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Raj EA, Hebbar P, N Srinivas P, V Rao N, Gudi N, Brand A, Patil DS. Health technology assessment implementation in WHO South-East Asia Region: a realist review protocol. Wellcome Open Res 2024; 8:351. [PMID: 39045314 PMCID: PMC11263902 DOI: 10.12688/wellcomeopenres.19619.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2024] [Indexed: 07/25/2024] Open
Abstract
Background A robust Health Technology Assessment (HTA) framework is crucial to address the rising burden of healthcare costs and to inform decision-making to promote high-quality health systems. This research aims to describe the HTA methods and mechanisms for the successful implementation of HTA in the WHO South-East Asia region, and contextualize the synthesized evidence relevant to Indian settings. Methods Realist review involves developing a program theory by conducting a systematic search strategy, screening, study selection, data extraction, and data synthesis. A systematic search for literature will be conducted on PubMed (NCBI), EMBASE (Elsevier), Scopus (Elsevier), Web of Science (Clarivate), and ProQuest Central for identifying the methods used for HTA of health technology interventions. Stakeholder consultations will be conducted to develop a program theory following the Context-Mechanism-Outcome configurations (CMOcs) framework. Searches for primary evidence will be conducted iteratively. Data will be extracted and tested against the programme theory. The proposed realist review will be reported as per the Realist and MEta-narrative Evidence Syntheses: Evolving Standards [RAMESES II] guidelines. Conclusions To our knowledge, there has been no comprehensive review conducted to understand the mechanisms of HTA methods in the WHO South-East Asia region. The findings from the realist review will help us understand the mechanisms through which the HTA could work in WHO South-East Asian countries. We will then contextualize the findings obtained from evidence to Indian settings, based on program theory development through stakeholder consultation. A framework will be developed that can be used by policymakers/HTA experts in India for effective implementation of the same.
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Affiliation(s)
- Elstin Anbu Raj
- Department of Health Information, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
- Department of Pharmacy Practice, Manipal College of Pharmaceutical Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
| | - Pragati Hebbar
- Cluster on Chronic Conditions and Public Policies, Institute of Public Health Bengaluru, Bengaluru, Karnataka, 560070, India
| | - Prashanth N Srinivas
- Health equity cluster, Institute of Public Health Bengaluru, Bengaluru, Karnataka, 560070, India
| | - Neethi V Rao
- Institute of Public Health Bengaluru, Bengaluru, Karnataka, 560070, India
- Independent Consultant, Bengaluru, India
| | - Nachiket Gudi
- Department of Health Information, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
- Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, Limburg, 6200 MD, The Netherlands
| | - Angela Brand
- Department of Health Information, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
- Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, Limburg, 6200 MD, The Netherlands
- United Nations University - Maastricht Economic and Social Research Institute on Innovation and Technology, Maastricht University, Maastricht, Limburg, NL - 6211 AX, The Netherlands
| | - Divya Sussana Patil
- Department of Health Information, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka, 576104, India
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Phimarn W, Saramunee K, Leelathanalerk A, Srimongkon P, Chanasopon S, Phumart P, Paktipat P, Babar ZUD. Economic evaluation of pharmacy services: a systematic review of the literature (2016-2020). Int J Clin Pharm 2023; 45:1326-1348. [PMID: 37233864 DOI: 10.1007/s11096-023-01590-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 04/01/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Economic evaluation is crucial for healthcare decision-makers to select effective interventions. An updated systematic review of the economic evaluation of pharmacy services is required in the current healthcare environment. AIM To conduct a systematic review of literature on economic evaluation of pharmacy services. METHOD Literature (2016-2020) was searched on PubMed, Web of Sciences, Scopus, ScienceDirect, and SpringerLink. An additional search was conducted in five health economic-related journals. The studies performed an economic analysis describing pharmacy services and settings. The reviewing checklist for economic evaluation was used for quality assessment. The incremental cost-effectiveness ratio and willingness-to-pay threshold were the main measures for cost-effective analysis (CEA) and cost-utility analysis (CUA), while cost-saving, cost-benefit-ratio (CBR), and net benefit were used for cost-minimization analysis (CMA) and cost-benefit analysis (CBA). RESULTS Forty-three articles were reviewed. The major practice settings were in the USA (n = 6), the UK (n = 6), Canada (n = 6), and the Netherlands (n = 6). Twelve studies had good quality according to the reviewing checklist. CUA was used most frequently (n = 15), followed by CBA (n = 12). Some inconsistent findings (n = 14) existed among the included studies. Most agreed (n = 29) that pharmacy services economically impact the healthcare system: hospital-based (n = 13), community pharmacy (n = 13), and primary care (n = 3). Pharmacy services were found to be cost-effectiveness or cost-saving among both developed (n = 32) and in developing countries (n = 11). CONCLUSION The increased use of economic evaluation of pharmacy services confirms the worth of pharmacy services in improving patients' health outcomes in all settings. Therefore, economic evaluation should be incorporated into developing innovative pharmacy services.
