Irina Cleemput

A review of the literature on the economics of noncompliance. Room for methodological improvement

Therapeutic noncompliance is a major issue in health care, having important negative consequences for clinical outcome as well as for health-care costs. This paper reviews the literature on the economics of therapeutic noncompliance, identifies methodological shortcomings and formulates recommendations for future economic research in this area. Medication noncompliance was explored more extensively, as the majority of articles dealt exclusively with this aspect of therapy. Eighteen studies were assessed according to their definition and measurement of medication noncompliance, study design, and identification and valuation of costs and outcomes. Very diverse designs and often invalid methods for calculating costs were found. Medication noncompliance is often ill-defined and measured in an inaccurate way. The economic consequences of therapeutic noncompliance have rarely been investigated according to the standard principles of good economic evaluation. Six studies examined both costs and consequences of noncompliance in a cost-outcome description or a cost-benefits, cost-effectiveness or cost-utility analysis. Eight studies dealt with the economic value of compliance-enhancing interventions. In general, studies on the economic consequences of noncompliance lack methodological rigour and fail to meet qualitative standards. There is a clear need for more and better research on the impact of noncompliance, on the cost-effectiveness of interventions and the potential of compliance-enhancing interventions to improve patient outcomes and/or reduce health-care costs.

Using threshold values for cost per quality-adjusted life-year gained in healthcare decisions

BACKGROUNDnIn many countries, the incremental cost-effectiveness ratio (ICER) is used to assess whether an intervention is worth its costs. At the same time, policy makers often feel uncomfortable with refusing reimbursement of any intervention purely on the basis of the fact that the ICER exceeds a specific threshold value. Reluctance to define a single threshold value for the ICER seems to have been stronger in social security systems than in national healthcare services systems. This study explores how basic differences between healthcare systems impact upon the potential usefulness of an ICER threshold value.nnnMETHODSnThis study is a narrative review of literature about the theoretical foundations of the ICER threshold value approach and its practical relevance in different types of healthcare systems.nnnRESULTSnA single ICER threshold value cannot be maintained, defined, or measured and should not be used as a policy-making tool. None of the solutions presented up until now to make the ICER threshold approach a valuable policy-making tool overcome the important weaknesses of the approach.nnnCONCLUSIONSnICERs and ICER threshold values are insufficient for assessing interventions value for money. Rather, they should be considered as one element in the decision-making process. Complete rationalization of the decision-making process by means of quantitative decision criteria is undesirable and not feasible. Increasing transparency in the criteria used for a decision and explicitness about the relative importance of each criterion should, therefore, be the major goal.

Federation of European Cancer Societies. Full Report. Economic evaluation in cancer care: questions and answers on how to alleviate conflicts between rising needs and expectations and tightening budgets

All Western countries have experienced a fast growth in their healthcare expenses over recent decades. It is expected that pressure for such growth will continue in the future. But spending an ever larger share of our nations resources on healthcare cannot be afforded. As a consequence, making choices will become more and more inevitable, even in cancer care. Economic evaluation is a very supportive tool for such decisions. This position statement concludes with recommendations for providers and healthcare policy-makers, to safeguard and further improve good clinical decision making and healthcare policy in cancer care under tightening budgets.

History of health technology assessment in Belgium

OBJECTIVESnThis paper gives an overview of health technology assessment (HTA) in Belgium.nnnMETHODSnThe information included in the overview is based on legal documents and publicly available year reports of the Belgian Health Care Knowledge Centre (KCE).nnnRESULTSnBelgium has a relatively young history in HTA. The principle of evidence-based medicine (EBM) was introduced in the drug reimbursement procedure in 2001, with the establishment of the Drug Reimbursement Committee (DRC). The DRC assesses the efficacy, safety, convenience, applicability, and effectiveness of a drug relative to existing treatment alternatives. For some drugs, relative cost-effectiveness is also evaluated. The activities of the DRC can, therefore, be considered to be the first official HTA activities in Belgium. Later, in 2003, KCE was established. Its mission was to perform policy preparing research in the healthcare and health insurance sector and to give advice to policy makers about how they can obtain an efficient allocation of limited healthcare resources that optimizes the quality and accessibility of health care. This broad mission has been operationalized by activities in three domains of research: HTA, health services research, and good clinical practice. KCE is independent from the policy maker. Its HTAs contain policy recommendations that may inform policy decisions but are not binding.nnnCONCLUSIONSnAlthough the Belgian history of HTA is relatively short, its foundations are strong and the impact of HTA increasing. Nevertheless KCE has many challenges for the future, including continued quality assurance, further development of international collaboration, and further development of methodological guidance for HTA.

