Outcome measurement in economic evaluations of public health interventions: a role for the capability approach?

Conceptualising quality of life outcomes for women participating in testing for sexually transmitted infections: A systematic review and meta-synthesis of qualitative research

Many public health interventions have aims which are broader than health alone; this means that there are difficulties in using outcome measures that capture health effects only, such as Quality Adjusted Life Years (QALYs). Sexually Transmitted Infections (STIs) are a major public health concern both in the UK and globally, with Chlamydia trachomatis being the most common bacterial STI worldwide. There is scope for the wider use of qualitative syntheses in health-related research; in this study we highlight their potential value in informing outcome identification, particularly for public health interventions where a broad range of outcomes may need to be considered. This article presents a systematic review and meta-ethnography of qualitative studies that investigated women's experiences of thinking about and participating in testing for chlamydia. The meta-ethnography highlights issues relating to beliefs about STIs and testing, assessing risk and interpreting symptoms, emotional responses to testing, coping with diagnosis, relationship with sex partners(s), informal support, and interaction with health care services. The study findings suggest that women can experience a range of impacts on their health and quality of life. It is important that this range of effects is taken into account within evaluations, to ensure that decision makers are fully informed about the outcomes associated with screening interventions, and ultimately, to make sure that appropriate interventions are available to support women in maintaining good sexual health.

Operationalising the capability approach as an outcome measure in public health: The development of the OCAP-18

There is growing interest in operationalising the capability approach to measure quality of life. This paper reports the results of a research project undertaken in 2007 that sought to reduce and refine a longer survey in order to provide a summary measure of wellbeing and capability in the realm of public health. The reduction and refinement of the questionnaire took place across a number of stages, using both qualitative (five focus group discussions and 17 in-depth interviews) and quantitative (secondary data analysis, N = 1048 and primary data collection using postal surveys and interviews, N = 45) approaches. The questionnaire was reduced from its original 60+ questions to 24 questions (including demographic questions). Each of Nussbaum's ten Central Human Capabilities are measured using one (or more) of the 18 specific capability items which are included in the questionnaire (referred to as the OCAP-18). Analysis of the questionnaire responses (N = 198) found that respondents differed with respect to the levels of capabilities they reported, and that these capabilities appear to be sensitive to one's gender, age, income and deprivation decile. An index of capability, estimated by assuming equal weight for each capability question, found that the average level of capability amongst respondents was 12.44 (range 3-17.75). This index was found to be highly correlated with a measure of health (EQ-5D) and wellbeing (global QoL), although some differences were apparent. This project operationalised the capability approach to produce an instrument to measure the effectiveness (and cost effectiveness) of public health interventions; the resulting OCAP-18 appears to be responsive and measure something supplementary to health and wellbeing, thus offers a promising addition to the current suite of outcome measures that are available.

Choice of Outcome Measure in an Economic Evaluation: A Potential Role for the Capability Approach

The last decade has seen a renewed interest in Sen's capability approach; health economists have been instrumental in leading much of this work. One particular stream of research is the application of the approach to outcome measurement. To date, there have been a dozen attempts (some combined) to operationalise the approach, and produce an outcome measure that offers a broader evaluative space than health-related quality-of-life measures. Applications have so far been confined to public health, physical, mental health and social care interventions, but the capability approach could be of benefit to evaluations of pharmacotherapies and other technologies. This paper provides an introduction to the capability approach, reviews the measures that are available for use in an economic evaluation, including their current applications, and then concludes with a discussion of a number of issues that require further consideration before the approach is adopted more widely to inform resource allocation decisions.

A Systematic Review of Studies Evaluating the Cost Utility of Screening High-Risk Populations for Latent Tuberculosis Infection

BACKGROUND

As tuberculosis screening trends to targeting high-risk populations, knowing the cost effectiveness of such screening is vital to decision makers.

OBJECTIVES

The purpose of this review was to compile cost-utility analyses evaluating latent tuberculosis infection (LTBI) screening in high-risk populations that used quality-adjusted life-years (QALYs) as their measure of effectiveness.

DATA SOURCES

A literature search of MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, Web of Knowledge, and PubMed was performed from database start to November 2014.

INCLUSION CRITERIA

Studies performed in populations at high risk of LTBI and subsequent reactivation that used the QALY as an effectiveness measure were included.

STUDY APPRAISAL AND SYNTHESIS

Quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Data extracted included tuberculin skin test (TST) and/or interferon-gamma release assay (IGRA) use, economic, screening, treatment, health state, and epidemiologic parameters. Data were summarized in regard to consistency in model parameters and the incremental cost-effectiveness ratio (ICER), with costs adjusted to 2013 US dollars.

RESULTS

Of 415 studies identified, ultimately eight studies were included in the review. Most took a societal perspective (n = 4), used lifetime time horizons (n = 6), and used Markov models (n = 8). Screening of adult immigrants was found to be cost effective with a TST in one study, but moderately cost effective with an IGRA in another study; screening immigrants arriving more than 5 years prior with an IGRA was moderately cost effective until 44 years of age (n = 1). Screening HIV-positive patients was highly cost effective with a TST (n = 1) and moderately cost effective with an IGRA (n = 1). Screening in those with renal diseases (n = 2) and diabetes (n = 1) was not cost effective.

LIMITATIONS

Very few studies used the QALY as their effectiveness measure. Parameter and study design inconsistencies limit the comparability of studies.

