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Partitioned Survival and State Transition Models for Health Care Decision Making in Oncology: Where are we now?

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JournalValue in Health
DateAccepted/In press - 17 Aug 2020
DateE-pub ahead of print - 17 Oct 2020
DatePublished (current) - 1 Dec 2020
Issue number12
Volume23
Number of pages9
Pages (from-to)1613-1621
Early online date17/10/20
Original languageEnglish

Abstract

Objectives: Partitioned Survival Models (PSMs) are routinely used to inform reimbursement decisions for oncology drugs. We discuss the appropriateness of PSMs compared to the most common alternative, state transition models (STMs).
Methods: In 2017, we published a NICE Technical Support Document (TSD 19) describing and critically reviewing PSMs. This article summarises findings from TSD 19, reviews new evidence comparing PSMs and STMs, and reviews recent NICE appraisals to understand current practice.
Results: PSMs evaluate state membership differently from STMs and do not include a structural link between intermediate clinical endpoints (e.g. disease progression) and survival. PSMs directly consider clinical trial endpoints and can be developed without access to individual patient data, but limit the scope for sensitivity analyses to explore clinical uncertainties in the extrapolation period. STMs facilitate these sensitivity analyses but require development of robust survival models for individual health-state transitions. Recent work has shown PSMs and STMs can produce substantively different survival extrapolations and that extrapolations from STMs are heavily influenced by specification of the underlying survival models. Recent NICE appraisals have not generally included both model types, reviewed individual clinical event data, or scrutinised life years accrued in individual health states.
Conclusions: The credibility of survival predictions from PSMs and STMs, including life years accrued in individual health states, should be assessed using trial data on individual clinical events, external data and expert opinion. STMs should be used alongside PSMs to support assessment of clinical uncertainties in the extrapolation period, such as uncertainty in post-progression survival.

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