Making Choices in Health: WHO Guide to Cost-Effectiveness Analysis

330 Pages·2003·3.81 MB·English

by  R. Baltussen

WHO
GUIDE TO
-
COST EFFECTIVENESS ANALYSIS
CONTENTS
The graphic on the cover is a stylized representation of Figure 5 in
Background Paper 7 showing uncertainty analysis.
MAKING CHOICES IN HEALTH:
WHO
GUIDE TO
-
COST EFFECTIVENESS ANALYSIS
EDITED BY
T. TAN-TORRES EDEJER, R. BALTUSSEN, T. ADAM,
R. HUTUBESSY, A. ACHARYA, D.B. EVANS AND
C.J.L. MURRAY
World Health Organization
Geneva
WHO Library Cataloguing-in-Publication Data
World Health Organization.
Making choices in health: WHO guide to cost-effectiveness analysis/
edited by T. Tan-Torres Edejer … [et al.]
1. Cost-benefit analysis – methods 2. Health care rationing – economics
3.Decision making 4.Health priorities – economics
5.Models, Econometric 6.Guidelines
I. Tan-Torres Edejer, Tessa. II.WHO-CHOICE III.Title.
ISBN 92 4 154601 8 (LC/NLM classification: HD 47.4)
© World Health Organization 2003
All rights reserved. Publications of the World Health Organization can be
obtained from Marketing and Dissemination, World Health
Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41
22 791 2476; fax: [phone]; email: [email protected]).
Requests for permission to reproduce or translate WHO publications—
whether for sale or for noncommercial distribution—should be addressed
to Publications, at the above address (fax: [phone]; email:
[email protected]).
The designations employed and the presentation of the material in this
publication do not imply the expression of any opinion whatsoever on
the part of the World Health Organization concerning the legal status of
any country, territory, city or area or of its authorities, or concerning the
delimitation of its frontiers or boundaries. Dotted lines on maps represent
approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products
does not imply that they are endorsed or recommended by the World
Health Organization in preference to others of a similar nature that are
not mentioned. Errors and omissions excepted, the names of proprietary
products are distinguished by initial capital letters.
The World Health Organization does not warrant that the information
contained in this publication is complete and correct and shall not be
liable for any damages incurred as a result of its use.
Printed in Switzerland
CONTENTS
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IX
List of Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . XXI
PART ONE: METHODS FOR GENERALIZED
COST-EFFECTIVENESS ANALYSIS
1. What is Generalized Cost-Effectiveness Analysis? . . . . . . . . . . . . 3
2. Undertaking a study using GCEA. . . . . . . . . . . . . . . . . . . . . . . 17
3. Estimating costs. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
4. Estimating health effects. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
5. Discounting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
6. Uncertainty in cost-effectiveness analysis. . . . . . . . . . . . . . . . . . 73
7. Policy uses of Generalized CEA . . . . . . . . . . . . . . . . . . . . . . . . 83
8. Reporting CEA results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
9. Summary of recommendations . . . . . . . . . . . . . . . . . . . . . . . . . 93
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Annex A.WHO-CHOICE activities on Generalized
Cost-Effectiveness Analysis. . . . . . . . . . . . . . . . . . . . . . . 107
Annex B. Draft list of intervention clusters for evaluation
by WHO-CHOICE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
Annex C.An illustration of the types of costs included in
a selection of intervention activities at central levels. . . . . 111
Annex D.Interpreting international dollars. . . . . . . . . . . . . . . . . . . 112
Annex E. DALYs to measure burden of disease. . . . . . . . . . . . . . . . 113
Annex F. Measuring intervention benefit at the population level. . . 115
Annex G.Epidemiological subregions as applied in WHO
Generalized CEA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Endnotes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
PART TWO: BACKGROUND PAPERS AND APPLICATIONS
1. Development of WHO guidelines on generalized
cost-effectiveness analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Christopher J.L. Murray, David B. Evans, Arnab Acharya,
Rob M.P.M. Baltussen
2. PopMod: A longitudinal population model with two
interacting disease states . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Jeremy A. Lauer, Klaus Röhrich, Harold Wirth,
Claude Charette, Steve Gribble, Christopher J.L. Murray
3. Programme costs in the economic evaluation of health
interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 177
Benjamin Johns, Rob Baltussen, Raymond Hutubessy
4. Econometric estimation of country-specific hospital costs . . . . 197
Taghreed Adam, David B. Evans, Christopher J.L. Murray
5. Stochastic league tables: communicating cost-effectiveness
results to decision-makers . . . . . . . . . . . . . . . . . . . . . . . . . . . 217
Raymond C.W. Hutubessy, Rob M.P.M. Baltussen,
David B. Evans, Jan J. Barendregt, Christopher J.L. Murray
6. Uncertainty in cost-effectiveness analysis: probabilistic
uncertainty analysis and stochastic league tables . . . . . . . . . . . 225
Rob M.P.M. Baltussen, Raymond C.W. Hutubessy,
David B. Evans, Christopher J.L. Murray
7. Effectiveness and costs of interventions to lower systolic blood
pressure and cholesterol: a global and regional analysis on
reduction of cardiovascular-disease risk . . . . . . . . . . . . . . . . . 237
Christopher J.L. Murray, Jeremy A. Lauer,
Raymond C.W. Hutubessy, Louis Niessen, Niels Tomijima,
Anthony Rodgers, Carlene M.M. Lawes, David B. Evans
