Tappenden, P and Brazier, J and Ratcliffe, J (2006): Does the National Institute for Health and Clinical Excellence take account of factors such as uncertainty and equity as well as incremental cost-effectiveness in commissioning health care services? A binary choice experiment.
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Background NICE is an independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health in England and Wales. One of NICE’s main roles is to produce national guidance on the use of health technologies within the NHS. Despite the Institute’s recent efforts to clarify the way in which its Appraisal Committees reach their recommendations concerning the use of health technologies, there remains ambiguity about how cost-effectiveness evidence is interpreted alongside other considerations such as the degree of clinical need within the patient population, and the degree of uncertainty surrounding cost-effectiveness estimates.
Objective To explore whether the NICE takes account of factors such as uncertainty and equity as well as incremental cost-effectiveness in commissioning health care services.
Methods A binary choice experiment was undertaken using NICE’s three Appraisal Committees. The experiment included five attributes: (1) Incremental cost-effectiveness (2) Degree of economic uncertainty (3) Age of the target population (4) Baseline health-related quality of life (5) Availability of other therapies A choice questionnaire detailing 18 scenarios was administered to NICE’s Appraisal Committees. For each scenario, respondents were asked to indicate whether they would recommend the intervention under consideration or not. The stated preference data obtained from respondents were analysed using a random effects logit regression model.
Results A response rate of 46% was obtained from the Appraisal Committees. The regression model suggests that increases in cost-effectiveness, economic uncertainty, and the availability of other therapies are associated with statistically significant reductions in the odds of adoption (p<0.05). The transition from a very low to a comparatively high level of health-related quality of life is also associated with a statistically significant reduction in the odds of a positive recommendation. Smaller changes in health-related quality of life, and the age of the target population are not associated with a statistically significant reduction in the odds of a positive recommendation. Analysis of revealed preference data indicates that the model is capable of distinguishing between those technologies which the Appraisal Committees would be highly likely to recommend, and those technologies which appear to be less attractive, although further external validation is warranted.
Conclusion The modelling suggests that cost-effectiveness, uncertainty and certain equity concerns influence the NICE Appraisal Committees’ recommendations on the use of health technologies. The modelling results appear to support Rawlins and Culyer’s notion of a probabilistic cost-effectiveness threshold approach; the “mythical” £30,000 per QALY gained threshold assumed within the literature is not supported by this stated preference modelling analysis.
|Item Type:||MPRA Paper|
|Original Title:||Does the National Institute for Health and Clinical Excellence take account of factors such as uncertainty and equity as well as incremental cost-effectiveness in commissioning health care services? A binary choice experiment|
|Keywords:||uncertainty; equity; cost-effectiveness; public health|
|Subjects:||I - Health, Education, and Welfare > I1 - Health > I18 - Government Policy; Regulation; Public Health|
|Depositing User:||Sarah McEvoy|
|Date Deposited:||24. Mar 2011 22:00|
|Last Modified:||19. Feb 2013 12:02|
Department of Health (1997). The New NHS. Modern. Dependable. White Paper. London: The Stationery Office.
National Institute for Clinical Excellence. A guide to NICE. 1-34. 2005. London: NICE.
Rawlins MD, Culyer AJ (2004). National Institute for Clinical Excellence and its value judgements. British Medical Journal 329:224-7.
Rawlins MD (2004). Scientific and social value judgements. 1-20. London: NICE.
Rawlins MD (2005). Social value judgements: Guidelines for the Institute and its advisory bodies. Draft for consultation. 1-31. London: NICE.
A National Health Service. 1944. London: HMSO.
Fuchs VR (1998). Who shall live? Health, Economics and Social Choice. London: World Scientific.
Sculpher M, Drummond M, O'Brien B (2001). Effectiveness, efficiency, and NICE. British Medical Journal 322:943-4.
Smith R (2000). The failings of NICE. British Medical Journal 321:1363-4.
Hutton J, Maynard A (2000). A NICE challenge for health economics. Health Economics 9:89-93.
National Institute for Clinical Excellence (2005). Legal context of NICE guidance. London: NICE.
National Institute for Clinical Excellence (2004). Guide to the technology appraisals process. 1-31. London: NICE.
National Institute for Clinical Excellence (2004). Guide to the methods for technology appraisal. 1-71. London: NICE.
Pritchard C (2002). Overseas approaches to decision making. In Towse A, Pritchard C, Devlin N (eds), Cost-effectiveness thresholds, pp 56-68. London: King's Fund/Office for Health Economics.
Loewry EH (1980). Cost should not be a factor in medical care [editorial]. New England Journal of Medicine 302:697.
Eddy DM (1992). A manual for assessing health pratices and designing practice policies: an explicit approach. Philadelphia: Oxford University Press.