CONCLUSIONS

With validity issues in terms of parameters and assumptions, any conclusion should be interpreted with caution. Despite this, some cautionary recommendations emerged: screening HIV patients with a TST is highly cost effective, while screening adult immigrants with an IGRA is moderately cost effective.

Exploring Outcomes to Consider in Economic Evaluations of Health Promotion Programs: What Broader Non-Health Outcomes Matter Most?

Background

Attention is increasing on the consideration of broader non-health outcomes in economic evaluations. It is unknown which non-health outcomes are valued as most relevant in the context of health promotion. The present study fills this gap by investigating the relative importance of non-health outcomes in a health promotion context.

Method

We investigated the relative importance of ten non-health outcomes of health promotion programs not commonly captured in QALYs. Preferences were elicited from a sample of the Dutch general public (N = 549) by means of a ranking task. These preferences were analyzed using Borda scores and rank-ordered logit models.

Results

The relative order of preference (from most to least important) was: self-confidence, insights into own (un)healthy behavior, perceived life control, knowledge about a certain health problem, social support, relaxation, better educational achievements, increased labor participation and work productivity, social participation, and a reduction in criminal behavior. The weight given to a particular non-health outcome was affected by the demographic variables age, gender, income, and education. Furthermore, in an open question, respondents mentioned a number of other relevant non-health outcomes, which we classified into outcomes relevant for the individual, the direct social environment, and for society as a whole.

Conclusion

The study provides valuable insights in the non-health outcomes that are considered as most important by the Dutch general population. Ideally, researchers should include the most important non-health outcomes in economic evaluations of health promotion.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0908-y) contains supplementary material, which is available to authorized users.

Mobility and cognition are associated with wellbeing and health related quality of life among older adults: a cross-sectional analysis of the Vancouver Falls Prevention Cohort

Background

Ascertaining individuals’ quality of life and wellbeing is essential in public health and clinical research. The impact of these two pressing geriatric syndromes – impaired mobility and cognitive function -- on wellbeing and quality of life is not well examined. Hence, our objective was to identify key clinically relevant outcome measures of mobility and cognitive function that explain variation in wellbeing and health related quality of life (HRQoL) among community dwelling older adults.

Methods

We conducted a cross-sectional analysis of 229 participants presenting to the Vancouver Falls Prevention Clinic from June 2010 through October 2013. The linear regression models included two dependent variables: the ICECAP-O assessing wellbeing and the EQ-5D-3L assessing HRQoL. Key independent variables included the Short Performance Physical Battery (SPPB) and the Montreal Cognitive Assessment (MoCA). Covariates included Functional Comorbidity Index (FCI), sex and age. In the two multiple linear regression models, age was statistically controlled. Other covariates (i.e., sex and FCI) were included based on statistical significance (i.e., p < 0.05).

Results

The SPPB was significantly associated with HRQoL and with wellbeing after adjusting for known covariates (p < 0.05, Unstandardized ß (Standard Error) 0.023 (0.006) for HRQoL and 0.016 (0.003) for wellbeing). The MoCA was significantly associated with wellbeing after adjusting for known covariates (p = 0.006), Unstandardized ß (Standard Error) 0.005 (0.002) but not with health related quality of life (p > 0.05).

Conclusion

We found that a measure of mobility and balance was associated with HRQoL and wellbeing. However, cognitive function was associated with wellbeing only. This study highlights the potential importance of considering wellbeing as an outcome measure if interventions are intended to have a broader impact than health alone.

Preventing domestic abuse for children and young people (PEACH): a mixed knowledge scoping review

Background

A range of interventions that aim to prevent domestic abuse has been developed for children and young people in the general population. While these have been widely implemented, few have been rigorously evaluated. This study aimed to discover what was known about these interventions for children and what worked for whom in which settings.

Review methods

This mixed knowledge review was informed by realist principles and comprised four overlapping phases: an online mapping survey to identify current provision; a systematic review of the existing literature; a review of the UK ‘grey’ literature; and consultation with young people and experts. Information from these four sources of evidence informed analysis of costs and benefits.

Results

The evidence for interventions achieving changes in knowledge and attitudes was stronger than that for behavioural change. Shifting social norms in the peer group emerged as a key mechanism of change. Media campaigns act to influence the wider social climate within which more targeted interventions are received, and they are also a source for programme materials. While most interventions are delivered in secondary schools, they are increasingly targeted at younger children. The review emphasised the importance of a school’s ‘readiness’ to introduce preventative interventions which need to be supported across all aspects of school life. Involving young people in the design and delivery of programmes increases authenticity and this emerged as a key ingredient in achieving impact. Longer interventions delivered by appropriately trained staff appeared likely to be more effective. Teachers emerged as well placed to embed interventions in schools but they require training and support from those with specialist knowledge in domestic abuse. There was evidence that small groups of students who were at higher risk might have accounted for some results regarding effectiveness and that programme effectiveness may vary for certain subgroups. Increasingly, boys are being identified as a target for change. The study identified a need for interventions for disabled children and children and young people from black, Asian, minority ethnic and refugee groups and a particular lack of materials designed for lesbian, gay, bisexual and transgender young people.

Limitations

Very little evidence was identified on costs and cost-effectiveness. Few studies showed an effect at the level of significance set for the review. Where it did exist, the effect size was small, except in respect of improved knowledge. The inability to calculate a response rate for the mapping survey, which used a snowballing approach, limits the ability to generalise from it.

Conclusions

While it is appropriate to continue to deliver interventions to whole populations of children and young people, effectiveness appeared to be influenced by high-risk children and young people, who should be directed to additional support. Programmes also need to make provision to manage any resulting disclosures. Interventions appear to be context specific, and so those already being widely delivered in the UK and which are likely to be acceptable should be robustly tested.

