When to wait for more evidence? Real options analysis in proton therapy.

PURPOSE: Trends suggest that cancer spending growth will accelerate. One method for controlling costs is to examine whether the benefits of new technologies are worth the extra costs. However, especially new and emerging technologies are often more costly, while limited clinical evidence of superiority is available. In that situation it is often unclear whether to adopt the new technology now, with the risk of investing in a suboptimal therapy, or to wait for more evidence, with the risk of withholding patients their optimal treatment. This trade-off is especially difficult when it is costly to reverse the decision to adopt a technology, as is the case for proton therapy. Real options analysis, a technique originating from financial economics, assists in making this trade-off. METHODS: We examined whether to adopt proton therapy, as compared to stereotactic body radiotherapy, in the treatment of inoperable stage I non-small cell lung cancer. Three options are available: adopt without further research; adopt and undertake a trial; or delay adoption and undertake a trial. The decision depends on the expected net gain of each option, calculated by subtracting its total costs from its expected benefits. RESULTS: In The Netherlands, adopt and trial was found to be the preferred option, with an optimal sample size of 200 patients. Increase of treatment costs abroad and costs of reversal altered the preferred option. CONCLUSION: We have shown that real options analysis provides a transparent method of weighing the costs and benefits of adopting and/or further researching new and expensive technologies.

The cost-effectiveness of hearing-aid fitting in the Netherlands.

OBJECTIVE: To determine the cost-effectiveness of hearing-aid fitting. DESIGN: Cost-effectiveness analysis using a Markov model based on aggregate data and results from a prospective intervention study. SETTING: The cost-effectiveness study was based in the general community. The prospective study was hospital based, as 85% of the first-time hearing-aid users attend a hospital in the process of hearing-aid fitting. PATIENTS: The prospective intervention study included adult first-time hearing-aid users with no contraindications for hearing-aid use. INTERVENTION: The usual process of hearing-aid fitting in the Netherlands. MAIN OUTCOME MEASURE: Costs per quality-adjusted life-year (QALY). The QALYs were based on EuroQol scores. We included direct and indirect costs in the analysis. RESULTS: The mean improvement on the EuroQol measure was 0.03 (95% confidence interval [CI], -0.03 to 0.08), and on the hearing-specific visual analog scale, 0.27 (95% CI, 0.22-0.31). The base-case outcome based on the EuroQol was 15 807/QALY (US dollars 17 072/QALY) (CI, -24 239/QALY to 3718/QALY). CONCLUSIONS: On the basis of this base-case estimate, fitting of hearing aids is considered a cost-effective health care intervention. The CI indicates that the result is not unambiguously positive, probably because the EuroQol lacked sensitivity for the evaluation of hearing-aid fitting. Until now, no study has found an effect of hearing-aid fitting on generic quality of life. Therefore, measures are needed that are suitable for the evaluation of the effects of interventions for sensory disabilities, such as the fitting of hearing aids, on generic quality of life.