Pharmacoeconomics

Introduction
 introduction
Capaian Pembelajaran : Mahasiswa mampu

• Menganalisis dan menetapkan maslah Kesehatan terkait penggunaan obat pasien dengan mempertimbangkan kebutuhan,
pedoman terapi, biaya, dan ketentuan regulasi

• Merencanakan, menetapkan prioritas dan menyelesaikan masalah terkait obat

• Menjelaskan keterkaitan FE dengan pengembangan obat dengan benar

• Mengevaluasi clinical outcome (efektifitas dan keamanan), economic outcome, humanistic outcome (pengukuran kualitas
hidup) dan biaya obat dengan benar

• Melakukan evaluasi FE dengan berbagai metode meliputi :

• Analisis biaya, analisis cost minimization, analisis cost benefit, analisis cost effectiveness, dan analisis cost utility
• Analisis keputusan dalam evaluasi farmakoekonomi dengan benar
Reference
The Importance of Pharmacoeconomics
Indonesia in the Universal Health Coverage (Jaminan Kesehatan Nasional/JKN) era
Referal system : before and after
UHC
BPJS Premium
Law First class Second class Third class PBI
Peraturan 80.000 51.000 25.500 23.000
presiden nomor (paid by
19 tahun 2016 government)
Peraturan 160.000 110.000 42.000 42.000
presiden nomor
64 tahun 2020
How do healthcare provider get
paid?
TERIMA KASIH
 The Role of
economic
evaluation and
priority setting in
health care
decision making
 10

why setting priorities

➜ resources are scarce and health care
expenditures have real opportunity costs
➜ balance between cost and benefits crucial
from a welfare economic perspective
➜ still, the fact that health care or particular
interventions are expensive is not a
problem in itselft as long as the related
benefits are high enough
 11

the criteria
➜ necessity (seriousness of illness
and reason for claim on
solidarity)
➜ effectiveness (how well treatment
works to solve problem)
➜ cost-effectiveness (balancing cost
& effects; includes (2), often in
QALYs)
 12

some dilema : a lesson from

dutch
 13

efficiency vs equity
 14

prioritas kesehatan indonesia

➜ rencana pembangunan jangka menengah

nasional (RPJMN) bidang kesehatan tahun
2020 - 2024
- meningkatkan pelayanan kesehatan
menuju cakupan kesehatan semesta
melalui peningkatan upaya promotif
dan preventif, didukung inovasi da
pemanfaatan teknologi
 15

fokus strategi pembangunan

kesehatan

➜ kesehatan ibu dan anak

➜ kesehatan reproduksi
➜ perbaikan gizi masyarakat
➜ pencegahan dan penguatan sistem kesehatan
➜ pengawasan obat dan makanan
 16

isu kesehatan yang harus

diselesaikan
➜ stunting
➜ angka kematian ibu dan angka kematian bayi
➜ perbaikan manajemen jaminan kesehatan nasional
➜ penguatan pelayanan kesehatan, obat serta
➜ kemandirian obat dan alat kesehatan
➜ covid-19 (public health emergency and international
concern)
 17

priority setting in health care

➜ in Indonesia, high volume, high

risk, high cost is considered
➜ pharmacoeconomics provide a
quantitative analysis in order to
help prioritization
Outcome Research :
how do we collect the
outcome information
health economic
outcomes
clinical

humanistic economic
clinical outcomes
primary vs secondary
data

21
economic outcomes
⬡ usually economic outcomes are converted
from clinical outcomes
∙ cost per patient avoided

22
23
humanistic outcomes
⬡ health - quality of life (QoL) - health related
quality of life (HrQoL)
⬡ quality adjusted life years
∙ utility

24
questionnaire
⬡ disease or condition specific questinnaire
∙ more detail for a specific condition
∙ EORTC QLQ 30
⬡ generic questionnaire
∙ can be implemented for wide range of
states
∙ EQ-5D, SF-36 etc

25
 5
o
26
f life
uality
pa n q nsion
euro dime 5D
EQ-
COSTING AND PERSPECTIVES :
HOW DO WE IDENTIFY AND COLLECT
THE COST INFORMATION
Cost Identification
and how to get it
direct cost

