A framework for incorporating cost-effectiveness in evidence-based clinical practice guidelines

In England, recent health care reforms emphasise the role of clinical guidelines in promoting effective and efficient health care. Introducing economic data into guidelines raises some methodological issues: specifically, the provision of valid and generalisable cost estimates, the weight placed upon cost 'evidence', and the presentation of cost-effectiveness information in a manner accessible to clinicians. A series of primary care guidelines, explicitly including consideration of health economic information, have recently been published, intended to help clinicians to aggregate the attributes of treatment choices to derive treatment recommendations consistent with both the clinical decision-making process and social objectives. Clinicians involved in developing guidelines responded well to the process and consistently managed to agree treatment recommendations, often after considerable debate about the evidence for treatment. In none of the guideline areas, all of which addressed common diseases, was there adequate information to estimate a cost per quality-adjusted-life-year, and it is unclear how helpful this approach would have been had it been possible. The implications of this method are discussed, guidance offered for economists new to guideline development and future areas of work identified.

Control of Herbaspirillum seropedicae NifA activity by ammonium ions and oxygen

The activity of a truncated form of Herbaspirillum seropedicae NifA in different genetic backgrounds showed that its regulatory domain is involved in nitrogen control but not in O2 sensitivity or Fe dependence. The model for nitrogen control involving PII could thus apply to the proteobacteria at large. NifA may have a role in controlling ADP-ribosylation of nitrogenase in Azospirillum brasilense.

Resource costing for multinational neurologic clinical trials: methods and results

We present the results of a multinational resource costing study for a prospective economic evaluation of a new medical technology for treatment of subarachnoid hemorrhage within a clinical trial. The study describes a framework for the collection and analysis of international resource cost data that can contribute to a consistent and accurate intercountry estimation of cost. Of the 15 countries that participated in the clinical trial, we collected cost information in the following seven: Australia, France, Germany, the UK, Italy, Spain, and Sweden. The collection of cost data in these countries was structured through the use of worksheets to provide accurate and efficient cost reporting. We converted total average costs to average variable costs and then aggregated the data to develop study unit costs. When unit costs were unavailable, we developed an index table, based on a market-basket approach, to estimate unit costs. To estimate the cost of a given procedure, the market-basket estimation process required that cost information be available for at least one country. When cost information was unavailable in all countries for a given procedure, we estimated costs using a method based on physician-work and practice-expense resource-based relative value units. Finally, we converted study unit costs to a common currency using purchasing power parity measures. Through this costing exercise we developed a set of unit costs for patient services and per diem hospital services. We conclude by discussing the implications of our costing exercise and suggest guidelines to facilitate more effective multinational costing exercises.

The role of pilot studies in the economic evaluation of health technologies

An increasing number of economic evaluations are being conducted alongside clinical trials. While this practice offers the prospect of collecting comprehensive and accurate cost data, it requires considerable time and effort. In the case of clinical data, key analytic decisions such as which data to collect and sample size are often made with reference to smaller (pilot) trials. However, this approach is not normally followed in the case of economic evaluation. This study was based on a recently completed health technology assessment comparing conventional radiotherapy with continuous hyperfractionated accelerated radiotherapy (CHART) for patients with head and neck cancer or carcinoma of the bronchus. In the full health technology assessment, cost data were available for 526 head and neck patients (314 CHART and 212 conventional therapy) and 286 bronchus patients (175 CHART and 109 conventional therapy). In order to simulate a pilot study, data were extracted for the patients recruited to both trials in the first 3 months. These were then compared with the full data set in order to assess whether such a pilot study would have given useful guidance on: a) the usefulness of undertaking a full study; b) the sample size required; and c) the important resource items for which comprehensive data collection would be required. Pilot studies can be helpful in determining the likely advantages of undertaking full economic evaluations and in identifying important resource items. Therefore, it is important that clinical researchers and research funding bodies create the necessary time window to enable such studies to take place. However, formal sample size calculations are more difficult to perform on limited data, since they also require knowledge of the unit cost (or prices) to be attached to the resource items and the correlation between costs and clinical effects.

Evaluating the BMJ guidelines for economic submissions: prospective audit of economic submissions to BMJ and The Lancet

CONTEXT

Editorial management of articles on health economics may benefit from guidelines for peer review and revision.

