Pharmacoeconomics

Auliya A. Suwantika, Ph.D., Apt.

Department of Pharmacology and Clinical Pharmacy
Faculty of Pharmacy
Universitas Padjadjaran
Terminology
• Health economics
Application of economics in health care
• Health economics evaluation / economic evaluation
Evaluation of economics and outcomes of healthcare
intervention or program
• Pharmacoeconomics
Health economic evaluation related to pharmacy/
pharmaceuticals. It has been used in a broader context
then “pharmaceuticals”
 Pharmacoeconomics vs Health economics

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

Clinicians and Public and

Hospitals
patients private payers
• Prescribing • Drug plan • Technology
decisions formularies acquisition
• Practice • Level of • Hospital
guidelines coverage formularies
4th Hurdle
 Bringing a New Drug to Market
Review and approval by FDA

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

Source: Tufts Center for the Study of Drug Development

• His decision last year to hike the price of a life-saving drug (Daraprim) for pregnant
women and AIDS patients from $13.50 to $750 per pill, overnight.
• And so, in May 2014, Retrophin acquired the rights to Thiola (to treat a rare disorder
that causes excruciatingly painful cystine stones in the kidneys, ureter and bladder)
and hiked the price from $1.50 to $30 per pill.
• The typical prescription for Thiola requires up to 15 pills every day, meaning the cost
of treatment shot from $8,212 a year to $164,250.
Berikut ini adalah matriks biaya dan efektifitas dari penggunaan 5 antibiotik
untuk penanganan infeksi saluran pernapasan di sebuah rumah sakit:

Dari kelima antibiotik tersebut, antibiotik

manakah yang paling tepat untuk
penanganan infeksi saluran pernafasan jika
dilihat dari segi biaya dan efektifitasnya?
Diare hingga saat ini masih menjadi salah satu penyebab kematian terbesar
bagi anak di bawah 5 tahun. Berikut ini adalah 5 upaya penanganan diare
untuk anak di bawah 5 tahun di sebuah rumah sakit:

Strategi Data (per 100 pasien) Selisih

Biaya (Rp) Kasus diare Biaya (Rp) Kasus dicegah
Tanpa intervensi (I0) 5.000.000 8
Intervensi 1 (I1) 6.000.000 7 1.000.000 1
Intervensi 2 (I2) 7.000.000 6 2.000.000 2
Intervensi 3 (I3) 8.000.000 2 3.000.000 6
Intervensi 4 (I4) 9.000.000 3 4.000.000 5
Intervensi 5 (I5) 12.000.000 1 7.000.000 7

Dari sudut pandang seorang farmasis di rumah sakit, intervensi manakah

yang paling efektif dari segi biaya?
 Economic evaluation studies

Tipe Analisis Biaya Efektivitas Hasil

Intervensi atau program
Efektivitas dianggap
Minimalisasi biaya Money sama
dengan biaya paling
minim

Common measure (e.g.,

Biaya per unit efektivitas
Efektivitas biaya Money life years gained, blood
(e.g., cost per LY gained)
pressure reduction)

Biaya per unit utilitas

Utilisasi biaya Money Utilitas, misalnya QALY
(e.g., cost per QALY)

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

• Outcome measure depends on the objective of the evaluation

• Determine the type of evaluation  CEA, CUA or CBA
• C/E ratio = net cost/net benefits
• Net cost = positive cost and negative cost
– Negative cost = cost saving (e.g., reduced LoS)
• Net benefit = positive benefit and negative benefit
– Negative benefit = reduced health (e.g., side-effect)
• Should changes in productivity be included?
– Depends on the perspective
– Provide a good reason why they should/not be included
 is there evidence on effectiveness of interventions?
YES NO

is effectiveness of
cost analysis
interventions equal?