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Affiliation(s)
- Wiraphol Phimarn
- Social Pharmacy Research Unit, Faculty of Pharmacy, Mahasarakham University, Kantharawichai, Maha Sarakham, 44150, Thailand
| | - Kritsanee Saramunee
- Social Pharmacy Research Unit, Faculty of Pharmacy, Mahasarakham University, Kantharawichai, Maha Sarakham, 44150, Thailand.
| | - Areerut Leelathanalerk
- Health Services and Pharmacy Practice Research and Innovation Research Unit, Faculty of Pharmacy, Mahasarakham University, Kantharawichai, Maha Sarakham, 44150, Thailand
- Clinical Trials and Evidence-Based Syntheses Research Unit, Faculty of Pharmacy, Mahasarakham University, Kantharawichai, Maha Sarakham, 44150, Thailand
| | - Pornchanok Srimongkon
- Health Services and Pharmacy Practice Research and Innovation Research Unit, Faculty of Pharmacy, Mahasarakham University, Kantharawichai, Maha Sarakham, 44150, Thailand
- Clinical Trials and Evidence-Based Syntheses Research Unit, Faculty of Pharmacy, Mahasarakham University, Kantharawichai, Maha Sarakham, 44150, Thailand
| | - Suratchada Chanasopon
- Health Services and Pharmacy Practice Research and Innovation Research Unit, Faculty of Pharmacy, Mahasarakham University, Kantharawichai, Maha Sarakham, 44150, Thailand
- Clinical Trials and Evidence-Based Syntheses Research Unit, Faculty of Pharmacy, Mahasarakham University, Kantharawichai, Maha Sarakham, 44150, Thailand
| | - Panumart Phumart
- Health Services and Pharmacy Practice Research and Innovation Research Unit, Faculty of Pharmacy, Mahasarakham University, Kantharawichai, Maha Sarakham, 44150, Thailand
- Clinical Trials and Evidence-Based Syntheses Research Unit, Faculty of Pharmacy, Mahasarakham University, Kantharawichai, Maha Sarakham, 44150, Thailand
| | - Pawich Paktipat
- Social Pharmacy Research Unit, Faculty of Pharmacy, Mahasarakham University, Kantharawichai, Maha Sarakham, 44150, Thailand
- Health Services and Pharmacy Practice Research and Innovation Research Unit, Faculty of Pharmacy, Mahasarakham University, Kantharawichai, Maha Sarakham, 44150, Thailand
- Clinical Trials and Evidence-Based Syntheses Research Unit, Faculty of Pharmacy, Mahasarakham University, Kantharawichai, Maha Sarakham, 44150, Thailand
| | - Zaheer-Ud-Din Babar
- Department of Pharmacy School of Applied Sciences, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH, UK
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Rand LZ, Melendez‐Torres GJ, Kesselheim AS. Alternatives to the quality-adjusted life year: How well do they address common criticisms? Health Serv Res 2023; 58:433-444. [PMID: 36537647 PMCID: PMC10012222 DOI: 10.1111/1475-6773.14116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To analyze whether other outcome measures used in health technology assessment (HTA) address the criticisms of quality-adjusted life years (QALYs). DATA SOURCES AND STUDY SETTING HTA methods guidance from 11 US comparator countries (the G10 and Australia) and six value frameworks from US organizations were reviewed to identify health outcome measures currently used to evaluate the benefits of a drug. STUDY DESIGN The study involved a documentary analysis of guidelines to identify outcome measures used by the sampled HTA organizations. Similar outcomes were grouped together into outcome types. Each type was analyzed to determine the extent to which it replicates key advantages and responds to criticisms of QALYs extracted from the literature. EXTRACTION METHODS Outcomes were included if guidance from at least one HTA organization identified the outcome as acceptable for HTA. Outcomes measuring or evaluating the benefit, clinical effect, or impact of a drug or health technology was included; methods of calculating costs were excluded. PRINCIPAL FINDINGS Seven types of outcome measures were identified falling into three groups: preference-based, single-dimension outcomes, and outcomes using non-health perspectives. Among the seven QALY alternative outcome measures currently used for HTA by the sampled countries, no one outcome measure addresses all the QALY criticisms while retaining the advantageous features of the QALY. CONCLUSIONS Proposals to adopt health technology assessment (HTA) to support value-based pricing of prescription drugs in the US have faced pushback over the use of the QALY. There is no single "right" outcome measure, and the criticisms of QALYs apply to other outcome measures used to evaluate health. The measures identified have different features and strengths, which may be appropriate for specific decision making goals, but the QALY remains the best option for decision making that requires comparisons of the overall societal value of health gains.
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Affiliation(s)
- Leah Z. Rand
- The Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Center for BioethicsHarvard Medical SchoolBostonMassachusettsUSA
| | - G. J. Melendez‐Torres
- Peninsula Technology Assessment Group (PenTAG), Faculty of Health and Life SciencesUniversity of ExeterExeterUK
| | - Aaron S. Kesselheim
- The Program on Regulation, Therapeutics, and Law (PORTAL), Division of Pharmacoepidemiology and Pharmacoeconomics, Department of MedicineBrigham and Women's Hospital and Harvard Medical SchoolBostonMassachusettsUSA
- Center for BioethicsHarvard Medical SchoolBostonMassachusettsUSA
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Mangoya D, Barham L, Moyo E, Moyo P, Dzinamarira T. The Use of Economic Evaluation Tools in Essential Health Benefits Package Selection for Universal Health Coverage. Value Health Reg Issues 2023; 36:1-9. [PMID: 36934592 DOI: 10.1016/j.vhri.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/15/2023] [Accepted: 01/28/2023] [Indexed: 03/19/2023]
Abstract
OBJECTIVES The sustainable development goals launched in 2015 are a follow-up commitment to the successful Millennium Development Goals. Goal number 3 of ensuring "good health and well-being" is a target to ensure universal health coverage. Universal health coverage means the provision of quality services that meet the needs of populations without risking financial impoverishment in the process. The guaranteed minimum health services in every health system constitute the health benefits package (HBP), which should be explicit and be composed of services that represent the best value for money and guarantee the best return on investment. The objective of this study was to review the application of cost-effectiveness analysis (CEA) and budget impact analysis in the development of HBP in low-to-middle income countries across the world. METHODOLOGY A literature review using a systematic approach was used. A search of PubMed, Google Scholar, World Health Organization, and World Bank databases was made for articles outlining the development of HBP in low- and middle-income countries, and a narrative synthesis was used for analysis. RESULTS Results from processes in Armenia, Ethiopia, Kyrgyz Republic, Lebanon, and Malawi showed CEA and budget impact analysis as 2 criteria used in HBP development in a limited number of countries with either no reference to the two or no reporting from the others. Local CEA estimates and cost data limitations were the biggest challenges to efforts to use robust methods. CONCLUSION Sustained efforts are needed to understand and address the challenges to the use of economic evaluation in the development of HBPs.
