HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Modelling the Cost-Eectiveness of HPV Vaccination: Evidence from High-Income Countries and Considerations for Low- and Middle-Income Countries
Luke B. Connelly
The University of Queensland ACERH; CONROD; and School of Economics
The First Conference on HPV Vaccination in the Asia-Paci c and Middle-East Regions Seoul, 1-2 June 2009
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Outline 1
HPV Vaccine Eectiveness and Cost-Eectiveness High-Income Countries Low- and Middle-Income Countries
2
Economic Issues Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries Endogenous Prices
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
Review
Source: Marra et al. (2009, Figure 1, p.131)
Selected Evidence
(Note: curriences, years, not directly comparable)
Source: Kim et al. (2008, Table 3, p.K82)
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
High-Income Countries Low- and Middle-Income Countries
Some Observations
When similar vaccination strategies are considered and similar
assumptions about duration of protection are made, in countries with comparable screening programs and ASR, the cost per QALY is subject to fairly small variance. Most studies on high-income countries conclude that adding HPV vaccination for girls, pre sexual debut, is cost-eective.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
High-Income Countries Low- and Middle-Income Countries
Some Observations
When similar vaccination strategies are considered and similar
assumptions about duration of protection are made, in countries with comparable screening programs and ASR, the cost per QALY is subject to fairly small variance. Most studies on high-income countries conclude that adding HPV vaccination for girls, pre sexual debut, is cost-eective.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
High-Income Countries Low- and Middle-Income Countries
Some Observations
Some studies suggest that catch-up programs may be cost-eective. Results from studies that consider the incremental cost-eectiveness (some report only average cost eectiveness) of vaccinating boys, produce high cost-per-QALY estimates concluding that vaccinating boys is probably not cost-eective, at current prices (and given current state of evidence of e cacy).
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
High-Income Countries Low- and Middle-Income Countries
Some Observations
Some studies suggest that catch-up programs may be cost-eective. Results from studies that consider the incremental cost-eectiveness (some report only average cost eectiveness) of vaccinating boys, produce high cost-per-QALY estimates concluding that vaccinating boys is probably not cost-eective, at current prices (and given current state of evidence of e cacy).
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
High-Income Countries Low- and Middle-Income Countries
Work on GAVI-Eligible Countries Preliminary work has been done by Goldie et al. (2008) using a static, Excel-based model, for 72 GAVI-eligible countries model does not include many of the features of more advanced models
the authors present the work cautiously, as exploratory and the ndings as preliminary an important constraint on their work is that data required for more complex modelling are not available for many of the countries considered screening is not considered work.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
Results for GAVI-Eligible Countries
Goldie et al. (2008, Figure 2, p.4083)
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
High-Income Countries Low- and Middle-Income Countries
Work on GAVI-Eligible Countries
Garland et al. (2008) 22 GAVI-eligible countries, Asia-Oceania estimates of cost-eectiveness: with three dose+delivery cost assumptions illustration of total costs of vaccinating 70% of 5 consecutive birth cohorts: India and China
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
GAVI-Eligible Countries, Asia Oceania: Vaccine Prices and Cost-Eectiveness
Garland et al. (2008, Figure 3 (Top Panel), p.M96)
GAVI-Eligible Countries, Asia Oceania: Vaccine Prices and Total Costs
Garland et al. (2008, Figure 3 (Bottom Panel), p.M96)
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
High-Income Countries Low- and Middle-Income Countries
Thailand Tangcharoensathien et al. (2008) thorough study of prevention strategies in Thailand collected QALY data locally (VAS and EQ-5D) and estimated ICERs for adding vaccination of 15-year old girls to current screening program
PPP$ -6,012 per LYS at 0% RoD PPP$ 24,343 per LYS at 3% RoD PPP$ 85,024 per LYS at 5% RoD Thai per capita GDP is PPP$ 8,138
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
High-Income Countries Low- and Middle-Income Countries
Thailand
Starting point for Tangcharoensathien et al. (2008) is that the assumption of a cost of US$5 per dose of the HPV vaccine are not credible. Propose a screening strategy of 5-yearly screening with VIA @ 30-45 years and pap smears @ 50-60 years;
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
High-Income Countries Low- and Middle-Income Countries
Thailand
Starting point for Tangcharoensathien et al. (2008) is that the assumption of a cost of US$5 per dose of the HPV vaccine are not credible. Propose a screening strategy of 5-yearly screening with VIA @ 30-45 years and pap smears @ 50-60 years;
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
High-Income Countries Low- and Middle-Income Countries
Thailand
But, note existence of substantial barriers including a lack of well-trained nurses to undertake those tasks. These appear to be long-standing and substantial problems is true cost of overcoming these greater than has been assumed for the screening alternatives? proportion of women never screened = approx 36%-46% according to the National Health Examination Survey (Tangcharoensathien et al. 2008).