⬡ all cost due to resource use that are completelyributable to the use of a health care
intervention or illness
∙ direct medical cost
∙ hospitalization, medicine, laboratory, professional fee, etc
∙ direct non medical cost
∙ transportation, additional room, parking, food, etc
⬡ what is the source of these information?
⬡ how to obtain the information?
data source (primary
data)

30
indirect cost

⬡ all cost that are indirectly spent by the patients or relatives due to illness (ex. productivity
loss)
∙ human capital approach, based on monthly income
∙ monthly income/30 days
∙ friction cost approach, based on how much time (or investment) is required to replace
the person who are ill
∙ the time required to replace cashier and professional chef are different
⬡ what is the source of information?
31
⬡ how to obtain the information?
data source (primary
data)
data dari wawancara pasien

32
33
⬡ biaya tidak langsung : human capital approach
⬡ a monetary value on loss of health as the lost value of economic productivity due to ill health,
disability, or premature mortality
∙ calculate using income based method
∙ multiply the number of days with the daily income
∙ in Indonesia ; GDP, min regional income (UMR), observational/interview
⬡ ex :
∙ monthly income 3,000,000 34
∙ LoS 10 days
∙ Productivity loss = (3,000,000/30 days) x 10 days
= 1,000,000
data source (secondary
data)

35
intangible cost
⬡ an unquantifiable cost relating to an
identifiable source (illness)
∙ ex : nyeri karena sakit kanker -
menyebabkan kehilangan pekerjaan
dll

⬡ what is the source of these information?

36
⬡ how to obtain the information?
do we need to collect
them all?
we need a perspective

37
common perspectives in
health economic
evaluation
perspectives vs cost

39
which perspective
should you choose?

40
 detail biaya yang dikeluarkan jumlah

pengaruh perspektif thd biaya obat 1.500.00

0
perhitungan biaya biaya alat kesehatan 505.634
⬡ contoh perhitungan biaya yang disesuaikan
biaya jasa profesional (utk 9x pemberian 405.000
dengan perspektif studi: layanan dr spesialis)
biaya pengobatan seorang pasien laki-laki biaya kamar 585.000
peserta BPJS usia 50 th, denga diagnosis
gangren dan DM yang mendapatkan biaya pemeriksaan lab dan dignosis 714.000
perawatan di sebuah RS selama 9 hari
biaya pelayanan kesehatan lainnya (termasuk 870.000
adalah sbb : biaya konsultasi gizi klinis, tindakan
*ket : diperoleh dari wawancara langsung pembersihan luka)
dengan pasien dan keluarga pasien jika biaya transportasi 110.000
studi dilakukan secara prospektif
biaya makan untuk istri yang mendampingi 375.000
selama perawatan
(istri pasien tdk membutuhkan biaya
penginapan krn bermalam di RS : adl ibu rumah
tangga yang tdk memiliki penghasilan)
exercise
⬡ define and calculate
∙ direct medical cost
∙ direct non medical cost
∙ indirect cost

42
 Cost-Analysis

Cost-minimization
Analysis (CMA)

Cost-effectiveness
Analysis (CEA)

Cost-Benefit
Analysis (CBA)

Cost-Utility
Tipe Evaluasi Analysis (CUA)
Farmakoekonomi
 COST ANALYSIS

• Menilai semua biaya dlm perlakuan/pengobatan

• Merupakan tipe analisis yg sederhana
• Tdk membandingkan perlakuan/pengobatan atau
mengevaluasi efikasi

Misal : biaya pemberian antibiotik scr intravena

Metode ini menunjukkan berapa biaya total sesungguhnya

dan dpt mengidentifikasi biaya-biaya tersembunyi
 COST ANALYSIS

Biaya Penggunaan antibiotik iv

acquisition cost, biaya penyiapan dan pemberian, biaya laboratorium

biaya komplikasi, biaya sub-optimal terapi

Total Biaya perhari Cephalosporin generasi 3

Acq.cost Delivery cost cost/dose Total

Ceftriaxone 19,38 7,13 26,51 26,51

1 g / hari

Cefotaxime 9,29 7,13 16,42 49,26

1 g 3 x sehari
 COST MINIMIZATION ANALYSIS

• membandingkan total biaya dari dua atau lebih perlakuan

• outcome klinik dari kedua perlakuan identik dlm populasi
yg sama

Misal : membandingkan biaya total penggunaan 2 atau lebih

obat yg efikasi dan efek sampingnya sama (ekivalen)