NO YES

can all outcomes be valued in cost-minimization

monetary terms? analysis
NO YES

can outcomes be measured as

cost-benefit analysis
quality-adjusted life-years?
YES NO

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)

• Analisis biaya sakit (ABS) dimaksudkan untuk

memperkirakan biaya yang disebabkan oleh suatu
penyakit pada sebuah populasi [1]
• Dalam kajian farmakoekonomi, biaya menjadi
pertimbangan penting karena adanya keterbatasan
sumber daya [1]
 Biaya
Biaya Definisi

Biaya rerata Jumlah biaya per unit hasil yg diperoleh [1]

Perubahan biaya atas penambahan atau pengurangan unit hasil yang

Biaya marjinal
diperoleh [1]

Biaya yang jumlahnya tidak berubah dengan perubahan kuantitas atau

volume produk atau layanan yang diberikan dalam jangka pendek
Biaya tetap
(umumnya dalam rentang waktu 1 tahun atau kurang), misalnya gaji
karyawan dan depresiasi aset [1]

Biaya yang berubah seiring perubahan hasil yang diperoleh, misalnya

Biaya variabel
komisi penjualan dan biaya penjualan obat [1]

Biaya atas pemberian tambahan pelayanan pada suatu prosedur medis,

Biaya tambahan
seperti jasa laboratorium, skrining sinar-X dan anestesi [1]

Biaya keseluruhan yang harus dikeluarkan untuk memproduksi

Biaya total
serangkaian pelayanan kesehatan [1]
Biaya perawatan kesehatan

Biaya langsung
(direct cost)

Biaya tidak langsung

(indirect cost)

Biaya nirwujud
(intangible cost)

Biaya terhindarkan
(averted cost)
Biaya langsung

• Biaya langsung  biaya yang terkait langsung dengan

perawatan kesehatan [1]
• Biaya obat, konsultasi dokter, biaya jasa perawat,
penggunaan fasilitas RS (kamar rawat inap, peralatan),
uji laboratorium, biaya pelayanan informal dan biaya
kesehatan lainnya [1]
• Seringkali diperhitungkan pula biaya non-medis
seperti biaya ambulan dan biaya transportasi pasien
lainnya [1]
Biaya tidak langsung

• Biaya tidak langsung  sejumlah biaya yang terkait

dengan hilangnya produktivitas akibat menderita
suatu penyakit [1]
• Biaya transportasi, biaya hilangnya produktivitas,
biaya pendamping (anggota keluarga yang menemani
pasien) [1]
Intangible and averted cost

• Intangible cost  biaya-biaya yang sulit diukur

dalam unit moneter, namun sering kali terlihat
dalam pengukuran kualitas hidup, misalnya rasa
sakit dan rasa cemas yang diderita pasien
dan/atau keluarganya [1]
• Averted cost  potensi pengeluaran yang dapat
dihindarkan karena penggunaan suatu intervensi
kesehatan [1]
 Istilah-istilah lain
Biaya Definisi
Biaya atas pembelian obat, alkes dan/atau intervensi kesehatan,
Acquisition cost
baik bagi individu pasien maupun institusi [1]
Biaya atas pemberian pelayanan atau teknologi kesehatan yang
Allowable cost masih dapat ditanggung oleh penyelenggara jaminan kesehatan
atau pemerintah maupun institusi [1]
Biaya yang harus dibayar oleh individu pasien dengan uangnya
Out-of-pocket cost
sendiri [1]
Biaya yang timbul akibat pengambilan suatu pilihan yang
Opportunity cost
mengorbankan pilihan lainnya [1]
Cost included in CoI studies, by perspective [2]
Morbidity Mortality Non-medical
Perspective Medical costs
costs costs costs

Societal All costs All costs All costs All costs

Healthcare
All costs - - -
system
Third-party
Covered costs - Covered costs -
payer
Lost Lost
Businesses Covered costs -
productivity productivity
Analisis minimalisasi-biaya (AMiB)

• AMiB adalah teknik analisis ekonomi untuk

membandingkan dua pilihan intervensi atau lebih
yang memberikan outcome kesehatan setara
untuk mengidentifikasi pilihan yang menawarkan
biaya lebih rendah.
• Menentukan kesetaraan (equivalence) dari intervensi
(misalnya obat) yang akan dikaji
Contoh implementasi AMiB