Funding

The National Institute for Health Research Public Health Research programme.

A longitudinal assessment of the responsiveness of the ICECAP-A in a randomised controlled trial of a knee pain intervention

PURPOSE

The ICECAP-A is a simple measure of capability well-being for use with the adult population. The descriptive system is made up of five key attributes: Stability, Attachment, Autonomy, Achievement and Enjoyment. Studies have begun to assess the psychometric properties of the measure, including the construct and content validity and feasibility for use. This is the first study to use longitudinal data to assess the responsiveness of the measure.

METHODS

This responsiveness study was completed alongside a randomised controlled trial comparing three physiotherapy-led exercise interventions for older adults with knee pain attributable to osteoarthritis. Anchor-based methodologies were used to explore the relationship between change over time in ICECAP-A score (the target measure) and change over time in another measure (the anchor). Analyses were completed using the non-value-weighted and value-weighted ICECAP-A scores. The EQ-5D-3L was used as a comparator measure to contextualise change in the ICECAP-A. Effect sizes, standardised response means and t tests were used to quantify responsiveness.

RESULTS

Small changes in the ICECAP-A scores were seen in response to underlying changes in patients' health-related quality of life, anxiety and depression. Non-weighted scores were slightly more responsive than value-weighted scores. ICECAP-A change was of comparable size to change in the EQ-5D-3L reference measure.

CONCLUSION

This first analysis of the responsiveness using longitudinal data provides some positive evidence for the responsiveness of the ICECAP-A measure. There is a need for further research in those with low health and capability, and experiencing larger underlying changes in quality of life.

Scoring the Icecap-a capability instrument. Estimation of a UK general population tariff

This paper reports the results of a best-worst scaling (BWS) study to value the Investigating Choice Experiments Capability Measure for Adults (ICECAP-A), a new capability measure among adults, in a UK setting. A main effects plan plus its foldover was used to estimate weights for each of the four levels of all five attributes. The BWS study was administered to 413 randomly sampled individuals, together with sociodemographic and other questions. Scale-adjusted latent class analyses identified two preference and two (variance) scale classes. Ability to characterize preference and scale heterogeneity was limited, but data quality was good, and the final model exhibited a high pseudo-r-squared. After adjusting for heterogeneity, a population tariff was estimated. This showed that 'attachment' and 'stability' each account for around 22% of the space, and 'autonomy', 'achievement' and 'enjoyment' account for around 18% each. Across all attributes, greater value was placed on the difference between the lowest levels of capability than between the highest. This tariff will enable ICECAP-A to be used in economic evaluation both within the field of health and across public policy generally.

Can Multi-attribute Utility Instruments Adequately Account for Subjective Well-being?

Introduction: The quality of life is included in cost utility analyses by weighting the relevant years of life by health state utilities. However, the utilities predicted by multi-attribute utility instruments (MAUIs) for this purpose do not correlate highly with the subjective well-being (SWB) of people experiencing the health states. This suggests that MAUIs may not take account of the SWB experienced by patients. This article explores an alternative hypothesis: that a failure of an MAUI to account for variation in SWB is primarily a result of the failure of its descriptive system to include the elements of health that determine SWB and that cannot therefore be included in assessment of the health state utility. Methods: Survey data are used to determine the extent to which 6 MAUIs with significantly different descriptive systems explain differences between the SWB of the healthy public and patients in 7 disease areas. Results: The EQ-5D-5L takes least account and AQoL-8D most account of SWB. AQoL-8D overpredicts the loss of SWB in 2 cases where hedonic adaptation is known to occur. Discussion: Results suggest that, to a large extent, utility can account for variation in SWB. The case for replacing utility with SWB in economic evaluation studies has arisen, in part, because elements of importance for SWB have been omitted from the descriptive systems of commonly used MAUIs.

Comparing measurement properties of the EQ-5D-3L, ICECAP-O, and ASCOT in frail older adults

BACKGROUND

The ICEpop CAPability measure for Older people (ICECAP-O) and the Adult Social Care Outcomes Toolkit (ASCOT) are preference-based measures for assessing quality of life (QOL) from a broader perspective than do traditional health-related QOL measures such as the EuroQol five-dimensional questionnaire (EQ-5D). Measurement properties of these instruments have not yet been directly compared.

OBJECTIVE

The purpose of this study was to compare the test-retest reliability, construct validity, and responsiveness of the three-level EQ-5D (EQ-5D-3L), ICECAP-O, and ASCOT in frail older adults living at home.

METHODS

Cross-sectional data and longitudinal data were used. Parameters for reliability (the intraclass correlation coefficient) and agreement (standard error of measurement) were used to assess test-retest reliability after 1 week. We formulated hypotheses about correlations with other measures and tested these to assess construct validity and responsiveness (longitudinal validity).

RESULTS

The reliability parameters for all three scales were considered good (intraclass correlation coefficient values above 0.70). Standard error of measurement values were less than 10% of the scale. Hypotheses regarding construct validity were in general accepted; the EQ-5D-3L was more strongly associated with physical limitations than were ICECAP-O and ASCOT and less strongly with instruments measuring aspects beyond health. Longitudinally, as hypothesized, mental health was most strongly associated with ICECAP-O, and self-perceived QOL, mastery, and client-centeredness of home care most strongly with ASCOT.