CMA memfokuskan pada penentuan obat mana yg biaya per

harinya paling murah
 COST MINIMIZATION ANALYSIS

Terapi obat pada pasien rawat inap di RS

Direct Medical Cost
Direct cost : biaya yg lansung berkaitan dengan pengobatan

Contoh :
• drug acquisition cost
• biaya pemberian obat (staf dan peralatan)
• Konsultasi
• biaya uji diagnostik
• perawatan rumah sakit
• biaya untuk mengatasi efek samping
 COST MINIMIZATION ANALYSIS

Direct non Medical Cost

Direct non medical cost : biaya yg berkaitan dg penyakit, tetapi
tdk
secara langsung berhubungan dgn pengobatan

Contoh :
• cleaning/catering/perawatan bangunan RS
• bantuan dari rumah
• perawatan anak
• biaya transport pasien dari dan ke RS
 COST MINIMIZATION ANALYSIS

Indirect Cost
Indirect cost : biaya yg berkaitan dg kehilangan produktivitas

Contoh :
• biaya karena kehilangan kesempatan utk mendapatkan uang
• biaya karena tidak masuk kerja
• kehilangan produktivitas di rumah
 COST EFFECTIVENESS ANALYSIS

• membandingkan dua perlakuan yg pengaruhnya tdk sama

• pengukuran efikasi menggunakan unit outcome yg sama
(misal : mmHg, mortalitas)
• Unit berupa penilaian : - biaya per outcome
- rasio (obat A : obat B)

Misal : dua obat atau lebih yg digunakan utk mengobati

suatu indikasi yg sama tetapi cost dan benefit (efikasi)
berbeda
 COST EFFECTIVENESS ANALYSIS

High cost Low cost

High ???? Accept

effectiveness

Low Reject ????

effectiveness
 COST EFFECTIVENESS ANALYSIS

• Pohon keputusan
- identifikasi alternatif intervensi
- menggambarkan hubungan antara input & sumber
daya yg digunakan dgn outcome kesehatan

• Pengukuran outcome
- pengumpulan data primer
- informasi dr penelitian yg sudah dipublikasikan
- opini ahli terkait
 COST EFFECTIVENESS ANALYSIS

• Independent programmes
ACER = cost of intervention
health effects produced

• Mutually exclusive intervention

ICER = difference in cost between
programmes P1 and P2
difference in health effects between
programmes P1 and P2
 COST UTILITY ANALYSIS

• Sama dengan CEA tetapi memasukkan komponen

kualitas hidup
• Dapat dikombinasikan bbrp outcome ke dlm satu
pengukuran utk analisis ekonomi
• Unit CUA yg sering digunakan Quality adjusted
life-year (QLAY)
• sesuai digunakan dlm manajemen penyakit kronis
 COST UTILITY ANALYSIS

Indikasi dilakukan CUA (Drummond) :

 Jika kualitas hidup merupakan kriteria yg penting
 Jika kualitas hidup merupakan parameter outcome
sesudah survival
 Jika ada hubungan antara morbiditas dan mortalitas
 Jika terdapat perbedaan yang luas pada outcome
beberapa alternatif yang dibandingkan
 Hasil dari CUA :

direct costs + indirect cost

QALY
 COST UTILITY ANALYSIS

An intervention giving 3 years extra life of “perfect quality” will give

3 x 1 = 3 QALY. Three years extra life at an index score of 0.5
would give 3 x 0.5 = 1.5 QALY. Cost-utility is then stated at cost per QALY.
 COST UTILITY ANALYSIS

Intervention A
Prevents certain death and gives
2 years of perfect health.
Costs £5000.
Intervention B
Improves the quality of life
significantly (scored as a move
from 0.7 on a scale to 0.99) for
the last 10 years of life.
Costs £10,000 over 10 years.

