Implication of Cost

effectiveness in the
management of Patients at
high CV-risk
Ronnie Rivany
Pusat Kajian Ekonomi Kesehatan
FKMUI

KARAKTERISTIK INDUSTRI KESEHATAN

Ekonomi Kesehatan

EKONOMI

KESEHATAN

Health Economics
Hospital Economics
Pharmacoeconomics
Dental Health Economics

Pharmacoeconomics
( Bootman et al, 1996)

The description and

analysis of the costs
of drug therapy to
health care systems
and society

Identifies, measures
and compares the
costs and
consequences of
pharmaceutical
products and
services

How to calculate ?

TEHNIK EVALUASI
EKONOMI KESEHATAN

Distinguishing Characteristic
of Health Care Evaluation
2

Scope of Examination: Both Cost and Consequences

o
r

NO

r
e

1A PARTIAL EVALUATION 1B

N Examine only
Consequences
m
O
o
Outcome
Description

YES

Examine only
Costs
2

PARTIAL EVALUATION

Cost
Description

A
l
3A PARTIAL EVALUATION 3B
t
e
r Y Efficacy or
Cost
n E Effectiveness
Analysis
a
Evaluation
t S
i
v
e
s

FULL ECONOMIC
EVALUATION
Cost-Minimization Analysis
Cost-Effectiveness Analysis
Cost-Utility Analysis
Cost-Benefit Analysis

Measurement of Costs & Consequences

Type of
Study

Measurement/
valuation of
cost in both
alternatives

Identification of Measurement/
consequences
valuation of
consequences

CMA

Dollars

Identical in all
None
relevant respects

CEA

Dollars

Single effect of
interest, common
to both
alternatives, but
achieved to
different degree

CBA

Dollars

Single or multiple Dollars

effect

CUA

Dollars

Single or multiple Healthy days,

effect
Quality adjusted
life years
(QALYs)

Natural units
(e.g. life years
gained, disability
days saved,

Tehnik Evaluasi
Ekonomi Kesehatan
(Drummond, 1995)
Tools

Cost
Benefit
Analysis

Cost
Cost
Effectivenes Utility
s
Analysis
Analysis

INPUT

Biaya
dalam
moneter

Biaya dalam
moneter

Biaya
dalam
moneter

CONSEQUENCES
( OUTPUT /
OUTCOME )

Perolehan
/penghind
aran hasil
dalam
nilai
moneter

Cakupan
yang
diperoleh

Perolehan
hasil
dalam
kualitas
hidup yg
terkait

Compone
nt

Cost
Minimizati
on
Analysis

COST
DIRECT COST

INDIRECT COST

Organizing and operating

costs within the health sector
(e.g. health professional time,
supplies, equipment, capital
costs)

Time lost from work

Costs borne by patients and

their families (e.g. out of
pocket expenses, patient and
family input into treatment)

Psychic cost

CONSEQUENCES
( OUTPUT / OUTCOME / EFFECT )
Changes

in physical, social and emotional

functioning (effects)
Changes

Changes

in resources use (benefits)

in the quality of life of patients

and their families (utility)

CONSEQUENCES
( OUTPUT / OUTCOME / EFFECT )
DIRECT BENEFIT

INDIRECT BENEFIT

Savings in resources use

Savings in lost work time

Savings in expenditure or
leisure time input

Savings in Cost of illness

How to calculate ? (1)

Drug # 1

Cost of
Illness
(a)

Cost of
Cost of
Interventio Savings
n
(c) = (a) (b)
(b)

dihitung
dari biaya
yang
dibutuhk
an untuk
Rawat
Inap (+)
Rawat
jalan

Dihitung dari
biaya program /
intervensi
dengan Drug #
1 yang telah
dilakukan dalam
kurun waktu
tertentu

Dihitung dari
biaya
penghematan
yang diperoleh
dari pengurangan
biaya RI (+) RJ
dengan Biaya
Program

Clinical Pathway
S.O.P
Tindakan a
Tindakan b
Tindakan c
Tindakan

Hari.1

Cost of Illness
Hari.2

Hari.3

Hari
..

Clinical Pathway
S.O.P
Perawatan

Hari
..
+

Pemeriksa
an
Tindakan

Operasi

Hari.1

Cost of Illness
Craniotomy
Hari.2

Hari.3

Komponen Biaya Cedera Kepala dengan

Craniotomy di RS X (> 17 th) 2003
MDC.1 DRG.2
Biaya
Rata-rata (Rp)
%
Perawatan
1.166.907
10,4
Obat & Alkes
3.357.413
30
Pemeriksaan
600.435
5,4
Penunjang
Sewa Kamar
2.433.364
21,7
Operasi
Jasa Yan
3.559.348
31,8
Medis
IGD
78.709
0,7
Total
11.196.177
100

How to calculate ? (2)

Cost

Benefit

Total biaya
yang
dibutuhkan
untuk
melaksanaka
n program

Biaya sakit
yang dapat
dihindari oleh
karena
intervensi
program

Rasio
C/B
(<1)

Drug # 1

Drug # 2

Cost Modeling (1)

STRUKTUR BIAYA.1
Alternative
s
Drug # 1

Drug # 2

INVESTASI OPERASIONA PEMELIHARAA

L
N

?
?