CONCLUSIONS

Our findings support the adoption of ICECAP-O and ASCOT as outcome measures in economic evaluations of care interventions for older adults that have a broader aim than health-related QOL because they are at least as reliable as the EQ-5D-3L and are associated with aspects of QOL broader than health.

An economic evaluation of a video- and text-based computer-tailored intervention for smoking cessation: a cost-effectiveness and cost-utility analysis of a randomized controlled trial

Background

Although evidence exists for the effectiveness of web-based smoking cessation interventions, information about the cost-effectiveness of these interventions is limited.

Objective

The study investigated the cost-effectiveness and cost-utility of two web-based computer-tailored (CT) smoking cessation interventions (video- vs. text-based CT) compared to a control condition that received general text-based advice.

Methods

In a randomized controlled trial, respondents were allocated to the video-based condition (N = 670), the text-based condition (N = 708) or the control condition (N = 721). Societal costs, smoking status, and quality-adjusted life years (QALYs; EQ-5D-3L) were assessed at baseline, six-and twelve-month follow-up. The incremental costs per abstinent respondent and per QALYs gained were calculated. To account for uncertainty, bootstrapping techniques and sensitivity analyses were carried out.

Results

No significant differences were found in the three conditions regarding demographics, baseline values of outcomes and societal costs over the three months prior to baseline. Analyses using prolonged abstinence as outcome measure indicated that from a willingness to pay of €1,500, the video-based intervention was likely to be the most cost-effective treatment, whereas from a willingness to pay of €50,400, the text-based intervention was likely to be the most cost-effective. With regard to cost-utilities, when quality of life was used as outcome measure, the control condition had the highest probability of being the most preferable treatment. Sensitivity analyses yielded comparable results.

Conclusion

The video-based CT smoking cessation intervention was the most cost-effective treatment for smoking abstinence after twelve months, varying the willingness to pay per abstinent respondent from €0 up to €80,000. With regard to cost-utility, the control condition seemed to be the most preferable treatment. Probably, more time will be required to assess changes in quality of life. Future studies with longer follow-up periods are needed to investigate whether cost-utility results regarding quality of life may change in the long run.

Trial Registration

Nederlands Trial Register NTR3102

Cost-effectiveness and cost-utility of a Web-based or print-delivered tailored intervention to promote physical activity among adults aged over fifty: an economic evaluation of the Active Plus intervention

Background

The adverse health effects of insufficient physical activity (PA) result in high costs to society. The economic burden of insufficient PA, which increases in our aging population, stresses the urgency for cost-effective interventions to promote PA among older adults. The current study provides insight in the cost-effectiveness and cost-utility of different versions of a tailored PA intervention (Active Plus) among adults aged over fifty.

Methods

The intervention conditions (i.e. print-delivered basic (PB; N = 439), print-delivered environmental (PE; N = 435), Web-based basic (WB; N = 423), Web-based environmental (WE; N = 432)) and a waiting-list control group were studied in a clustered randomized controlled trial. Intervention costs were registered during the trial. Health care costs, participant costs and productivity losses were identified and compared with the intervention effects on PA (in MET-hours per week) and quality-adjusted life years (QALYs) 12 months after the start of the intervention. Cost-effectiveness ratios (ICERs) and cost-utility ratios (ICURs) were calculated per intervention condition. Non-parametric bootstrapping techniques and sensitivity analyses were performed to account for uncertainty.

Results

As a whole (i.e. the four intervention conditions together) the Active Plus intervention was found to be cost-effective. The PB-intervention (ICER = €-55/MET-hour), PE-intervention (ICER = €-94/MET-hour) and the WE-intervention (ICER = €-139/MET-hour) all resulted in higher effects on PA and lower societal costs than the control group. With regard to QALYs, the PB-intervention (ICUR = €38,120/QALY), the PE-intervention (ICUR = €405,892/QALY) and the WE-intervention (ICUR = €-47,293/QALY) were found to be cost-effective when considering a willingness-to-pay threshold of €20,000/QALY. In most cases PE had the highest probability to be cost-effective.

Conclusions

The Active Plus intervention was found to be a cost-effective manner to increase PA in a population aged over fifty when compared to no-intervention. The tailored Active Plus intervention delivered through printed material and with additional environmental information (PE) turned out to be the most cost-effective intervention condition as confirmed by the different sensitivity analyses. By increasing PA at relatively low costs, the Active Plus intervention can contribute to a better public health.

Trial registration

Dutch Trial Register: NTR2297

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-014-0122-z) contains supplementary material, which is available to authorized users.

Consumer willingness to invest money and time for benefits of lifestyle behaviour change: an application of the contingent valuation method

OBJECTIVE

To use contingent valuation (CV) to derive individual consumer values for both health and broader benefits of a public-health intervention directed at lifestyle behaviour change (LBC) and to examine the feasibility and validity of the method.

METHOD

Participants of a lifestyle intervention trial (n = 515) were invited to complete an online CV survey. Respondents (n = 312) expressed willingness to invest money and time for changes in life expectancy, health-related quality of life (HRQOL) and broader quality of life aspects. Internal validity was tested for by exploring associations between explanatory variables (i.e. income, paid work, experience and risk factors for cardiovascular diseases) and willingness to invest, and by examining ordering effects and respondents' sensitivity to the scope of the benefits.

RESULTS

The majority of respondents (94.3%) attached value to benefits of LBC, and 87.4% were willing to invest both money and time. Respondents were willing to invest more for improvements in HRQOL (€42/month; 3 h/week) and broader quality of life aspects (€40/month; 2.6 h/week) than for improvements in life expectancy (€24/month; 2 h/week). Protest answers were limited (3%) and findings regarding internal validity were mixed.