• Membandingkan OGB dengan obat generik

bermerek dengan bahan kimia obat sejenis dan telah
dibuktikan kesetaraannya melalui uji
bioavailabilitas/bioekuivalen (BA/BE)
• Membandingkan obat standar dengan obat baru
yang memiliki efek setara
Economic analysis of Oncoplatin alone (a chemotheraphy agent) compared with
Oncoplatin combined with Nonausea (an antinausea agent)

• BACKGROUND: Oncoplatin is administered intravenously in physician offices

and clinics. Because of problems with chemotherapy-induced nausea, the
recommended administration directions were to split the monthly dose
needed for each cycle in half and administer each half 5 days apart. Follow-
up studies found that if patients were given NoNausea at the same visit, the
full monthly dose of Oncoplatin could be given at one visit.
• OBJECTIVE: To perform a CMA comparing the cost of Oncoplatin given in two
doses with Oncoplatin combined with NoNausea administered in one dose.
The perspective of the study is the third-party payer.
• METHODS: Over a 6-month period (February-July 2007), patients from two
oncology clinics were enrolled in this study and randomized to receive either
the split dose of Oncoplatin (25 mg/m2 on days 1 and 5) or the single dose of
Oncoplatin (50 mg/m2) plus the oral antinausea medication (35 mg of
NoNausea)
Patient Split dosing of Full dose of Oncoplatin
comparisons Oncoplatin (n=293) plus NoNausea (n=295)
Gender (% women) 54.6% 52.5%
Mean age (SD) 58.3 (10.0) 59.2 (11.0)
Ethnicity (% white) 79.9% 80.7%
Adverse events
Nausea 13 (4.4%) 12 (4.1%)
Fever 14 (4.8%) 13(4.4%)
Fatigue 10 (3.4%) 8 (2.7%)
Pain 6 (2.0%) 7 (2.4%)
Other 8 (2.7%) 9 (3.0%)
Cost for first cycle Split dosing of Full dose of Oncoplatin
of treatment Oncoplatin (n=293) plus NoNausea (n=295)
Average cost of
$2964 $2980
Oncoplatin
Average cost of
N/A $40
NoNausea (35 mg)
Cost of IV
$160 $80
administration
Cost of physician or
$128 $64
clinical visit
Total cost per
$3252 $3164
patient
 Split dosing of Full dose of Oncoplatin
Sensitivity analyses
Oncoplatin plus NoNausea

Baseline costs $3252 $3164

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)

• CONCLUSION: Direct medical costs associated with

the once-per-cycle dose of Oncoplatin plus
NoNausea were lower than when the monthly dose
was split.
Abstract
Introduction
Methods
Methods
Discussion
Conclusion
 Analisis Efektivitas Biaya

• Membandingkan biaya dan konsekuensinya dari dua

atau lebih alternatif
• Menghitung cost per unit of effect
• Mengidentifikasi hasil:
 Cost per unit of produced effect
 Biaya per unit yang lebih rendah  lebih baik
 Intermediate effect (e.g., number of people who stop
smoking) and final outcomes (e.g., averted cases of lung
cancer, averted deaths due to lung cancer or COPD)

45
Costing dalam Analisis Efektivitas Biaya

 Biaya yang berkaitan dengan intervensi

tersebut
 Biaya yang dapat dicegah
 Biaya tidak langsung, misalnya berkaitan
dengan kehilangan produktivitas
 Struktur dalam Analisis Efektivitas Biaya
Standard treatment New intervention

Health outcomes Resource use Health outcomes Resource use

Physical Total cost = resource Physical quantities, Total cost = resource use *
quantities, QALYs, use * unit cost QALYs, Monetary value unit cost
Monetary value

Benefit with Cost associated with Patient-specific Patient-specific cost

standard standard treatment benefit with new under new intervention
treatment intervention

