Enhanced Cost-Effectiveness Analysis Using EHR Data for Real World Value


Swaminathan A1, Xu C2, Zhang S3, Du K3, Siu E3, Kalesinskas L3, Lite S3, Song Y4, Snider J3, Ramsey S5, Bargo D3, Adamson B3
1Flatiron Health, Wood Ridge, NJ, USA, 2Flatiron Health, Brooklyn, NY, USA, 3Flatiron Health, New York, NY, USA, 4Flatiron Health, Aliso Viejo, CA, USA, 5Hutchinson Institute for Cancer Outcomes Research, Fred Hutchinson Cancer Research Center, Seattle, WA, USA

Presentation Documents


Real-world evidence (RWE) generated from electronic health records (EHR) has been shown to be more relevant, timely, and representative for health technology assessment decision-making compared to evidence from clinical trials. We assessed how using EHR-derived RWE instead of published clinical trial data can impact point estimates and uncertainty ranges in cost-effectiveness estimates for advanced non-small cell lung cancer (NSCLC) therapies.


We replicated a cost-effectiveness analysis of NSCLC therapies developed by the Institute for Clinical and Economic Review in 2016 (“traditional”), replacing meta-analysis-derived hazard ratios from clinical trials with RWE-derived hazard ratios for progression-free and overall survival (“RWE-enhanced”). Hazard ratios were calculated using Cox proportional hazards models adjusted for age, sex, race, practice type, performance status, and smoking history. The study used the Flatiron Health database, a nationwide (US-based) longitudinal, de-identified EHR-derived database. We compared the cost-effectiveness of immunotherapy (atezolizumab, pembrolizumab, nivolumab) vs. chemotherapy (single-agent docetaxel) in the second line of therapy. The analytic cohort included 3,492 adults with EGFR- NSCLC that progressed after first-line treatment with a platinum-based chemotherapy doublet. We report traditional and RWE-enhanced incremental cost-effectiveness ratios (ICERs) and differences in uncertainty as percent change in the size of 95% credible intervals (CIs).


The traditional vs RWE-enhanced ICERs were as follows: atezolizumab — $84,000/quality-adjusted life year (QALY) vs. $138,000/QALY; nivolumab — $136,000/QALY vs. $123,000/QALY; pembrolizumab — $181,000/QALY vs $111,000/QALY. Compared to uncertainty in traditional ICERs, 95% CIs for RWE-enhanced ICERs were reduced by 37%, 69%, and 83% for atezolizumab, nivolumab, and pembrolizumab respectively.


This proof-of-concept demonstrated how clinical depth, longer follow-up time, and larger sample sizes in EHR-derived data may reduce uncertainty in cost-effectiveness analysis. The approach has potential to inform dynamic value-based pricing and highlights the importance of reassessments once RWE is available.

Conference/Value in Health Info

2021-05, ISPOR 2021, Montreal, Canada

Value in Health, Volume 24, Issue 5, S1 (May 2021)




Economic Evaluation, Health Policy & Regulatory, Health Technology Assessment, Methodological & Statistical Research

Topic Subcategory

Cost-comparison, Effectiveness, Utility, Benefit Analysis, Decision & Deliberative Processes, Reimbursement & Access Policy



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