Expert Review of Pharmacoeconomics & Outcomes Research Downloaded from informahealthcare.com by Nanyang Technological University on 04/24/15 For personal use only.
Review
Incorporation of future costs in health economic analysis publications: current situation and recommendations for the future Expert Rev. Pharmacoecon. Outcomes Res. Early online, 1–5 (2015)
Blanca Gros1, ´ lvarez*2 Javier Soto A and ´ ngel Casado3 Miguel A 1 Market Access Department, JanssenCilag, Madrid, Spain 2 Health Economics and Outcomes Research, Corporate Affair, Health and Value Unit, Pfizer, Avda de Europa 20-B, Parque Empresarial de laMoraleja, 28108 Alcobendas, Madrid, Spain 3 PharmacoEconomics and Outcomes Research Iberia, Madrid, Spain *Author for correspondence: Tel.: Tel.: +34 914 909 572 [email protected]
Future costs are not usually included in economic evaluations. The aim of this study was to assess the extent of published economic analyses that incorporate future costs. A systematic review was conducted of economic analyses published from 2008 to 2013 in three general health economics journals: PharmacoEconomics, Value in Health and the European Journal of Health Economics. A total of 192 articles met the inclusion criteria, 94 of them (49.0%) incorporated future related medical costs, 9 (4.2%) also included future unrelated medical costs and none of them included future nonmedical costs. The percentage of articles including future costs increased from 2008 (30.8%) to 2013 (70.8%), and no differences were detected between the three journals. All relevant costs for the perspective considered should be included in economic evaluations, including related or unrelated, direct or indirect future costs. It is also advisable that pharmacoEconomic guidelines are adapted in this sense. KEYWORDS: economic analysis
.
future costs
.
health economic analysis
Economic evaluations are normally used to inform policy makers and healthcare professionals about the costs and the health outcomes of a new therapeutic option compared to a reference that is on the market, in order to ascertain if the health benefits achieved outweigh the associated costs. Therefore, it is obviously crucial to determine which costs and health outcomes should be included in a health economic analysis. The most widely adopted perspective in the world of health economics is the societal one, which aims to account for all costs and health outcomes of a therapeutic intervention, regardless of whom they accrue to [1]. While there is a general consensus about the necessity of including health effects that occur in the lifeyears gained when performing an economic analysis, there is currently some controversy about how to handle the so-called future costs. These costs can be divided into three categories – future related medical costs: medical costs that happen because of the treatment of informahealthcare.com
10.1586/14737167.2015.1021689
.
publications
the target disease during the added years of life (e.g., when conducting a health economic evaluation of a new antihypertensive drug that prolongs life, future related medical costs would include all the antihypertensive medications, laboratory tests and other hypertensionrelated costs in the added years of life, such as a heart attack); future unrelated medical costs (also called indirect medical costs): medical costs that occur because of the treatment of other diseases during the added years of life, but which are not related to the original target disease (e.g., in the example of the new antihypertensive drug, a patient with well-controlled hypertension might develop rheumatoid arthritis, the treatment of which will generate costs, but is unrelated to the original disease); and future nonmedical costs (also called production and consumption costs): all the nonmedical costs that are incurred during the added years of life (i.e., consumption of nonmedical goods and services, net of the contribution taking place via production) [2].
2015 Informa UK Ltd
ISSN 1473-7167
1
Review
´ lvarez & A ´ ngel Casado Gros, Soto A
Expert Review of Pharmacoeconomics & Outcomes Research Downloaded from informahealthcare.com by Nanyang Technological University on 04/24/15 For personal use only.
Records identified through journal search n = 230
PharmacoEconomics n = 58 Value in health n = 129 Eur J Health Econ n = 43
Records screened n = 220
Full-text articles assessed for elegibility and references screened n = 205
Full-text articles excluded n = 13
Economic analyses included in final systematic review n = 192
PharmacoEconomics n = 48 Value in health n = 109 Eur J Health Econ n = 35
Figure 1. Flow chart of the literature research.