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Affiliation(s)
| | - Leela Barham
- Faculty of Life Science and Education, Learna, Cardiff, Wales, UK
| | - Enos Moyo
- Medical Centre Oshakati, Oshakati, Namibia.
| | | | - Tafadzwa Dzinamarira
- School of Health Systems and Public Health, University of Pretoria, Pretoria, South Africa
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5
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Syeed MS, Nonthasawadsri T, Nelson RE, Chaiyakunapruk N, Nathisuwan S. Integrating Real-World Evidence in Economic Evaluation of Oral Anticoagulants for Stroke Prevention in Non-valvular Atrial Fibrillation in a Developing Country. Am J Cardiovasc Drugs 2023; 23:173-183. [PMID: 36735211 DOI: 10.1007/s40256-023-00570-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2023] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This study aimed to estimate the cost effectiveness of non-vitamin K oral anticoagulants (NOACs) compared with warfarin for stroke prevention in patients with non-valvular atrial fibrillation (NVAF) in Thailand where suboptimal anticoagulation control is common. MATERIALS AND METHODS A hypothetical cohort of 65-year-old patients with NVAF and their disease progression was simulated in the Markov model. The following anticoagulant agents were used: warfarin, dabigatran, rivaroxaban, and apixaban. Warfarin with high, intermediate, and low time in therapeutic ranges (TTR) was used as the three different reference treatments. Baseline clinical events were obtained from a recently published real-world study in Thailand. A lifetime horizon was utilized in this model, and all analyses were performed from societal and healthcare perspectives. The results were reported as incremental cost-effectiveness ratios (ICERs) in 2021 US dollars per quality-adjusted life-year (QALY) gained. The sensitivity analyses were performed to assess the influence of parameter uncertainty. RESULTS Apixaban was a cost-effective intervention compared with warfarin with low and intermediate TTR groups. In the low TTR group, the ICERs were $779 and $816 per QALY gained from the societal and healthcare perspectives, respectively, and in the intermediate TTR group, the ICERs were $2038 and $3159 per QALY gained from the societal and healthcare perspectives, respectively. Both ICERs were below the accepted willingness-to-pay threshold ($4806) in the context of Thailand's healthcare. CONCLUSIONS In a developing country where suboptimal anticoagulation control is common, apixaban was the cost-effective alternative to warfarin for patients with both low and intermediate TTR control.
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Affiliation(s)
- M Sakil Syeed
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Teerawat Nonthasawadsri
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
| | - Richard E Nelson
- Division of Epidemiology, School of Medicine, University of Utah, Salt Lake City, UT, USA.,Informatics, Decision Enhancement and Analytics Sciences (IDEAS) Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA.,Informatics, Decision Enhancement and Analytics Sciences (IDEAS) Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
| | - Surakit Nathisuwan
- Clinical Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, 447 Sri-Ayutthaya Road, Ratchathewi, 10400, Bangkok, Thailand.
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Tozan Y, Odhiambo Sewe M, Kim S, Rocklöv J. A Methodological Framework for Economic Evaluation of Operational Response to Vector-Borne Diseases Based on Early Warning Systems. Am J Trop Med Hyg 2023; 108:627-633. [PMID: 36646075 PMCID: PMC9978551 DOI: 10.4269/ajtmh.22-0471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/18/2022] [Indexed: 01/18/2023] Open
Abstract
Despite significant advances in improving the predictive models for vector-borne diseases, only a few countries have integrated an early warning system (EWS) with predictive and response capabilities into their disease surveillance systems. The limited understanding of forecast performance and uncertainties by decision-makers is one of the primary factors that precludes its operationalization in preparedness and response planning. Further, predictive models exhibit a decrease in forecast skill with longer lead times, a trade-off between forecast accuracy and timeliness and effectiveness of action. This study presents a methodological framework to evaluate the economic value of EWS-triggered responses from the health system perspective. Assuming an operational EWS in place, the framework makes explicit the trade-offs between forecast accuracy, timeliness of action, effectiveness of response, and costs, and uses the net benefit analysis, which measures the benefits of taking action minus the associated costs. Uncertainty in disease forecasts and other parameters is accounted for through probabilistic sensitivity analysis. The output is the probability distribution of the net benefit estimates at given forecast lead times. A non-negative net benefit and the probability of yielding such are considered a general signal that the EWS-triggered response at a given lead time is economically viable. In summary, the proposed framework translates uncertainties associated with disease forecasts and other parameters into decision uncertainty by quantifying the economic risk associated with operational response to vector-borne disease events of potential importance predicted by an EWS. The goal is to facilitate a more informed and transparent public health decision-making under uncertainty.