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
High-Income Countries Low- and Middle-Income Countries
Thailand
But, note existence of substantial barriers including a lack of well-trained nurses to undertake those tasks. These appear to be long-standing and substantial problems is true cost of overcoming these greater than has been assumed for the screening alternatives? proportion of women never screened = approx 36%-46% according to the National Health Examination Survey (Tangcharoensathien et al. 2008).
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Vaccination and Screening: Complements or Substitutes? On this question, the position of most agencies and authors is unambiguous: current vaccines do not prevent the full range of oncogenic HPVs unvaccinated women, including older women, have already been exposed (etc.) Screening is still necessary
screening and vaccination are complements. So, are screening and vaccination (n)ever substitutes?
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Vaccination and Screening: Complements or Substitutes? On this question, the position of most agencies and authors is unambiguous: current vaccines do not prevent the full range of oncogenic HPVs unvaccinated women, including older women, have already been exposed (etc.) Screening is still necessary
screening and vaccination are complements. So, are screening and vaccination (n)ever substitutes?
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
Vaccination and Screening as (Imperfect) Substitutes: HR-HPV (all types) Näive Cohort Stylised Representation of Substitution and Relative Prices I
Screening Coverage
A S*
60% Reduction in Lifetime Risk of Cervical Cancer
50% Reduction in Lifetime Risk of Cervical Cancer
V* Vaccination Coverage
Vaccination and Screening: HR-HPV (all types) Näive Cohort Stylised Representation of Substitution and Relative Prices II: Vaccine Price Fall
Screening Intensity
A S*
B
S1*
60% Reduction in Lifetime Risk of Cervical Cancer
50% Reduction in Lifetime Risk of Cervical Cancer
V*
V1* Vaccination Intensity
Vaccination and Screening: HR-HPV (all types) Näive Cohort
Stylised Representation of Substitution and Relative Prices III: Economic Growth
Screening Intensity
A
S*
C
S2* B
S1*
65% Reduction in Lifetime Risk of Cervical Cancer
V*
V1*
V2* Vaccination Intensity
Vaccination and Screening: HR-HPV (all types) Exposed Cohort
Screening Coverage
S*
50% Reduction in Lifetime Risk of Cervical Cancer
40% Reduction in Lifetime Risk of Cervical Cancer
Vaccination Coverage
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Scope and Accuracy?
The existing CE literature measures most of the bene ts of vaccination as physical units, i.e. QALYs or DALYs. Two relevant questions Are all
sources
of expected bene t captured?
Are included measures
accurate?
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Scope and Accuracy?
The existing CE literature measures most of the bene ts of vaccination as physical units, i.e. QALYs or DALYs. Two relevant questions Are all
sources
of expected bene t captured?
Are included measures
accurate?
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Accuracy?
Many models, and most EEs do not capture disease transmission dynamics; In such studies, the (usually) bene cial eects of herd immunity are therefore not captured bene ts are likely to be underestimated, cost-eectiveness ratios will be in ated (i.e., cost per QALY will be higher than the true cost per QALY).
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Accuracy?
Many models, and most EEs do not capture disease transmission dynamics; In such studies, the (usually) bene cial eects of herd immunity are therefore not captured bene ts are likely to be underestimated, cost-eectiveness ratios will be in ated (i.e., cost per QALY will be higher than the true cost per QALY).
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Transmission Dynamics in HPV (Australia)
e.g., results from our Australian study (Kulasingam et al. 2006), vaccinating girls @ 12 years: AU$18,735 per QALY without positive externality eects (assumes lifetime immunity) AU$13,316 per QALY with positive externality eects (assumes lifetime immunity)
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
Positive Externalities in HPV Vaccination (Stylised Representation)
Private Marginal Cost (PMC)
Marginal Cost or Benefit
=Social Marginal Cost (SMC)
Marginal Private Benefit (MPB)
($)
A
Marginal Social Benefi Marginal Social Benefit (MSB)
B F
Marginal External = Benefit (MEB)
C E
(External Benefits of Vaccination)
D P*
V*
Vaccine Coverage (% Population)
Dynamic and Static Speci cations in Practice (Varicella Example)
Source: Brisson and Edmunds (2006)
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Negative Externalities (VZV)?
