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Farmakoekonomi s1
Farmakoekonomi s1
Pharmacoeconomics
Health
Economics
Health
Economic
Evaluation
Health economics:
Health care financing system, Optimization of health care system,
Understanding demand and supply of health care, etc.
3
Health economics are used to support many
health care decisions
1 compound approved
Phase III: Confirms effectiveness and monitors
adverse reactions from long-term use in 1,000 to
5,000 patient volunteers.
Phase II: Assesses effectiveness and looks for
side effects in 100 to 500 patient volunteers.
Phase I: Evaluates safety and dosage in 20 to
100 healthy human volunteers. 5 compounds enter
clinical trials
5,000 compounds Discovery and pre clinical testing:
evaluated Compounds are identified and evaluated
in laboratory and animal studies for safety,
biological activity, and formulation.
0 2 4 6 8 10 12 14 Years 16
Efektivitas divaluasi
Manfaat biaya Money dalam unit moneter
Rasio manfaat biaya
Steps on economic evaluation studies
• Identification
– Mortality, quality of life, etc.
– Cost vs benefit
– Productivity changes
• Measurement
– In natural physical units (e.g., number of lives saved)
– Intermediate vs final outcomes
• Valuation
– Utility (for CUA)
– Money (for CBA)
Measurement
• Effectiveness or efficacy?
– Efficacy = measure of effect under ideal conditions
– Effectiveness/efficiency = effect under real life conditions
– Efficacy does not imply effectiveness
• Natural physical units
– Number of lives/life years
– Change in blood pressure
– Change in cholesterol levels
• Intermediate or final outcomes
– Intermediate outcomes reflect change in clinical indicators
– Final outcomes reflect change in health status
Intermediate vs final outcomes
Condition being Final outcome Surrogate Outcome Indicators
treated indicator
Coronary thrombosis Quality-adjusted Number surviving Number with specified Number achieving coronary
(thrombolysis survival level of left ventricular re-perfusion
function
Stable angina Quality-adjusted Number with Number who can walk Number with adequate
(various interventions) survival acceptable a specified distance relief of pain
quality of life
Asthma Quality-adjusted Number surviving Number with adequate Number achieving a target
(various drugs) survival control of bronchial level of airways functions
hyperreactivity
Depression Quality-adjusted Number avoiding Quality of life (may be Number achieving a target
(various drugs) survival suicide improved by drugs) Hamilton or Montgomery-
Asberg Depression Rating
Scale
Hypertension Quality-adjusted Number avoiding Quality of life (may be Number achieving a target
(various drugs) survival a stroke worsened by drugs) blood pressure
Sources of effectiveness data
• Clinical trials (RCTs) considered strongest evidence as minimal
bias and few confounding factors, but
– often establishes efficacy
– selective subjects and time horizon
• Epidemiological studies, cohort studies, real life setting so
establish effectiveness, but
– potential for bias and numerous confounding factors
– causal links can be weak and disputed
• Synthesis methods, meta analysis/systematic review, allows
for singular insufficient data to be combined, but
– ‘heterogeneity’ in observations
– potential biases in searching and reviewing
Randomized Controlled Trial (RCT)
Identification
is effectiveness of
cost analysis
interventions equal?
NO YES
cost-effectiveness
cost-utility analysis
analysis
Analisis biaya sakit (cost of illness)
Kebijakan
Reformasi
strategis & Alokasi sumber
kesehatan
perencanaan daya yang efektif
masyarakat
berbasis bukti
Analisis biaya sakit (ABS)
Biaya langsung
(direct cost)
Biaya nirwujud
(intangible cost)
Biaya terhindarkan
(averted cost)
Biaya langsung
Healthcare
All costs - - -
system
Third-party
Covered costs - Covered costs -
payer
Lost Lost
Businesses Covered costs -
productivity productivity
Analisis minimalisasi-biaya (AMiB)
Costs of medication
$3993 $3919
increased by 25%
Costs of medication
$2511 $2409
decreased by 25%
Cost of IV adm.
$3292 $3184
increased by 25%
Cost of IV adm.