2 x 1 = 2 QALY B: 10 x 0.29 = 2.9 QALY

£2500 per QALY B: £3450 per QALY
 COST BENEFIT ANALYSIS

• membandingkan perlakuan yg berbeda utk kondisi

yg berbeda
• Mengukur biaya & keuntungan dalam unit uang yg sama
• Mrpkn tipe penilaian farmakoekonomi yg komprehensif
& sulit dilakukan (mengkonversi benefit kedalam
nilai uang)
 COST BENEFIT ANALYSIS

Pengukuran Benefit
• Direct benefit
• Indirect benefit
• Intangible benefit

Benefit-to-cost ratio = total benefit

total cost

If B/C > 1, then benefits exceed costs & the program is

socially valuable
If B/C = 1, then benefits equal costs
If B/C < 1, then benefits are less than costs; therefore, the
program is not socially benefecial
 TIPE EVALUASI
FARMAKOEKONOMI

Analysis Cost Measurement Outcome

measurement

Cost-Benefit $$$ $$$

Cost-Effectiveness $$$ Single outcome,

natural units (life-
years gained, mmHg
blood pressure)
Cost-Minimization $$$ Equivalence
demonstrated in
comparative groups
Cost-Utility $$$ Natural units
adjusted for quality
(Quality of life)
 Algoritme untuk menentukan metode

Perbandingan statistik, efikasi klinik A vs efikasi klinik B

Jika efikasi A lebih

Jika efikasi A sama
besar secara bermakna
Dengan efikasi B
dari efikasi B

CMA

Clinical unit Economic unit Utility Unit

CEA CBA CUA

Langkah-langkah dlm melakukan evaluasi Farmakoekonomi

DESIGN • Tujuan
• Sampel
• Deskripsi perbandingan
• Mengukur konsekuensi
• Mengukur biaya
 1. TUJUAN

• Permasalahan/Pertanyaan yang akan dijawab

• Perspektif
• Alternatif terapi
• Populasi atau kelompok yang akan diteliti
• Apa relevansi klinik dari studi
 2. SELEKSI SAMPEL

Apakah kelompok uji sudah representatif ?

• Pasien tepat
• karakteristik demografi pasien
• Kriteria diagnostik
 3. DESKRIPSI PEMBANDING

Apakah alternatif yg dibandingkan sudah ditetapkan ?

• Biaya
• Konsekuensi : Apa kesimpulannya ?
Apakah alternatif terapi sesuai dgn tujuan studi ?
Apakah semua alternatif sudah dipertimbangkan ?
 4. MENGUKUR KONSEKUENSI/OUTCOME

Apakah outcome sudah diidentifikasi & diukur ?

• Apakah outcome terkait sudah diukur dalam istilah
yang tepat (mis. Unit moneter, tekanan darah, mortalitas,
atau kualitas hidup)
• Apakah end point obyektif dan relevan
 5. MENGUKUR BIAYA

Apakah semua biaya sudah diidentifikasi & diukur ?

• Apakah semua biaya sudah diukur dengan akurat dalam
unit yang tepat (sesuai dgn perspektif studi)
• Apakah semua biaya operasional sudah dimasukkan ?
• Apakah digunakan harga riil ?
• Apakah biaya spesifik pada sistem pelayanan kesehatan
atau daerah ?
Langkah-langkah dlm melakukan evaluasi Farmakoekonomi

ANALISIS • Tipe Analisis

• Analisis Incremental
• Discounting
• Analisis Sensitivitas
 1. TIPE ANALISIS

Apakah analisis farmakoekonomi yg digunakan sudah tepat ?

• Metode tepat

(cost analysis, CMA, CEA, CUA, CBA)

• Apakah judul sudah tepat utk tipe analisis ?
• Apakah kesimpulan yang diukur sudah tepat ?
 2. ANALISIS INCREMENTAL

Apakah dilakukan analisis incremental ?

• Rasio biaya dan outcome
• Membandingkan incremental costs dan incremental outcomes
• Apakah incremental analysis dilakukan (jika relevan)

Hasil dari analisis C/E dilaporkan sbg rasio rata-rata atau

Incremental C/E (atau dua-duanya)
 3. DISCOUNTING

• Digunakan jika biaya dan/atau konsekuensi diterapkan

dalam periode waktu yang lama
• Apakah angka discounting ditetapkan
 4. ANALISIS SENSITIVITAS

• ‘What if’ analysis

• Apakah dilakukan analisis sensitivitas dalam rentang nilai
yg dianalisa
• Apakah kesimpulan sensitif terhadap perubahan nilai
Langkah-langkah dlm melakukan evaluasi Farmakoekonomi

INTERPRETASI • HASIL
• DISKUSI
• KESIMPULAN
 1. HASIL

Apakah hasil disampaikan dengan jelas ?

