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Introduction To Modelling Sutton

The document provides an introduction to decision modelling for economic evaluation. It discusses the roles and types of decision modelling, including decision trees and Markov models. It also covers the key steps in constructing and analysing a decision tree model, including structuring the tree, estimating probabilities and outcomes, and analysing the tree.

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Geetank Kamboj
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0% found this document useful (0 votes)
28 views42 pages

Introduction To Modelling Sutton

The document provides an introduction to decision modelling for economic evaluation. It discusses the roles and types of decision modelling, including decision trees and Markov models. It also covers the key steps in constructing and analysing a decision tree model, including structuring the tree, estimating probabilities and outcomes, and analysing the tree.

Uploaded by

Geetank Kamboj
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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Introduction to

decision modelling

Andrew Sutton
Learning objectives

Understand:
• the role of modelling in economic evaluation
• the construction and analysis of decision trees
• the design and interpretation of a simple
Markov model
• the appropriate circumstances for their use
Role of modelling in economic evaluation
• Extrapolate costs and effectiveness beyond trial data
• Reflect all appropriate evidence
• Compare all relevant options
• Link intermediate clinical endpoints to final outcomes
• Generalise results obtained in one clinical setting to
other settings
• Inform resource allocation decisions in the absence of
“hard data”
• Make head-to-head comparisons of alternative
competing interventions when relevant trials do not
exist
The main types of model

• Decision trees

• Markov models

• Other types of models beyond this lecture


A decision model….

• has a structure to represent clinical pathways


• allows synthesis of evidence to estimate costs
and effectiveness
• weighs up risks and benefits of an intervention
• can allow events occurring over time
• allows an assessment of different types of
uncertainty
• can identify priorities for future research
Decision Trees

• Use for “one off” decisions


• Particularly suited to
– Acute care problems (“kill or cure”)
– Once-only diseases
– Short-term diagnostic/screening
decisions
Steps in constructing and analysing
decision trees

1. Structure the tree


2. Estimate probabilities
3. Estimate outcomes
4. Analyse the tree
5. Sensitivity analysis
Decision Tree Structure
Elements of a tree

• Have one decision node at the root


• The branches off the initial decision node
represent all the strategies that are to be
compared
• A series of chance nodes off of each strategy
branch
• The outcomes at the end of each pathway
Decision Tree Example
• Illustrative example: Heparin for the prevention of
deep vein thrombosis (DVT) in hip replacement
patients
• Patients are at risk of DVT (and pulmonary embolism)
post-surgery
• Heparin can be injected pre-surgery and for 7-10 days
post-surgery to try and prevent clots
• However, there are risks of bleeding
• The research question:
– ‘Which is the more cost-effective treatment for hip
replacement patients, heparin or conventional
treatment?’
Decision tree for heparin
Bleed
DVT
No bleed
L MW heparin
Bleed
No DVT
No bleed
Hip replacement patients
Bleed
DVT
No bleed
Conventional treatment
Bleed
No DVT
No bleed
Estimating probabilities
• Usually derived from published studies
– Existing data: trial data or observational data
– Meta analysis: aggregating from multiple sources

• For each branch following a chance node, the


conditional probability P is needed:
Number following that branch
P=
Number leaving chance node

• Probabilities are numbers between 0 and 1


• Probabilities for all branches out of a given
chance node add to 1
Entering probabilities
Bleed
DVT 0.1
0.14 No bleed
L MW heparin 0.9
Bleed
No DVT 0.1
0.86 No bleed
Hip replacement patients 0.9
Bleed
DVT 0.01
0.25 No bleed
Conventional treatment 0.99
Bleed
No DVT 0.01
0.75 No bleed
0.99
Estimating outcomes

• Outcomes include:
– Total cost
– Total utilities
– Life years (LY)
– Quality-adjusted life years (QALYs)

• Outcomes are entered at terminal nodes


Costs and Utilities
• Costs assumed for example here
– Cost of heparin - £300
– Cost of conventional treatment - £50
– Cost of deep vein thrombosis event - £2000
– Cost of bleed - £500