CONCLUSION

The importance of broader quality of life outcomes to consumers suggests that these outcomes are relevant to be considered in the decision making. Our research showed that CV is a feasible method to value both health and broader outcomes of LBC, but generalizability to other areas of public health still needs to be examined. Mixed evidence regarding internal validity pleads for caution to use CV as only the base for decision making.

Economic evaluation of a web-based tailored lifestyle intervention for adults: findings regarding cost-effectiveness and cost-utility from a randomized controlled trial

BACKGROUND

Different studies have reported the effectiveness of Web-based computer-tailored lifestyle interventions, but economic evaluations of these interventions are scarce.

OBJECTIVE

The objective was to assess the cost-effectiveness and cost-utility of a sequential and a simultaneous Web-based computer-tailored lifestyle intervention for adults compared to a control group.

METHODS

The economic evaluation, conducted from a societal perspective, was part of a 2-year randomized controlled trial including 3 study groups. All groups received personalized health risk appraisals based on the guidelines for physical activity, fruit intake, vegetable intake, alcohol consumption, and smoking. Additionally, respondents in the sequential condition received personal advice about one lifestyle behavior in the first year and a second behavior in the second year; respondents in the simultaneous condition received personal advice about all unhealthy behaviors in both years. During a period of 24 months, health care use, medication use, absenteeism from work, and quality of life (EQ-5D-3L) were assessed every 3 months using Web-based questionnaires. Demographics were assessed at baseline, and lifestyle behaviors were assessed at both baseline and after 24 months. Cost-effectiveness and cost-utility analyses were performed based on the outcome measures lifestyle factor (the number of guidelines respondents adhered to) and quality of life, respectively. We accounted for uncertainty by using bootstrapping techniques and sensitivity analyses.

RESULTS

A total of 1733 respondents were included in the analyses. From a willingness to pay of €4594 per additional guideline met, the sequential intervention (n=552) was likely to be the most cost-effective, whereas from a willingness to pay of €10,850, the simultaneous intervention (n=517) was likely to be most cost-effective. The control condition (n=664) appeared to be preferred with regard to quality of life.

CONCLUSIONS

Both the sequential and the simultaneous lifestyle interventions were likely to be cost-effective when it concerned the lifestyle factor, whereas the control condition was when it concerned quality of life. However, there is no accepted cutoff point for the willingness to pay per gain in lifestyle behaviors, making it impossible to draw firm conclusions. Further economic evaluations of lifestyle interventions are needed.

TRIAL REGISTRATION

Dutch Trial Register NTR2168; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2168 (Archived by WebCite at http://www.webcitation.org/6MbUqttYB).

A lesson in business: cost-effectiveness analysis of a novel financial incentive intervention for increasing physical activity in the workplace

BACKGROUND

Recently both the UK and US governments have advocated the use of financial incentives to encourage healthier lifestyle choices but evidence for the cost-effectiveness of such interventions is lacking. Our aim was to perform a cost-effectiveness analysis (CEA) of a quasi-experimental trial, exploring the use of financial incentives to increase employee physical activity levels, from a healthcare and employer's perspective.

METHODS

Employees used a 'loyalty card' to objectively monitor their physical activity at work over 12 weeks. The Incentive Group (n=199) collected points and received rewards for minutes of physical activity completed. The No Incentive Group (n=207) self-monitored their physical activity only. Quality of life (QOL) and absenteeism were assessed at baseline and 6 months follow-up. QOL scores were also converted into productivity estimates using a validated algorithm. The additional costs of the Incentive Group were divided by the additional quality adjusted life years (QALYs) or productivity gained to calculate incremental cost effectiveness ratios (ICERs). Cost-effectiveness acceptability curves (CEACs) and population expected value of perfect information (EVPI) was used to characterize and value the uncertainty in our estimates.

RESULTS

The Incentive Group performed more physical activity over 12 weeks and by 6 months had achieved greater gains in QOL and productivity, although these mean differences were not statistically significant. The ICERs were £2,900/QALY and £2,700 per percentage increase in overall employee productivity. Whilst the confidence intervals surrounding these ICERs were wide, CEACs showed a high chance of the intervention being cost-effective at low willingness-to-pay (WTP) thresholds.

CONCLUSIONS

The Physical Activity Loyalty card (PAL) scheme is potentially cost-effective from both a healthcare and employer's perspective but further research is warranted to reduce uncertainty in our results. It is based on a sustainable "business model" which should become more cost-effective as it is delivered to more participants and can be adapted to suit other health behaviors and settings. This comes at a time when both UK and US governments are encouraging business involvement in tackling public health challenges.

Operationalising the capability approach for outcome measurement in mental health research

