Why Its Time to Abandon the ICER Dr Mike Paulden, Assistant - - PowerPoint PPT Presentation

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Why Its Time to Abandon the ICER Dr Mike Paulden, Assistant - - PowerPoint PPT Presentation

Jul 10, 2023 257 likes •993 views

Why Its Time to Abandon the ICER Dr Mike Paulden, Assistant Professor, School of Public Health, University of Alberta @mikepaulden paulden@ualberta.ca Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 1

Why It’s Time to Abandon the ICER

Dr Mike Paulden, Assistant Professor, School of Public Health, University of Alberta

@mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 2

Introduction

  • The incremental cost-effectiveness ratio (ICER) is widely used to report

the results of economic analyses of health technologies

  • Yet reporting ICERs is unnecessary - alternative measures exist, based on

the concepts of net health benefit (NHB) or net monetary benefit (NMB)

  • Yet ICERs remain popular with decision makers, and there is a common

perception that there are advantages to using ICERs, particularly if the cost- effectiveness threshold (λ) is unknown

  • This paper argues that this common perception is false - there are

no advantages to using ICERs and many important limitations

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 3

Calculating ICERs where there are only two strategies

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 4

ICER = ∆Cost / ∆QALYs

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 5

Result: ICERs are easy to calculate with only two strategies

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 6

Interpreting the ICER where there are only two strategies

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 7

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 8

Question: Is strategy B cost-effective?

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 9

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 10

Question: Would a different strategy with an ICER of $25,000 per QALY be cost-effective?

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 11

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 12

Question: Would a different strategy with a negative ICER be cost-effective?

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 13

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 14

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 15

Question: Does a lower ICER imply that a strategy is necessarily more cost-effective?

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 16

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 17

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 18

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 19

Limitations of ICERs in comparisons of two strategies

  • 1. A threshold is required to determine whether a strategy is cost-effective,

unless it is dominated/dominating (in which case an ICER is not required)

  • 2. An ICER cannot be interpreted without also knowing the quadrant of the

CE plane in which the strategy lies

  • 3. Change in an ICER during a sensitivity analysis does not necessarily imply

that the strategy is more or less cost-effective

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 20

Result: ICERs are difficult to interpret with only two strategies and any interpretation is limited

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 21

Calculating ICERs where there are multiple strategies

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 22

Strategy Cost QALYs A $600,000 24 B $1,300,000 34 C $400,000 16 D $500,000 26 E $700,000 20 F $100,000 6 G $1,000,000 30 H $350,000 8

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 23

Step 1: Rank strategies by cost

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 24

Strategy Cost QALYs F $100,000 6 H $350,000 8 C $400,000 16 D $500,000 26 A $600,000 24 E $700,000 20 G $1,000,000 30 B $1,300,000 34

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 25

Step 2: Rule out ‘dominated’ strategies

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 26

Strategy Cost QALYs F $100,000 6 H $350,000 8 C $400,000 16 D $500,000 26 A $600,000 24 E $700,000 20 G $1,000,000 30 B $1,300,000 34

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 27

Strategy Cost QALYs F $100,000 6 H $350,000 8 C $400,000 16 D $500,000 26 A $600,000 24 E $700,000 20 G $1,000,000 30 B $1,300,000 34

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 28

Step 3: Calculate initial estimates of incremental values

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 29

Strategy Cost QALYs ΔCost ΔQALYs ICER F $100,000 6 H $350,000 8 C $400,000 16 D $500,000 26 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 B $1,300,000 34

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 30

Strategy Cost QALYs ΔCost ΔQALYs ICER F $100,000 6 N/A N/A N/A H $350,000 8 C $400,000 16 D $500,000 26 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 B $1,300,000 34

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 31

Strategy Cost QALYs ΔCost ΔQALYs ICER F $100,000 6 N/A N/A N/A H $350,000 8 $250,000 2 $125,000 C $400,000 16 $50,000 8 $6,250 D $500,000 26 $100,000 10 $10,000 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 $500,000 4 $125,000 B $1,300,000 34 $300,000 4 $75,000