There have been continuous disagreements about the management of future costs in economic evaluations over years. While there has always been broad agreement on the inclusion of future related medical costs in economic analyses, there have been discrepancies in the literature about how to account for future unrelated medical costs and for future nonmedical costs during the additional years of life [3]. Therefore, whereas most authors have proposed to include only future related medical costs in economic evaluations [4], some have argued that future unrelated medical costs should also be included [5]. Others have even suggested that future nonmedical costs, which are the production and consumption of nonmedical resources during the added years of life, should also be incorporated into the economic analysis [6]. Nevertheless, there have been other authors who argue that neither future consumption nor future production should be included, as these components are not included when measuring quality-adjusted lifeyears [7,8]. However, it is well established that the inclusion or exclusion of future costs in economic evaluations may have important healthcare policy implications. It has been demonstrated that the incorporation of these types of costs might have a significant impact on the practical results of economic analyses [9–11]; if future costs are omitted, therapeutic options aimed at older age groups may be favored, whereas the inclusion of future costs could significantly improve the results of alternatives that decrease mortality among young adults [12,13]. The aim of this study was to describe the extent of published economic analyses that incorporate future costs and the types of future costs included. doi: 10.1586/14737167.2015.1021689
Material & methods Selection of papers for review
We performed a systematic review of economic analyses published in three general health economics journals: PharmacoEconomics, Value in Health and the European Journal of Health Economics; these journals were selected because they are quite representative of health economics journals, have published many economic evaluations annually and have a lot of prestige and relevance for health professionals and other decision-makers. The three journals were reviewed to identify economic evaluations from 2008 to 2013, regardless of whether these were performed alongside prospective designs (clinical trials or cohort studies) or through decision-analytic models as long as they met the inclusion criteria of the review. The search terms used were ‘economic analysis’, ‘health economic analysis’, ‘cost–effectiveness analysis’, ‘pharmacoEconomic analysis’ and ‘cost-utility analysis’. In order to be included in this study, the articles had to comply with the following criteria: a complete economic evaluation (comparing costs and health outcomes of two or more alternatives), time horizon longer than 1 year and evaluating drugs, medical devices, healthcare technologies and other kinds of public health programs. The following exclusion criteria were set: systematic reviews of economic analyses, opinion papers, economic analyses through either clinical trials or observational studies, comparative cost analyses and budget impact analyses. Once the possible articles to be included in the systematic review had been identified, titles and abstracts were screened against the inclusion criteria to identify potentially relevant papers. Once the valid references were selected from the corresponding abstracts, the original articles were analyzed and those meeting the inclusion criteria were finally included. A flow chart showing the study selection process is shown in FIGURE 1. Data extraction
All studies were manually searched, and data were extracted from each paper using a data extraction form, which was developed to retrieve and organize information from each paper based on main topics. The data extraction items included the following descriptive information: year of publication, name of journal, type of future cost included in the paper and type of intervention evaluated in the economic analysis. Two health economists, trained in economic analysis methodology and critical appraisal, independently extracted the data. k statistics were calculated to assess interobserver agreement [14]. Any discrepancies during the independent data extraction process were resolved through discussion and consensus. Results
A total of 192 articles were found from the three journals fulfilling the inclusion criteria. Of those, 94 (49.0%) incorporated future related medical costs, 9 (4.2%) also included future unrelated medical costs and none of them included future Expert Rev. Pharmacoecon. Outcomes Res.
Review
nonmedical costs (TABLE 1). The interobserver agreement was measured using Cohen’s K; the K-value for reporting results was 0.96 or greater. The percentage of articles including future costs increased from 2008 (30.8%) to 2013 (70.8%), and no differences were detected between the three journals with regard to the proportion of economic evaluations incorporating future costs (FIGURE 2). Considering the intervention evaluated, economic evaluations of screening and preventive interventions were more likely to include future costs (related and unrelated) (FIGURE 3). Discussion, expert commentary & five-year view
The inclusion of future costs in life-years gained in economic evaluations of medicines and healthcare technologies has been controversial for many years. In fact, this cost category is normally not included in economic evaluations, as many guidelines for elaborating economic analysis of drugs or healthcare technologies either instruct analysts to exclude these costs or leave inclusion to the discretion of the analyst [5]. Although recent arguments in favor of incorporating such future costs appear to be gaining support [15,16], the debate is ongoing [17]. To our knowledge, there has not been any study that has assessed the percentage of economic evaluations published in scientific journals that include future costs in their design and conduct, so this work is the first to have reviewed the issue. We have found that less than 50% of published economic evaluations included future costs; most of them were future related
Table 1. Inclusion of future costs in published EEs in the journals analyzed. Year
Published EEs
EEs including related future costs (%)
EEs including unrelated future costs (%)
2008
26
30.8
3.8
2009
41
36.6
2.4
2010
40
50.0
7.5
2011
41
58.5
4.9
2012
20
50.0
0
2013
24
70.8
4.2
Total
192
49.0
4.2
EEs: Economic evaluations.
medical costs, whereas the inclusion of future unrelated medical costs was much lower. No article was found to include future nonmedical costs. In the literature, the inclusion of future related medical costs in economic evaluations has been fairly uncontroversial, because they are clearly related to the drug or healthcare program being evaluated. However, the inclusion in economic analyses of unrelated medical costs over additional life-years gained has long been controversial; this is also true for future nonmedical costs (survivor consumption costs) [18], whose inclusion in economic evaluations has been questioned even more.