HEALTH TECHNOLOGY ASSESSMENT IN BELGIUM

The Belgian healthcare system has a Bismarck-type compulsory health insurance, covering almost the entire population, combined with private provision of care. Providers are public health services, independent pharmacists, independent ambulatory care professionals, and hospitals and geriatric care facilities. Healthcare responsibilities are shared between the national Ministries of Public Health and Social Affairs, and the Dutch-, French-, and German-speaking Community Ministries of Health. The national ministries are responsible for sickness and disability insurance, financing, determination of accreditation criteria for hospitals and heavy medical care units, and construction of new hospitals. The six sickness and disability insurance funds are responsible for reimbursing health service benefits and paying disability benefits. The systems strength is that care is highly accessible and responsive to patients. However, the healthcare systems size remained relatively uncontrolled until recently, there is an excess supply of certain types of care, and there is a large number of small hospitals. The national government created a legal framework to modernize the insurance system to control budgetary deficits. Measures for reducing healthcare expenditures include regulating healthcare supply, healthcare evaluation, medical practice organization, and hospital budgets. The need to control healthcare facilities and quality of care in hospitals led to formal procedures for opening hospitals, acquiring expensive medical equipment, and developing highly specialized services. Reforms in payment and regulation are being considered. Health technology assessment (HTA) has played little part in the reforms so far. Belgium has no formal national program for HTA. The future of HTA in Belgium depends on a changing perception by providers and policy makers that health care needs a stronger scientific base.

PHP12 3THE ECONOMIC IMPLICATIONS OF NONCOMPLIANCE AFTER RENAL TRANSPLANTATION

OBJECTIVES: The economic impact of therapeutic noncompliance in chronic diseases has rarely been examined following qualitative standards for economic evaluation. This study illustrates the potential impact of noncompliance on the cost-utility of chronic treatments using the case of renal transplantation versus haemodialysis and examines the economic scope for compliance enhancing interventions. METHODS: Long term cost and outcomes in compliant and noncompliant renal transplant patients were simulated in a Markov model. The cost and outcome data that were imputed in the model were derived from a prospective study in renal transplantation candidates. Probabilities of adverse events, graft rejection, graft loss and death, in compliant and noncompliant renal transplant patients were derived from literature. A societal viewpoint was taken. RESULTS: Compared with dialysis, renal transplantation offers a better outcome in both compliant and non-compliant patients. Lifetime costs after transplantation in the compliant patient group are higher than lifetime dialysis costs and than life-time costs in the non-compliant patient group, mainly because compliant patients live longer after transplantation. Long-term outcomes after transplantation are better for compliant than for non-compliant patients. The mean cost per quality-adjusted life-year gained (QALY) in compliant patients relative to non-compliant patients is €36,606.94/QALY (95% confidence interval [35,157.13–37,986.57]). CONCLUSIONS: This study shows that renal transplantation is an optimal treatment for end stage renal disease patients, regardless of patients’ level of compliance post-transplantation, as illustrated by the lower costs and better outcomes. In view of the incremental cost-utility ratio of haemodialysis, which is considered to be a cost-effective treatment, of €65,912/QALY, it can be concluded that there is scope for complianceenhancing interventions. The improvement of outcome in compliance justifies the additional costs that need to be borne and therefore the introduction of compliance-enhancing interventions.