$3212 $3144
decreased by 25%
Cost of physician
$3284 $3180
increased by 25%
Cost of physician
$3220 $3148
decreased by 25%
Economic analysis of Oncoplatin alone (a chemotheraphy agent) compared with
Oncoplatin combined with Nonausea (an antinausea agent)
45
Costing dalam Analisis Efektivitas Biaya
Physical Total cost = resource Physical quantities, Total cost = resource use *
quantities, QALYs, use * unit cost QALYs, Monetary value unit cost
Monetary value
Cost-effectiveness analysis
47
Average vs Incremental Cost-effectiveness Ratios
Breast screening
Programme Costs Effects C/E ΔC/ΔE
A 110 20 5.50 -
B 120 29 4.14 1.11
C 150 50 3.00 1.43
D 190 60 3.17 4.00
E 240 70 3.42 5.00
48
600
500
average
300 100/10 = 10
incremental
200
100
0
0 50 100 150 200 250
Effects
Incremental cost-effectiveness ratio
More costly
IV I
Less effective III II More effective
Less costly
Kelompok Alternatif Berdasarkan Efektivitas Biaya
BIAYA
< = >
E
A B C
F < (ICER) (didominasi)
E
K
T
D E F
I =
V
I
T
G H I
A > (dominan) (ICER)
S
Interpretation of Cost-effectiveness Measures
Management of angina
Programme Costs Effects
A 20 8
Dominated: B has lower
B 30 4 effects and higher cost
C 50 19 than A
D 60 23
E 110 20
Ages 65-74
Daily dose Cost ($bn) Life years Cost/Life
year
20 mg 3.615 348,272 10,400
40 mg 7.051 477,204 14,800
Contoh Perhitungan ICER
Untuk terapi sebuah penyakit dapat digunakan tiga macam
obat yang masing-masing memiliki kinerja sebagai berikut:
• Obat A membutuhkan biaya Rp 6.000.000/100 pasien
dengan tingkat survival 3%
• Obat B membutuhkan biaya Rp 22.000.000/100 pasien
dengan tingkat survival 5%
• Obat C membutuhkan biaya Rp30.000.000/100 pasien
dengan tingkat survival 6%
Berapa ICER jika terapi dialihkan dari menggunakan Obat A
ke Obat B atau Obat A ke Obat C?
Biaya Kematian dihindarkan ACER (Rp/kematian
Obat
(per 100 pasien) (per 100 pasien) yang dicegah
A 6.000.000 3 2.000.000
B 20.000.000 5 4.000.000
C 30.000.000 6 5.000.000
< = >
E
A terhadap B
F < A terhadap C
E
K
T
I = C terhadap B B terhadap C
V
I
T
B terhadap A
A > C terhadap A
S
• Nilai ICER:
– ICER A -> B = (Rp 537.000 – Rp 320.000) / (0,60 – 0,35) = Rp 868.000
– ICER A -> C = (Rp 381.000 – Rp 320.000) / (0,61 – 0,35) = Rp 234.615
Cost Utility Analysis
• Utility = satisfaction/value/preference
• Utility weights are necessarily subjective
– Represent individual’s preferences for, or value
of, one or more health states.
• Must
– Have interval properties
– Be “anchored” at death (0) and good health (1)
[can be negative]
Choice of technique [1]
• Depends on values/utilities
• In general this is also preference order, but choice
often contingent on time
• Different generic scales use different scoring
techniques (eg., EQ-5D)
Generic instrument example: EQ-5D [1]
Example values:
Health state 11111 = 1.00
Health state 12111 = 0.82
Health state 11223 = 0.26
• Dalam suatu kasus pengobatan kanker malignant melanoma stadium II di
RS X, dibandingkan 2 jenis intervensi, yaitu program A (tanpa uji skrining
dan tanpa pemberian interferon) dengan program B (uji sentinel lymph-
node biopsy kemudian yang ditemukan positif mikrometastase/terkena
malignant melanoma stadium II, diberi pengobatan interferon).
• Data literatur menunjukkan utilitas masing-masing program adalah:
– Program A nilai QALY = 3,06
– Program B nilai QALY = 3,37
• Biaya yang rerata yang teridentifikasi di RS X adalah:
– Program A Rp 184.000.000/pasien
– Program B Rp 242.000.000/pasien
• Tentukan posisi alternatif pengobatan dalam tabel atau diagram
efektivitas-biaya!
• Tentukan nilai ICER A -> B!
• Nilai ACER:
– A = Rp 184.000.000/3,06 = Rp 60.130.719/QALY
– B = Rp 242.000.000/3,37 = Rp 71.810.089/QALY
BIAYA
< = >
E
F B terhadap A
E
K <
T
I =
V
I
T
A > A terhadap B
S
• Nilai ICER:
– ICER A -> B = (Rp 242.000.000 – Rp 184.000.000) / (3,37 – 3,06) = Rp
187.096.774/QALY
Analisis manfaat-biaya (AMB)
measuring
measuring puting costs and
program
program benefits benefits together
costs
Plus-Minus dari AMB
Net benefits = total benefits – total costs
Benefit-cost ratio = total benefits in dollars / total costs
Kelebihan Kekurangan
84
DECISION TREES: PREVENTION OF VERTICAL TRANSMISSION OF HIV
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