OBJECTIVE

To assess whether publication (in August 1996) of the BMJ guidelines on peer review of economics submissions made any difference to editorial and peer review processes, quality of submitted manuscripts, and quality of published manuscripts.

DESIGN AND SETTING

Before-after study conducted in the editorial offices of BMJ and The Lancet of the effect of the BMJ guidelines on review and revision of economics submissions, defined as those making explicit comments about resource allocation and/or costs of interventions.

MAIN OUTCOME MEASURES

Editorial fate and changes in the quality of submissions.

RESULTS

A total of 2982 manuscripts were submitted to the 2 journals during the before periods, 105 (3.5%) of which were economics submissions. Of these, 27 (24.3%) were full economics evaluations, and 78 (75.7%) were other economics submissions. Overall acceptance rate was 11.6% (12/105). During the after period 2077 manuscripts were submitted to the 2 journals, 87 (4.2%) of which were economics submissions. Eighteen (20.7%) were full economics evaluations, and 69 (79.3%) were other economics submissions. Overall acceptance rate was 6.9% (6/87). Although a number of manuscripts could not be traced to determine whether they were economics submissions, there appeared to be little difference between the 2 journals in numbers or editorial fate of the manuscripts. There was no change in the quality of submitted manuscripts, but BMJ editors found the guidelines and checklists useful and sent fewer economics submissions for external peer review in the after phase.

CONCLUSIONS

Publication of the guidelines helped the BMJ editors improve the efficiency of the editorial process but had no impact on the quality of economics evaluations submitted or published.

[Evaluation of cost effectiveness in primary health care]

Evaluation of Cost-Effectiveness in Health Care considers the background, methodology and potential political influence of economic evaluation (EE) in health care, the following conclusions can be drawn: EE is not just about cost cutting--it considers both costs and outcomes. EE needs to be integrated with decision-making procedures at different levels, namely the macro (policy) level, the meso (management) level, and the micro (clinical) level. EE needs to be seen as a part of a broader effort in health technology assessment and in relation to parallel efforts, e.g. guidelines development, quality assurance, evidence-based medicine. EE needs to be methodologically sound, but is not always possible to undertake the perfect study due to constraints of resources, time, information availability. Ways of setting priorities for EE need to be developed; this means selecting relevant topics and researchable questions. EE needs to be locally relevant; this means taking into account the variations of setting--within and between countries--and differences between trials (efficacy) and regular practice (community effectiveness). Factors that either encourage or inhibit the adoption of study results, i.e. adequate dissemination, professional support, financial incentives or political will, have to be considered.

Economic evaluation under managed competition: evidence from the U.K

Although economic evaluation in health care has a long-standing tradition in the United Kingdom, very little is known about its impact on decision making, particularly following the introduction of the internal market. Since managed competition appears to be growing in popularity worldwide, the U.K. is an interesting case study, as the reforms are well underway and there have been a number of efforts to conduct and disseminate economic evaluations. In this paper the potential for using economic evaluation in health care decision making in the U.K. is discussed. Then its actual impact is assessed in two ways. First, two case studies are discussed, on heart transplantation and the use of pharmaceuticals in the management of labour in pregnancy. Second, new data from a recent survey of potential users of economic evaluations are presented, with the emphasis on exploring the reasons for the impact, or lack of impact, of economic results. It is concluded that the NHS reforms increase the potential for the use of economic evaluation. However, there is a need to increase decision makers' awareness of economic studies and to help them interpret study methodology and results. Although worries about validity of economic studies are one of the major barriers to their use, other important barriers relate to the multiple objectives being pursued, of which increased efficiency is just one, and the difficulties of freeing resources from existing services in order to divert them to more cost-effective treatments and programmes.

Biotechnology: a special case for health technology assessment?

Many substances produced naturally in a wide range of living organisms have been identified to be of benefit in the treatment of human disease. Current health biotechnologies recreate DNA-recombinant cellular processes in laboratory settings to produce 'natural' therapeutics: these are potentially a step forward from traditional pharmacology which has developed synthetic analogues or sought to extract products from donor material. However, with increasing financial pressures, decision makers require evidence that the benefits of biotechnologies justify their costs. The challenges experienced when evaluating the cost-effectiveness of biotechnologies are explored with reference to three examples: HA-1A human monoclonal antibody, erythropoietin and DNase. Difficulties in economic evaluation are similar to those experienced with conventional pharmaceuticals: use of short-term clinical endpoints rather than meaningful health outcomes, the artificial nature of clinical trial protocols, and uncertainty about the applicability of economic data. However, early clinical and economic assessments are required by decision-makers, particularly where biotechnology products fill major gaps in therapy. The financial structure of biotechnology companies may limit movement towards adequate clinical and economic research for health technology assessment. Governments should negotiate with the industry to promote more relevant studies, and develop policies for the managed introduction of products as evidence on effectiveness and cost expands. New technologies often present additional costs requiring reallocation of existing resources. Careful resource planning is required so that cost-effective innovation are not denied to patients.