Amartya Sen's multidimensional capability approach focuses on the importance of freedoms to be or do things people have reason to value. It is an alternative to standard utilitarian welfarism, the theoretical approach to quality-adjusted life years (QALYs) and cost-utility analyses. Despite the limitations of the utility approach in capturing non-health benefits and broader welfare inequalities, there have been very limited applications of the capability approach in the mental health context where these issues are imperative. We report the development and application of a multidimensional instrument, the OxCAP-MH, which aims to operationalise the capability approach for outcome measurement in mental health research. The study was carried out as part of an ongoing programme on community coercion experienced by service users with severe and enduring mental illness being treated using Community Treatment Orders. Capabilities data were collected at baseline in the OCTET RCT for 333 'revolving door' mental health service users who were in involuntary hospital treatment at the time of recruitment in England (2008-2011). The research focused on the identification of capabilities domains most affected by mental illness and their association with socio-demographic and clinical factors and other measures of well-being such as the EQ-5D and Global Assessment of Functioning (GAF) scales. The OxCAP-MH item response rate was 90%-68%. There were significant correlations between service users' overall capability scores and the GAF, EQ-5D VAS and EQ-5D-3L utilities (corr = 0.249, 0.514, 0.415, respectively). The most affected capability domains were: 'Daily activities', 'Influencing local decisions', 'Enjoying recreation', 'Planning one's life' and 'Discrimination'. Age had a mixed effect, while female service users and those with a primary diagnosis of schizophrenia or longer illness duration reported significantly lower capability scores. The results support the feasibility and validity of directly measuring human capabilities for the mentally ill and the potential for applying the approach to outcome measurement.

A comparison of the EQ-5D-3L and ICECAP-O in an older post-acute patient population relative to the general population

BACKGROUND

The measurement and valuation of quality of life forms a major component of economic evaluation in health care and is a major issue in health services research. However, differing approaches exist in the measurement and valuation of quality of life from a health economics perspective. While some instruments such as the EQ-5D-3L focus on health-related quality of life alone, others assess quality of life in broader terms, for example, the newly developed ICECAP-O.

OBJECTIVE

The aim of this study was to utilize two generic preference-based instruments, the EQ-5D-3L and the ICECAP-O, to measure and value the quality of life of older adult patients receiving post-acute care. An additional objective was to compare the values obtained by each instrument with those generated from two community-based general population samples.

METHOD

Data were collected from a clinical patient population of older adults receiving post-acute outpatient rehabilitation or residential transition care and two Australian general population samples of individuals residing in the general community. The individual responses to the ICECAP-O and EQ-5D-3L instruments were scored using recently developed Australian general population algorithms. Empirical comparisons were made of the resulting patient and general population sample values for the total population and dis-aggregated according to age (65-79 and 80+ years) and gender.

RESULTS

A total of 1,260 participants aged 65-99 years (n = 86 clinical patient sample, n = 385 EQ-5D-3L general population sample, n = 789 ICECAP-O general population sample) completed one or both of the EQ-5D-3L and ICECAP-O instruments. As expected, the patient group demonstrated lower quality of life than the general population sample as measured by both quality-of-life instruments. The difference in values between the patient and general population groups was found to be far more pronounced for the EQ-5D-3L than for the ICECAP-O. The ICECAP-O was associated with a mean difference in values of 0.04 (patient group mean 0.753, SD 0.18; general population group mean 0.795, SD 0.17, respectively, p = 0.033). In contrast, the EQ-5D-3L was associated with a mean difference in values of 0.19 (patient group mean 0.595, SD 0.20; general population group mean 0.789, SD 0.02, respectively, p ≤ 0.001).

CONCLUSIONS

The study findings illustrate the magnitude of the difference in patient and general population values according to the instrument utilized, and highlight the differences in both the theoretical underpinnings and valuation algorithms for the EQ-5D-3L and ICECAP-O instruments. Further empirical work is required in larger samples and alternative patient groups to investigate the generalizability of the findings presented here.

Can capabilities be self-reported? A think aloud study

Direct assessment of capability to function may be useful in healthcare settings, but poses many challenges. This paper reports a first investigation of the feasibility of individuals self-reporting their capabilities and the meaning of the responses. The study was conducted in 2010, using think-aloud interviews with participants in the UK. The findings of the study suggest that the majority of participants were able to comprehend questions about their capabilities, felt able to judge their own capability wellbeing and provided responses in line with this judgement. In a number of cases, for example in relation to ‘autonomy’, participants highlighted that their capability was potentially greater than their functioning. The findings also show varying interpretations of the capability concept, with some participants finding the capability concept unintuitive in relation to specific aspects of life (in particular, ‘attachment’). The findings suggest that guiding individuals in the process of identifying their capabilities may be important in generating consistent responses to capability questions.

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Think-aloud interviews were used, in the UK, to study the response to capability wellbeing questions.

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Most people felt able to judge their capabilities and made few obvious ‘errors’ in doing so.

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The capability concept was unintuitive for some people in some aspects of their life.

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Occasional divergence between capability and functioning was reported.

Approaches to economic evaluations of stroke rehabilitation

Many stroke rehabilitation services and interventions are complex in that they involve a number of components, interactions, and outcomes. Much of the onus of stroke care lies with rehabilitation services and because stroke rehabilitation is highly resource intensive, it is important for policy makers to consider the potential trade-offs between all relevant costs and benefits. The primary aim of this systematic review was to assess the methods used to conduct economic evaluations of stroke rehabilitation. Studies that compared two or more alternative stroke rehabilitation interventions or services with the costs and outcomes being examined for each alternative were included. EMBASE, MEDLINE In-Process, and National Health Service's Economic Evaluation Database were searched using search strategies. The methodological quality of the included studies was appraised using a checklist for the conduct and reporting of economic evaluations. Twenty-one studies met the selection criteria. The economic evaluations in the majority of these studies were inadequate based on their ability to identify, measure, and value all resources and benefits pertinent to the complexity of stroke rehabilitation. This study highlights that complex interventions such as stroke rehabilitation have widespread effects, which may not be represented by the changes on a single outcome. This study recommends the adoption of a wider cost and benefit perspective in the economic evaluations of complex interventions. It supports a move away from conventional economic evaluation and decision making, based purely on cost-effectiveness, toward multicriteria decision analysis frameworks for complex interventions, where a broader range of criteria may be assessed by policy makers.