Brisson and Edmunds (2006) analyse the varicella-zoster virus (VZV) varicella (chickenpox) results from primary infection with VZV after infection, virus establishes latent infection in nerve cells that can reactivate later in life to cause zoster (shingles)
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Negative Externalities (VZV)? Public health concerns about vaccination: through herd immunity, vaccination could lead to an upwards shift in the average age at infection
this could give rise to higher overall morbidity due to varicella (even though incidence declines) suggestion that exposure to varicella reduces risk of reactivation (zoster), by boosting speci c immunity to the virus
reducing varicella cases (and thus exposure) via mass vaccination could increase the incidence of zoster in unvaccinated individuals.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Negative Externalities (HPV)?
The Brisson and Edmunds (2006) result depends upon complications increasing with age of infection ...which is not the case in HPV infection (Newall et al. 2007) ...herd protection only seems to improve the cost-eectiveness of HPV infection (Ferko et al. 2008)
Any evidence of (e.g.) higher probability of HR-HPV progression to CC in older women could complicate this story.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Negative Externalities (HPV)?
The Brisson and Edmunds (2006) result depends upon complications increasing with age of infection ...which is not the case in HPV infection (Newall et al. 2007) ...herd protection only seems to improve the cost-eectiveness of HPV infection (Ferko et al. 2008)
Any evidence of (e.g.) higher probability of HR-HPV progression to CC in older women could complicate this story.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Missing Bene ts? Existing models miss a source of bene t that could be important (depending upon the discount rate): the costs of leaving children without mothers. Goldie et al. (2008) estimate that HPV16/18 vaccination in 72 GAVI-eligible countries, plus China, Thailand, Latin America, Caribbean would prevent 4 million future deaths of women from CC prevent the loss of a mother to CC for approximately 10 million children
between 1.5 million and 2.9 million of whom would be under age 18. Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Missing Bene ts? Existing models miss a source of bene t that could be important (depending upon the discount rate): the costs of leaving children without mothers. Goldie et al. (2008) estimate that HPV16/18 vaccination in 72 GAVI-eligible countries, plus China, Thailand, Latin America, Caribbean would prevent 4 million future deaths of women from CC prevent the loss of a mother to CC for approximately 10 million children
between 1.5 million and 2.9 million of whom would be under age 18. Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
QALY Weights The QALY weights that are used tend to come from fairly small studies of asymptomatic women. Myers et al. (2004): US data based on TTO and VAS from 150 volunteers;
Duration data from treatment experience in US (Insinga et al. (2007) (cf Kulasingam et al. 2007)). Thai study (Tangcharoensathien et al. 2008) generated original QALY weights (but used UK population weights for EQ-5D). The DALY weights are derived from expert panels, not the general public.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
QALY Weights The QALY weights that are used tend to come from fairly small studies of asymptomatic women. Myers et al. (2004): US data based on TTO and VAS from 150 volunteers;
Duration data from treatment experience in US (Insinga et al. (2007) (cf Kulasingam et al. 2007)). Thai study (Tangcharoensathien et al. 2008) generated original QALY weights (but used UK population weights for EQ-5D). The DALY weights are derived from expert panels, not the general public.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
QALY Weights The QALY weights that are used tend to come from fairly small studies of asymptomatic women. Myers et al. (2004): US data based on TTO and VAS from 150 volunteers;
Duration data from treatment experience in US (Insinga et al. (2007) (cf Kulasingam et al. 2007)). Thai study (Tangcharoensathien et al. 2008) generated original QALY weights (but used UK population weights for EQ-5D). The DALY weights are derived from expert panels, not the general public.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
QALY Weights The QALY weights that are used tend to come from fairly small studies of asymptomatic women. Myers et al. (2004): US data based on TTO and VAS from 150 volunteers;
Duration data from treatment experience in US (Insinga et al. (2007) (cf Kulasingam et al. 2007)). Thai study (Tangcharoensathien et al. 2008) generated original QALY weights (but used UK population weights for EQ-5D). The DALY weights are derived from expert panels, not the general public.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Cost-Eectiveness Thresholds Cost-Eectiveness Analysis (including Cost-Utility Analysis) is a comparative technique: it can be used to compare programs that have outcomes expressed in common units (e.g., QALYs) it cannot be used, without further assumption, to determine if a program/investment is worthwhile
that is the domain of cost-bene t analysis (CBA), where the costs and bene ts are both expressed in monetary units and are directly comparable. An incremental cost-eectiveness ratio (ICER) does not have a
natural threshold value. Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Cost-Eectiveness Thresholds Cost-Eectiveness Analysis (including Cost-Utility Analysis) is a comparative technique: it can be used to compare programs that have outcomes expressed in common units (e.g., QALYs) it cannot be used, without further assumption, to determine if a program/investment is worthwhile
that is the domain of cost-bene t analysis (CBA), where the costs and bene ts are both expressed in monetary units and are directly comparable. An incremental cost-eectiveness ratio (ICER) does not have a
natural threshold value. Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Appendix: Cost-Eectiveness Thresholds
A threshold is, itself, derived from information about (i) the resources available, and (ii) the opportunities available (in the health and other sectors).
