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The following extract from a recent project illustrates the quality of work we provide in reports. The hierarchical matrix illustrated was developed by John Nixon and colleagues with the aim of representing all the possible permutations of economic evaluations in such a way as to make the results clear for the purpose of decision-making by those who may not be health economists.
Since the first version, as described in the British Medical Journal (details below), the matrix has been updated to deal with the issue of colour not routinely being used in journal articles. To address this the cell groups have been given a prefix ('R' for red outcomes, 'A' for amber outcomes, and 'G' for green outcomes - analagous to a traffic light according to the original concept).
The figure summarises the results of a comparison of Letrozole versus tomoxifen in breast cancer treatment.
Nixon et al. (2001) hierarchical matrix for economic evaluations
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Cost
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Effect
|
|
+
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R1
|
-
|
|
=
|
R2
|
-
|
|
+
|
R3
|
=
|
|
-
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A1
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-
|
|
=
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A2
|
=
|
|
+
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A3=5
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+
|
|
-
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G1
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=
|
|
=
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G2
|
+
|
|
-
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G3
|
+
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|
Dranitsaris et al [6] = £5,744 [US$ 11,534] per quality-adjusted progression-free year gained; < £9,190[US$ 18,454] from sensitivity analyses.
Karnon et al [7] = £9,742 (CI: £6,943 - £26,957) [US$ 19,562 (CI: 13,942 – 54,130)] per QALY gained.
Karnon & Jones [8] = £3,349 - £4,541 [US$ 6,725-9,118] per QALY gained.
Marchetti et al [9] = £11,936 [US$ 23,967] per QALY (CI = £644-10,932) [US$ 12,940-21,951], letrozole cost < £10,105 [US$ 20,291] per QALY in 90% of simulations.
Okubo et al [10] = £3,994-5,416 [US$8,020-10,875] per QALY gained.
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[Full details of methods can be found in: Nixon, J., Khan, K.S., Kleijnen, J. (2001) 'Summary methods for economic evaluations included in systematic reviews,' BMJ, 322; 1596-1598. (FULL ARTICLE)
Legend: The hierarchical matrix shows the nine possible permutations at baseline. R1, R2 and R3 are ‘red’ cells indicating the intervention should be rejected; G1, G2 and G3 are ‘green’ cells indicating the intervention should be accepted. The ‘amber’ cell A2 indicates equivalence in health outcomes and costs, A3 indicates incremental cost-effectiveness of the intervention with respect to the comparator, and A1 indicates the intervention is less costly and less effective than the comparator.
In this example all five studies included in the review found that letrozole was more effective and more costly that the comparator drug, tamoxifen (Amber cell 3 = 5).
The text to the right of the matrix indicates how stable the results are under sensitivity analyses, and the ranges of incremental cost-effectiveness ratios (ICER) are provided to determine if the results are under the willingness to pay (WTP) threshold of the provider.
The table below shows how a standard checklist for economic evaluations can be adapted, using a formula (last row of table) to calculate a quality score for each economic evaluation included included in a review. This technique was developed initially by John Nixon and Francis Pang (Nixon, J., Pang, F. (2000) 'Economic Evaluations in Japan: A Review of Published Studies, Methodological Issues and Practice, PSAM 5 Vol 3/4, Eds. S. Kondo & K. Furuta; Universal Academy Press, Inc., Tokyo, Japan.) Full details of this particular example are provided in the Rogers et al. 2006 HTA report and link in the 'sample projects' page.
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Hofland et al.
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Mariani et al.
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1. The research question is stated.
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Y
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Y
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|
2. The economic importance of the research question is stated.
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Y
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Y
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|
3. The view point(s) of the analysis are stated.
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Y
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N
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|
4. The rationale for choosing the alternative programmes or interventions are stated.
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Y
|
Y
|
|
5. The alternatives being compared are clearly described.
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Y
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P
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|
6. The form of economic evaluation is stated.
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Y
|
P
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|
7. The choice of form of economic evaluation is justified in relation to the questions addressed.
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P
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N
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|
8. The source(s) of effectiveness estimates are stated.
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Y
|
Y
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|
9. Details of the design and results of effectiveness study are given (if based on a single study).
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Y
|
Y
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|
10. Details of methods of synthesis or meta-analysis of estimates are given (if based on an overview of a number of effectiveness studies).
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N/A
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N/A
|
|
11. The primary outcome measure(s) for the economic evaluation are clearly stated.
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Y
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Y
|
|
12. Methods to value health states and other benefits are stated.
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N/A
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N/A
|
|
13. Details from the subjects from whom valuations are obtained are given.
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N/A
|
N/A
|
|
14. Productivity changes (if included) are reported separately.
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N/A
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N/A
|
|
15. The relevance of productivity changes to the study question is discussed.
|
N
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N
|
|
16. Quantities of resources are reported separately from their unit costs.
|
Y
|
Y
|
|
17. Methods for the estimation of quantities and unit costs are described.
|
Y
|
P
|
|
18. Currency and price data are recorded.
|
Y
|
Y
|
|
19. Details of currency of price adjustments for inflation or currency conversion are given.
|
N/A
|
N/A
|
|
20. Details of any model used are given.
|
N/A
|
N/A
|
|
21. The choice of model used and key parameters on which it is based are justified.
|
N/A
|
N/A
|
|
22. The horizon of costs and benefits is stated.
|
Y
|
Y
|
|
23. The discount rate is stated.
|
N/A
|
N
|
|
24. The choice of rate is justified.
|
N/A
|
N
|
|
25. An explanation is given if costs or benefits are not discounted.
|
N/A
|
N
|
|
26. Details of statistical test and confidence intervals are given for stochastic data.
|
N
|
N
|
|
27. The approach to sensitivity analysis is given.
|
N
|
N
|
|
28. The choice of variables for sensitivity analysis is justified.
|
N/A
|
N/A
|
|
29. The ranges over which the variables are varied is stated.
|
N/A
|
N/A
|
|
30. Relevant alternatives are compared.
|
N/A
|
N/A
|
|
31. Incremental analysis is reported.
|
P
|
Y
|
|
32. Major outcomes are reported in a disaggregated as well as aggregated form.
|
Y
|
Y
|
|
33. The answer to the study question is given.
|
Y
|
Y
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|
34. Conclusions followed from the data reported.
|
Y
|
Y
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|
35. Conclusions are accompanied by the appropriate caveats.
|
Y
|
Y
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|
36. Generalisability issues are addressed.
|
N
|
N
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|
Total Yes (‘Y’)
|
17.5
|
15
|
|
Total Not Applicable (‘N/A')
|
13
|
10
|
|
Quality = Y/(36-N/A) x 100
|
76%
|
58%
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