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Different Values In Cost-Effectiveness Research: Institute for Clinical and Economic Review (ICER) VS. The National Institute for Care Excellence (NICE)

      Objectives

      NICE relies on an ICER threshold of <£30,000/QALY in most circumstances for making reimbursement decisions about drugs. ICER, on the other hand, relies on a small committee of voting experts to evaluate the “care value” of a drug, which includes evidence on ICERs as well as additional benefits, disadvantages, and contextual considerations. Examining points of disagreement between the two agencies can highlight differences in the values of these organizations.

      Methods

      We compared ICER’s multiple myeloma and PCSK9 evaluations with NICE technology appraisals to identify disagreements. We then examined the stated justifications for decisions to identify potential differences in values between the two organizations.

      Results

      ICER determined that panobinostat for the third-line treatment of multiple myeloma demonstrated no net clinical benefit and low-to-intermediate care value. NICE found panobinostat clinically- and cost-effective and recommended it for use. The view of a single clinical expert that “no myeloma expert would consider panobinostat clinically superior” to alternatives and disagreements on the strength of data concerning toxicity influenced the ICER committee’s voting. NICE stated that panobinostat was clinically effective based on the final overall survival data and cost-effective with an ICER <£25,000. NICE, in a draft report, found evolocumab for primary heterozygous-familial hypercholesterolaemia clinically- and cost-effective after a discount from the manufacturer, while ICER’s committee was divided on how to balance the drug’s high ICER against unmet need.

      Conclusions

      For panobinostat, NICE placed value on a hard clinical endpoint, and NICE focused on cost-effectiveness for both panobinostat and evolocumab. ICER’s voting committee placed significant weight on expert testimony, unmet need, and toxicity, and relatively close votes on both drugs indicate that there was disagreement on how to address these points. It is noteworthy that NICE only employs voting in exceptional circumstances while ICER appears to routinely and transparently provide a platform for dissenting opinions.