• Utilities assumed
– DVT – 0.70
– Bleed – 0.95
– DVT & bleed – 0.65
– No event – 1.00
Entering outcomes (QALYs) QALY
Bleed
0.65
DVT 0.1
0.14 No bleed
0.7
L MW heparin 0.9
Bleed
0.95
No DVT 0.1
0.86 No bleed
1.00
Hip replacement patients 0.9
Bleed
0.65
DVT 0.01
0.25 No bleed
0.7
Conventional treatment 0.99
Bleed
0.95
No DVT 0.01
0.75 No bleed
1.00
0.99

Assume timeframe is one year


Entering outcomes (Costs) Cost £
Bleed
2800
DVT 0.1
0.14 No bleed
2300
L MW heparin 0.9
Bleed
800
No DVT 0.1
0.86 No bleed
300
Hip replacement patients 0.9
Bleed
2550
DVT 0.01
0.25 No bleed
2050
Conventional treatment 0.99
Bleed
550
No DVT 0.01
0.75 No bleed
50
0.99
Analysing the decision tree

• Decision tree is averaged out and “rolled-back” to


get the expected value for each strategy (work
from terminal nodes towards decision nodes)

• Expected value is the sum of products of the


estimates of the probability of events and their
outcomes
Example: analysing the tree (output
as QALYs)
Bleed
0.65
DVT 0.1 A
0.14 No bleed
0.7
L MW heparin 0.9
0.95 QA LYs C
Bleed
0.95
No DVT 0.1 B
0.86 No bleed
1.00
Hip replacement patients 0.9
L MW heparin : 0.95 QA LYs
Bleed
0.65
DVT 0.01
0.25 No bleed D
0.7
Conventional treatment 0.99
0.92 QA LYs F Bleed
0.95
No DVT 0.01
0.75 No bleed E
1.00
0.99
Rollback Calculations

• Work from terminal nodes towards decision nodes


• QALYs of heparin arm is

Point A = (0.65*0.1) + (0.70*0.9) = 0.695


Point B = (0.95*0.1) + (1.0*0.9) = 0.995
Point C = (0.695*0.14) + (0.995*0.86) = 0.953
Rollback Calculations

• QALYs of conventional treatment arm is

Point D = (0.65*0.01) + (0.70*0.99) = 0.6995


Point E = (0.95*0.01) + (1.0*0.99) = 0.9995
Point F = (0.6995*0.25) + (0.9995*0.75) = 0.9245
Example: analysing the tree (output
as costs)
Bleed
2800
DVT 0.1
0.14 No bleed
2300
L MW heparin 0.9
£ 630
Bleed
800
No DVT 0.1
0.86 No bleed
300
Hip replacement patients 0.9
Conventional treatment : £ 555
Bleed
2550
DVT 0.01
0.25 No bleed
2050
Conventional treatment 0.99
£ 555
Bleed
550
No DVT 0.01
0.75 No bleed
50
0.99
Full structure of cost-effectiveness
analysis Bleed
2800 / 0.65
DVT 0.1
0.14 No bleed
2300 / 0.7
L MW heparin 0.9
Bleed
800 / 0.95
No DVT 0.1
0.86 No bleed
300 / 1.00
Hip replacement patients 0.9
Bleed
2450 / 0.65
DVT 0.01
0.25 No bleed
2050 / 0.7
Conventional treatment 0.99
Bleed
550 / 0.95
No DVT 0.01
0.75 No bleed
50 / 1.00
0.99
Example: Result from analysing the
tree (CEA)

Strategy Cost Incremental QALY Incremental ICER


Cost QALY (£ per
QALY)
Conventional £555 0.92
Treatment
LMW heparin £630 £75 0.95 0.03 £2500

ICER = 630 – 555 = 75 = £2500 per QALY


0.95 - 0.92 0.03
Sensitivity analysis

• Previous calculations assume that probabilities and


costs are known exactly
• Suppose the cost of LMW heparin reduced to £200

Strategy Cost Incremental QALY Incremental ICER


Cost QALY
Conventional £555 0.92
Treatment
LMW heparin £530 - £25 0.95 0.03 Dominant
Limitations of decision trees

