6 C URR ENT I SS U ES

Comparing international pharmacoeconomic guidelines

We must recognise that there is more than onc 'right' way to conduct pharmacoeconomic analyses. point out Canadian-based investigators. They believe that pharmacoeconomic guidelines need to be flexible to accommodate differences in the purposes and value judgements of such analyses.

Guidelines on the appropriate concepts to consider when conducting phannacoeconomic evaluations have recently been developed by the Australian Pharmaceutical Benefits Advisory Committee, the Canadian Coordinating Office on Health Technology Assessment, the Ontario Ministry of Health, and the England and Wales Department of Health.

According to the investigators. differences in pharmacocconomic guidelines can be attributed to 4

Identifying the differences 1. DmItenI ".."..: The Ausnian QI.icIehs b:us IX'I

deciIions asaooie8j wI1lhe WiIg and pii1g of mIIIicOIs. The

~~ ........ -~-­hDMMr, Irike I'IOe8 iI AusIraia, hrf saek., hDplID al8Iyges that C(IT'fIlm eN spec:iIic aug MIl RJttw lor fle ..,. cisease, and how ~"'.1tI bone ... :st'icdj be COI'JlIlIf'8d with Ihose tor oIhar IiaIes. The CInaIian g.ideires also ,. kI broad CIOtTl'*"e across P'0QI&mneS; howewIr, fie Bins af fl89II gtDIIin8s II'8lO1fl8'M'el btoedat ... 110IIII ... AustrlIIia IW1d

QnIari), u they also alCOlIJlllSS ~ studies. Z. Corarptuaf rau.: The • 1&' d jBIienls' own tmt is generatt net GOIeid&ed illle AusIraian ~ \IIIheraas I: is i'8COlTITIBIdad ilthe 0nIari0 gtidei'ies, but WIn no eIaboIatioi L

Patient time aM'I be 'CfJIIY at;JSIad' or I: can be trea1ed as a I'89OI.I'CI!I tI ¥Iticti an ~ cost can be assiI)'ied. Wtie the CanaIian glideIines .;tess the iaue of patient time, they make no f9OOIT'ITllIOOal on the appropiale approach for /TIIB8SIri'1g tNs --3. ...."."..,., Iatws: 1lwe is little unioonity illhe i8COIIII. dad rTI8IlSlQITl8II 01 cost - a Ilandard cost list is reccmT& dad ilthe Australian IJldeIi1e$. 'IIh1e 'U 006Ii'ig' analyses. i1ooIpe;tD'II1di a.wtIeads ard dapiecialioi is, n aa.'OC8Ied i1 the lA< g.ittaines. Thant n also dillei8i iCeS between thevari:us pwr.. i1"~uachi!ls UI8d b ~dm In the Austraian ard C'Irario pwnes, f18 ... cI hi;tI-q..IaIy dricaI _1s __ "l.O<~ .. ",,",_ ~ 1he "" d """"""""" __ ........ 111OI1itIIig. • wellS <*iaII .... In corira!t, hi C8naIIan !J.idahIs IIlIke no ~ 1 ...... ,il.dadialS on tis issue. ... v.u ,Iudpi ••• : The CendlwlgIidI*1es i'8OOIllli8ida

wide variety of IJIIS ard consIUnts b CXlSHiII!diwn!I __ ,1hey_1heI<rly1he ...... _ be_OnIy"'lA(~ __ .1he __ d

0Lt:::0me IT'I88SI..r& In most c:ira.rnsances, fie CanIIIan nI 0nIari0 ~ 11'IfnI118OOi III. d" LI88 cI t.dty or ~ife.jenIClALY.),_"'_ glideIines crit i8COIl.,'8I'd the use cllhese IT'i8IIU'8S \IItlen they ... _ Tho """""" .... """" ~_1heI I*Iict*u vaUt ;..tger1.,1S are en1x:diad i1 the Q.lJ.y ~ For these 2 eets of gukIeha, a heirvy tudan is aJso placed on the use of sensitMIy analysis; here I: is being used tI r880IYe fTIEI8SI.I9fI'1 errors and b 8Y8UIe oonc::eptuaI dfJerMces and vaUt judgemei I1S. Al4 _ of glideIines acMx:a&e the use cia disc:oI..ri facIor b oosts n:I beneIiI:s.

• s.p 1l1li PHARMACORESOUACS

factors: the purposes of the analyses, the way conceptual and measurement issues are addressed and value judgements underlying the analyses. TIle investigaton> discussed the observed differences between these 4 international models [see boxed ta tl.

An increased awareness of the different assumptions that underlie pharmacoeconomic guidelines will enhance the readers' ability to use such guidelines more effectively, conclude the investigators. JKObI p. 81dl)'Qlky J, Balldi J·F. A«II'I'IJ*1Iti~ rev>o:w ofpharrMco-CCODOIIIio: pid!:liDeI. f'tIarmKo&:ODomics 3: 132. 139. Sep 1m _ '.

Managing rare diseases: don't forget to assess cost effectiveness

When trcating a rare disease such as insulinoma, one must consider the same issues of cost-effectiveness and outcomes analysis that are addressed for more common conditions, reminds Dr Lloyd Axelrod from Massachusetts General Hospital in Boston, US.'

In a srudy of preoperative insulinoma localisation, Dr John Doppman and colleagues from the US found that intra·arterial calcium stimuJation with hepatic venous sampling was as sensitive and less invasive than portal venous sampling in localising insulin­secreting rumours to regions of the pancreas.2 TIley suggested that calcium stimulation should be the method of choice for preoperative testing of this rare disorder.

Use an appropriate comparator Their analysis compared the sensitivity of calcium

stimulation with that of 5 other methods of localisation -computed tomography, magnetic resonance imaging, arteriography and ponal venous sampling. However, Dr Axelrod believes thai these comparators are 'not relevant to the current clinical contat '.' He recommends intraoperative ultrasonography and pancreatic exploration by a skilled surgeon as the appropriate comparison.

He also points out that Dr Doppman and colleagues failed to show that calcium stimulation had any effect on health outcomes. Notably, this intervention leads to a considerable increase in costs and morbidity, he adds.

' It is no longer cu:ceplable to adllocate or use costly mlllJ$ille prou duns fOT minimal (if IIny) marginal lllilltlnlllge', claims Dr AAelrod. As for commonly­used heaJthcare interventions, he emphasises thai the treatment options for rare diseases must also be assessed on cost-effectiveness grounds . I . AActrod L lnRilinorna; COM-c:ffceti~ care ill patiaUa with. rare disc.osc. Annab 0( IIUCZ'Ul Medio:iDe 123: )11· ) 12. 15 Alll1WS 2. DoppnwIIL. et aI. I (JealiUlion of inIIIlinomas to rqioM of. paDCrUS by mlrHnaial stimu1Ilioa with calcium. AMah of1mc:rnal Medicine 123: 269·27). IS Aua 1m __

Drugs & Therapy Perspectives For Rational Drug Selection and Use

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