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The economics of intensive care:
the decision-maker’s perspective
Prof Rachel Elliott, Professor of Health Economics,
Manchester Centre for Health Economics, School of Health
Sciences, University of Manchester
A few questions
• Can ICU care be “uneconomic”?
• Is ICU care an efficient use of NHS resources?
• What does “efficient” mean?
How health economists view health care
INPUTS Process of health care
OUTPUTS
Resources:
Staff
Equipment
Drugs
Effectiveness
Quality adjusted life years
“Willingness to pay”
Options:
1) Intervention A
2) Intervention B
Elliott RA, Payne K. Essentials of economic evaluation for health care.
Pharmaceutical Press, London. 2005
How health economists choose between different
health care interventions
Intervention A Costs Benefits
Intervention B Costs Benefits
Cost required to achieve each extra unit of outcome is
calculated: Incremental cost/effectiveness ratio (ICER)
Costs of providing health care: the value of
perspective
Hospital: operating theatre, ICU, ward, surgeon, anaesthetist, physiotherapist, nurses, pharmacist, drugs, prosthesis, X-rays etc
GP visits, drugs
Domestic help, disability allowance
Costs to social services
Costs to primary care
Costs to secondary
care
hospital
health service
Public sector
Comparing outcomes across different
diseases EQ-5D (3L) www.euroqol.org
5 dimensions, 3 levels = 245
health states (35)
Example values:
Health state 11111 = 1.00
Health state 12111 = 0.82
Health state 11223 = 0.26
7
Generating ICERs using quality-adjusted life-years (QALYs)
High frequency
oscillatory ventilation
for ARDS
Conventional
ventilation for ARDS
Total QALYs at 1
year per patient
0.302 0.246
NHS costs at 1 year
per patient
44,550 40,130
Incremental cost
effectiveness ratio
£78,261
Which therapy is cost effective? Which therapy should be chosen?
Lall, R., et al., A randomised controlled trial and cost-effectiveness analysis of high-frequency oscillatory ventilation against conventional artificial ventilation for adults with acute respiratory distress syndrome. The OSCAR (OSCillation in ARDS) study. Health Technol Assess, 2015. 19(23): p. 1-177, vii.
Using an incremental cost effectiveness ratio
Increased cost
decreased cost
Increased effect decreased
effect
NW quadrant
SE quadrant
NE quadrant
SW quadrant
0.2 QALYs
£2000
£2000 dominant
λ dominated
λ
9
Increased
cost
decreased
cost
Increased
effect decreased
effect
NW quadrant
SE quadrant
NE quadrant
SW quadrant
£8000
£4000
But when is something cost effective?
0.2 QALYs
£20,000 per QALY
£40,000 per QALY
£30,000 per QALY
Which treatment should be funded?
Disease Cost per extra QALY
High frequency oscillatory ventilation in ARDS
£78260
Trastuzumab added to anastrazole for HER-2 +ve advanced breast Ca
£54300
Trastuzumab for HER-2 +ve early stage breast Ca
£18000
Alpha blockers vs watchful waiting for moderate BPH symptoms
£10720
Ticagrelor plus aspirin vs clopidogrel plus aspirin in angina
£7900
Simvastatin in ARDS -£26875
A few more questions
• Is intensive care “uneconomic”?
• Is ICU care an efficient use of NHS resources?
• What does “efficient” mean?
• Is ICU care expensive?
• Is ICU care effective?
• Is ICU care cost-effective?
Compared with
what?
What is the aim of an ICU intervention?
ICU LOS? hospital LOS?
ICU mortality? hospital mortality?
Longer term mortality?
Maintenance/improvement of QoL in the short or long term?
Compared with
what?
Ask the question differently
What is the most cost-effective way to:
• Sedate patients on mechanical ventilation?
• Manage sepsis-induced acute kidney injury?
• Prevent ventilator-associated pneumonia?
• Provide prolonged mechanical ventilation?
• A specific intervention with a specific comparator in a specific patient group
Answer the question differently
Welsh Government. Together for Health – A Delivery Plan for the Critically Ill. A Delivery Plan up to 2016 for NHS. http://www.wales.nhs.uk/documents/delivery-plan-for-the-critically-ill.pdf
• Use meaningful comparators
• Don’t rely on top-down costs • Ward bed: £413 per night • Level 2 High Dependency bed: £857 per night • Level 3 Intensive Care bed: £1932 per night
• Use a longer follow-up period for costs and outcomes • Measure meaningful patient outcomes
What is the right question?
Is intensive care “uneconomic”?
Is intervention A cost-effective compared with intervention B in patient group C for
indication D?
Useful resources (1)
• Husereau D, et al. Consolidated Health Economic Evaluation Reporting
Standards (CHEERS)—Explanation and Elaboration: A Report of the ISPOR
Health Economic Evaluation Publication Guidelines Good Reporting Practices
Task Force. Value Health. 2013;16(2):231-50.
• Drummond MF, et al. Methods for the economic evaluation of health care
programmes: Oxford University Press; 2015.
• NICE 2013. Guide to the Methods of Technology Appraisal, London, NICE.
Available at https://www.nice.org.uk/article/pmg9/chapter/foreword
• Database of Instruments for Resource Use Measurement (http://www.dirum.org)
• National Health Service Executive. NHS Reference Costs 2014-15
(https://www.gov.uk/government/publications/nhs-reference-costs-2014-to-2015).
• Personal Social Services Research Unit (PSSRU). Unit Costs of Health and
Social Care. http://www.pssru.ac.uk/index-kent-lse.php
• Davis, S et al. NICE DSU Technical Support Document 15: Cost-effectiveness
modelling using patient-level simulation. 2014. Available from
http://www.nicedsu.org.uk
Useful resources (2)
• Fenwick E, Byford S. A guide to cost-effectiveness acceptability curves. The
British Journal of Psychiatry. 2005;187(2):106-8. doi:10.1192/bjp.187.2.106.
• Fenwick E, Claxton K, Sculpher MJ. Representing uncertainty: the role of cost
effectiveness acceptability curves. Health Economics. 2001;10:779-87.
• Department of Health. HSHC 2013. Health Service Cost Index, Annual
Summaries. 2013. http://www.info.doh.gov.uk/doh/
• Golicki D, Niewada M, Karlinska A, Buczek J, Kobayashi A, Janssen MF, et al.
Comparing responsiveness of the EQ-5D-5L, EQ-5D-3L and EQ VAS in stroke
patients. Qual Life Res. 2015;24(6):1555-63.
• Group:EuroQol E. EQ-5D-5L: Available modes of administration 2016 [updated
Version 14DEC2016.
• Feng Y, Devlin N, Herdman M. Assessing the health of the general population in
England: how do the three- and five-level versions of EQ-5D compare? Health
Qual Life Outcomes. 2015;13:171.
