The CEA Registry Blog

By CEA Registry Team on 10/26/2010 9:07 AM

The most recent issue of Health Economics gives us an opportunity to highlight the diversity of interventions addressed by studies catalogued in the CEA Registry.  A study in that issue by Sperber et al. evaluates a law banning cell phone use by drivers in the Canadian province of Alberta.  The study concluded that a ban would both improve health and save money.(1) This study will be included in the CEA Registry in due course.

The CEA registry includes all cost-utility analyses (CUAs) indexed in Medline, including many that address interventions outside the domain of medicine.  After reading cost-effectiveness analysis on cell phones and driving, I searched the registry for other CUAs related to car safety.  Below is a brief summary of selected studies.

By CEA Registry Team on 10/22/2010 8:49 AM

On August 25th the Centers for Medicare and Medicaid Services (CMS) announced a national coverage determination (NCD) for counseling to prevent tobacco use (CAG-00420N).  Here at CEVR we maintain the Tufts Medical Center NCD database, which includes data on various parameters on each NCD made since 1999.  The decision memo for CAG-00420N was reviewed for inclusion in this database.

This coverage decision is particularly interesting as it includes the review of a cost-utility study.

By James D. Chambers
 

By CEA Registry Team on 10/20/2010 9:17 AM

Steve Pearson and Peter Bach make several good points in their excellent new Health Affairs paper, (Pearson SD, Bach PB.  How Medicare Could Use Comparative Effectiveness Research in Deciding on New Coverage and Reimbursement.  Health Affairs. 2010;29:1796-1803)

They propose that Medicare pay more for services demonstrated by adequate evidence to provide superior health benefits compared to alternatives.  New services without such evidence would receive usual reimbursement rates and then be reevaluated as new evidence emerges.

Incorporating information and incentives in this fashion is eminently reasonable and one really wonders why Medicare doesn’t already follow such a policy.  One answer is that the evidence base has been insufficient – precisely why we need more CER. The other answer, as Pearson and Bach note, is that there are substantial political hurdles to changing Medicare reimbursement and to using CER in such an explicit manner. 

In some ways, the Patient Protection and Affordable Care Act imposes new restrictions, such as stating that CER cannot be construed as a mandate for coverage or payment decisions and that the Secretary can only use CER as part of larger evidence base.

Ideally, CER would be used to inform payment policy as Pearson and Bach propose.  In addition to ongoing political opposition and perhaps statutory barriers, the biggest challenge will be determining what constitutes “superior” evidence.  One way would be to use cost/QALY ratios to help define this.  However, don’t expect to see that anytime soon (see blog post from October 14, 2010, as well as Neumann and Weinstein, NEJM, “Legislating against Use of Cost-Effectiveness Information, October 14, 2010).  Also, see the NY Times story on the topic by David Leonhardt on October 20th.

By Peter J. Neumann
 

By CEA Registry Team on 10/18/2010 3:10 PM

Twice each month we highlight recently published cost utility studies and selected reviews and editorials. The CEA registry includes every cost-utility study published and indexed in Medline (through April 2010).

By CEA Registry Team on 10/14/2010 8:27 AM

In a new paper in the New England Journal of Medicine, my colleague Milton Weinstein and I analyze the U.S.’s new restrictions against the use of cost-effectiveness analysis (Neumann PJ and Weinstein MC, Legislating against Use of Cost-Effectiveness Information. N Engl J Med, 2010;363:1495-97).

 Specifically, the recently enacted Patient Protection and Affordable Care Act states:
 
“…the Patient Centered Outcomes Research Institute … shall not develop or employ a dollars per quality adjusted life year (or similar measure that discounts the value of a life because of an individual’s disability) as a threshold to establish what type of health care is cost-effective or recommended. The Secretary shall not utilize such an adjusted life year (or such a similar measure) as a threshold to determine coverage, reimbursement, or incentive programs under title XVIII...”
 
Importantly, the ACA forbids the use of cost per QALYs "as a threshold.” The precise intent and consequence of this language is unclear.  One might interpret it to mean that the PCORI, or its contractors or grantees, can still calculate a cost per QALY ratio, as long as it not compared to a threshold (e.g., $50,000/QALY) or used to make a recommendation based on such a threshold.  Comparisons of cost per QALY ratios across interventions could still be useful to decision makers even without the invocation of an explicit threshold.  However, the provision suggests a broader ban on the use of cost-utility analysis and, unfortunately, could have a chilling effect on the field.

 

By: Peter J. Neumann

By CEA Registry Team on 10/7/2010 8:47 AM

In new paper just published in Health Affairs’ special issue on comparative effectiveness research (CER), my colleagues – Lou Garrison, Paul Radensky, and Sheila Walcoff – and I  argue for flexible evidentiary standards for CER. [PMID: 20921480]

We point out that the Patient Protection and Affordable Care Act (ACA) established a new Patient-Centered Outcomes Research Institute (PCORI) to identify and address research priorities for CER.  Also, the PCORI is charged with developing methodological standards, and communicating research results to decision makers.

As we emphasize in the paper, the law addresses methodological standards, not evidentiary standards.  Methodological standards have to do with the best practice for a given type of methodology, be it a clinical trial, an observational study, or the analysis of data from either of these types of studies.  Evidentiary standards pertain to decision makers’ choices, such as whether to require data from controlled trials. The ACA does not call for rigid evidentiary standards; nor does it assign the institute the task of developing and updating such standards. Thus, we argue that to maximize the value of the information it produces, the PCORI should take a balanced and flexible approach to the types of research it sponsors, being careful not to let rigorous scientific methods become a rigid evidentiary standard.

By Peter J. Neumann
 

By CEA Registry Team on 10/1/2010 10:59 AM

Twice each month we highlight recently published cost utility studies and selected reviews and editorials. The CEA registry (www.cearegistry.org) includes every cost-utility study published and indexed in Medline.

Please view the blog archive for earlier entries

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