What does an ICER threshold of $5,000/QALY mean? Programs with ICERs≤$5,000 should be funded. Programs with ICERs>$5,000 should be funded.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Appendix: Cost-Eectiveness Thresholds
e.g., Commission on Macroeconomics and Health (2001) thresholds. The acceptance of such thresholds, de facto implies that the necessary resources
are available
to fund all programs that
meet the ICER criterion; AND that funding such programs will produce greater social bene t than any other investment opportunities available (e.g., in education, law and order) to the country concerned.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Appendix: Cost-Eectiveness Thresholds
e.g., Commission on Macroeconomics and Health (2001) thresholds. The acceptance of such thresholds, de facto implies that the necessary resources
are available
to fund all programs that
meet the ICER criterion; AND that funding such programs will produce greater social bene t than any other investment opportunities available (e.g., in education, law and order) to the country concerned.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Price is Endogenous
Tell me the threshold I'll tell you the price
Company
X has a vaccine that is on the market that, in Country
Y, with 10,000 courses, will produce 1,000 QALYs.
The The
ICER threshold for Country Y is $5,000. (maximum) achievable price for the vaccine is thus $500 per
course (=[1,000x$5,000)/10,000]).
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Why Discount? In economic evaluations, cost and bene t ows are discounted to present values Costs and bene ts are discounted by applying (multiplying by) the following (discount factor) formula:
1 (1+r )t where r is the rate of time preference and t is the number of years from the present year (Year 0).
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Why Discount? In economic evaluations, cost and bene t ows are discounted to present values Costs and bene ts are discounted by applying (multiplying by) the following (discount factor) formula:
1 (1+r )t where r is the rate of time preference and t is the number of years from the present year (Year 0).
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Vaccination and Screening: Complements or Substitutes? Measuring Bene ts Externalities Bene t Measurement in Low- and Middle-Income Countries ICER Thresholds Endogenous Prices Discounting
Why Discount? In economic evaluations, cost and bene t ows are discounted to present values Costs and bene ts are discounted by applying (multiplying by) the following (discount factor) formula:
1 (1+r )t where r is the rate of time preference and t is the number of years from the present year (Year 0).
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
IIlustration by Rate and Time Discount
Discount
Discount
PV of
PV of
rate (r)
factor
factor
100,000
100,000
(1+r )20
(1+r )30
1
1
lives,
lives
saved at
saved at
t
=20
t
=30
0.01
0.8195
0.7419
81,954
74,192
0.03
0.5537
0.4120
55,368
41,199
0.05
0.3769
0.2314
37,689
23,138
0.07
0.2584
0.1314
25,842
13,137
0.09
0.1784
0.0754
17,843
7,537
0.12
0.1037
0.0334
10,367
3,338
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Substitutes, Complements & Constrained Optimisation
Vaccination and screening are complements, but they are also (imperfect) substitutes in production. denying this simply adds a further constraint to decision-making.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Measurement Error Bene ts measurement in existing models is typically incomplete incomplete capture of all sources of bene ts noisy measurement of some of those bene ts which are captured
non-existence of QALY weights for most low- and middle-income countries is a problem, as is the non-existence of population weights for pre-scored instruments. Admittedly, high discount factors (for positive rs) may render these points somewhat moot.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Measurement Error Bene ts measurement in existing models is typically incomplete incomplete capture of all sources of bene ts noisy measurement of some of those bene ts which are captured
non-existence of QALY weights for most low- and middle-income countries is a problem, as is the non-existence of population weights for pre-scored instruments. Admittedly, high discount factors (for positive rs) may render these points somewhat moot.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
ICER Thresholds and Average CERs
The ICER threshold is an abused concept: treat such thresholds with scepticism. Prices are endogenous with respect to ICER thresholds. Beware average CERs, in which analysts seek to bundle extensions (e.g., catch-up programs, vaccinating boys) with basic vaccination strategies insist on
incremental
CERs for each add-on program.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
ICER Thresholds and Average CERs
The ICER threshold is an abused concept: treat such thresholds with scepticism. Prices are endogenous with respect to ICER thresholds. Beware average CERs, in which analysts seek to bundle extensions (e.g., catch-up programs, vaccinating boys) with basic vaccination strategies insist on
incremental
CERs for each add-on program.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
ICER Thresholds and Average CERs
The ICER threshold is an abused concept: treat such thresholds with scepticism. Prices are endogenous with respect to ICER thresholds. Beware average CERs, in which analysts seek to bundle extensions (e.g., catch-up programs, vaccinating boys) with basic vaccination strategies insist on
incremental
CERs for each add-on program.
