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Jager A, Wong G, Papoutsi C, Roberts N. The usage of data in NHS primary care commissioning: a realist review. BMC Med 2023; 21:236. [PMID: 37400837 DOI: 10.1186/s12916-023-02949-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/19/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Primary care has been described as the 'bedrock' of the National Health Service (NHS) accounting for approximately 90% of patient contacts but is facing significant challenges. Against a backdrop of a rapidly ageing population with increasingly complex health challenges, policy-makers have encouraged primary care commissioners to increase the usage of data when making commissioning decisions. Purported benefits include cost savings and improved population health. However, research on evidence-based commissioning has concluded that commissioners work in complex environments and that closer attention should be paid to the interplay of contextual factors and evidence use. The aim of this review was to understand how and why primary care commissioners use data to inform their decision making, what outcomes this leads to, and understand what factors or contexts promote and inhibit their usage of data. METHODS We developed initial programme theory by identifying barriers and facilitators to using data to inform primary care commissioning based on the findings of an exploratory literature search and discussions with programme implementers. We then located a range of diverse studies by searching seven databases as well as grey literature. Using a realist approach, which has an explanatory rather than a judgemental focus, we identified recurrent patterns of outcomes and their associated contexts and mechanisms related to data usage in primary care commissioning to form context-mechanism-outcome (CMO) configurations. We then developed a revised and refined programme theory. RESULTS Ninety-two studies met the inclusion criteria, informing the development of 30 CMOs. Primary care commissioners work in complex and demanding environments, and the usage of data are promoted and inhibited by a wide range of contexts including specific commissioning activities, commissioners' perceptions and skillsets, their relationships with external providers of data (analysis), and the characteristics of data themselves. Data are used by commissioners not only as a source of evidence but also as a tool for stimulating commissioning improvements and as a warrant for convincing others about decisions commissioners wish to make. Despite being well-intentioned users of data, commissioners face considerable challenges when trying to use them, and have developed a range of strategies to deal with 'imperfect' data. CONCLUSIONS There are still considerable barriers to using data in certain contexts. Understanding and addressing these will be key in light of the government's ongoing commitments to using data to inform policy-making, as well as increasing integrated commissioning.
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Affiliation(s)
- Alexandra Jager
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Chrysanthi Papoutsi
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, Medical Sciences, University of Oxford, Oxford, UK
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Almazrou SH, Alaujan SS, Al-Aqeel SA. Barriers and facilitators to conducting economic evaluation studies of Gulf Cooperation Council (GCC) countries: a survey of researchers. Health Res Policy Syst 2021; 19:71. [PMID: 33933093 PMCID: PMC8088636 DOI: 10.1186/s12961-021-00721-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 04/12/2021] [Indexed: 12/21/2022] Open
Abstract
Background The number of published economic evaluations of Gulf Cooperation Council (GCC) countries is notably scarce. Limited local evidence could have a major impact on the implementation of economic evaluation recommendations in the decision-making process in GCC countries. Little is known about the factors affecting researchers who seek to conduct economic evaluations. Therefore, we aimed to assess researcher barriers and facilitators in conducting such studies of GCC countries. Methods A cross-sectional survey of health economic researchers working in GCC countries was conducted online between January and February 2020. The survey instrument collected researchers’ perceived barriers and facilitators and demographic information. For barriers, respondents rated their agreement on a 5-point Likert scale ranging from “strongly disagree” to “strongly agree”. For facilitators, respondents rated the importance of each facilitator on a six-point scale ranging from “extremely important” to “not very important”. Then, participants were asked to select the three most important barriers and facilitators from the lists. The data collected were examined using descriptive analysis. Results Fifty-one researchers completed the survey (37% response rate). The majority of participants (more than 80%) agreed that lack of quality of effectiveness data and restricted access to unit cost data are the main barriers to conducting economic research. Availability of relevant local data was reported as an important facilitator, followed by collaboration between health economic researchers, policy-makers and other stakeholders. Conclusions The results of this study provide an exploratory view of the issues faced by health economics researchers in GCC countries. Recommendations to GCC countries based on international experiences, such as to use real-world data in economic evaluation research, were provided.
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Affiliation(s)
- Saja H Almazrou
- Clinical Pharmacy Department, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia.