Predicting the ICECAP-O Capability Index from the WOMAC Osteoarthritis Index

Background. There is a growing interest in the application of the capability approach in health economic analysis. The aim of the research reported here is to assess the feasibility of mapping from a condition-specific questionnaire (Western Ontario and McMaster Universities [WOMAC] Osteoarthritis Index) to a capability well-being questionnaire (ICEpop CAPability measure for Older people [ICECAP-O]). Methods. One hundred five osteoarthritis patients requiring joint replacement completed the 5 attributes on the ICECAP-O (attachment, security, role, enjoyment, and control) and the 3 WOMAC categories (pain, stiffness, and physical function). The prediction data set consisted of baseline scores, whereas follow-up data were used to validate the predictions. The mapping algorithms used ordinary least squares and multinomial logistic regression models to predict the relationship between WOMAC scores, categories, or items and ICECAP-O scores or the 5 ICECAP-O attributes. Results. ICECAP-O scores predicted from WOMAC category scores produced the lowest mapping error statistics (mean absolute error = 0.0832; mean squared error = 0.0142) as well as highest goodness of fit (R2 = 0.3976). Prediction of ICECAP-O attributes from WOMAC category scores was possible for the majority of capability dimensions. The “control” attribute and physical function WOMAC category exhibited the strongest relationship (R2 = 0.2143). The “attachment” attribute proved difficult to predict from any WOMAC category, which is in line with intuition given this attribute captures psychological well-being rather than pain, stiffness, or physical function. Conclusion. This is the first study to investigate the predictive ability of a condition-specific measure of health onto capability. The results presented here suggest it is feasible to map from condition-specific measures to an overall capability index, although WOMAC cannot predict individual capability in its entirety. Although the results here are encouraging for those interested in using ICECAP-O, given the small validation sample size applied, further research will be required to verify these findings.

Valuing the economic benefits of complex interventions: when maximising health is not sufficient

Complex interventions, involving interlinked packages of care, challenge the application of current methods of economic evaluation that focus on measuring only health gain. Complex interventions may be problematic on two levels. The complexity means the intervention may not fit into one of the current appraisal systems, and/or maximising health is not the only objective. This paper discusses the implications of a programme of work that focused on clinical genetics services, as an example of a complex intervention, and aimed to identify the following: the attributes that comprise both health and non-health aspects of benefits and whether it is possible to evaluate such an intervention using current National Institute for Health and Clinical Excellence appraisal processes. Genetic services and tests are a good example of a complex intervention and have broader objectives than just health gain, which may usefully be measured using the concept related to capability, which we have called 'empowerment'. Further methodological work is required to identify the trade-off between non-health (empowerment) and health benefits for other complex interventions. We do not advocate a move away from QALY maximisation but do suggest that there is a need for a more considered approach that can take account of the perceived value for non-health attributes for some complex interventions.

Treating patients as persons: a capabilities approach to support delivery of person-centered care

Health services internationally struggle to ensure health care is "person-centered" (or similar). In part, this is because there are many interpretations of "person-centered care" (and near synonyms), some of which seem unrealistic for some patients or situations and obscure the intrinsic value of patients' experiences of health care delivery. The general concern behind calls for person-centered care is an ethical one: Patients should be "treated as persons." We made novel use of insights from the capabilities approach to characterize person-centered care as care that recognizes and cultivates the capabilities associated with the concept of persons. This characterization unifies key features from previous characterisations and can render person-centered care applicable to diverse patients and situations. By tying person-centered care to intrinsically valuable capability outcomes, it incorporates a requirement for responsiveness to individuals and explains why person-centered care is required independently of any contribution it may make to health gain.

Consumer preferences for health and nonhealth outcomes of health promotion: results from a discrete choice experiment

OBJECTIVE

Health promotion (HP) interventions have outcomes that go beyond health. Such broader nonhealth outcomes are usually neglected in economic evaluation studies. To allow for their consideration, insights are needed into the types of nonhealth outcomes that HP interventions produce and their relative importance compared with health outcomes. This study explored consumer preferences for health and nonhealth outcomes of HP in the context of lifestyle behavior change.

METHODS

A discrete choice experiment was conducted among participants in a lifestyle intervention (n = 132) and controls (n = 141). Respondents made 16 binary choices between situations that can be experienced after lifestyle behavior change. The situations were described by 10 attributes: future health state value, start point of future health state, life expectancy, clothing size above ideal, days with sufficient relaxation, endurance, experienced control over lifestyle choices, lifestyle improvement of partner and/or children, monetary cost per month, and time cost per week.

RESULTS

With the exception of "time cost per week" and "start point of future health state," all attributes significantly determined consumer choices. Thus, both health and nonhealth outcomes affected consumer choice. Marginal rates of substitution between the price attribute and the other attributes revealed that the attributes "endurance," "days with sufficient relaxation," and "future health state value" had the greatest impact on consumer choices. The "life expectancy" attribute had a relatively low impact and for increases of less than 3 years, respondents were not willing to trade.

CONCLUSIONS

Health outcomes and nonhealth outcomes of lifestyle behavior change were both important to consumers in this study. Decision makers should respond to consumer preferences and consider nonhealth outcomes when deciding about HP interventions.

An investigation of the construct validity of the ICECAP-A capability measure

Purpose

To investigate the construct validity of the ICECAP-A capability wellbeing measure.

