Cost-effectiveness of integrated care in frail elderly using the ICECAP-O and EQ-5D: does choice of instrument matter?

Abstract

Economic evaluations likely undervalue the benefits of interventions in populations receiving both health and social services, such as frail elderly, by measuring only health-related quality of life. For this reason, alternative preference-based instruments have been developed for economic evaluations in the elderly, such as the ICECAP-O. The aim of this paper is twofold: (1) to evaluate the cost-effectiveness using a short run time frame for an integrated care model for frail elderly, and (2) to investigate whether using a broader measure of (capability) wellbeing in an economic evaluation leads to a different outcome in terms of cost-effectiveness. We performed univariate and multivariate analyses on costs and outcomes separately. We also performed incremental net monetary benefit regressions using quality adjusted life years (QALYs) based on the ICECAP-O and EQ-5D. In terms of QALYs as measured with the EQ-5D and the ICECAP-O, there were small and insignificant differences between the instruments, due to negligible effect size. Therefore, widespread implementation of the Walcheren integrated care model would be premature based on these results. All results suggest that, using the ICECAP-O, the intervention has a higher probability of cost-effectiveness than with the EQ-5D at the same level of WTP. In case an intervention's health and wellbeing effects are not significant, as in this study, using the ICECAP-O will not lead to a false claim of cost-effectiveness of the intervention. On the other hand, if differences in capability QALYs are meaningful and significant, the ICECAP-O may have the potential to measure broader outcomes and be more sensitive to differences between intervention and comparators.

Comparing Measurement Properties of the EQ-5D-3L, ICECAP-O, and ASCOT in Frail Older Adults

“…The results of cost-effectiveness analysis are indeed influenced by the reliability and content of outcome measures, as was shown in a recent economic evaluation in which personal health budgets were considered cost-effective using ASCOT and not cost-effective using the EQ-5D [57]. Two other studies showed that conclusions of the economic evaluation of integrated care in frail elderly [58] and telehealth for patients with long-term conditions [59] did not differ using ICECAP-O or the EQ-5D, although at the same level of willingness to pay, interventions had a higher probability of cost-effectiveness using ICECAP-O.…”

Choice of Outcome Measure in an Economic Evaluation: A Potential Role for the Capability Approach

“…While the ASCOT instrument can be used in a QALY estimation (so-called social care QALYs) as it is anchored at dead, the ICECAP measures should not be. Makai et al [39] estimated both capability QALYs and health QALYs (using the EQ-5D) and compared them; this is incorrect. A CUA using an ICECAP instrument should estimate the incremental cost per unit of capability gained.…”

“…This then raises the question: what is the value of a capability improvement? Aside from Makai et al [39] and Henderson et al [54], no other economic evaluation employing an ICECAP measure has to date produced an ICER with respect to the measure. This is likely to be due to the measure being new and unfamiliar to decision makers, so the evaluation team has used EQ-5D/ QALYs (as Henderson et al [54] do) or a clinical measure [55].…”

“…A number of these are trials (including the CTO trial which is employing the OxCAP-MH also [36]) and include other measures in order to assess the sensitivity and validity of the ICECAP instrument (as would be expected with a new measure 4 ). A large majority of the trials/studies focus on physical interventions (e.g., fall prevention [38]), social care interventions (e.g., integrated care models [39]) and mental health interventions (e.g., the CTO trial [36], carers of dementia patients [40]). However, the measures are being used in pharmaceutical trials; ICECAP-A is a secondary outcome measure in a trial comparing aflibercept therapy with panretinal photocoagulation (PRP) in patients with diabetic retinopathy [41] and is also a secondary outcome measure in a trial evaluating the effectiveness and cost effectiveness of different hormonal treatments after surgery for endometriosis [42].…”

Maximizing Health or Sufficient Capability in Economic Evaluation? A Methodological Experiment of Treatment for Drug Addiction

“…Capability wellbeing has so far been utilised alongside health-related measures of quality of life using the maximisation principle and not in terms of equalisation or sufficient capability as recommended [91]. Even as such, a parallel use of the ICECAP measures in economic evaluations alongside the commonly used instruments may act as a safety-pillar to basecase analyses if results are verified [92,93]. The two instruments, however, are quite distinct in what they measure and, therefore, the health effects of an intervention may not always be translated into a capability improvement, and similarly an absence of a health effect may not always imply the absence of important capability wellbeing gains.…”