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Not Simply More of the Same

Author

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  • Pepijn Vemer
  • Lucas M. A. Goossens
  • Maureen P. M. H. Rutten-van Mölken

Abstract

In cost-effectiveness (CE) Markov models, heterogeneity in the patient population is not automatically taken into account. We aimed to compare methods of dealing with heterogeneity on estimates of CE, using a case study in chronic obstructive pulmonary disease (COPD). We first present a probabilistic sensitivity analysis (PSA) in which we sampled only from distributions representing parameter uncertainty. This ignores any heterogeneity. Next, we explored heterogeneity by presenting results for subgroups, using a method that samples parameter uncertainty simultaneously with heterogeneity in a single-loop PSA. Finally, we distinguished parameter uncertainty from heterogeneity in a double-loop PSA by performing a nested simulation within each PSA iteration. Point estimates and uncertainty differed substantially between methods. The incremental CE ratio (ICER) ranged from €4900 to €13,800. The single-loop PSA led to a substantially different shape of the CE plane and an overestimation of the uncertainty compared with the other 3 methods. The CE plane for the double-loop PSA showed substantially less uncertainty and a stronger negative correlation between the difference in costs and the difference in effects compared with the other methods. This came at the cost of higher calculation times. Not accounting for heterogeneity, subgroup analysis and the double-loop PSA can be viable options, depending on the decision makers’ information needs. The single-loop PSA should not be used in CE research. It disregards the fundamental differences between heterogeneity and sampling uncertainty and overestimates uncertainty as a result.

Suggested Citation

  • Pepijn Vemer & Lucas M. A. Goossens & Maureen P. M. H. Rutten-van Mölken, 2014. "Not Simply More of the Same," Medical Decision Making, , vol. 34(8), pages 1048-1058, November.
  • Handle: RePEc:sae:medema:v:34:y:2014:i:8:p:1048-1058
    DOI: 10.1177/0272989X14550499
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    References listed on IDEAS

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    1. Briggs, Andrew & Sculpher, Mark & Claxton, Karl, 2006. "Decision Modelling for Health Economic Evaluation," OUP Catalogue, Oxford University Press, number 9780198526629.
    2. Douglas Coyle & Martin J. Buxton & Bernie J. O'Brien, 2003. "Stratified cost‐effectiveness analysis: a framework for establishing efficient limited use criteria," Health Economics, John Wiley & Sons, Ltd., vol. 12(5), pages 421-427, May.
    3. Karl Claxton & Mark Sculpher & Chris McCabe & Andrew Briggs & Ron Akehurst & Martin Buxton & John Brazier & Tony O'Hagan, 2005. "Probabilistic sensitivity analysis for NICE technology assessment: not an optional extra," Health Economics, John Wiley & Sons, Ltd., vol. 14(4), pages 339-347, April.
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    Cited by:

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    2. Nikolaj Harmon & Raymond Fisman & Emir Kamenica, 2019. "Peer Effects in Legislative Voting," American Economic Journal: Applied Economics, American Economic Association, vol. 11(4), pages 156-180, October.

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