35 30 EE not including FC EE including FC
25 20 15 10
2008
2009
2010
2011
2012
Eur J Health Econ
PharmacoEconomics
Value in health
Eur J Health Econ
PharmacoEconomics
Value in health
Eur J Health Econ
PharmacoEconomics
Value in health
Eur J Health Econ
PharmacoEconomics
Value in health
Eur J Health Econ
PharmacoEconomics
Value in health
Eur J Health Econ
0
PharmacoEconomics
5
Value in health
Expert Review of Pharmacoeconomics & Outcomes Research Downloaded from informahealthcare.com by Nanyang Technological University on 04/24/15 For personal use only.
Incorporation of future costs in health economic analysis publications
2013
Figure 2. Published economic evaluations from 2008 to 2013. EE: Economic evaluation; Eur J Health Econ: European Journal of Health Economics; FC: Future costs.
informahealthcare.com
doi: 10.1586/14737167.2015.1021689
Review
´ lvarez & A ´ ngel Casado Gros, Soto A
Drugs Patient global management
57.1%
42.9%
Preventive Expert Review of Pharmacoeconomics & Outcomes Research Downloaded from informahealthcare.com by Nanyang Technological University on 04/24/15 For personal use only.
48.1%
51.9%
60%
40.0%
Psychological therapy
100% 61.5%
38.5%
Screening Surgical/medical devices
47.8%
52.2% 0%
20%
40%
60%
80%
100%
EE not considering FC EE considering FC
Figure 3. Inclusion of future costs according to the intervention evaluated. EE: Economic evaluation; FC: Future costs.
We find it quite strange that the matter related to this study had not been assessed before, as the inclusion/exclusion of future costs in economic evaluations is not a trivial issue. The impact of including these costs may be substantial, as they can change the cost–effectiveness ratio of interventions that vary, depending on the age of patients treated and the effects of the intervention on the length and quality of life. Therefore, it seems timely that health economics analysts and the scientific community should assess the suitability of including or not including the future costs of additional life-years in economic evaluations, along with the reporting of these costs in the publications of these economic evaluations. It is likely that their inclusion will be facilitated through new research about improving methods to estimate future costs and the standardization of methodology in the coming years [19,20]. Some researchers have recommended a change in pharmacoEconomic guidelines that exist in countries worldwide so that they recommend the inclusion of all costs relevant to the perspective chosen (including future costs), whether these are
related or unrelated, direct or indirect. According to their opinion, it would also be advisable for research analysts to routinely include future costs in sensitivity analyses for all economic evaluations in which this kind of cost was not included in the base case analysis [21]. Some authors have recently pointed out that there may be ethical objections to excluding future costs (partially or completely) in economic analyses; this could generate a wider debate in the future about the inclusion or not of future costs in economic analyses [22]. Because in many cases it is difficult to separate related and unrelated future medical costs, a possible solution would be to ignore the distinction between related and unrelated costs in the context of life-prolonging interventions and to count all changes in medical costs as representing real opportunity costs within the healthcare sector. This study has some limitations, such as the small number of journals reviewed, the relatively small period analyzed and the fact that some economic evaluations are currently published in medical journals, not specialized in economic analysis, more than in health economics journals; this could lead to differences between them, an issue not fully addressed in this article. Editors and peer reviewers in biomedical and economic journals should also encourage the discussion of the authors on the inclusion of all future costs in economic analyses that are submitted for publication and the reasons for this decision. Results of economic evaluations can change dramatically depending on the inclusion of future costs [9–13]. It is probably the right time for the scientific community and health economics analysts to consider the advisability of including future costs in the base case of economic analyses. Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
Key issues .
There are three different types of future costs: future related medical costs, future unrelated medical costs and future nonmedical costs.
.
There is currently some controversy about the inclusion or not of future costs in economic evaluations.
.
While there is broad agreement on the inclusion of future related medical costs in economic analyses, there are discrepancies in the literature and guidelines about how to manage future unrelated medical costs and future nonmedical costs when performing economic evaluations.
.
A systematic review has been performed from 2008 to 2013 in three general health economics journals: PharmacoEconomics, Value in Health and the European Journal of Health Economics to know the extent of published economic analyses that incorporated future costs and the kind of future costs that were included.