Cost Modeling (1)

STRUKTUR BIAYA.2
Alternative
s
Drug # 1

Drug # 2

FIXED
COST

VARIABEL
COST

TOTAL COST

Cost Modeling (2)

ANALISIS BIAYA & BIAYA SATUAN
Alternative
s

Semester Semester
1
2
0 6 bln 6 12 bln

Semester
3
12 18
bln

Semester
4
18 24
bln

Drug # 1

Total
Cost/jumla
h cakupan

Drug # 2

Total
Cost/jumla
h cakupan

Cost Modeling (3) RASIO

Alternat
if
Drug # 1

Drug # 2

Cost
Minimizati
on
Analysis

Cost
Benefit
Analysis

Cost
Cost
Effectivenes Utility
s
Analysis
Analysis

CEA of
Alternatives Immunizations.1
No Alternative Cost
s

Effectivenes
s

Campaign

$
75,000

15.000

MCM
Clinics

$
45,000

15.000

Mobile
Units

$
65,000

15.000

CEA of
Alternatives Immunizations.2
No Alternative Cost
s

Effectivenes CE
s
Ratio

Campaign

$
75,000

15.000

$ 5.00
/ imm

MCM
Clinics

$
45,000

15.000

$ 3.00
/ imm

Mobile
Units

$
65,000

15.000

$ 4.33
/ imm

CEA of
Alternatives Immunizations.3
No Program Cost
s

Effectivenes CE Ratio
$ per life
s
No. of lives saved

$
10
100,000

$
12
100,000

$
15
200,000

saved

CEA of
Alternatives Immunizations.4
No Program Cost
s

Effectivenes CE Ratio
$ per life
s
No. of lives saved

saved

$
10
100,000

10,000

$
12
100,000

8,333

$
15
200,000

13,333

Gambar IV.1
Pola pikir Cost Utility Analysis

Direct
Cost
Total Cost
Indirect
Cost
Cost
QALYs

EQ-5D
INA-HRQol

Utility

HUI-3

QALY's
Time
preference

The Benefits of Ramipril

Ramipril significantly
reduces the rates of
death, myocardial
infarction, and stroke
in a broad range of
high-risk patients who
are not known to
have a low ejection
fraction or heart
failure ( N Engl J Med
2000;342:145-53 )

Aortic artery
Superior
vena cava

Pulmonary artery

Pulmonary veins
Pulmonary veins

Left atrium

Left coronary artery

Right atrium

Anterior
interventricular artery
Great cardiac
vein
Right coronary
artery

Fat

Right ventricle

Inferior
vena cava

Anterior
cardiac veins

HEART

Descending aorta

Definisi Operasional
Ramipril

Placebo

Standard (+) Obat2an yang

diberikan
Ramipril
secara
Standard
Dari SOP
Cardiovascula
r

Effects of an Angiostensin-Converting-Enzyme
Inhibitor, Ramipril,on Cardiovasculer events in
High-Risk patients ( HOPE Investigator,2000)
Reduces of

Ramipril

Placebo

The rate of death

6,1 %

8,1 %

Myocardial
infarction

9,9 %

12,3 %

Stroke

3,4 %

4,9 %

Death from any

cause

10,4 %

12,2 %

Revascularization
Procedure

16,0 %

18,3 %

Cardiac arrest

0,8 %

1,3 %

Heart failure

9,0 %

11,5 %

Complication
related
to Diabetes

6,4 %

7,6 %

The cost-effectiveness of Ramipril in the

treatment of patients at high risk of
cardiovascular events
(BJORHOLT et al,2002)
Reduces of

Ramipril

Placebo

The rate of death

6,1 %

8,1 %

10,4 %

12,2 %

All cause mortality

The cost-effectiveness of Ramipril in the treatment

of patients at high risk of cardiovascular events
(BJORHOLT et al,2002)
Cost

Cost/LYG
SEK

Cost/CVE avoided
SEK

Direct medical

16 600

76 100

Direct medical
+direct non
medical + indirect

16 100

73 800

Direct medical

45 400

207 300

Direct medical
+direct non
medical + indirect

54 600

249 600

Cardiovascular only

All disease

Cost Implications of the Use of Ramipril in HighRisk Patients Based on the Heart Outcomes
Prevention Evaluation (HOPE) Study
(Lamy et al, 2003)
Primary
outcomes