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

400 500/200 = 2.5

Costs

average
300 100/10 = 10
incremental
200

100

0
0 50 100 150 200 250
Effects
 Incremental cost-effectiveness ratio

ICER = ΔC = Cost new treatment – cost current treatment

ΔE Effect new treatment – effect current treatment

More costly

New treatment more costly

Old treatment dominates
and more effective

IV I
Less effective III II More effective

New treatment less costly

and less effective New treatment dominates

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

Dominance  Program A dominates B when its effectiveness is

greater and its cost lower than program B
Interpretation of Cost-effectiveness Measures

Dosis alternatif lovastatin dalam pencegahan sekunder

heart disease (Goldman et al., 1991, JAMA 265: 1145-51)

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

ICER A -> B = (20.000.000 – 6.000.000) / (5 – 3)

= Rp 7.000.000/kematian yang dicegah
ICER A -> C = (30.000.000 – 6.000.000) / (6 – 3)
= Rp 8.000.000/kematian yang dicegah
Contoh Analisis Efektivitas Biaya
Asma merupakan penyakit kronis yang ditandai oleh bronkokonstriksi
(penyempitan saluran nafas).
Inhalasi kortikosteroid telah menjadi cara pengobatan rutin. Tetapi, pengobatan
inhalasi kortikosteroid tunggal kadang tidak cukup efektif untuk mengontrol
gejala asma.
Dua pengobatan baru digunakan sebagai terapi penunjang, yaitu BreatheAgain®
dan AsthmaBeGone®.
Pada kasus ini akan dibandingkan efektivitas-biaya pengobatan dari:
A. Inhalasi kortikosteroid tunggal
B. Kombinasi inhalasi kortikosteroid + BreatheAgain®
C. Kombinasi inhalasi kortikosteroid + AsthmaBeGone®
• Studi literatur menunjukkan bahwa efektivitas pengobatan:
– A = 35%
– B = 60%
– C = 61%.
• Biaya rerata pengobatan diketahui sebagai berikut:
– A = Rp 320.000/pasien
– B = Rp 537.000/pasien
– C = Rp 381.000/pasien
• Tentukan nilai ACER untuk ketiga pengobatan!
• Tentukan posisi alternatif pengobatan dalam tabel atau diagram
efektivitas-biaya!
• Tentukan nilai ICER A -> B dan ICER A -> C !
• Nilai ACER:
– A = Rp 320.000/0,35 = Rp 914.286
– B = Rp 537.000/0,60 = Rp 895.000
– C = Rp 381.000/0,61 = Rp 624.590
BIAYA

< = >
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

• Value is determined by benefits sacrificed elsewhere

• Measurement does not require a trade-off between
benefits, but valuation does
• Valuation either in terms of
– Utility (e.g., QALY)
– Money (e.g., WTP)
Quality-adjusted life years (QALYs)
• Adjust quantity of life years saved to reflect a valuation of
the quality of life
– If healthy QALY = 1
– If unhealthy QALY < 1
– QALY can be <0
• QALY procedure
– Identify possible health states - cover all important or
relevant dimensions of QoL
– Derive utility ‘weights’ for each state
– Multiply life years (spent in each state) by ‘weight’ for
that state
Quality-adjusted life years (QALYs)

• QALY atau ‘Jumlah Tahun yang Disesuaikan’ (JTKD) adalah

suatu hasil yang diharapkan dari suatu intervensi kesehatan
yang terkait erat dengan besaran kualitas hidup.
• Secara teknis, JTKD diperoleh dari perkalian antara nilai
utilitas dan nilai time preference.
Quality-adjusted life years (QALYs)

• Benefits are measured as QALYs

Example of calculating QALYs
• Weights:
– Good health = 1
– moderate health = 0.8
– poor health = 0.5
• LYs:
– Year 1 + year 2 + year 3 = 3LYs (1+1+1)
• QALYs:
– Year 1(x0.5), year 2(x0.8), year 3(x1) = 2.3 QALYs (0.5+0.8+1)
• Intervention may increase recovery such that
– year 1(x0.8), year 2(x1), year 3(x1) = 2.8 QALYs (0.8+1+1)
Utility weight

• 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]

5 dimensions, 3 levels = 245 health

states (35)

Example values:
Health state 11111 = 1.00
Health state 12111 = 0.82
Health state 11223 = 0.26
• 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)