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Affiliation(s)
- Yesim Tozan
- School of Global Public Health, New York University, New York, New York
| | - Maquines Odhiambo Sewe
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health & Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
| | - Sooyoung Kim
- School of Global Public Health, New York University, New York, New York
| | - Joacim Rocklöv
- Department of Public Health and Clinical Medicine, Epidemiology and Global Health & Umeå Centre for Global Health Research, Umeå University, Umeå, Sweden
- Heidelberg Institute of Global Health, Interdisciplinary Centre for Scientific Computing, Heidelberg University, Heidelberg, Germany
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7
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Hendrix N, Kwete X, Bolongaita S, Megiddo I, Memirie ST, Mirkuzie AH, Nonvignon J, Verguet S. Economic evaluations of health system strengthening activities in low-income and middle-income country settings: a methodological systematic review. BMJ Glob Health 2022; 7:bmjgh-2021-007392. [PMID: 35277429 PMCID: PMC8919450 DOI: 10.1136/bmjgh-2021-007392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 01/29/2022] [Indexed: 12/04/2022] Open
Abstract
Objective Health system strengthening (HSS) activities should accompany disease-targeting interventions in low/middle-income countries (LMICs). Economic evaluations provide information on how these types of investment might best be balanced but can be challenging. We conducted a systematic review to evaluate how researchers address these economic evaluation challenges. Methods We identified studies about economic evaluation of HSS activities in LMICs using a two-stage approach. First, we conducted a broad search to identify areas where economic evaluations of HSS activities were being conducted. Next, we selected specific interventions for more targeted literature review. We extracted study characteristics using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Finally, we summarised authors’ modelling decisions using a framework that examines how models are developed to emphasise generalisability, precision, or realism. Findings Our searches produced 1978 studies, out of which we included 36. Most studies used data from prospective trials and calculated cost-effectiveness directly from these trial inputs, rather than using simulation methods. As a group, these studies primarily emphasised precision and realism over generalisability, meaning that their results were best suited to specific settings. Conclusions The number of included studies was small. Our findings suggest that most economic evaluations of HSS do not leverage methods like sensitivity analyses or inputs from literature review that would produce more generalisable (but potentially less precise) results. More research into how decision-makers would use economic evaluations to define the expansion path to strengthening health systems would allow for conceptualising impactful work on the economic value of HSS.
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Affiliation(s)
- Nathaniel Hendrix
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Xiaoxiao Kwete
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Global Health Research and Consulting, Yaozhi, Yangzhou, Jiangsu, China
| | - Sarah Bolongaita
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Itamar Megiddo
- Department of Management Science, University of Strathclyde, Glasgow, UK
| | - Solomon Tessema Memirie
- Addis Center for Ethics and Priority Setting, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Alemnesh H Mirkuzie
- National Data Management Centre for Health, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | | | - Stéphane Verguet
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Patton T, Revill P, Sculpher M, Borquez A. Using Economic Evaluation to Inform Responses to the Opioid Epidemic in the United States: Challenges and Suggestions for Future Research. Subst Use Misuse 2022; 57:815-821. [PMID: 35157549 PMCID: PMC8969147 DOI: 10.1080/10826084.2022.2026969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background: Several aspects of the opioid epidemic and of public health care organization in the United States (US) make the conduct of economic evaluation and the design of policies to respond to this crisis particularly challenging. Objectives: This commentary offers suggestions for how economic evaluation may address and overcome four key features of the opioid epidemic: 1) its magnitude and geographical distribution, 2) its intersection with multiple epidemics, 3) its rapidly changing dynamics, 4) its multi-sectoral causes and consequences. Results: We first offer pragmatic suggestions to address the difficulties in delivering a coordinated response given the fragmented nature of health care in the US. In view of the broad suite of responses required to address opioid use disorder and its associated comorbidities, we highlight the need for economic evaluations which consider interventions throughout the continuum of care (i.e. primary, secondary and tertiary levels of prevention). We examine how the use of predictive modelling alongside economic evaluation might be adopted to address the rapidly evolving situation affecting distinct populations and geographic areas and encourage investments in epidemic preparedness. Finally, we propose methods to capture the interdependence of various sectors of government affected by the opioid crisis in economic evaluations to ensure optimal levels of investment towards a comprehensive response. Conclusions: The opioid epidemic in the US represents an unprecedented public health challenge, but sound epidemiological modelling and economic analysis can help to guide use of limited resources committed to addressing it in ways that can have greatest impact in limiting its adverse consequences.