Ramipril

Placebo

Cardiovascular
death

6,1 %

8,1 %

Myocardial
infarction

9,9 %

12,3 %

Stroke

3,4 %

4,9 %

10,4 %

12,2 %

Death from any

cause

Summary of the Impact of Ramipril in the HOPE Study

Cost Implications of the Use of Ramipril in HighRisk Patients Based on the Heart Outcomes
Prevention Evaluation (HOPE) Study
(Lamy et al, 2003)
Secondary
outcomes

Ramipril

Placebo

Revascularization

16,0 %

18,4 %

Hospitalization for
unstable Angina

11,9 %

12,2 %

Complications of
Diabetes

6,5 %

7,7 %

Hospitalization for
Congestive Heart
failure

3,0 %

3,5 %

Summary of the Impact of Ramipril in the HOPE Study

Cost Implications of the Use of Ramipril in High-Risk

Patients Based on the Heart Outcomes Prevention
Evaluation (HOPE) Study
(Lamy et al, 2003)
Other outcomes

Ramipril

Placebo

9,0 %

11,5 %

23,8 %

26,3 %

New diabetes

3,6 %

5,4 %

Overt nephropathy

3,1 %

4,0 %

Nonfatal cardiac
arrest

0,3 %

0,6 %

Hospitalization for
ventricular
arrhythmia

0,2 %

0,5 %

Transient ischemia
attack

1,0 %

1,4 %

Heart failure
Worsening angina

Unstable angina +
3,8 %
ECG
changes
Summary
of the Impact of Ramipril in the HOPE Study

3,9 %

Effects of an Angiostensin-Converting-Enzyme
Inhibitor, Ramipril,on Cardiovasculer events in
High-Risk patients ( HOPE Investigator,2000)
Reduces of

Ramipril

Placebo

The rate of death

6,1 %

8,1 %

Myocardial
infarction

9,9 %

12,3 %

Stroke

3,4 %

4,9 %

Death from any

cause

10,4 %

12,2 %

Revascularization
Procedure

16,0 %

18,3 %

Cardiac arrest

0,8 %

1,3 %

Heart failure

9,0 %

11,5 %

Complication
related
to Diabetes

6,4 %

7,6 %

How to calculate the benefit of

Ramipril

Ramipril

Cost of
Illness
(a)

Cost of
Cost of
Interventio Savings
n
(c) = (a) (b)
(b)

dihitung
dari biaya
yang
dibutuhk
an untuk
Rawat
Inap (+)
Rawat
jalan

Dihitung dari
biaya program /
intervensi
dengan Ramipril
yang telah
dilakukan dalam
kurun waktu
tertentu

Dihitung dari
biaya
penghematan
yang diperoleh
dari pengurangan
biaya RI (+) RJ
dengan Biaya
Program

Clinical Pathway
Cost of Illness
Cardio Vascular Disease
S.O.P
Tindakan a
Tindakan b
Tindakan c
Tindakan

Hari.1

Hari.2

Hari.3

Hari
..

Cost per hospitalization CVD by DRG

(BJORHOLT et al, 2002)
DRG

DRG
Code

Cost/hos
p (SEK)

122

20.440

14

25.298

Unstable angina pectoris

140

10.691

Congestive heart failure

127

17.479

Supraventricullar arrhytmia

139

6.173

Myocardial Infarction
Stroke

Clinical Pathway
S.O.P

Ramipril

Placebo

Cost of Illness

Semester Semester Semester Semester

1
2
3
4
0 6 bln 6 12 bln
12 18
18 24
bln
bln
+

Cost Effectiveness Analysis of Ramipril

Cost
Total biaya
yang
dibutuhkan
untuk
melaksanak
an program

Effectivita Rasio
s
C/E
Hasil yang
(<1)
diperoleh
karena
intervensi
program

Ramipril

Placebo

Cost Modeling (1)

STRUKTUR BIAYA.1
Alternative
s
Ramipril

Placebo

INVESTASI OPERASIONA PEMELIHARAA

L
N

?
?

Cost Modeling (2)

ANALISIS BIAYA & Biaya Satuan
S.O.P

Semester Semester
1
2
0 6 bln 6 12 bln

Semester
3
12 18
bln

Semester
4
18 24
bln

Ramipril

Total
Cost/jumla
h cakupan

Placebo

Total
Cost/jumla
h cakupan

Cost Modeling (4) RASIO

S.O.P

Cost
Minimizati
on
Analysis

Cost
Benefit
Analysis

Cost
Cost
Effectivenes Utility
s
Analysis
Analysis

Ramipril

Placebo