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
HPV Vaccine Eectiveness and Cost-Eectiveness Economic Issues Concluding Remarks
Slides will be available at www.acerh.edu.au
Luke B. Connelly
Modelling the Cost-Eectiveness of HPV Vaccination
References Brisson, M. & Edmunds, W. J. (2006) Impact of Model, Methodological, and Parameter Uncertainty in the Economic Analysis of Vaccination Programs. Medical Decision Making, 26, 434-446. Commission on Macroeconomics and Health (2001) Macroeconomics and . World Health Organization: Geneva. Health: Investing in Health for Economic Development
Ferko, N.; Postma, M.; Gallivan, S.; Kruzikas, D. & Drummond, M. (2008) Evolution of the Health Economics of Cervical Cancer Vaccination. Vaccine, 26 Suppl 5, F3-15. Garland, S. M.; Cuzick, J.; Domingo, E. J.; Goldie, S. J.; Kim, Y.-T.; Konno, R.; Parkin, D. M.; Qiao, Y.-L.; Sankaranarayanan, R.; Stern, P. L.; Tay, S. K. & Bosch, F. X. (2008) Recommendations for Cervical Cancer Prevention in Asia Paci c.Vaccine, 26 Suppl 12, M89-M98.
References Goldie, S. J., O'Shea, M.; Campos, N. G.; Diaz, M.; Sweet, S. & Kim, S.-Y. (2008a) Health and Economic Outcomes of HPV 16,18 Vaccination in 72 GAVI-Eligible Countries. Vaccine, 26, 4080-4093. Insinga, R.P., Glass, A.G., Myers, E.R. and Rush, B.B. (2007) Abnormal Outcomes Following Cervical Cancer Screening: Event Duration and Health Utility Loss, Medical Decision Making, 27, 414-422. Insinga, R. P.; Dasbach, E. J.; Allen, S. E.; Carides, G. W. & Myers, E. R. (2008) Reductions in Human Papillomavirus-Disease Resource Use and Costs with Quadrivalent Human Papillomavirus (Types 6, 11, 16, and 18) Recombinant Vaccination: The FUTURE Study Economic Evaluation. Value in Health, 11, 1022-1032. Kim, J. J.; Brisson, M.; Edmunds, W. J. & Goldie, S. J. (2008) Modeling Cervical Cancer Prevention in Developed Countries. Vaccine, 26 Suppl 10, K76-K86.
References Kulasingam, S.; Connelly, L.; Conway, E.; Hocking, J. S.; Myers, E.; Regan, D. G.; Roder, D.; Ross, J. & Wain, G. (2007) A Cost-Eectiveness Analysis of Adding a Human Papillomavirus Vaccine to the Australian National Cervical Cancer Screening Program. Sexual Health, 4, 165-175. Marra, F.; Cloutier, K.; Oteng, B.; Marra, C. & Ogilvie, G. (2009) Eectiveness and Cost-Eectiveness of Human Papillomavirus Vaccine: A Systematic Review. Pharmacoeconomics, 27, 127-147. Newall, A. T.; Beutels, P.; Wood, J. G.; Edmunds, W. J. & MacIntyre, C. R. (2007) Cost-Eectiveness Analyses of Human Papillomavirus Vaccination. The Lancet Infectious Diseases, 2007, 7, 289-296. Tangcharoensathien, V.; Chaugwon, R.; Praditthikorn, N.; Tantivess, S. & Teerawattananon, Y. (2008) Research for Development of an Optimal Policy Strategy for Prevention and Control of Cervical Cancer in Thailand: A Report to the World Bank (Population and Reproductive Health Capacity Building Program), Thailand Ministry of Public Health, Nonthaburi.