Economic evaluations of drug therapy: attitudes of primary care prescribing advisers in Great Britain

All health authorities in Great Britain have both medically or pharmaceutical qualified staff to advise both the authority and the local primary care medical practitioners about drug use and prescribing. This study used a piloted postal questionnaire to assess the attitudes of these advisers to economic evaluations of drug therapy, and their perceptions of the barriers to achieving cost effective prescribing by use of these evaluations. There was a 65% response rate to the questionnaire. Economic issues were rated by advisers to be less important than clinical issues, but were considered at most meetings between advisers and primary care medical practitioners. Advisers wished to consider true cost effective prescribing but often felt obliged to consider drug acquisition costs and risks of budgetary overspends. The perceived inflexibility of existing structures within the British National Health Service and the lack of credibility of the evaluations (often perceived as pharmaceutical industry marketing) were the major barriers to the application of the evaluations. The paper concludes that advisers were keen to use economic evaluations to promote cost effective prescribing but were impeded by the perceived bias of existing studies and by rigid current NHS structures.

The role of economic evaluation in the pricing and reimbursement of medicines

In most countries, governments or health insurers have taken initiatives to influence the price and utilization of medicines. One stated objective of these schemes is to encourage efficiency, or cost-effectiveness. In principle, economic evaluation should to be relevant to decisions about the pricing and reimbursement of health technologies, since it offers a way of estimating the additional value to society of a new intervention (e.g. medicine) relative to current therapy. However, the application of economic evaluation in drug pricing and reimbursement schemes is variable. Therefore, this paper reviews the actual and potential role of economic evaluation in different drug pricing and reimbursement schemes, such as 'free pricing' systems (United Kingdom, United States), two-stage administered systems (France), reference pricing systems (Germany, Netherlands, Sweden) and economic evaluation systems (Australia, Canada). It is concluded that, other than in the case of Australia and Canada, the potential role of economic evaluation could be greatly developed, especially in the case of new medicines, for which there is no close substitute. Comments are also given on the practical problems of using this approach. However, it is noted that economic evaluation alone cannot set a price for a medicine, since a decision has to be made about the proportion of added value going to society and the proportion going to the pharmaceutical company as a reward for innovation.

The iterative use of economic evaluation as part of the process of health technology assessment

The economic evaluation of health care technologies has a key role within the new National Health Service health technology assessment process. There has, however, been little discussion of the best way of combining economic and clinical research. Economic evaluation should be iterative, generating progressively firmer estimates of cost-effectiveness and helping to maximise the efficiency of health care R&D. Here, four stages of economic analysis are suggested, starting with stage I when the basic clinical science is complete, and finishing with stage IV analysis to generalise the results of earlier studies to routine clinical practice.

Optometrist screening for diabetic retinopathy: evidence and environment

A recent English government-funded study has suggested that optometrists are not best suited to screening for diabetic retinopathy. This is surprising given the level of training of optometrists and their aptitude in detecting other conditions such as glaucoma and cataract. The need to screen for diabetic retinopathy is discussed. The major unresolved issue concerns the choice of screening modality, i.e. who should perform screening, when and how. A literature search is reported. Given the available evidence, to make conclusions about the relative performance of optometrists with other screeners would be inappropriate. Unresolved controversies could be addressed by new prospective studies of optometrists, and others, in screening. A pragmatic design, mirroring the current environment of care, may be important. In particular, the manner in which diabetics currently present to the health service would make screening by one modality of limited use. If thoughtfully applied, shared care concepts may achieve a broader coverage of patients with diabetics mellitus. Smaller trials investigating sub-issues, and surveys of patients and potential screeners may produce a valuable backdrop in designing appropriate studies. Issues for the development of screening schemes are considered, including the role of training, the development of protocols for care and sharing data, reimbursement and audit.