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Affiliation(s)
- Thomas Patton
- Division of Infectious Diseases and Global Public Health, University of California San Diego, California, USA
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, UK
| | - Annick Borquez
- Division of Infectious Diseases and Global Public Health, University of California San Diego, California, USA
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Reis LA, Drouet L, Tavoni M. Internalising health-economic impacts of air pollution into climate policy: a global modelling study. Lancet Planet Health 2022; 6:e40-e48. [PMID: 34998459 DOI: 10.1016/s2542-5196(21)00259-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Climate change and air pollution are two major societal problems. Their complex interplay calls for an advanced evaluation framework that can support decision making. Previous assessments have looked at the co-benefits of climate policies for air pollution, but few have optimised air pollution benefits. In our study, we lay out a modelling framework that internalises air pollution's economic impacts on human mortality, while considering climate constraints and aerosol feedback. METHODS We developed a modelling framework based on an integrated assessment model (World Induced Technical Change Hybrid [WITCH]) designed to assess optimal climate change mitigation policies. We included structural and end-of-pipe measures in a detailed process integrated assessment model, that is hard-linked to air pollution and climate models. We analysed a large set of baseline scenarios, including five shared socioeconomic pathways (SSPs). SSP scenarios were also tested with three different levels of value per statistical life, and were combined with the Paris Agreement temperature targets (TTs), focusing on the 2°C and 1·5°C TTs by the end of the century. FINDINGS We found that, in the baseline scenarios, where no policies are applied, the number of annual premature deaths grew before declining slightly to 4·45 (range 3·86-6·11) million annual premature deaths by 2050. Reaching the Paris Agreement TT decreases mortality by approximately 0·47 million premature deaths by 2050 (up to 1·28 million premature deaths in SSP3 -1·5°C) with respect to the baseline. We showed that welfare-maximising policies accounting for air pollution benefits reduces premature mortality by 1·62 million deaths annually. This is three times greater than the co-benefits of climate policies. China is the region where most of the avoided mortality is possible, whereas the reforming economies (ie, non-EU eastern European countries, including Russia) region has the greatest welfare benefits. We find that global and regional welfare increases when air pollution impacts are internalised, with no negative repercussions on global inequality. INTERPRETATION Air pollution control strategies are found to be an important complement to structural emission reductions. Accounting for air pollution impacts reduces climate mitigation costs and inequality and increases global and regional welfare. Results are robust to a broad set of scenarios and assumptions, including debated normative choices on how to value improved health. FUNDING EU Commission projects: INNOPATHS, NAVIGATE, ENGAGE, and COMMIT.
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Affiliation(s)
- Lara Aleluia Reis
- RFF-CMCC European Institute on Economics and the Environment (EIEE), Centro Euro-Mediterraneo sui Cambiamenti Climatici (CMCC), Milan, Italy.
| | - Laurent Drouet
- RFF-CMCC European Institute on Economics and the Environment (EIEE), Centro Euro-Mediterraneo sui Cambiamenti Climatici (CMCC), Milan, Italy
| | - Massimo Tavoni
- RFF-CMCC European Institute on Economics and the Environment (EIEE), Centro Euro-Mediterraneo sui Cambiamenti Climatici (CMCC), Milan, Italy; Department of Management, Economics and Industrial Engineering, Politecnico di Milano, Milano, Italy
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10
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The 2019 Conference on Health and Active Transportation: Research Needs and Opportunities. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182211842. [PMID: 34831599 PMCID: PMC8622688 DOI: 10.3390/ijerph182211842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 11/17/2022]
Abstract
Active transportation (AT) is widely viewed as an important target for increasing participation in aerobic physical activity and improving health, while simultaneously addressing pollution and climate change through reductions in motor vehicular emissions. In recent years, progress in increasing AT has stalled in some countries and, furthermore, the coronavirus (COVID-19) pandemic has created new AT opportunities while also exposing the barriers and health inequities related to AT for some populations. This paper describes the results of the December 2019 Conference on Health and Active Transportation (CHAT) which brought together leaders from the transportation and health disciplines. Attendees charted a course for the future around three themes: Reflecting on Innovative Practices, Building Strategic Institutional Relationships, and Identifying Research Needs and Opportunities. This paper focuses on conclusions of the Research Needs and Opportunities theme. We present a conceptual model derived from the conference sessions that considers how economic and systems analysis, evaluation of emerging technologies and policies, efforts to address inclusivity, disparities and equity along with renewed attention to messaging and communication could contribute to overcoming barriers to development and use of AT infrastructure. Specific research gaps concerning these themes are presented. We further discuss the relevance of these themes considering the pandemic. Renewed efforts at research, dissemination and implementation are needed to achieve the potential health and environmental benefits of AT and to preserve positive changes associated with the pandemic while mitigating negative ones.
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11
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Culyer AJ, Chalkidou K. Organising Research and Development for evidence-informed health care: some universal characteristics and a case study from the UK. HEALTH ECONOMICS, POLICY, AND LAW 2021; 16:489-504. [PMID: 33843559 PMCID: PMC8460448 DOI: 10.1017/s1744133121000074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 07/13/2020] [Accepted: 01/20/2021] [Indexed: 11/19/2022]
Abstract
Research and Development (R&D) in health and health care has several intriguing characteristics which, separately and in combination, have significant implications for the ways in which it is organised, funded and managed. We review the characteristics, some of which apply under most circumstances and others of which may be context-specific, explore their implications for the organisation and management of health-related R&D, and illustrate the main features from the UK experience in the 1990s.