.
It was found that 49% of all published economic evaluations incorporated related future medical costs, 4.2% also included future unrelated medical costs and none of them included future nonmedical costs.
.
All relevant costs for the perspective selected should probably be included in economic evaluations including related or unrelated, direct or indirect future costs.
doi: 10.1586/14737167.2015.1021689
Expert Rev. Pharmacoecon. Outcomes Res.
Incorporation of future costs in health economic analysis publications
References
Expert Review of Pharmacoeconomics & Outcomes Research Downloaded from informahealthcare.com by Nanyang Technological University on 04/24/15 For personal use only.
1.
2.
3.
4.
5.
6.
7.
Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost-effectiveness in health and medicine. New York: Oxford University Press; 1996 Brouwer WBF, Rutten FFH, Koopmanschap MA. Costing in economic evaluations. In: Drummond MF, McGuire A, eds. Economic evaluation in health care: merging theory with practice. New York: Oxford University Press; 2001 Meltzer D. Future costs in medical cost-effectiveness analysis. In: Jones AM, ed. The Elgar companion to health economics.2nd ed.; 2012. Available from: http://www.elgaronline.com [Last accessed on September 2014] Drummond MF, Sculpher MJ, Torrance GW, et al. Methods for the economic evaluation of healthcare programmes. 3rd ed. New York: Oxford University Press; 2005 Rappange DR, van Bacal PHM, van Evel JA, et al. Unrelated medical costs in life-years gained. Should they be included in economic evaluation of healthcare interventions? Pharmacoeconomics 2008;26: 815-30
8.
Nyman JA. More on survival consumption costs in cost-utility analysis. Health Econ 2006;15:319-22
16.
9.
Johannesson M, Meltzer D, O´Conor RM. Incorporating future costs in medical cost-effectiveness analysis: implications for the cost-effectiveness of the treatment of hypertension. Med Decis Making 1997;17: 382-9
van Baal PHM, Feenstra TL, Hoogenveen RT, et al. Unrelated medical care in life years gained and the cost utility of primary prevention: in search of a ‘perfect’ cost-utility ratio. Health Econ 2007;16:421-33
17.
10.
Manns B, Meltzer D, Taub K, Donaldson C. Illustrating the impact of including future costs in economic evaluations: an application to end-stage renal diseases care. Health Econ 2003;12: 949-58
Lee RH. Future costs in cost-effectiveness analysis. J Health Econ 2008;27:809-18
18.
Nyman JA. Measurement of QALYs and the welfare implications of survivor consumption and leisure forgone. Health Econ 2011;20:56-67
19.
van Baal PHM, Feenstra TL, Polder JJ, et al. Economic evaluation and the postponement of healthcare cost. Health Econ 2011;20:432-45
20.
van Baal PHM, Wong A, Slobbe LCJ, et al. Standardizing the inclusion of indirect medical costs in economic evaluations. Pharmacoeconomics 2011;29:175-87
21.
van Baal P, Meltzer D, Brouwer W. Pharmacoeconomic guidelines should prescribe inclusion of indirect medical costs! A response to Grima et al. Pharmacoeconomics 2013;31:369-73
22.
Gandjour A, Mu¨ller D. Ethical objections against including life-extension costs in cost-effectiveness analysis: a consistent approach. Appl Health Econ Health Policy 2014;12:471-6
11.
12.
13.
Grime DT, Bernard LM, Dunn ES, et al. Cost-effectiveness analysis of therapies for chronic kidney patients on dialysis: a case for excluding dialysis costs. Pharmacoeconomics 2012;30:981-9 Kruse M, Sorensen J, Gyrd-Hansen D. Future costs in cost-effectiveness analysis: an empirical assessment. Eur J Health Econ 2012;39:10-16 Meltzer D, Egleston B, Stoffel D, Dasbach E. Effect of future costs on cost-effectiveness of medical interventions among young adults: the example of intensive therapy for type 1 diabetes. Med Care 2000;38:679-85
Meltzer D. Accounting for future costs in medical cost-effectiveness analysis. J Health Econ 1997;16:33-64
14.
Liljas B, Karlsson GS, Stalhammer NO. On future non-medical costs in economic evaluations. Health Econ 2008;17:579-91
Viera AJ, Garrett JM. Understanding inter observer agreement: the kappa statistic. Fam Med 2005;37:360-3
15.