Acceptance for chronic dialysis treatment: insufficient and unequal

BACKGROUND

Evidence suggests that a number of end-stage renal disease (ESRD) patients die without receiving dialysis. We investigated and compared ESRD patients who died without receiving treatment and those who were accepted for dialysis.

METHODS

All patients starting chronic dialysis in 1991 in the city of Sao Paulo and prospectively registered in the Health Secretariat files were studied. From death certificates we obtained data from all patients dying with an underlying cause associated with chronic renal failure. Medical records from a sample of patients who died without receiving dialysis were reviewed.

RESULTS

Of 2127 patients, 1582 (74.7%) received dialysis and 545 (25.6%) did not. The best chance of being dialysed occurred in the 20-29 age group. The age groups with the least chance of receiving dialysis were 0-9 years and over 79 years old. The odds ratio (95% Cl) of not receiving dialysis was 12.42 (6.63-23.82) times greater for patients over 60 years old compared to those aged 10-19 years. Patients with renal failure due to congenital diseases, chronic pyelonephritis, unknown cause, and hypertension were less likely to receive dialysis than those with glomerulonephritis or diabetes.

CONCLUSIONS

Our results suggest that many ESRD patients die without receiving dialysis. Age and cause of renal disease influence the chance of being accepted for treatment. Restrictions of treatment need to be corrected to guarantee that maintenance dialysis will be accessible to ESRD patients.

An economic evaluation of propofol/fentanyl compared with midazolam/fentanyl on recovery in the ICU following cardiac surgery

A comparison was made of the drug costs and nursing dependency of patients undergoing elective cardiac surgery and routine postoperative recovery for two anaesthetic techniques using either propofol with low dose fentanyl or midazolam with high dose fentanyl. Estimates of resource use were based on a randomised clinical trial undertaken at the Northern General Hospital, Sheffield. Times from entry to the intensive care unit until extubation and discharge were recorded for 70 patients and were transformed to nursing shifts. Nursing dependency was calculated on the basis of one nurse per ventilated patient and 0.5 nurse from the start of the shift after extubation. Nursing costs were allocated on the basis of the patient's status at the beginning of each shift in line with the hospital's staffing policy. All drugs used from the morning of the operation until discharge were recorded. Costs of nursing and drugs were calculated. The total cost of patients in the propofol group was 13.3% less than midazolam patients (p = 0.043, for geometric means Cl 0.4% to 27.8%). The clinical study was not designed for economic endpoints; however, it demonstrated achievable savings in propofol-treated patients.

[Access to chronic dialysis treatment: deficient and unequal]

OBJECTIVE

To determine the fraction of patients with end-stage renal disease (ESRD) who received dialysis treatment in the city of São Paulo in 1991 and to investigate the influence of age in the access to dialysis.

MATERIAL AND METHODS

All patients who received dialysis for ESRD in the city of São Paulo during 1991, and were registered in the Secretary of Health of São Paulo files were included in the study. In the same year, information was also collected on individuals who died having as basic cause of death a disease related to chronic renal failure. These data were obtained from death certificates files. Using simultaneously information from both data bases it was possible to ascertain the patients who died without receiving dialysis and to calculate the treated fraction in several age groups.

RESULTS

Overall 25.6% of ESRD patients did not receive treatment. There was a progressive reduction in the fraction of patients treated for those older than 40 years. In children less or equal to 9 years of age the percentage of treatment was also reduced (29%). Individuals in the age groups 60-69 and 70-79 years had a chance about 5 and 11 times greater, respectively, of dying without receiving dialysis than those in the 20-29 years group.

CONCLUSIONS

We estimate that at least one fourth of the ESRD patients died in São Paulo in 1991 without receiving dialysis treatment. Age is a major factor of discrimination for acceptance in chronic dialysis programs.