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Affiliation(s)
- Anthony J. Culyer
- University of York – Centre for Health Economics, York, United Kingdom of Great Britain and Northern Ireland
| | - Kalipso Chalkidou
- University of York – Centre for Health Economics, York, United Kingdom of Great Britain and Northern Ireland
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Turner HC, Archer RA, Downey LE, Isaranuwatchai W, Chalkidou K, Jit M, Teerawattananon Y. An Introduction to the Main Types of Economic Evaluations Used for Informing Priority Setting and Resource Allocation in Healthcare: Key Features, Uses, and Limitations. Front Public Health 2021; 9:722927. [PMID: 34513790 PMCID: PMC8424074 DOI: 10.3389/fpubh.2021.722927] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 07/31/2021] [Indexed: 11/13/2022] Open
Abstract
Economic evidence is increasingly being used for informing health policies. However, the underlining principles of health economic analyses are not always fully understood by non-health economists, and inappropriate types of analyses, as well as inconsistent methodologies, may be being used for informing health policy decisions. In addition, there is a lack of open access information and methodological guidance targeted to public health professionals, particularly those based in low- and middle-income country (LMIC) settings. The objective of this review is to provide a comprehensive and accessible introduction to economic evaluations for public health professionals with a focus on LMIC settings. We cover the main principles underlining the most common types of full economic evaluations used in healthcare decision making in the context of priority setting (namely cost-effectiveness/cost-utility analyses, cost-benefit analyses), and outline their key features, strengths and weaknesses. It is envisioned that this will help those conducting such analyses, as well as stakeholders that need to interpret their output, gain a greater understanding of these methods and help them select/distinguish between the different approaches. In particular, we highlight the need for greater awareness of the methods used to place a monetary value on the health benefits of interventions, and the potential for such estimates to be misinterpreted. Specifically, the economic benefits reported are typically an approximation, summarising the health benefits experienced by a population monetarily in terms of individual preferences or potential productivity gains, rather than actual realisable or fiscal monetary benefits to payers or society.
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Affiliation(s)
- Hugo C Turner
- MRC Centre for Global Infectious Disease Analysis, School of Public Health, Imperial College London, London, United Kingdom
| | - Rachel A Archer
- Health Intervention and Technology Assessment Program, Ministry of Public Health, Nonthaburi, Thailand
| | - Laura E Downey
- School of Public Health, Imperial College London, London, United Kingdom
| | - Wanrudee Isaranuwatchai
- Health Intervention and Technology Assessment Program, Ministry of Public Health, Nonthaburi, Thailand.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Kalipso Chalkidou
- School of Public Health, Imperial College London, London, United Kingdom
| | - Mark Jit
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom.,Modelling and Economics Unit, Public Health England, London, United Kingdom
| | - Yot Teerawattananon
- Health Intervention and Technology Assessment Program, Ministry of Public Health, Nonthaburi, Thailand.,Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
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Abstract
This chapter begins with a brief introduction to health technology assessment (HTA). HTA is concerned with the systematic evaluation of the consequences of the adoption and use of new health technologies and to improve the evidence on existing technologies. The objective of mainstream HTA is to support evidence-based decision- and policy-making that encourage the uptake of efficient and effective health-care technologies. This chapter provides a basic framework for conducting an HTA, as well as some fundamental concepts and challenges in assessing health technologies. Whether HTA is beneficial-supporting timely access to needed technologies-or detrimental depends on three critical issues: when the assessment is performed; how it is performed; and how the findings are used.
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14
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Ramponi F, Walker S, Griffin S, Parrott S, Drummond C, Deluca P, Coulton S, Kanaan M, Richardson G. Cost-effectiveness analysis of public health interventions with impacts on health and criminal justice: An applied cross-sectoral analysis of an alcohol misuse intervention. HEALTH ECONOMICS 2021; 30:972-988. [PMID: 33604984 DOI: 10.1002/hec.4229] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 11/23/2020] [Accepted: 01/14/2021] [Indexed: 05/13/2023]
Abstract
Cost-effectiveness analyses of health care programs often focus on maximizing health and ignore nonhealth impacts. Assessing the cost-effectiveness of public health interventions from a narrow health care perspective would likely underestimate their full impact, and potentially lead to inefficient decisions about funding. The aim of this study is to provide a practical application of a recently proposed framework for the economic evaluation of public health interventions, evaluating an intervention to reduce alcohol misuse in criminal offenders. This cross-sectoral analysis distinguishes benefits and opportunity costs for different sectors, makes explicit the value judgments required to consider alternative perspectives, and can inform heterogeneous decision makers with different objectives in a transparent manner. Three interventions of increasing intensity are compared: client information leaflet, brief advice, and brief lifestyle counseling. Health outcomes are measured in quality-adjusted life-years and criminal justice outcomes in reconvictions. Costs considered include intervention costs, costs to the NHS and costs to the criminal justice system. The results are presented for four different perspectives: "narrow" health care perspective; criminal justice system perspective; "full" health care perspective; and joint "full" health and criminal justice perspective. Conclusions and recommendations differ according to the normative judgment on the appropriate perspective for the evaluation.
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Affiliation(s)
- Francesco Ramponi
- Centre for Health Economics, Alcuin A Block, University of York, York, UK
| | - Simon Walker
- Centre for Health Economics, Alcuin A Block, University of York, York, UK
| | - Susan Griffin
- Centre for Health Economics, Alcuin A Block, University of York, York, UK
| | - Steve Parrott
- Department of Health Sciences, University of York, York, UK
| | - Colin Drummond
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Paolo Deluca
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Simon Coulton
- Centre for Health Services Studies, University of Kent, Canterbury, Kent, UK
| | - Mona Kanaan
- Department of Health Sciences, University of York, York, UK
| | - Gerry Richardson
- Centre for Health Economics, Alcuin A Block, University of York, York, UK
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Broomhead SC, Mars M, Scott RE, Jones T. EHealth Investment Appraisal in Africa: A Scoping Review. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2021; 58:469580211059999. [PMID: 34905975 PMCID: PMC8679012 DOI: 10.1177/00469580211059999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
eHealth is an opportunity cost, competing for limited available funds with other
health priorities such as clinics, vaccinations, medicines and even salaries. As
such, it should be appraised for probable impact prior to allocation of funds.
