Pharmacoeconomics analyses

Hill, S., A. Mitchell and D. Henry (2000), Problems with the interpretation of pharmacoeconomic analyses , Journal ofthe American Medical Association, 283, 2116-21. 

Amendments to the National Health Act in 1987 introduced the additional requirement for the PBAC to consider cost and effectiveness. Sponsors were encouraged to provide cost-effectiveness substantiation from 1991, and from 1 January 1993 it became mandatory to include pharmacoeconomic analyses in listing applications - the fourth hurdle. ... 

The underlying premise of pharmacoeconomic analyses is that fiscal resources are scarce and that there is a need to make decisions based on... 

HUl, S. R., A. S. MitcheU, and D. A. Henry. 2000. Problems with the Interpretation of Pharmacoeconomic Analyses A Review of Submissions to the Australian Pharmaceu-hcal Benefits Scheme. Journal of the American Medical Association 283 2116-2121. 

The pharmacist uses pharmacoeconomic analyses to prospectively evaluate existing or new phar-... 

The pharmacist reports results of clinical research and pharmacoeconomic analyses to the pharmacy and medical community at regional and national meetings. 

The increasing use of pharmacoeconomic analyses as tools in health policy decision making has highlighted the fact that the value of a drug... 

The underlying premise of pharmacoeconomic analyses is that fiscal resources are scarce and that there is a need to make decisions based on the relative value of different interventions in creating better health and/or longer life. There are five main analytical techniques used to evaluate the incremental value of products. These are cost-consequence analysis (CCA) cost-effectiveness analysis (CEA) cost-benefit analysis (CBA) cost-minimisation analysis (CMA) and cost-utility analysis (CUA). Although the identification and valuation of the cost component (numerator) of these analyses are similar, it is the identification and valuation of the consequences (denominator) that truly differentiate these analytic techniques. A brief description of each of these techniques follows. 

Use of economic models and performance of pharmacoeconomic analyses on a local level both can be useful and relevant sources of pharmacoeconomic data when rigorous methods are employed, as outlined in this chapter. 

Direct medical costs are the costs incurred for medical products and services used to prevent, detect, and/or treat a disease. Direct medical costs are the fundamental transactions associated with medical care that contribute to the portion of gross national product spent on health care. Examples of these costs include drugs, medical supplies and equipment, laboratory and diagnostic tests, hospitalizations, and physician visits. Direct medical costs can be subdivided into fixed and variable costs. Fixed costs are essentially overhead costs (e.g., heat, rent, electricity) that are not readily influenced at the treatment level and thus remain relatively constant. For this reason, they are often not included in most pharmacoeconomic analyses. Variable costs, which change as a function of volume, include medications, fees for professional services, and supphes. As more services are used, more funding must be used to provide them. 

Intangible costs are those of other nonfinancial outcomes of disease and medical care. Examples include pain, suffering, inconvenience, and grief, and these are difficult to measure quantitatively and impossible to measure in terms of economic or financial costs. In pharmacoeconomic analyses, frequently intangible costs are identified but not quantified formally. 

Consequences also can be discussed in terms of intermediate and final outcomes. Intermediate outcomes can serve as a proxy for more relevant final outcomes. For example, achieving a decrease in low-density lipoprotein cholesterol levels with a lipid-lowering agent is an intermediate consequence that may serve as a proxy for a more final outcome such as a decrease in myocardial infarction rate. Intermediate consequences are used commonly in clinical and pharmacoeconomic analyses as proxies predictive of final outcomes because their use reduces the cost and time required to conduct a trial. 

Which ratio is the right ratio to use in pharmacoeconomic analyses Experts differ over which ratio, ACER or ICER, is the most appropriate and useful. ACER reflects the cost per benefit of a new strategy independent of other alternatives, whereas ICER reveals the cost per unit of benefit of switching from one treatment strategy (that already may be in place) to another. ... 

Recent data suggest that these differences in bioavailability and variability may have clinical implications. For example, several studies have suggested that torsemide is absorbed reliably and is associated with better outcomes than the more variably absorbed furosemide. And while the costs of torsemide exceed those of furosemide, pharmacoeconomic analyses suggest that the costs of care are similar or less with torsemide. These data require confirmation in controlled, double-blinded clinical trials but provide preliminary evidence that the more reliably absorbed loop dimetics may be superior to fmosemide. 

Friedman and colleagnes condncted a post hoc pharmacoeco-nomic evalnation of two mnlticenter, randomized trials comparing the combination of ipratropium and albnterol with both dmgs used as monotherapy. Patients who received a combination of ipratropium and albnterol had lower rates of exacerbations, lower overall treatment costs, and improved cost-effectiveness compared with either drng nsed alone. With the introdnction of new bronchodilator therapies, and with no clearly consistent advantage of one class of agents over another, pharmacoeconomic analyses may be nsefnl for clinicians in determining the most appropriate therapy for their patients. 

GAD is associated with high rates of health care use and disability. The number of days missed increases when GAD is comorbid with one or more other psychiatric disorders. Patients with GAD tend to use family practitioners and gastroenterologists more frequently than healthy controls. GAD ranks third among anxiety disorders in the rate of use of primary care physician time and it is the leading cause of disability in the workplace in the United States. Pharmacoeconomic analyses in the management of GAD have not been conducted. 

D. Rennie and H.S. Luft, Pharmacoeconomic analyses. Making them transparent, making them credible, JAMA 283 (2000), 2158-2160. 

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