Cloning, sequence analysis and overexpression of the rhodanese gene of Azotobacter vinelandii

A gene encoding rhodanese (rhdA) was cloned from Azotobacter vinelandii on a 2.3-kb SphI fragment. This fragment was identified by its hybridization to a PCR product obtained by amplification of genomic DNA using degenerate primers encoding the N-terminal sequence of rhodanese purified from A. vinelandii. The sequence of a 1.2-kb region revealed an 813-bp open reading frame that encoded a polypeptide of 271 amino acids, the N-terminal sequence of which was identical to that of A. vinelandii rhodanese. In a search of database entries, eukaryotic rhodaneses and rhodanese-like proteins from bacteria gave the highest scores of identity (27-30%) with the predicted product of the 813-bp open reading frame. A. vinelandii RhdA shows less sequence similarity to vertebrate rhodaneses than it does to prokaryotic rhodanese-like proteins which did not show typical rhodanese activity. Basic residues thought to be catalytically important in bovine rhodanese are not conserved in A. vinelandii rhodanese. The sequence similarity between the two structurally similar domains of rhodanese is more pronounced for the A. vinelandii enzyme than the bovine enzyme, and supports the hypothesis that the complete structure was originally generated by gene duplication. When rhdA was overexpressed in Escherichia coli, rhodanese represented 30% of total cell protein and thiosulfate:cyanide sulfurtransferase activity increased >600 fold in cell-free extracts. A. vinelandii rhdA insertion/deletion mutants had no discernible phenotype distinct from the wild-type strain with respect to growth on various sulfur sources or nitrogenase activity. Mutants retained 20% of wild-type rhodanese thiosulfate:cyanide sulfurtransferase activity suggesting the presence of redundant sulfurtransferase enzymes in A. vinelandii.

Expression from the nifB promoter of Azotobacter vinelandii can be activated by NifA, VnfA, or AnfA transcriptional activators

In Azotobacter vinelandii, nifB is required for the activity of all three nitrogenases. Expression of a nifB-lacZ fusion was examined to determine which regulatory gene products are important for nifB expression and how its transcription is regulated in response to metals. In all conditions, expression in A. vinelandii was eliminated by an rpoN mutation, confirming the absolute requirement for sigma N. In the wild type, nifB-lacZ expression was approximately twofold higher in cells grown with Mo than without. Expression was negligible in a nifA mutant grown with Mo but was much higher in Mo-free medium, suggesting that in these conditions, another sigma N-dependent activator was responsible for nifB expression, possibly VnfA, AnfA, or NtrC. Although expression of the nifB-lacZ fusion in A. vinelandii vnfA, anfA, and ntrC mutants was little different from that in the wild type, nifB transcription could be activated by NifA, VnfA, or a truncated form of AnfA in Escherichia coli. The two potential NifA binding sites centered at -87 and -129 bp upstream of the transcription start site each overlapped a VnfA recognition sequence, motifs also found in Azotobacter chroococcum in two exactly conserved regions. Deletion analysis showed that both regions are important for nifB expression. Activation of the full-length promoter by AnfA was impaired by overexpressing the DNA-binding domain of NifA, suggesting that binding of NifA and AnfA can be competitive.

Cost effectiveness of antituberculosis interventions

The treatment of tuberculosis (TB) is ranked as the most cost effective of all therapeutic programmes in terms of cost per year of life saved. Nevertheless, TB kills or debilitates more adults aged between 15 and 59 years than any other disease in the world; furthermore, about 2 to 4% of the burden of disease, 7% of all deaths and 26% of all preventable deaths are directly attributable to TB. About one-third of the world's population is infected with the TB bacillus. In the developing world, more women of childbearing age die from TB than from causes directly associated with pregnancy and childbirth. The death of adults in their prime, who are parents, community leaders and producers in most societies, causes a particularly onerous burden besides being a serious public health problem. In the poorest countries, where the magnitude of the TB problem is greatest, those TB control strategies that are economically feasible tend to be less effective. Therefore, in low and middle income countries, cost-effectiveness considerations aimed at prioritising resource allocation in the health sector in general, and in TB control programmes in particular, are of paramount importance. Operationally, the main components of a TB control programme are: (i) detection and treatment of TB; and (ii) prevention of TB through BCG vaccination and chemoprophylaxis. Priority should be given to ensuring that TB patients complete their prescribed course of chemotherapy. Adequate treatment is the most effective way of preventing the spread of TB and the emergence of drug resistance. This article reviews evidence of the effectiveness and cost effectiveness of different approaches to TB care, particularly those that are applicable to low income countries, in both HIV-infected and noninfected patients. Financial implications and ways to implement directly observed therapy for TB in large urban areas are discussed, and the need to address some relevant operational issues is highlighted. The current role of chemoprophylaxis and BCG vaccination is also reviewed.