Gandjour A, Lauterbach KW. Does prevention save costs? Considering deferral
informahealthcare.com
Review
of the expensive last year of life. J Health Econ 2005;24:715-24
doi: 10.1586/14737167.2015.1021689
Review
Incorporation of future costs in health economic analysis publications: current situation and recommendations for the future Expert Rev. Pharmacoecon. Outcomes Res. Early online, 1–5 (2015)
Blanca Gros1, ´ lvarez*2 Javier Soto A and ´ ngel Casado3 Miguel A 1 Market Access Department, JanssenCilag, Madrid, Spain 2 Health Economics and Outcomes Research, Corporate Affair, Health and Value Unit, Pfizer, Avda de Europa 20-B, Parque Empresarial de laMoraleja, 28108 Alcobendas, Madrid, Spain 3 PharmacoEconomics and Outcomes Research Iberia, Madrid, Spain *Author for correspondence: Tel.: Tel.: +34 914 909 572 [email protected]
Future costs are not usually included in economic evaluations. The aim of this study was to assess the extent of published economic analyses that incorporate future costs. A systematic review was conducted of economic analyses published from 2008 to 2013 in three general health economics journals: PharmacoEconomics, Value in Health and the European Journal of Health Economics. A total of 192 articles met the inclusion criteria, 94 of them (49.0%) incorporated future related medical costs, 9 (4.2%) also included future unrelated medical costs and none of them included future nonmedical costs. The percentage of articles including future costs increased from 2008 (30.8%) to 2013 (70.8%), and no differences were detected between the three journals. All relevant costs for the perspective considered should be included in economic evaluations, including related or unrelated, direct or indirect future costs. It is also advisable that pharmacoEconomic guidelines are adapted in this sense. KEYWORDS: economic analysis
.
future costs
.
health economic analysis
Economic evaluations are normally used to inform policy makers and healthcare professionals about the costs and the health outcomes of a new therapeutic option compared to a reference that is on the market, in order to ascertain if the health benefits achieved outweigh the associated costs. Therefore, it is obviously crucial to determine which costs and health outcomes should be included in a health economic analysis. The most widely adopted perspective in the world of health economics is the societal one, which aims to account for all costs and health outcomes of a therapeutic intervention, regardless of whom they accrue to [1]. While there is a general consensus about the necessity of including health effects that occur in the lifeyears gained when performing an economic analysis, there is currently some controversy about how to handle the so-called future costs. These costs can be divided into three categories – future related medical costs: medical costs that happen because of the treatment of informahealthcare.com
10.1586/14737167.2015.1021689
.
publications
the target disease during the added years of life (e.g., when conducting a health economic evaluation of a new antihypertensive drug that prolongs life, future related medical costs would include all the antihypertensive medications, laboratory tests and other hypertensionrelated costs in the added years of life, such as a heart attack); future unrelated medical costs (also called indirect medical costs): medical costs that occur because of the treatment of other diseases during the added years of life, but which are not related to the original target disease (e.g., in the example of the new antihypertensive drug, a patient with well-controlled hypertension might develop rheumatoid arthritis, the treatment of which will generate costs, but is unrelated to the original disease); and future nonmedical costs (also called production and consumption costs): all the nonmedical costs that are incurred during the added years of life (i.e., consumption of nonmedical goods and services, net of the contribution taking place via production) [2].
2015 Informa UK Ltd
ISSN 1473-7167
1
Review
´ lvarez & A ´ ngel Casado Gros, Soto A
Expert Review of Pharmacoeconomics & Outcomes Research Downloaded from informahealthcare.com by Nanyang Technological University on 04/24/15 For personal use only.
Records identified through journal search n = 230
PharmacoEconomics n = 58 Value in health n = 129 Eur J Health Econ n = 43
Records screened n = 220
Full-text articles assessed for elegibility and references screened n = 205
Full-text articles excluded n = 13
Economic analyses included in final systematic review n = 192
PharmacoEconomics n = 48 Value in health n = 109 Eur J Health Econ n = 35
Figure 1. Flow chart of the literature research.