• AMB adalah teknik untuk menghitung rasio antara

biaya intervensi kesehatan dan manfaat (benefit)
yang diperoleh, dimana outcome diukur dengan unit
moneter (rupiah)
• “An intervention yields $3.00 in savings for every
$1.00 spent on the program.”
 Outcome
Outcome dalam AMB dapat berupa:
• nilai terkait pasien (kesembuhan dan pulihnya
kemampuan fisik)
• nilai pilihan (manfaat keberadaan intervensi saat
dibutuhkan)
• nilai altruistik (manfaat peningkatan kesehatan orang
lainnya)
Parameter outcome diukur dengan satuan moneter 
kemauan untuk membayar (Willingness to Pay, WTP)
 Willingness to pay (WTP)

• Dasar dari AMB adalah surplus manfaat  manfaat yang

diperoleh dikurangi dengan surplus biaya
• Bila surplus manfaat suatu intervensi/program bernilai
positif, maka umumnya intervensi/program tersebut layak
untuk dilaksanakan
• WTP adalah suatu teknik untuk mengukur nilai manfaat
kesehatan dengan secara langsung menunjukkan preferensi
individual yang diwakili oleh populasi sampel dari
masyarakat umum yang diminta menjawab pertanyaan
berapa banyak mereka bersedia membayar untuk
memperoleh manfaat atau menghindari hal tertentu [1]
 How to conduct a CBA?

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

Memungkinkan perbandingan Menerjemahkan kondisi

dengan nilai moneter antar klinis non-moneter dan outcome
intervensi yang sama sekali tidak kualitas hidup menjadi nilai
berkaitan moneter
Satu-satunya teknik yang dapat Jarang digunakan untuk
digunakan untuk membandingkan obat atau
membandingkan internal suatu alternatif terapi medis karena
intervensi pertimbangan etika
 Example: Childhood immunization [2]

A hypothetical CBA for a children’s immunization program resulted in the

following:
• Monetary benefits totaling $1.2 million per year
• Monetary costs of running the program totaling $600,000 per year
• A ratio of benefits to costs equal to $1,200,000/$600,000, which can be
expressed as a benefit to cost ratio of 2:1.
• The benefits in this CBA are based on the savings that result from
averting disease among people that otherwise wouldn’t be immunized
• “For every dollar spent on this immunization program, two dollars are
saved in medical and lost work time costs”
 Conclusion

• Although some view CBA as a superior technique,

it is difficult and time consuming. CEA may provide
a good starting point by requiring the evaluator to
identify the most important outcome and relate
that outcome to the dollars spent on the project
Bahan Diskusi

• Buatlah sebuah desain penelitian farmakoekonomi

(CMA, CEA, CUA atau CBA) bertemakan “Chronic
diseases treatment for elderly population” yang
terdiri dari latar belakang, tujuan dan metode
penelitian!
Sensitivity Analysis
 Tests the robustness of the conclusions by varying
uncertain parameters across their “plausible” range
 In absence of empirical data, one must make
informed assumptions (e.g. about the effectiveness
of new technologies)
 When there are methodological debates different
scenarios can be modeled (e.g. discount rate,
productivity losses)
 (a) Two-dose vaccine
Discount rate
Vaccine price
Vaccine coverage
Cost-effectiveness of Vaccine efficacy
Total severe cost
Hepatitis A Total moderate cost
Total mild cost
Vaccination in Mortality rate
Severe cases
Indonesia Moderate cases
Mild cases
$5,000
$5.000 $6,000
$6.000 $7,000
$7.000 $8,000
$8.000 $9,000
$9.000 $10,000
$10.000
high low ICER (cost per QALY gained)
ICER
Suwantika AA, et al.
(b) One-dose vaccine

Human Vaccines & Discount rate

Vaccine price
Immunotherapeutics. Vaccine coverage
Vaccine efficacy
10(8), 1-10 (2014) Total severe cost
Total moderate cost
Total mild cost
Mortality rate
Severe cases
Moderate cases
Mild cases
$2,000
$2.000 $3,000
$3.000 $4,000
$4.000 $5,000
$5.000
high low ICER (cost per QALY gained)
ICER
 Evaluation Checklist for
Economic Evaluation Studies
 Evaluation Checklist for
Economic Evaluation Studies
Complete title? Relevant outcomes?

