Presentation (CTI)

OBJECTIVES: Incremental Cost-Effectiveness Ratios (ICERs) are a standard tool for assessing cost-effectiveness. Their calculation must be appropriate to inform efficient decision making. We reviewed the Institute for Clinical and Economic Review organization's (ICERO) 2022 report on obesity treatments. ICERO evaluated semaglutide, liraglutide, phentermine/topiramate, and bupropion/naltrexone (each added to lifestyle modification) and lifestyle alone. Based on ICERO’s ICERs calculated versus lifestyle, phentermine/topiramate was designated cost-effective; "[b]upropion/naltrexone was cost-effective at higher thresholds.” ICERO also calculated the price reduction it suggested as necessary to make semaglutide cost-effective based on reducing its ICER to a conventional threshold.
METHODS: We used long-established methods to calculate appropriate ICERs to determine cost-effectiveness and, with those, evaluated cost reductions needed to make semaglutide cost-effective.
RESULTS: Standard methods suggest that only 2 ICERs were needed (phentermine/topiramate compared to lifestyle and semaglutide compared to phentermine/topiramate); respective values were $8000 and $469,000 per Quality-Adjusted Life-Year. Other treatments were dominated and, therefore, could not be cost-effective. ICERO’s semaglutide/lifestyle ICER ($237,000) was not meaningful in conventional economic evaluation. Despite this error, ICERO’s conclusion that phentermine/topiramate was cost-effective was correct as both correct and incorrect ICERs for semaglutide exceeded conventional thresholds. Its statement that bupropion/naltrexone “was cost-effective at higher thresholds” is incorrect as a dominated treatment cannot become cost-effective by altering the threshold. Its suggested semaglutide cost reduction to become cost-effective (its ICER equal to the threshold) was severely underestimated as ICERO used an inappropriate alternative for its ICER (lifestyle instead of phentermine/topiramate).
CONCLUSIONS: Despite its non-standard approach in calculating ICERs versus a common alternative, ICERO correctly suggested phentermine/topiramate was cost-effective in its base case analysis. However, utilizing its approach will generally lead to incorrect conclusions as we have shown here in analyses beyond the base case. Incorrect conclusions, if implemented, can negatively affect healthcare system the efficiency. We should expect more from policy-influencing institutions.