There have been continuous disagreements about the management of future costs in economic evaluations over years. While there has always been broad agreement on the inclusion of future related medical costs in economic analyses, there have been discrepancies in the literature about how to account for future unrelated medical costs and for future nonmedical costs during the additional years of life [3]. Therefore, whereas most authors have proposed to include only future related medical costs in economic evaluations [4], some have argued that future unrelated medical costs should also be included [5]. Others have even suggested that future nonmedical costs, which are the production and consumption of nonmedical resources during the added years of life, should also be incorporated into the economic analysis [6]. Nevertheless, there have been other authors who argue that neither future consumption nor future production should be included, as these components are not included when measuring quality-adjusted lifeyears [7,8]. However, it is well established that the inclusion or exclusion of future costs in economic evaluations may have important healthcare policy implications. It has been demonstrated that the incorporation of these types of costs might have a significant impact on the practical results of economic analyses [9–11]; if future costs are omitted, therapeutic options aimed at older age groups may be favored, whereas the inclusion of future costs could significantly improve the results of alternatives that decrease mortality among young adults [12,13]. The aim of this study was to describe the extent of published economic analyses that incorporate future costs and the types of future costs included. doi: 10.1586/14737167.2015.1021689
Material & methods Selection of papers for review
We performed a systematic review of economic analyses published in three general health economics journals: PharmacoEconomics, Value in Health and the European Journal of Health Economics; these journals were selected because they are quite representative of health economics journals, have published many economic evaluations annually and have a lot of prestige and relevance for health professionals and other decision-makers. The three journals were reviewed to identify economic evaluations from 2008 to 2013, regardless of whether these were performed alongside prospective designs (clinical trials or cohort studies) or through decision-analytic models as long as they met the inclusion criteria of the review. The search terms used were ‘economic analysis’, ‘health economic analysis’, ‘cost–effectiveness analysis’, ‘pharmacoEconomic analysis’ and ‘cost-utility analysis’. In order to be included in this study, the articles had to comply with the following criteria: a complete economic evaluation (comparing costs and health outcomes of two or more alternatives), time horizon longer than 1 year and evaluating drugs, medical devices, healthcare technologies and other kinds of public health programs. The following exclusion criteria were set: systematic reviews of economic analyses, opinion papers, economic analyses through either clinical trials or observational studies, comparative cost analyses and budget impact analyses. Once the possible articles to be included in the systematic review had been identified, titles and abstracts were screened against the inclusion criteria to identify potentially relevant papers. Once the valid references were selected from the corresponding abstracts, the original articles were analyzed and those meeting the inclusion criteria were finally included. A flow chart showing the study selection process is shown in FIGURE 1. Data extraction
All studies were manually searched, and data were extracted from each paper using a data extraction form, which was developed to retrieve and organize information from each paper based on main topics. The data extraction items included the following descriptive information: year of publication, name of journal, type of future cost included in the paper and type of intervention evaluated in the economic analysis. Two health economists, trained in economic analysis methodology and critical appraisal, independently extracted the data. k statistics were calculated to assess interobserver agreement [14]. Any discrepancies during the independent data extraction process were resolved through discussion and consensus. Results
A total of 192 articles were found from the three journals fulfilling the inclusion criteria. Of those, 94 (49.0%) incorporated future related medical costs, 9 (4.2%) also included future unrelated medical costs and none of them included future Expert Rev. Pharmacoecon. Outcomes Res.
Review
nonmedical costs (TABLE 1). The interobserver agreement was measured using Cohen’s K; the K-value for reporting results was 0.96 or greater. The percentage of articles including future costs increased from 2008 (30.8%) to 2013 (70.8%), and no differences were detected between the three journals with regard to the proportion of economic evaluations incorporating future costs (FIGURE 2). Considering the intervention evaluated, economic evaluations of screening and preventive interventions were more likely to include future costs (related and unrelated) (FIGURE 3). Discussion, expert commentary & five-year view
The inclusion of future costs in life-years gained in economic evaluations of medicines and healthcare technologies has been controversial for many years. In fact, this cost category is normally not included in economic evaluations, as many guidelines for elaborating economic analysis of drugs or healthcare technologies either instruct analysts to exclude these costs or leave inclusion to the discretion of the analyst [5]. Although recent arguments in favor of incorporating such future costs appear to be gaining support [15,16], the debate is ongoing [17]. To our knowledge, there has not been any study that has assessed the percentage of economic evaluations published in scientific journals that include future costs in their design and conduct, so this work is the first to have reviewed the issue. We have found that less than 50% of published economic evaluations included future costs; most of them were future related
Table 1. Inclusion of future costs in published EEs in the journals analyzed. Year
Published EEs
EEs including related future costs (%)
EEs including unrelated future costs (%)
2008
26
30.8
3.8
2009
41
36.6
2.4
2010
40
50.0
7.5
2011
41
58.5
4.9
2012
20
50.0
0
2013
24
70.8
4.2
Total
192
49.0
4.2
EEs: Economic evaluations.
medical costs, whereas the inclusion of future unrelated medical costs was much lower. No article was found to include future nonmedical costs. In the literature, the inclusion of future related medical costs in economic evaluations has been fairly uncontroversial, because they are clearly related to the drug or healthcare program being evaluated. However, the inclusion in economic analyses of unrelated medical costs over additional life-years gained has long been controversial; this is also true for future nonmedical costs (survivor consumption costs) [18], whose inclusion in economic evaluations has been questioned even more.