Weinstein MC, Stason WB (1977). Foundations of cost-effectiveness analysis for health and medical practices. New England Journal of Medicine 296:716-21.
Drummond M, Torrance G, Mason J (1993). Cost-effectiveness league tables: More harm than good? Social Science and Medicine 37:33-40.
Gold M, Siegel JE, Russell LB, Weinstein MC (eds) (1996). Cost-effectiveness in health and medicine. New York: Oxford University Press.
Cookson R, McDaid D, Maynard A (2001). Wrong SIGN, NICE mess: is national guidance distorting allocation of resources? British Medical Journal 323:743-5.
Miners AH, Garau M, Fidan D, Fischer AJ (2004). Comparing estimates of cost effectiveness submitted to the National Institute for Clinical Excellence (NICE) by different organisations: retrospective study. British Medical Journal 330.
Birch S, Gafni A (2002). On being NICE in the UK: guidelines for technology appraisal for the NHS in England and Wales. Health Economics 11:185-91.
Devlin N, Parkin D (2004). Does NICE have a cost-effectiveness threshold and what other factors influence its decisions? A binary choice analysis. Health Economics 13:437-52.
Hill S, Garattini S, van Loenhout J, O'Brien BJ, de Joncheere K (2003). Technology Appraisal Programme of the National Institute for Clinical Excellence: A review by WHO. World Health Organisation.
Littlejohns P (2002). Does NICE have a threshold? A response. In: Towse A, Pritchard C, Devlin N, eds. Cost-effectiveness thresholds, pp 31-7. London: King's Fund/Office for Health Economics.
National Institute for Clinical Excellence (2001). Supplementary evidence to the House of Commons Health Select Committee. Paper 2. 1-9. London: NICE.
National Institute for Clinical Excellence. Guidance on the use of orlistat for the treatment of obesity in adults. Guidance no.22. 2001:1-12. London: NICE.
Raftery J (2001). NICE: Faster access to modern treatments? Analysis of guidance on health technologies. British Medical Journal 323:1300-3.
National Institute for Clinical Excellence (2001). Guidance on the use of riluzole (Rilutek) for the treatment of motor neurone disease. Guidance no. 20. 1-10. London: NICE.
Williams A (2004). What could be NICER than NICE? Office for Health Economics Annual Lecture.
Briggs AH, Gray AM (1999). Handling uncertainty when performing economic evaluations of healthcare interventions. Health Technology Assessment 3:i-134.
Claxton K (1999). The irrelevance of inference: a decision-making approach to the stochastic evaluation of health care technologies. Journal of Health Economics 18:341-64.
Claxton K, Sculpher M, Drummond M (2002). A rational framework for decision making by the National Institute for Clinical Excellence (NICE). The Lancet 360:711-5.
Yamey G (1999). Chairman of NICE admits that its judgements are hard to defend. British Medical Journal 319:1222.
Dobson F (1999). Secretary of State's speech launching the National Institute for Clinical Excellence. 31st March 1999. Available from: http://www.nice.org.uk/embcat.aspx?page=oldsite/back/frank_dobson.htm [Accessed 02/04/2005].
Culyer AJ (2001). Equity — some theory and its policy implications. Journal of Medical Ethics 7:275-83.
Culyer AJ (2001). Economics and ethics in health care. Journal of Medical Ethics 27:217-22.
Dolan P, Olsen JA (2002). Distributing health care: Economic and ethical issues. New York: Oxford University Press.
Rawls J (1971). A theory of justice. Cambridge, Massachusetts: Harvard University Press.
Harris J (1991). Unprincipled QALYs - a response to Cubbin. Journal of Medical Ethics 17:185-8.
Williams A (1997). Intergenerational equity: an exploration of the "fair innings" argument. Health Economics 6:117-32.
Nord E (1999). Cost-value analysis in health care: Making sense out of QALYs. Cambridge: Cambridge University Press.
Jonsen AR (1986). Bentham in a box: technology assessment and health care allocation. Law, Medicine and Health Care 14:172-4.
LeGrand J (1987). Equity, health and health care. Social Justice Research 1:257-74.
Dolan P, Shaw R, Tsuchiya A, Williams A (2005). QALY maximisation and people's preferences: a methodological review of the literature. Health Economics 14:197-208.
Dolan P, Tsuchiya A, Brazier J, Ratcliffe J (2005). Social QALY Project: Summary. Available from http://www.shef.ac.uk [Accessed 23/05/2005].
Ratcliffe J (2000). Valuing the benefits of health care technologies: a case study of liver transplantation. PhD Thesis. London, Health Economics Research Group, Brunel University.
Louviere J, Hensher D, Swait J (2000). Stated choice methods: Analysis and application. Cambridge, UK: Cambridge University Press.