Methods

A face-to-face interview-administered survey was conducted with 418 members of the UK general population, randomly sampled from the Postcode Address File. Pre-specified hypotheses were developed about the expected associations between individuals’ ICECAP-A responses and their socio-economic circumstances, health and freedom. The hypotheses were investigated using statistical tests of association.

Results

The ICECAP-A responses and scores reflected differences across different health and socioeconomic groups as anticipated, but did not distinguish individuals by the level of local deprivation. Mean ICECAP-A scores reflected individuals’ perceived freedom slightly more closely than did measures of health and happiness.

Conclusion

This study suggests that the ICECAP-A measure can identify expected differences in capability wellbeing in a general population sample. Further work could establish whether self-reported capabilities exhibit desirable validity and acceptability in sub-groups of the population such as patients, social care recipients and informal carers.

Economic evaluation of a weight control program with e-mail and telephone counseling among overweight employees: a randomized controlled trial

BACKGROUND

Distance lifestyle counseling for weight control is a promising public health intervention in the work setting. Information about the cost-effectiveness of such interventions is lacking, but necessary to make informed implementation decisions. The purpose of this study was to perform an economic evaluation of a six-month program with lifestyle counseling aimed at weight reduction in an overweight working population with a two-year time horizon from a societal perspective.

METHODS

A randomized controlled trial comparing a program with two modes of intervention delivery against self-help. 1386 Employees from seven companies participated (67% male, mean age 43 (SD 8.6) years, mean BMI 29.6 (SD 3.5) kg/m2). All groups received self-directed lifestyle brochures. The two intervention groups additionally received a workbook-based program with phone counseling (phone; n=462) or a web-based program with e-mail counseling (internet; n=464). Body weight was measured at baseline and 24 months after baseline. Quality of life (EuroQol-5D) was assessed at baseline, 6, 12, 18 and 24 months after baseline. Resource use was measured with six-monthly diaries and valued with Dutch standard costs. Missing data were multiply imputed. Uncertainty around differences in costs and incremental cost-effectiveness ratios was estimated by applying non-parametric bootstrapping techniques and graphically plotting the results in cost-effectiveness planes and cost-effectiveness acceptability curves.

RESULTS

At two years the incremental cost-effectiveness ratio was €1009/kg weight loss in the phone group and €16/kg weight loss in the internet group. The cost-utility analysis resulted in €245,243/quality adjusted life year (QALY) and €1337/QALY, respectively. The results from a complete-case analysis were slightly more favorable. However, there was considerable uncertainty around all outcomes.

CONCLUSIONS

Neither intervention mode was proven to be cost-effective compared to self-help.

Measuring and valuing quality of life for public health research: application of the ICECAP-O capability index in the Australian general population

OBJECTIVES

To assess the applicability of the newly developed ICECAP-O capability index in the measurement and valuation of quality of life in a large community based sample of the Australian general population. With origins in Sen's capability theory, the ICECAP-O may more fully encapsulate the multi-dimensional outcomes of public health policies and interventions than traditional health economic constructs.

METHODS

2,937 Australian residents participated in face-to-face interviews. The relationships between ICECAP-O scores according to age groups (<65 or >65 years) and socio-economic status were investigated using descriptive statistics and multivariable linear regression models.

RESULTS

Lower income levels and being unemployed or physically unable to work were negatively associated with capability for both age groups. Capability was strongly and positively associated with marriage and cohabitation in the younger age group, whilst being Australian-born was a positive indicator for the older group.

CONCLUSIONS

The results provide insights into the assessment of capability in the Australian general population. The ICECAP-O shows promise for application in the measurement and valuation of quality of life in general population surveys, and incorporation into economic evaluations of public health interventions.

Exploring non-health outcomes of health promotion: the perspective of participants in a lifestyle behaviour change intervention

OBJECTIVE

To provide insights into health promotion outcomes that are not captured by conventional measures of health outcome used in economic evaluation studies, such as EQ5D based QALYs.

METHODS

Twelve semi-structured interviews and five focus group discussions were conducted with participants of a randomized controlled trial (n=52) evaluating the effectiveness of a theory-based lifestyle intervention in Dutch adults at risk for diabetes mellitus and/or cardiovascular disease. Transcripts were analysed by two independent researchers using a thematic analysis approach.

RESULTS

In total we identified twelve non-health outcome themes that were important from the participant perspective. Four of these were reported as direct outcomes of the lifestyle intervention and eight were reported as consequences of lifestyle behaviour change. Our findings also suggest that lifestyle behaviour change may have spillover effects to other people in the participants' direct environment.

CONCLUSION

This study provides evidence that in the context of lifestyle behaviour change EQ5D based QALYs capture health promotion outcomes only partially. More insights are needed into non-health outcomes and spillover effects produced by health promotion in other contexts and how participants and society value these. Methods to account for these outcomes within an economic evaluation framework need to be developed and tested.

[Health assessment and economic assessment in health: introduction to the debate on the points of intersection]

The study aims to infer the existence of a continuum between Health Assessment and Economic Assessment in Health, by highlighting points of intersection of these forms of appraisal. To achieve this, a review of the theoretical foundations, methods and approaches of both forms of assessment was conducted. It was based on the theoretical model of health evaluation as reported by Hartz et al and economic assessment in health approaches reported by Brouwer et al. It was seen that there is a continuum between the theoretical model of evaluative research and the extrawelfarist approach for economic assessment in health, and between the normative theoretical model for health assessment and the welfarist approaches for economic assessment in health. However, in practice the assessment is still conducted using the normative theoretical model and with a welfarist approach.