Clear objective? Adjustment/discounting?

Appropriate alternatives? Reasonable assumptions?

Alternatives described? Sensitivity analyses?

Perspective stated? Limitations addressed?

Type of study? Generalizations appropriate?

Relevant costs? Unbiased conclusions?

Lembar Kerja untuk Penelaahan Kritis Artikel
Farmakoekonomi
VALIDITAS
• Apa strategi pengobatan yang dibandingkan dalam analisis?
• Apakah kemungkinan hasil yang bisa terjadi karena pilihan intervensi
digambarkan?
• Perspektif apa yang digunakan ketika menghitung biaya?
• Berapa lama preferensi waktu yang digunakan?
• Apakah kemungkinan hasil pengobatan (probabilitas) diukur?
• Bagiamana komponen biaya diukur?
• Apakah dilakukan sensitivity analysis?
Lembar Kerja untuk Penelaahan Kritis Artikel
Farmakoekonomi
HASIL
• Bagaimana menghitung biaya inkremental dan hasil pengobatan
inkremental dari setiap pilihan pengobatan?
• Apakah hasil secara keseluruhan (estimasi biaya) berubah secara esensial
setelah dilakukan analisis sentivitas?
• Pada kondisi apa estimasi tersebut berubah?
• Bagaimana hasil secara keseluruhan?
• Gambarkan bagaimana ketidakpastian mengubah biaya inkremental dan
hasil pengobatan inkremental dari setiap pilihan pengobatan?
Lembar Kerja untuk Penelaahan Kritis Artikel
Farmakoekonomi
PENERAPAN
• Apakah manfaat dari pengobatan lebih besar dibandingkan risiko dan
biaya yang dikeluarkan?
• Apakah hasil bisa diterapkan pada pasien saya?
• Akankah analisis ini mengubah cara menangani pasien saya?
Conceptual Model
• Flow diagram of the relevant interventions
• Decision Tree or other way to model the process
(Markov Model)
• The quality of the results depends on the quality
of the model

84
 DECISION TREES: PREVENTION OF VERTICAL TRANSMISSION OF HIV

Vertical transmission COSTS PROBABILITY

Acceptance of
interventions p=0.07 £800 0.0665
p=0.95 No vertical transmission
Policy of
intervening C=£800 p=0.93
£800 0.8835
Vertical transmission
No acceptance of
p=0.26 £0 0.013
interventions
p=0.05 No vertical transmission
C=£0 £0 0.037
p=0.74
Vertical transmission
£0 0.26
p=0.26
Policy of not No vertical transmission
intervening £0 0.74
p=0.74

Adapted from Ratcliffe et al. AIDS 1998;12:1381-1388

References
• Budget impact analysis – Principles of Good Practice: Report of the ISPOR 2012
Budget Impact Analysis Good Practice II Task Force www.ispor.org
• Guidelines for the Budget Impact Analysis of Health Technologies in Ireland 2013.
www.hiqa.ie
• Health Technology Assessment of robot-assisted surgery in Ireland. HIQA 2011.
www.hiqa.ie
• Health Technology Assessment of a Deep Brain Stimulation Service in Ireland. HIQA
2012. www.hiqa.ie
• Kemenkes RI. Buku Pedoman Farmakoekonomi. 2012
• http://www.ispor.org/RegionalChapters/GetActivityFile/195
• eprints.kingston.ac.uk/17922/1/PowerPoint_1.ppt
• siteresources.worldbank.org/EXTIMPEVA/Resources/Day3a.ppt
• www.economicsnetwork.ac.uk/health/CAP_lecture_4.ppt
• http://www.ncbi.nlm.nih.gov/mesh/68015986
• http://library.downstate.edu/EBM2/2200.htm
• http://explorable.com/confounding-variables

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