• Seluruhnya, jelas dan akurat

• Perhatian pada biaya dan benefit yang berbeda
 2. DISKUSI

Apakah penulis menjelaskan penelitiannya secara penuh ?

• Diskusi asumsi, keterbatasan dan kemungkinan bias
• Apakah hasil dibandingkan dengan penelitian sebelumnya
dgn masalah yg sama
• Apakah implikasi klinik disebutkan ?
• Apakah semua masalah yg diteliti disebutkan ?
• Apakah masalah etik disebutkan ?
 3. KESIMPULAN

• Valid & didasarkan pada hasil dan desain studi

• Apakah kesimpulan ditetapkan ?
(satu obat lebih efektif dibandingkan lainnya)
• Apakah dibuat rekomendasi ?
• Penerapan hasil penelitian
 CONTOH APLIKASI

COST MINIMIZATION ANALYSIS

Tittle
A cost-minimization analysis of diuretic-based antihypertensive
therapy reducing cardiovascular events in older adults with
isolated systolic hypertension

Purpose
to assess the cost of alternative antihypertensive treatments
in older adults with isolated systolic hypertension (ISH)
 COST MINIMIZATION ANALYSIS

Method
The cost was presented as the cost of number-needed to treat
(NNT) of patients for 5 years to prevent one adverse event
associated with cardiovascular disease (CVD)

Result
It was found that the cost of 5 year NNT to prevent one adverse
CVD event ranged widely from $6,843 to $37,408. The incremental
cost of the 5 year NNT was lower to treat older patients in the
very high CVD risk group relative to patients in the lower
CVD risk group, ranging from $456 to $15,511. Compared
to the cost of the 5 year NNT of other commonly prescribed
antihypertensive drugs, the cost of SHEP-based therapy is the lowest
COST MINIMIZATION ANALYSIS

Conclusion
Antihypertensive therapy that is diuretic-based and that includes
either low-dose reserpine or atenolol is an effective and relatively
inexpensive strategy to prevent cardiovascular events in older
adults with isolated systolic hypertension. Use of the diuretics-
based therapy is the most cost-effective in patients at high risk
for developing cardiovascular disease
 CONTOH APLIKASI

COST EFFECTIVENESS ANALYSIS

TITTLE :
Cost-effectiveness Analysis of Improved Blood Pressure
Control in Hypertensive

OBJECTIVES :
to estimate the economic efficiency of tight blood pressure
control, with ACE inh or β-blocker, compared with less
tight control in hypertensive patient with
type 2 diabetes
COST EFFECTIVENESS ANALYSIS

Design
cost effectiveness analysis incorporating within trial analysis
and estimation of impact on life expectancy through use of the
within trial hazards of reaching a defined clinical point.
Setting
20 hospital based clinics in England, Scotland & northern
Ireland

Subject
1148 hypertensive patients with type 2 DM from
UK prospective diabetes study randomised to
tight control of blood pressure (n=758) or
less tight control (n=390)
COST EFFECTIVENESS ANALYSIS

Main Outcome measure

cost-effectiveness ratio based on (a) use of healthcare
resources assosiated with tight control & less tight control and
treatment of complication and (b) within trial time free from
diabetes related endpoints, and life years gained
COST EFFECTIVENESS ANALYSIS

Result
based on use of resources driven by protocol, the incremental
cost-effectiveness of tight control compared with less tight
control was cost saving. Based on use of resources in standard
clinical practice, incremental cost per extra year free from
end points amounted to £ 1049. The incremental cost per life
years gained was £ 720 (cost & effects discounted at 6%
per year).
COST EFFECTIVENESS ANALYSIS

Conclusions
tight control of blood pressure in hypertensive patients with
type 2 DM substantially reduced the cost of complications,
increased the interval without complications & survival, and
had a cost effectiveness ratio
 CONTOH APLIKASI

COST UTILITY ANALYSIS

TITTLE : Cost-Utility Analysis of Chemotherapy Using Paclitaxel,

Docetaxel, or Vinorelbine for Patients With Anthracycline-Resistant
Breast Cancer