Ryan M (1996). Using consumer preferences in health care decision making: the application of conjoint analysis. London: OHE Publications.
Kocur G, Alder T, Hyman W, Aunet B (1982). A guide to forecasting travel demand with direct utility assessment. Washington DC: US Department of Transportation.
Bates J (1986). Sensitivity to level of service: Evidence from stated preference work. Research for Transport Policy 13:289-305.
Wardman M (1986). Route choice and the value of motorists' travel time: empirical findings. Institute for Transport Studies Working Paper 224. University of Leeds.
Magat WA, Viscusi WK, Huber J (1988). Paired comparison and contingent valuation approaches to morbidity risk valuation. Journal of Environmental Economics and Management 15:396-411.
Yoo DI, Ohta H (1995). Optimal pricing and product planning for new multiattribute products based on conjoint analysis. International Journal of Production Economics 38:245-53.
Dennis DF (1998). Analysing public inputs to multiple objective decisions on national forests using conjoint analysis. Forest Science 44:421-9.
Sculpher M, Bryan S, Fry P, de Winter P, Payne H, Emberton M (2004). Patients' preferences for the management of non-metastatic prostate cancer: discrete choice experiment. British Medical Journal 328.
Ryan M, Farrar S (2000). Using conjoint analysis to elicit preferences for health care. British Medical Journal 320:1530-3.
Propper C (1991). Contingent valuation of time spent on NHS waiting lists. The Economic Journal 100:193-9.
Ubach C, Scott A, French F, Awramenko M, Needham G (2003). What do hospital consultants value about their jobs? A discrete choice experiment. British Medical Journal 326.
Ryan M (1999). Using conjoint analysis to take account of patients' preferences and go beyond health outcomes. An application to in-vitro fertilisation. Social Science and Medicine 48:535-46.
Von Neumann J, Morgenstern O (1944). Theory of Games and Economic Behavior. Princeton University Press, New Jersey.
Beach LR (1997). The psychology of decision-making. London: Sage.
Miller GA (1956). The magical number seven, plus or minus two: some limits on our capacity for processing information. The Psychological Review 63:81-97.
Mayor S (2005). NICE says that patients' age should affect treatment. British Medical Journal 330:1102.
Harvard Center for Risk Analysis. Catalog of Preference Scores. 2005.
National Institute for Clinical Excellence (2004). Clopidogrel in the treatment of non-STsegment-elevation acute coronary syndrome. Technology Appraisal Guidance 80. London: NICE.
Main C, Palmer S, Griffin S, Jones L, Orton V, Sculpher M, et al (2003). A rapid and systematic review of the clinical effectiveness and costeffectiveness of clopidogrel used in combination with aspirin compared to aspirin alone in the treatment of non-ST-segment-elevation acute coronary syndromes (ACS). Technology assessment report prepared for the National Institute for Clinical Excellence, 1-180.
National Institute for Clinical Excellence (2002). Guidance on the use of routine antenatal anti-D prophylaxis for RhD-negative women. Technology Appraisal Guidance No 41. London: NICE.
National Institute for Clinical Excellence (2003). Anakinra for rheumatoid arthritis. Technology Appraisal Guidance 72. London: NICE.
Clark W, Jobanputra P, Barton P, Burls A (2003). The clinical and cost-effectiveness of anakinra for the treatment of rheumatoid arthritis in adults. Technology Assessment Report prepared for the National Institute for Clinical Excellence, 1-117.
National Institute for Clinical Excellence (2003). Rituximab for aggressive non-Hodgkin's lymphoma. Technology Appraisal 65. London: NICE.
Knight C, Hind D, Brewer N, Abbott V (2003). Rituximab (MabThera) for aggressive non-Hodgkin's lymphoma: systematic review. Technology Assessment Report prepared for the National Institute for Clinical Excellence, i-81.
National Institute for Clinical Excellence (2003). Guidance on the use of liquid-based cytology for cervical screening. Technology Appraisal Guidance 69. London: NICE.
Karnon J, Peters J, Platt J, Chilcott J, and McGoogan E (2003). Liquid-based cytology in cervical screening: an updated rapid and systematic review. Technology Assessment Report prepared for the National Institute for Clinical Excellence, i-67.
National Institute for Clinical Excellence (2002). Beta interferon and glatiramer acetate for the treatment of multiple sclerosis. Technology Appraisal Guidance 32. London: NICE.
Tappenden P, Chilcott J, O'Hagan A, McCabe C, Cooper N, Abrams K, et al (2001). Cost effectiveness of beta interferons and glatiramer acetate in the management of multiple sclerosis. Technology Assessment Report prepared for the National Institute for Clinical Excellence, i-51.
National Institute for Clinical Excellence (2003). Guidance on the use of Ribavirin and Interferon Alpha for Hepatitis C. London: NICE.