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 32

Step 4: Rule out initial ‘extendedly dominated’ strategies

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 33

Strategy Cost QALYs ΔCost ΔQALYs ICER F $100,000 6 N/A N/A N/A H $350,000 8 $250,000 2 $125,000 C $400,000 16 $50,000 8 $6,250 D $500,000 26 $100,000 10 $10,000 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 $500,000 4 $125,000 B $1,300,000 34 $300,000 4 $75,000

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 34

Strategy Cost QALYs ΔCost ΔQALYs ICER F $100,000 6 N/A N/A N/A H $350,000 8 ED ED ED C $400,000 16 $50,000 8 $6,250 D $500,000 26 $100,000 10 $10,000 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 ED ED ED B $1,300,000 34 $300,000 4 $75,000

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 35

Step 5: Recalculate incremental values

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 36

Strategy Cost QALYs ΔCost ΔQALYs ICER F $100,000 6 N/A N/A N/A H $350,000 8 ED ED ED C $400,000 16 $50,000 8 $6,250 D $500,000 26 $100,000 10 $10,000 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 ED ED ED B $1,300,000 34 $300,000 4 $75,000

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 37

Strategy Cost QALYs ΔCost ΔQALYs ICER F $100,000 6 N/A N/A N/A H $350,000 8 ED ED ED C $400,000 16 $300,000 10 $30,000 D $500,000 26 $100,000 10 $10,000 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 ED ED ED B $1,300,000 34 $300,000 4 $75,000

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 38

Strategy Cost QALYs ΔCost ΔQALYs ICER F $100,000 6 N/A N/A N/A H $350,000 8 ED ED ED C $400,000 16 $300,000 10 $30,000 D $500,000 26 $100,000 10 $10,000 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 ED ED ED B $1,300,000 34 $300,000 4 $75,000

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 39

Strategy Cost QALYs ΔCost ΔQALYs ICER F $100,000 6 N/A N/A N/A H $350,000 8 ED ED ED C $400,000 16 $300,000 10 $30,000 D $500,000 26 $100,000 10 $10,000 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 ED ED ED B $1,300,000 34 $800,000 8 $100,000

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 40

Step 6: Rule out any additional ‘extendedly dominated’ strategies

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 41

Strategy Cost QALYs ΔCost ΔQALYs ICER F $100,000 6 N/A N/A N/A H $350,000 8 ED ED ED C $400,000 16 $300,000 10 $30,000 D $500,000 26 $100,000 10 $10,000 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 ED ED ED B $1,300,000 34 $800,000 8 $100,000

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 42

Strategy Cost QALYs ΔCost ΔQALYs ICER F $100,000 6 N/A N/A N/A H $350,000 8 ED ED ED C $400,000 16 ED ED ED D $500,000 26 $100,000 10 $10,000 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 ED ED ED B $1,300,000 34 $800,000 8 $100,000

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 43

Step 7: Recalculate incremental values

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 44

Strategy Cost QALYs ΔCost ΔQALYs ICER F $100,000 6 N/A N/A N/A H $350,000 8 ED ED ED C $400,000 16 ED ED ED D $500,000 26 $100,000 10 $10,000 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 ED ED ED B $1,300,000 34 $800,000 8 $100,000

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 45

Strategy Cost QALYs ΔCost ΔQALYs ICER F $100,000 6 N/A N/A N/A H $350,000 8 ED ED ED C $400,000 16 ED ED ED D $500,000 26 $400,000 20 $20,000 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 ED ED ED B $1,300,000 34 $800,000 8 $100,000

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 46

Calculation complete

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 47

Result: ICERs can be difficult to calculate in evaluations of multiple strategies

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 48

Interpreting ICERs where there are multiple strategies

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 49

Decision rule: The most cost-effective strategy is that with the highest ICER below the threshold

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 50

Strategy Cost QALYs ΔCost ΔQALYs ICER F $100,000 6 N/A N/A N/A H $350,000 8 ED ED ED C $400,000 16 ED ED ED D $500,000 26 $400,000 20 $20,000 A $600,000 24 D D D E $700,000 20 D D D G $1,000,000 30 ED ED ED B $1,300,000 34 $800,000 8 $100,000

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 51

Question: Can ICERs be used to rank strategies from most to least cost-effective?

