Gillian Sanders Schmidler, PhD

Value-based care approaches require some initial judgement about the relative value of different options for addressing a particular health problem so that incentives and disincentives are designed to encourage use of the most effective, and, ideally, cost-effective, strategies. These judgments are often based on formal evidence-synthesis methods, including meta-analysis and cost-effectiveness analysis (CEA). Many key aspects of CEA, including which costs and outcomes to include and the analytic horizon over which those costs and outcomes are measured, are determined by the perspective of the analysis. Differences in perspective may lead to differences in judgments about relative value, which in turn may contribute to difficulty with design and implementation of value-based care. This project seeks to compare the effect of changing analytic perspectives in decision analytic models on conclusions about the relative value of different strategies across several therapeutic areas. We will re-analyze three previously published cost-effectiveness analyses from four different perspectives: (a) society, (b) overall healthcare sector, (c) individual payer, and (d) patient. Differences between these perspectives include the inclusion or exclusion of out-of-pocket and nonmedical costs, the analytic horizon, and the choice of aggregate outcomes such as quality-adjusted life years (QALYs) or discrete benefits (such as cancer deaths prevented) and harms (such as specific treatment complications or side effects). By illustrating the impact of changing perspective on value estimation in terms of both traditional economic measures such as cost/QALY, and in clinical metrics such as the ratio of discrete harms to benefits, this project will provide insight into the utility of incorporating additional perspectives beyond those of society and the healthcare sector into economic analyses, particularly those being done to support value-based care approaches. This insight should prove helpful in design, communication, and dissemination of those approaches by identifying potential conflicts in value conclusions earlier in the process, and by enhancing transparency during dissemination.