35 30 EE not including FC EE including FC
25 20 15 10
2008
2009
2010
2011
2012
Eur J Health Econ
PharmacoEconomics
Value in health
Eur J Health Econ
PharmacoEconomics
Value in health
Eur J Health Econ
PharmacoEconomics
Value in health
Eur J Health Econ
PharmacoEconomics
Value in health
Eur J Health Econ
PharmacoEconomics
Value in health
Eur J Health Econ
0
PharmacoEconomics
5
Value in health
Expert Review of Pharmacoeconomics & Outcomes Research Downloaded from informahealthcare.com by Nanyang Technological University on 04/24/15 For personal use only.
Incorporation of future costs in health economic analysis publications
2013
Figure 2. Published economic evaluations from 2008 to 2013. EE: Economic evaluation; Eur J Health Econ: European Journal of Health Economics; FC: Future costs.
informahealthcare.com
doi: 10.1586/14737167.2015.1021689
Review
´ lvarez & A ´ ngel Casado Gros, Soto A
Drugs Patient global management
57.1%
42.9%
Preventive Expert Review of Pharmacoeconomics & Outcomes Research Downloaded from informahealthcare.com by Nanyang Technological University on 04/24/15 For personal use only.
48.1%
51.9%
60%
40.0%
Psychological therapy
100% 61.5%
38.5%
Screening Surgical/medical devices
47.8%
52.2% 0%
20%
40%
60%
80%
100%
EE not considering FC EE considering FC
Figure 3. Inclusion of future costs according to the intervention evaluated. EE: Economic evaluation; FC: Future costs.
We find it quite strange that the matter related to this study had not been assessed before, as the inclusion/exclusion of future costs in economic evaluations is not a trivial issue. The impact of including these costs may be substantial, as they can change the cost–effectiveness ratio of interventions that vary, depending on the age of patients treated and the effects of the intervention on the length and quality of life. Therefore, it seems timely that health economics analysts and the scientific community should assess the suitability of including or not including the future costs of additional life-years in economic evaluations, along with the reporting of these costs in the publications of these economic evaluations. It is likely that their inclusion will be facilitated through new research about improving methods to estimate future costs and the standardization of methodology in the coming years [19,20]. Some researchers have recommended a change in pharmacoEconomic guidelines that exist in countries worldwide so that they recommend the inclusion of all costs relevant to the perspective chosen (including future costs), whether these are
related or unrelated, direct or indirect. According to their opinion, it would also be advisable for research analysts to routinely include future costs in sensitivity analyses for all economic evaluations in which this kind of cost was not included in the base case analysis [21]. Some authors have recently pointed out that there may be ethical objections to excluding future costs (partially or completely) in economic analyses; this could generate a wider debate in the future about the inclusion or not of future costs in economic analyses [22]. Because in many cases it is difficult to separate related and unrelated future medical costs, a possible solution would be to ignore the distinction between related and unrelated costs in the context of life-prolonging interventions and to count all changes in medical costs as representing real opportunity costs within the healthcare sector. This study has some limitations, such as the small number of journals reviewed, the relatively small period analyzed and the fact that some economic evaluations are currently published in medical journals, not specialized in economic analysis, more than in health economics journals; this could lead to differences between them, an issue not fully addressed in this article. Editors and peer reviewers in biomedical and economic journals should also encourage the discussion of the authors on the inclusion of all future costs in economic analyses that are submitted for publication and the reasons for this decision. Results of economic evaluations can change dramatically depending on the inclusion of future costs [9–13]. It is probably the right time for the scientific community and health economics analysts to consider the advisability of including future costs in the base case of economic analyses. Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
Key issues .
There are three different types of future costs: future related medical costs, future unrelated medical costs and future nonmedical costs.
.
There is currently some controversy about the inclusion or not of future costs in economic evaluations.
.
While there is broad agreement on the inclusion of future related medical costs in economic analyses, there are discrepancies in the literature and guidelines about how to manage future unrelated medical costs and future nonmedical costs when performing economic evaluations.
.
A systematic review has been performed from 2008 to 2013 in three general health economics journals: PharmacoEconomics, Value in Health and the European Journal of Health Economics to know the extent of published economic analyses that incorporated future costs and the kind of future costs that were included.
