
colorectal cancer• Mammography for women
with dense breast tissue• PET for lung cancer staging• MRI for breast cancer
screening
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• Objective:– Examine the cost effectiveness of MRI and mammography for breast
cancer screening in BRCA1/2 mutation carriers
• Current practice:– 6 mo. alternating MRI and mammography for confirmed BRCA1/2
carriers (& family)
– Annual mammography for others at high hereditary risk
• Rationale:– MRI is more sensitive than mammography (75% vs. 32%) but less
specific (96.1% vs. 98.5%) and more expensive
Markov Model Design
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Study Sample – from HCP data871 women with BRCA1/2 test results in 2002-2007
203 confirmed BRCA1/2 mutation
positive 99 with no cancer (or no CAIS record of cancer)
105 BRCA1/2 positive cancer cases
87 patients with first cancer
668 mutation negative or uninformative
18 with other cancer or missing stage information
68 patients with complete records
19 patients diagnosed before
1995
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Data Sources for Model
Model Input Sources
Cancer Incidence Literature (meta-analysis)
Screening Sensitivity and Specificity
Literature (meta-analysis)
Cancer Survival BCCA Surveillance and Outcomes data
Treatment procedures BCCA records for BRCA1/2 population
Treatment Costs BCCA Pharmacy, Radiation Therapy and Administration; BC Medical Services Commission
Utilities Literature
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• Costs:– MRI screen: $277 (IH, BCCA and VIHA)– Bilateral mammography: $95 (2008 MSP)– Average diagnostic work-up: $187 (2008 MSP)
Screening and Diagnostics
Sensitivity Specificity
MRI 0.77 0.86
Mammography (in MRI arm) 0.39 0.95
MRI & Mammo (pooled) 0.94 0.77
Mammography (Mammography alone arm)
< 50 yrs 0.67 0.88
> 50 yrs 0.83 0.88
from meta-analysis by Warner 2008; Kerlikowske 2000
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Treatment Costs
In Situ Local Regional Distant
Surgery 3,394 3,365 3,595 3,057Chemo 33 3,625 9,108 5,753Radiation 0 3,785 10,909 6,835TOTAL 3,427 10,940 23,612 15,645
MR
Chemo 11,082Radiation 2,152Hospitalization 12,714TOTAL 26,704
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Utilities
• Derived from published quality of life studies
• Screening has ‘full health’ utility (1.00)
State Utility
Diagnostics 0.987
In situ 0.965
Local 0.860
Regional 0.675
Distant 0.380
Remission 0.965
MR 0.380
Results
Other ICER Results• Screening Mammography
annual screening mammography for women with greater than 75% mammographic breast density had an ICER range of $565,912/QALY
• PET/CT PET for NSCLC staging: $10,932/LYG PET for SPN diagnosis: $64,062/LYG
• Adjuvant Trastuzumab for breast cancer use of adjuvant trastuzumab saves approximately $1,200,000 from the
Systemic Therapy budget annually projecting survival scenarios forward 28-years produced an ICER of
$13,095/QALY• Bevacizumab for metastatic colorectal cancer
Introduction of bevacizumab associated with an ICER of $43,058/QALY
Cost-effectiveness of Personalized Medicine
Treatmentdecision
Diagnostictest
FLT3-ITD and NPM1 mutational testingICER=$65,186/LYG
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• Sustainability• Investments and disinvestments
• Personalized medicine – drugs• Personalized medicine - tests
Points for discussion
Advancing Health Economics, Services, Policy and Ethics
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