• Need to be able to assess full implications


of each possibility (patient pathway)

• Less suitable for longer-term outcomes


– possible to add branches (not efficient)

• Difficult to handle recurrence


Markov models

• Markov models represent disease processes


which evolve over time
• Suited to modelling the progression of
chronic disease
• Can handle recurrence
• Estimate long term costs and life years
gained/QALYs
Simple Markov model

WELL ILL

DEAD
Elements of Markov models
• Markov states should be mutually exclusive and
exhaustive

• Markov cycle length: a fixed period of time

• Transition probabilities
– Transition from one state to another at end of a single cycle
– Fixed transition probabilities out of each state, adding up to 1

• Markov rewards
– Values assigned to each health state that represent the cost
and utility of spending one cycle in that state
Simple Markov model
0.97
0.9

WELL ILL
0.02
0.1
0.01

DEAD 1.0
Steps in constructing a Markov model
1. Define states and allowable transitions
2. Choose a cycle length
3. Specify a set of transition probabilities between
states
4. Assign a cost and utility to each health state
5. Identify the initial distribution of the population
6. Methods of evaluation
Markov model: Simple example
• Stroke prevention model
– Atrial fibrillation is a chronic heart arrhythmia which
increases the risk of stroke (ischaemic)
– Therapy available to reduce the risk of stroke - e.g.
warfarin
– Disabling stroke incurs costs over a long period of time
and reduces quality of life
– A Markov model is designed to evaluate the cost-
effectiveness of treatments to prevent stroke in AF
– Following example will concentrate on model structure
Markov states

• Patients are classified in one of three states


– Well with atrial fibrillation (AF) (Health state 1)
– Disabled from stroke (Health state 2)
– Dead (Health state 3)
Stroke prevention: Markov states

P11 P22

P12
WELL, AF STROKE
P13 P33
P23

DEAD
Decide on a cycle length

• Markov cycles - a constant increment of time


• Choice of cycle length should
– depend on the timing of events in disease process
– depend on the study question and available data

For stroke prevention example, time cycle


could be one year
Define transition probabilities

Transitions From
Well (1) Stroke (2) Dead (3)
time t to time t+1

P11
Well (1) P12=0.07 P13=0.01
(=1-P12-P13=0.92)

P22
Stroke (2) 0 P23=0.25
(=1-P23=0.75)

Dead (3) 0 0 1
Attach costs and utilities to states

Each health state has a cost and utility attached

Markov state Cost Utility


Well, AF £150 1
(on treatment)
Disabling stroke £10,000 0.40

Death 0 0
Define initial distribution of population

• A set of starting probabilities is required to describe


the initial distribution of the Markov cohort among
the states
• Determined by modellers
– Start all patients in the same state (1 0 0)
– Different proportion in different states
(0.90 0.10 0)
Methods of evaluation
• Cohort simulation
– Hypothetical cohort of patients
– Expected values
– Deterministic

• Monte Carlo simulation


– Sample one patient at a time, specify number of
patients (“trials”)
– Random, stochastic
– More in later modules
Stroke prevention: cohort analysis
Cycle Well, AF Disabled stroke Dead Total
Start 1000 0 0 1000
1 920 70 10
1000
(1000 x 0.92) (1000 x 0.07) (1000 x 0.01)
2 846 117 37
1000
(920 x 0.07) + 10+ (920 x 0.01) +
(920 x 0.92) (70 x 0.75) (70 x 0.25)
3 778 147 75 1000

(846 x 0.07) + 37+ (846 x 0.01) +


(846 x 0.92) (117 x 0.75) (117 x 0.25)
4 716 165 119

(778 x 0.07) + 75+ (778 x 0.01) +


(778x 0.92) (147 x 0.75) (147 x 0.25) 1000
Limitations of Markov models

• No account taken of history


• Assumes uniform population and equal and
constant risk
• May overcome these limitations by using a larger
number of states
• Alternatively use other methods (Individual
sampling models, discrete event simulation)
Summary
• Models provide a practical method to
synthesise information from multiple sources
• Decision trees suited to model one-off
treatments and short-term effects
• Markov models allow recurring processes to be
modelled

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