City University notes

AJ Fischer

October 2003

Nancy’s QuestionsQ1 Different people present material with

different cost perspectives?

A With all such conundrums, one hopes the different ways are not material to the

decision to be made. If not, NICE muddles through. Wouldn’t you? Proper answer: NICE subjects data to Bayesian analysis, contributions being weighted by beliefs about the relative merits of each component. (Wish it were true!)

Nancy’s Questions

Q2 What does NICE do when faced with CE ratios using different output measures?

A In terms of cost per QALY, the CE ratio should contain all relevant output measures. If benefits are not in terms of QALYs, the decision becomes difficult. Answers will be made on a case-by-case basis. Depends how clear-cut things are: if very high or very low cost per QALY, the correct decision will not be in doubt. If the case is near the threshold, then the extra uncertainty will not result in

a great efficiency loss if the wrong decision is made.

Nancy’s QuestionsQ3 What does NICE do when faced with

QALYs measured in two different ways in a particular appraisal?

A Again, one hopes firstly that the decision to be made does not depend on the measurement method. If the method matters, then probably even God doesn’t know the right answer.

Nancy’s Naughty QuestionQ4 How would NICE assess the costs and benefits of

IVF?

A The costs do not pose much of a problem. The benefits, as ever, are more difficult. How many life years are to be given to a live embryo compared with a dead one or the absence of one? At 39 weeks? At 30 weeks? At 12 weeks? At 3 weeks? Who knows the answer? The Committee will make a decision, but will not really like doing so. They do so in the absence of any scientific or research guidance about what the answer should be. Further, is this about health or about lifestyle? Who should judge? Should the taxpayer pay for lifestyle improvements?

Nancy’s QuestionsQ5 How does NICE weigh up “scientific”

evidence with patient evidence?

A If patient evidence is “scientific”, it will become part of the scientific evidence. Therefore, what is left is not “scientific” and should be disregarded.

Fortunately, that is not the end of the question: (1) we are all humans

(2) X-inefficiency

Nancy’s QuestionsQ6 How does NICE weigh up RCT

evidence with evidence of poorer quality? A If sufficient RCT evidence is available,

then there will be no need to go to other, potentially biased, sources of evidence, such as case series or case studies. If no RCT evidence is available, or is sparse or of poor

quality, then it makes sense to look towards other evidence.

Nancy’s QuestionsQ7 NICE provides guidance at national

level which must be followed locally. What if some local projects have lower cost per QALY?

A This is in part an equity-efficiency trade-off. It is not equitable to have postcode prescribing, so it has been made mandatory to follow NICE guidance. But there are limits. Currently, we just don’t know the worth of projects forgone.