This is especially pertinent as recognition grows for the role of eHealth in
attaining Universal Health Coverage. Despite optimism about eHealth’s potential
role, in Africa there remain insufficient data and skills for adequate economic
appraisals to select optimal investments from numerous competing initiatives.
The aim of this review is to identify eHealth investment appraisal approaches
and tools that have been used in African countries, describe their
characteristics and make recommendations regarding African eHealth investment
appraisal in the face of limited data and expertise. Methods: Literature on
eHealth investment appraisals conducted in African countries and published
between January 1, 2010 and June 30, 2020 was reviewed. Selected papers’
investment appraisal characteristics were assessed using the Joanna Briggs
Institute checklist for economic evaluations and a newly developed Five-Case
Model for Digital Health (FCM-DH) checklist for investment appraisal. 5 papers
met inclusion criteria. Their assessments revealed important appraisal gaps. In
particular, none of the papers addressed risk exposure, affordability,
adjustment for optimism bias, clear delivery milestones, practical plans for
implementation, change management or procurement, and only 1 paper described
plans for building partnerships. Discussion: Using this insight, an extended
5-Case Model is proposed as the foundation of an African eHealth investment
appraisal framework. This, combined with building local eHealth appraisal
capabilities, may promote optimal eHealth investment decisions, strengthen
implementations and improve the number and quality of related publications.
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Affiliation(s)
- Sean C Broomhead
- Department of TeleHealth, College of Health Sciences, 72753University of KwaZulu-Natal, Durban, South Africa.,72753Health Information Systems Program South Africa, Pretoria, South Africa.,72753African Centre for EHealth Excellence, Cape Town, South Africa
| | - Maurice Mars
- Department of TeleHealth, College of Health Sciences, 72753University of KwaZulu-Natal, Durban, South Africa.,College of Nursing and Health Sciences, 72753Flinders University, Adelaide, South Australia
| | - Richard E Scott
- Department of TeleHealth, College of Health Sciences, 72753University of KwaZulu-Natal, Durban, South Africa.,Department of Community Health Sciences, Cumming School of Medicine, 72753University of Calgary, Calgary, Canada
| | - Tom Jones
- 72753African Centre for EHealth Excellence, Cape Town, South Africa
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16
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On value frameworks and opportunity costs in health technology assessment. Int J Technol Assess Health Care 2019; 35:367-372. [PMID: 31530332 DOI: 10.1017/s0266462319000643] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Proceeding from a basic concept underpinning economic evaluation, opportunity cost, this study aims to explain how different approaches to economics diverge quite dramatically in their ideas of what constitutes appropriate valuation, both in principle and practice. Because the concept of opportunity cost does not inherently specify how valuation should be undertaken or specify how appropriate any economic value framework (EVF) might be, the three main economics-based approaches to providing evidence about value for health technology assessment are described. METHODS This paper describes how the three main EVFs-namely, the extra-welfarist, welfarist, and classical-are most typically understood, applied, and promoted. It then provides clarification and assessment of related concepts and terminology. RESULTS Although EVFs differ, certain underlying characteristics of valuation were identified as fundamental to all approaches to economic evaluation in practice. The study also suggests that some of the rhetoric and terms employed in relation to the extra-welfarist approach are not wholly justified and, further, that only the welfarist approach ensures adherence to welfare-economic principles. Finally, deliberative analysis, especially when connected with a classical economic approach, can serve as a useful supplement to other analytical approaches. CONCLUSIONS All three approaches to economic evaluation have something to offer assessment processes, but they all display limitations too. Therefore, the author concludes that the language of economic evaluation should be used with sufficient humility to prevent overselling of EVFs, especially with regard to the qualities of evidence they provide for priority setting processes.
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Marques A, Jácome C, Rebelo P, Paixão C, Oliveira A, Cruz J, Freitas C, Rua M, Loureiro H, Peguinho C, Marques F, Simões A, Santos M, Martins P, André A, De Francesco S, Martins V, Brooks D, Simão P. Improving access to community-based pulmonary rehabilitation: 3R protocol for real-world settings with cost-benefit analysis. BMC Public Health 2019; 19:676. [PMID: 31151409 PMCID: PMC6544941 DOI: 10.1186/s12889-019-7045-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 05/24/2019] [Indexed: 12/02/2022] Open
Abstract
Background Pulmonary rehabilitation (PR) has demonstrated patients’ physiological and psychosocial improvements, symptoms reduction and health-economic benefits whilst enhances the ability of the whole family to adjust to illness. However, PR remains highly inaccessible due to lack of awareness of its benefits, poor referral and availability mostly in hospitals. Novel models of PR delivery are needed to enhance its implementation while maintaining cost-efficiency. We aim to implement an innovative community-based PR programme and assess its cost-benefit. Methods A 12-week community-based PR will be implemented in primary healthcare centres where programmes are not available. Healthcare professionals will be trained. 73 patients with CRD and their caregivers (dyads patient-caregivers) will compose the experimental group. The control group will include dyads age- and disease-matched willing to collaborate in data collection but not in PR. Patients/family-centred outcomes will be dyspnoea (modified Medical Research Council Questionnaire), fatigue (Checklist of individual strength and Functional assessment of chronic illness therapy – fatigue), cough and sputum (Leicester cough questionnaire and Cough and sputum assessment questionnaire), impact of the disease (COPD Assessment Test), emotional state (The Hospital Anxiety and Depression Scale), number of exacerbations, healthcare utilisation, health-related quality of life and family adaptability/cohesion (Family Adaptation and Cohesion Scale). Other clinical outcomes will be peripheral (biceps and quadriceps-hand held dynamometer, 1 or 10 repetition-maximum) and respiratory (maximal inspiratory and expiratory pressures) muscle strength, muscle thickness and cross sectional area (biceps brachialis, rectus femoris and diaphragm-ultrasound imaging), exercise capacity (six-minute walk test and one-minute sit to stand test), balance (brief-balance evaluation systems test) and physical activity (accelerometer). Data will be collected at baseline, at 12 weeks, at 3- and 6-months post-PR. Changes in the outcome measures will be compared between groups, after multivariate adjustment for possible confounders, and effect sizes will be calculated. A cost-benefit analysis will be conducted. Discussion This study will enhance patients access to PR, by training healthcare professionals in the local primary healthcare centres to conduct such programmes and actively involving caregivers. The cost-benefit analysis of this intervention will provide an evidence-based insight into the economic benefit of community-based PR in chronic respiratory diseases. Trial registration The trial was registered in the ClinicalTrials.gov U.S. National Library of Medicine, on 10th January, 2019 (registration number: NCT03799666). Electronic supplementary material The online version of this article (10.1186/s12889-019-7045-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alda Marques
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences (ESSUA), University of Aveiro, Agras do Crasto - Campus Universitário de Santiago, Edifício 30, 3810-193, Aveiro, Portugal. .,Institute of Biomedicine (iBiMED), University of Aveiro, Agras do Crasto - Campus Universitário de Santiago, Edifício 30, 3810-193, Aveiro, Portugal.