8. Generalized cost-effectiveness analysis: an aid to decision
making in health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Raymond C.W. Hutubessy, Rob M.P.M. Baltussen,
Tessa Tan-Torres Edejer, David B. Evans
9. Ethical issues in the use of cost effectiveness analysis for
the prioritization of health care resources . . . . . . . . . . . . . . . . 289
Dan W. Brock
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 313
ACKNOWLEDGEMENTS
Many individuals have contributed to the refinement of the framework,
methods and tools for generalized cost-effectiveness analysis. Their
contributions are recognized collectively under the name WHO-CHOICE
Collaboration. In addition to them, a number of experts provided
valuable input in anonymous reviews for the published papers, during the
consultative meeting in Geneva in 2001, and during other scientific
meetings where WHO-CHOICE or generalized cost-effectiveness analysis
was presented. Their contributions are gratefully acknowledged. Another
important source of feedback has been the policy-makers and analysts
from many different countries who have attended the workshops on
generalized cost-effectiveness analysis that we have conducted over the
past years. Close interaction with them as they applied the tools and
techniques gave us insights into a range of concerns from a user’s
perspective, and made us aware of the need to be responsive to different
audiences.
Lastly, we would like to give special thanks to Margaret Squadrani,
Marilyn Vogel, Kai Lashley and Keith Wynn who, with their dedication,
patience and painstaking attention to detail, made the actual production
of the book possible.
This guide benefited from the input of many experts, including those
participating in a meeting on Methods for Cost-Effectiveness Analysis
held in Geneva in January 2002. Those who participated were:
Dr Arnab Acharya, The Institute of Development Studies, UK
Dr Jan Barendregt, Erasmus University, The Netherlands
Dr Stephen Birch, McMaster University, Canada
Dr Dan Brock, National Institutes of Health, USA
Dr Werner Brouwer, Erasmus University Rotterdam, The Netherlands
Dr Vilma Carande-Kulis, Centers for Disease Control & Prevention, USA
Dr Michael Drummond, University of York, UK
Dr Alastair Gray, University of Oxford, UK
Dr Paul Kind, University of York, UK
Dr Martin Meltzer, Centers for Disease Control and Prevention, USA
Dr Mark Miller, National Institutes of Health, USA
Professor Anne Mills, London School of Hygiene & Tropical Medicine,
UK
Dr Raul Molina, Universidad Autonoma Metropolitana-Iztapalapa,
Mexico
Dr Benjamin Nganda, University of Nairobi, Kenya
Dr Louis Niessen, Erasmus University, The Netherlands
Dr Max Price, University of the Witwatersrand, South Africa
Professor Jeff Richardson, Centre for Health Programme Evaluation,
Australia
Dr Juan Rovira, The World Bank, USA
Dr Orville Solon, University of the Philippines, Philippines
Dr Siripen Supakankunti, Chulalongkorn University, Thailand
Dr Ben van Hout, Utrecht University, The Netherlands
Dr Leena K. Eklund, WHO Regional Office for Europe, Denmark
Dr Hossein Salehi, WHO Regional Office for the Eastern Mediterranean,
Egypt
The views expressed in these guidelines are those of the authors and not
necessarily those of the participants.
PREFACE
A number of guidelines on cost-effectiveness analysis (CEA) already exist.
There are two reasons for producing another set. The first is that
traditional analysis has focused on assessing new or additional
interventions in comparison with current practice in that area. It is
difficult to use this type of “incremental” analysis to determine if the
current mix of interventions represents an efficient use of resources.
Secondly, for all but the richest countries, the cost and time required to
evaluate the large number of interventions and identify opportunities to
enhance efficiency are prohibitive. It is important to maximize the
possibility of generalizing results from one setting to another. The
approach of generalized CEA (GCEA) proposed in this Guide seeks to
provide analysts with a method of assessing whether the current mix of
interventions is efficient as well as whether a proposed new technology or
intervention is appropriate. It also seeks to maximize the generalizability
of results across settings.
The WHO Guide to Cost-Effectiveness Analysis should be considered
as complementary to existing guidelines on CEA. GCEA proposes the
evaluation of interventions against the counterfactual of “doing
nothing”, thereby providing decision-makers with information on what
could be achieved if they could start again to build the health system, i.e.
reallocate all health resources. As will be shown in the Guide, this
information is a prerequisite to the definition of an efficient mix of
interventions, achievable in the long run. This specific feature—not
addressed in traditional CEA which typically evaluates new interventions
in comparison with the current mix (intervention mix constrained CEA
or IMC-CEA)—categorizes GCEA as a different, more fundamental, type
of economic analysis. For many narrower applications of CEA, such as
the appraisal of a new version of an existing drug in a specific country,
the currently practised CEA remains an appropriate method although it
should be realized that this does not inform decision-makers on the best
use of health resources in general.i It is also possible to undertake a
traditional analysis as part of a GCEA.
The main objective of this Guide is to provide policy-makers and
researchers with a clear understanding of the concepts and benefits of
GCEA. It provides guidance on how to undertake studies using this form
of analysis and how to interpret the results. The main focus is on those