OBJECTIVES :
Paclitaxel, docetaxel, and vinorelbine have been approved for
chemotherapy in patients with advanced breast cancer that is
resistant to anthracyclines. Selecting which agent to use is difficult
because each possesses advantages and disadvantages related to
clinical response, toxicity, method of administration, and cost.
A cost-utility analysis was therefore performed to create a rank
order on the basis of effectiveness, quality of life, and economic
considerations.
COST UTILITY ANALYSIS

PATIENTS AND METHODS: Eighty-eight anthracycline-resistant

breast cancer patients who had received paclitaxel (n = 34),
docetaxel (n = 29), or vinorelbine (n = 25) during the past 2 years
were identified. Total resource consumption was collected,
which included expenditures for chemotherapy, supportive care,
laboratory tests, management of adverse effects, and all related
physician fees. Utilities from 25 oncology care providers and 25
breast cancer patients were estimated using the time trade-off
technique. The economic estimates from the chart review and
clinical data from the literature were then modeled using the
principles of decision analysis.
COST UTILITY ANALYSIS

RESULTS:
Each of the three drugs led to a similar duration of
quality-adjusted progression-free survival (paclitaxel, 37.2 days;
docetaxel, 33.6 days; vinorelbine, 38.0 days). Vinorelbine was the
least costly strategy, with an overall treatment expenditure of
Can $3,259 per patient, compared with Can $6,039 and
Can $10,090 for paclitaxel and docetaxel, respectively.
COST UTILITY ANALYSIS

CONCLUSION:
Palliative chemotherapy with vinorelbine in anthracycline-resistant
metastatic breast cancer patients has economic advantages over
the taxanes and provides at least equivalent quality-adjusted
progression-free survival. These benefits are largely related to
its lower drug acquisition cost and better toxicity profile.
 CONTOH APLIKASI

COST BENEFIT ANALYSIS

Tittle
A cost-benefit Analysis of Testing for influenza A in High-Risk
Adults

Purpose
to determine when rapid testing, empiric treatment, or no
treatment is most cost-beneficial for high risk adults with influenza-
like respiratory tract illnesses
COST BENEFIT ANALYSIS

Method
performed a cost-benefit analysis evaluating the comparative
advantage of the strategies of empiric therapy, no treatment, or
test & treat patients whose tests are positive. The analysis focused
on a hypothetical population of patients who are at a high-risk
for complications of influenza.
COST BENEFIT ANALYSIS

Results
For older antiinfluenza drugs (amantadine & rimantadine), rapid
testing is not as cost-beneficial as empiric treatment, even when
prevalence of influenza is low. For the neuraminidase inhibitors,
there is a narrow window of disease prevalence between 30%
and 40% where testing is most cost-beneficial. When the disease
likelihood is above this window, empiric treatment is preferred.
Below this window, no treatment is more cost-beneficial. Even
under the most favorable conditions, testing is preferred only
for a small range of prevalence rates of influenza
COST BENEFIT ANALYSIS

Conclusion
When clinicians are planning to use the nonneuraminidase inhibitors
to treat influenza, rapid testing is not the most cost-beneficial
approach. Even when the more expensive neuraminidase
inhibitors will be used, testing has a limited role in managing
influenza in high-risk patients.
 Health Care Service

People will generally suffer, due to :

Limited access to service
Low quality of service
Inability to afford the service
Universal Health Coverage

Current pooled funds is always limited

Need a budget allocation methods

Health Economic Evaluation

Health Economic Evaluation
Provide information (evidence) to decision makers for
efficient use of available resources for maximizing
health benefits

•Health economic evaluation is two dimentional

analysis from two (or more) alternatives of health
technology

• Two dimention : input (cost) and output (health, monetary, humanistic)

• Health technology : drugs, medication technology, diagnostic tools,
prevention strategy
Cost Effectiveness Plane (CEP)
 How cost effectiveness analysis work
Drugs Cost ( ＄ ) Outcomes
A 10,000 0,75
B1 10,500 0,83
B2 9,800 0,80
B3 10,800 0,78
 Incremental cost effectiveness ratio
(ICER)

• The unit of ICER?

• How to interpret ICER?

Decision maker needs a cut off points or threshold called willingness to pay (WTP)
Willingness to pay
Decision making process