| | - Cristina Jácome
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences (ESSUA), University of Aveiro, Agras do Crasto - Campus Universitário de Santiago, Edifício 30, 3810-193, Aveiro, Portugal.,CINTESIS - Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Patrícia Rebelo
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences (ESSUA), University of Aveiro, Agras do Crasto - Campus Universitário de Santiago, Edifício 30, 3810-193, Aveiro, Portugal.,Institute of Biomedicine (iBiMED), University of Aveiro, Agras do Crasto - Campus Universitário de Santiago, Edifício 30, 3810-193, Aveiro, Portugal
| | - Cátia Paixão
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences (ESSUA), University of Aveiro, Agras do Crasto - Campus Universitário de Santiago, Edifício 30, 3810-193, Aveiro, Portugal.,Institute of Biomedicine (iBiMED), University of Aveiro, Agras do Crasto - Campus Universitário de Santiago, Edifício 30, 3810-193, Aveiro, Portugal
| | - Ana Oliveira
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences (ESSUA), University of Aveiro, Agras do Crasto - Campus Universitário de Santiago, Edifício 30, 3810-193, Aveiro, Portugal
| | - Joana Cruz
- School of Health Sciences (ESSLei), Center for Innovative Care and Health Technology (ciTechCare), Polytechnic Institute of Leiria, Leiria, Portugal
| | - Célia Freitas
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences (ESSUA), University of Aveiro, Agras do Crasto - Campus Universitário de Santiago, Edifício 30, 3810-193, Aveiro, Portugal.,CINTESIS - Center for Health Technology and Services Research, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Marília Rua
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences (ESSUA), University of Aveiro, Agras do Crasto - Campus Universitário de Santiago, Edifício 30, 3810-193, Aveiro, Portugal.,Research Centre on Didactics and Technology in the Education of Trainers (CIDTFF), University of Aveiro, Aveiro, Portugal
| | - Helena Loureiro
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences (ESSUA), University of Aveiro, Agras do Crasto - Campus Universitário de Santiago, Edifício 30, 3810-193, Aveiro, Portugal.,Institute of Biomedicine (iBiMED), University of Aveiro, Agras do Crasto - Campus Universitário de Santiago, Edifício 30, 3810-193, Aveiro, Portugal
| | - Cristina Peguinho
- Higher Institute for Accountancy and Administration (ISCA-UA), University of Aveiro, Aveiro, Portugal
| | - Fábio Marques
- ESTGA - Águeda School of Technology and Management, Águeda, Portugal.,IEETA - Institute of Electronics and Informatics Engineering of Aveiro, Aveiro, Portugal
| | | | | | - Paula Martins
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences (ESSUA), University of Aveiro, Agras do Crasto - Campus Universitário de Santiago, Edifício 30, 3810-193, Aveiro, Portugal.,Institute of Biomedicine (iBiMED), University of Aveiro, Agras do Crasto - Campus Universitário de Santiago, Edifício 30, 3810-193, Aveiro, Portugal
| | - Alexandra André
- College of Health Technology of Coimbra (ESTeSC), Polytechnic Institute of Coimbra, Coimbra, Portugal
| | - Sílvia De Francesco
- Respiratory Research and Rehabilitation Laboratory (Lab3R), School of Health Sciences (ESSUA), University of Aveiro, Agras do Crasto - Campus Universitário de Santiago, Edifício 30, 3810-193, Aveiro, Portugal.,IEETA - Institute of Electronics and Informatics Engineering of Aveiro, Aveiro, Portugal
| | - Vitória Martins
- Pulmonology Department, Hospital Distrital da Figueira da Foz, Figueira da Foz, Portugal
| | - Dina Brooks
- Respiratory Medicine, West Park Healthcare Centre, and University of Toronto, Toronto, Canada.,School of Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Paula Simão
- Pulmonology Department, Unidade Local de Saúde de Matosinhos, Matosinhos, Portugal
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