.
It was found that 49% of all published economic evaluations incorporated related future medical costs, 4.2% also included future unrelated medical costs and none of them included future nonmedical costs.
.
All relevant costs for the perspective selected should probably be included in economic evaluations including related or unrelated, direct or indirect future costs.
doi: 10.1586/14737167.2015.1021689
Expert Rev. Pharmacoecon. Outcomes Res.
Incorporation of future costs in health economic analysis publications
References
Expert Review of Pharmacoeconomics & Outcomes Research Downloaded from informahealthcare.com by Nanyang Technological University on 04/24/15 For personal use only.
1.
2.
3.
4.
5.
6.
7.
Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost-effectiveness in health and medicine. New York: Oxford University Press; 1996 Brouwer WBF, Rutten FFH, Koopmanschap MA. Costing in economic evaluations. In: Drummond MF, McGuire A, eds. Economic evaluation in health care: merging theory with practice. New York: Oxford University Press; 2001 Meltzer D. Future costs in medical cost-effectiveness analysis. In: Jones AM, ed. The Elgar companion to health economics.2nd ed.; 2012. Available from: http://www.elgaronline.com [Last accessed on September 2014] Drummond MF, Sculpher MJ, Torrance GW, et al. Methods for the economic evaluation of healthcare programmes. 3rd ed. New York: Oxford University Press; 2005 Rappange DR, van Bacal PHM, van Evel JA, et al. Unrelated medical costs in life-years gained. Should they be included in economic evaluation of healthcare interventions? Pharmacoeconomics 2008;26: 815-30
8.
Nyman JA. More on survival consumption costs in cost-utility analysis. Health Econ 2006;15:319-22
16.
9.
Johannesson M, Meltzer D, O´Conor RM. Incorporating future costs in medical cost-effectiveness analysis: implications for the cost-effectiveness of the treatment of hypertension. Med Decis Making 1997;17: 382-9
van Baal PHM, Feenstra TL, Hoogenveen RT, et al. Unrelated medical care in life years gained and the cost utility of primary prevention: in search of a ‘perfect’ cost-utility ratio. Health Econ 2007;16:421-33
17.
10.
Manns B, Meltzer D, Taub K, Donaldson C. Illustrating the impact of including future costs in economic evaluations: an application to end-stage renal diseases care. Health Econ 2003;12: 949-58
Lee RH. Future costs in cost-effectiveness analysis. J Health Econ 2008;27:809-18
18.
Nyman JA. Measurement of QALYs and the welfare implications of survivor consumption and leisure forgone. Health Econ 2011;20:56-67
19.
van Baal PHM, Feenstra TL, Polder JJ, et al. Economic evaluation and the postponement of healthcare cost. Health Econ 2011;20:432-45
20.
van Baal PHM, Wong A, Slobbe LCJ, et al. Standardizing the inclusion of indirect medical costs in economic evaluations. Pharmacoeconomics 2011;29:175-87
21.
van Baal P, Meltzer D, Brouwer W. Pharmacoeconomic guidelines should prescribe inclusion of indirect medical costs! A response to Grima et al. Pharmacoeconomics 2013;31:369-73
22.
Gandjour A, Mu¨ller D. Ethical objections against including life-extension costs in cost-effectiveness analysis: a consistent approach. Appl Health Econ Health Policy 2014;12:471-6
11.
12.
13.
Grime DT, Bernard LM, Dunn ES, et al. Cost-effectiveness analysis of therapies for chronic kidney patients on dialysis: a case for excluding dialysis costs. Pharmacoeconomics 2012;30:981-9 Kruse M, Sorensen J, Gyrd-Hansen D. Future costs in cost-effectiveness analysis: an empirical assessment. Eur J Health Econ 2012;39:10-16 Meltzer D, Egleston B, Stoffel D, Dasbach E. Effect of future costs on cost-effectiveness of medical interventions among young adults: the example of intensive therapy for type 1 diabetes. Med Care 2000;38:679-85
Meltzer D. Accounting for future costs in medical cost-effectiveness analysis. J Health Econ 1997;16:33-64
14.
Liljas B, Karlsson GS, Stalhammer NO. On future non-medical costs in economic evaluations. Health Econ 2008;17:579-91
Viera AJ, Garrett JM. Understanding inter observer agreement: the kappa statistic. Fam Med 2005;37:360-3
15.
Gandjour A, Lauterbach KW. Does prevention save costs? Considering deferral
informahealthcare.com
Review
of the expensive last year of life. J Health Econ 2005;24:715-24
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