The impact of different types of NHS expenditure on health: Marginal cost per QALY estimates for England for 2016/17

Does shortage of GPs matter? A cross-sectional study of practice population life expectancy

BACKGROUND

There are not enough GPs in England. Access to general practice and continuity of care are declining.

AIM

To investigate whether practice characteristics are associated with life expectancy of practice populations.

DESIGN AND SETTING

A cross-sectional ecological study of patient life expectancy from 2015-2019.

METHOD

Selection of independent variables was based on conceptual frameworks describing general practice's influence on outcomes. Sixteen non-correlated variables were entered into multivariable weighted regression models: population characteristics (Index of Multiple Deprivation, region, % White ethnicity, and % on diabetes register); practice organisation (total NHS payments to practices expressed as payment per registered patient, full-time equivalent fully qualified GPs, GP registrars, advanced nurse practitioners, other nurses, and receptionists per 1000 patients); access (% seen on the same day); clinical performance (% aged ≥45 years with blood pressure checked, % with chronic obstructive pulmonary disease vaccinated against flu, % with diabetes in glycaemic control, and % with coronary heart disease on antiplatelet therapy); and the therapeutic relationship (% continuity).

RESULTS

Deprivation was strongly negatively associated with life expectancy. Regions outside London and White ethnicity were associated with lower life expectancy. Higher payment per patient, full-time equivalent fully qualified GPs per 1000 patients, continuity, % with chronic obstructive pulmonary disease having the flu vaccination, and % with diabetes with glycaemic control were associated with higher life expectancy; the % being seen on the same day was associated with higher life expectancy in males only. The variable aged ≥45 years with blood pressure checked was a negative predictor in females.

CONCLUSION

The number of GPs, continuity of care, and access in England are declining, and it is worrying that these features of general practice were positively associated with life expectancy.

Marginal cost per QALY estimates: What are they good for?

Estimates of the marginal cost per quality-adjusted life year (MCPQ) are available for health care systems worldwide. Researchers routinely make claims about these estimates and how they should inform policymaking. This commentary considers these claims by taking a recent article from Health Policy as a case study. Claims are made about the past performance of the health service and about future decisions and relate to such considerations as productivity, the impact of technology approvals, cost-effectiveness thresholds, and budget allocation. We argue that the evidence does not justify these claims and MCPQ estimates should instead inform questions about the consequences of changes in expenditure.

Systematic review of the impact of health care expenditure on health outcome measures: implications for cost-effectiveness thresholds

OBJECTIVE

Empirical estimates of the impact of healthcare expenditure on health outcome measures may inform the cost-effectiveness threshold (CET) for guiding funding decisions. This study aims to systematically review studies that estimated this, summarize and compare the estimates by country income level.

METHODS

We searched PubMed, Scopus, York Research database, and [anonymized] for Reviews and Dissemination database from inception to 1 August 2023. For inclusion, a study had to be an original article, estimating the impact of healthcare expenditure on health outcome measures at a country level, and presented estimates, in terms of cost per quality-adjusted life year (QALY) or disability-adjusted life year (DALY).

RESULTS

We included 18 studies with 385 estimates. The median (range) estimates were PPP$ 11,224 (PPP$ 223 - PPP$ 288,816) per QALY gained and PPP$ 5,963 (PPP$ 71 - PPP$ 165,629) per DALY averted. As ratios of Gross Domestic Product per capita (GDPPC), these estimates were 0.376 (0.041-182.840) and 0.318 (0.004-37.315) times of GDPPC, respectively.

CONCLUSIONS

The commonly used CET of GDPPC seems to be too high for all countries, but especially low-to-middle-income countries where the potential health losses from misallocation of the same money are greater.

REGISTRATION

The review protocol was published and registered in PROSPERO (CRD42020147276).