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 52

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 53

Limitations of ICERs in comparisons of multiple strategies

  • 1. The decision rule to identify the most cost-effective strategy is unintuitive:

it is the strategy with the highest ICER below the threshold

○ If all ICERs are above the threshold, the cheapest strategy is cost-effective

  • 2. A threshold is required to determine the most cost-effective strategy,

unless one strategy dominates all others

  • 3. It is not possible to to rank strategies from most to least cost-effective
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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 54

Result: ICERs are difficult to interpret with multiple strategies and any interpretation is limited

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 55

Calculating NHB or NMB

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 56

NHB = QALYs - Cost / λ NMB = QALYs * λ - Cost

Key differences vs ICERs: not incremental and requires λ for calculation

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 57

Threshold for this example: λ = $50,000 per QALY

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 58

Strategy Cost QALYs NHB NMB F $100,000 6 H $350,000 8 C $400,000 16 D $500,000 26 A $600,000 24 E $700,000 20 G $1,000,000 30 B $1,300,000 34

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 59

Strategy Cost QALYs NHB NMB F $100,000 6 4 H $350,000 8 C $400,000 16 D $500,000 26 A $600,000 24 E $700,000 20 G $1,000,000 30 B $1,300,000 34

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 60

Strategy Cost QALYs NHB NMB F $100,000 6 4 $200,000 H $350,000 8 C $400,000 16 D $500,000 26 A $600,000 24 E $700,000 20 G $1,000,000 30 B $1,300,000 34

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 61

Strategy Cost QALYs NHB NMB F $100,000 6 4 $200,000 H $350,000 8 1 $50,000 C $400,000 16 8 $400,000 D $500,000 26 16 $800,000 A $600,000 24 12 $600,000 E $700,000 20 6 $300,000 G $1,000,000 30 10 $500,000 B $1,300,000 34 8 $400,000

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 62

Result: NHB/NMB is easy to calculate for any number of strategies

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 63

Interpreting NHB or NMB

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 64

Strategies with greater NHB or NMB are more cost-effective

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 65

Strategy Cost QALYs NHB Ranking F $100,000 6 4 H $350,000 8 1 C $400,000 16 8 D $500,000 26 16 1st A $600,000 24 12 E $700,000 20 6 G $1,000,000 30 10 B $1,300,000 34 8

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 66

Strategy Cost QALYs NHB Ranking F $100,000 6 4 H $350,000 8 1 C $400,000 16 8 D $500,000 26 16 1st A $600,000 24 12 2nd E $700,000 20 6 G $1,000,000 30 10 B $1,300,000 34 8

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 67

Strategy Cost QALYs NHB Ranking F $100,000 6 4 7th H $350,000 8 1 8th C $400,000 16 8 4th= D $500,000 26 16 1st A $600,000 24 12 2nd E $700,000 20 6 6th G $1,000,000 30 10 3rd B $1,300,000 34 8 4th=

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 68

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 69

Result: NHB/NMB is easy to interpret for any number of strategies

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 70

The need to specify a threshold

  • A threshold is required for calculating NHB/NMB
  • Yet a threshold is also required for interpreting ICERs

○ Without interpretation, ICERs cannot be used for decision making

  • The need to specify a threshold is identical for ICERs and NHB/NMB
  • Ultimately, unless one strategy ‘dominates’ all others, trade-offs must be

made between costs and QALYs, and using ICERs does not avoid this

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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 71

Summary

  • NHB/NMB are easier to calculate than ICERs

○

ICERs are difficult to calculate for comparisons of multiple strategies ○ NHB/NMB are easy to calculate, regardless of the number of strategies

  • NHB/NMB are easier to interpret than ICERs

○ ICERs are difficult to interpret, regardless of the number of strategies ○ NHB/NMB are easy to interpret, regardless of the number of strategies

  • ICERs have many limitations compared to NHB/NMB

○ A higher/lower ICER does not imply that a strategy is more/less cost-effective

  • It’s time to abandon the ICER and use measures of NHB/NMB instead
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Dr Mike Paulden, University of Alberta @mikepaulden paulden@ualberta.ca mikepaulden.com +1 (844) PAULDEN Slide 72

Any questions?

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