| | - Shiekha S Alaujan
- Clinical Pharmacy Department, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Sinaa A Al-Aqeel
- Clinical Pharmacy Department, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
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Modes of coordination for health technology adoption: Health Technology Assessment agencies and Group Procurement Organizations in a polycentric regulatory regime. Soc Sci Med 2020; 265:113528. [PMID: 33261901 DOI: 10.1016/j.socscimed.2020.113528] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/06/2020] [Accepted: 11/12/2020] [Indexed: 11/22/2022]
Abstract
The challenge of novel and high cost health technologies has encouraged the growth of regulatory agencies such as Health Technology Assessment (HTA) organizations and Group Procurement Organizations (GPO). Yet the existence of several agencies in the same polycentric regulatory regime raises questions about whether and how their work can be coordinated. Drawing on a case study of GPOs and HTA agencies across four provinces in Canada, involving document review and key informant interviews (n = 44) conducted between 2013 and 2016, we explore the separate evolution of these agencies, emerging connections between them for non-drug technologies, and the organizational processes and evaluative judgments that underpin coordination efforts. HTA agencies and GPOs developed separately; connections emerged recently in three provinces and suggest four modes of coordination. One mode aligns most closely with that recommended by health economists and HTA practitioners, whereby HTA precedes procurement, with coverage decisions informing technology acquisition. The second mode is a version of the first, where procurement refers cases to HTA for coverage or technology management support; unlike the first, it recognizes procurement's evaluative strengths. Yet both the first and second modes focus on exceptional cases and will be infrequent. The third mode is more systemic, reflecting a generalized complementary of purpose as public agencies. HTA could support GPOs in contested technology acquisition efforts through timely and responsive input, while procurement could expand HTA's impact and inform HTA's growing interest in responsible innovation and environmental sustainability. The final mode is non-coordination, reflecting the potential for agencies to occupy quite distinct regulatory niches within the same regime. We conclude that consistency and convergence around a single model of resource allocation is not inevitable; nor is it necessary for coordinated effort. Thus, where differences in regulatory practice and epistemology persist, mutual accommodation and shared learning may prove most productive.
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Matlala M, Gous AGS, Meyer JC, Godman B. Formulary Management Activities and Practice Implications Among Public Sector Hospital Pharmaceutical and Therapeutics Committees in a South African Province. Front Pharmacol 2020; 11:1267. [PMID: 32973508 PMCID: PMC7466677 DOI: 10.3389/fphar.2020.01267] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 07/31/2020] [Indexed: 02/03/2023] Open
Abstract
Introduction The World Health Organization identified Pharmaceutical and Therapeutics Committees (PTCs) at district and hospital levels as one of the pivotal models to promote rational use of medicines (RUM). This is endorsed by the Government in South Africa. Formulary development and management is one of the main functions of PTCs. This study aimed to describe the formulary management activities among PTCs in public hospitals in Gauteng Province, South Africa, following initiatives to promote RUM in South Africa. Methods Qualitative, nonparticipatory, observational study, observing 26 PTC meetings. Data were coded and categorized using NVivo9® qualitative data analysis software. Themes and sub-themes were developed. The themes and sub-themes on formulary management are the principal focus of this paper. Results More than half of the observed PTCs reviewed their formulary lists. There was variation in the review process among institutions providing different levels of care. Various aspects were considered for formulary management especially requests for medicines to be added. These included cost considerations (mainly focusing on acquisition costs), evidence-based evaluation of clinical trials, patient safety, clinical experience and changes in the National Essential Medicines List (NEML). The tertiary PTCs mostly dealt with applications for new non-EML medicines, while PTCs in the other hospitals mainly requested removal or addition of EML medicines to the list. Conclusion This is the first study from Gauteng Province, South Africa, reporting on how decisions are actually taken to include or exclude medicines onto formularies within public sector hospitals providing different levels of care. Various approaches are adopted at different levels of care when adding to- or removing medicines from the formulary lists. Future programs should strengthen PTCs in specialized aspects of formulary management. A more structured approach to formulary review at the local PTC level should be encouraged in line with the national approach when reviewing possible additions to the NEML.
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Affiliation(s)
- Moliehi Matlala
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-rankuwa, South Africa
| | - Andries G S Gous
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-rankuwa, South Africa
| | - Johanna C Meyer
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-rankuwa, South Africa
| | - Brian Godman
- School of Pharmacy, Sefako Makgatho Health Sciences University, Ga-rankuwa, South Africa.,Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, United Kingdom.,Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
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Azharuddin M, Adil M, Khan RA, Ghosh P, Kapur P, Sharma M. Systematic evidence of health economic evaluation of drugs for postmenopausal osteoporosis: A quality appraisal. Osteoporos Sarcopenia 2020; 6:39-52. [PMID: 32715093 PMCID: PMC7374246 DOI: 10.1016/j.afos.2020.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/04/2020] [Accepted: 05/22/2020] [Indexed: 12/19/2022] Open
Abstract
This paper systematically and critically reviewed all published economic evaluations of drugs for the treatment of postmenopausal osteoporosis. A systematic search was conducted using relevant databases for economic evaluations to include all relevant English articles published between January 2008 to January 2020. After extracting the key study characteristics, methods and outcomes, we evaluated each article using the Quality of Health Economic Studies (QHES) and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) instruments. A total of 49 studies met the inclusion criteria. Majority of studies were funded by the industry and reported favorable cost-effectiveness. Based on the QHES total scores, studies (n = 35) were found to be industry-funded with higher QHES mean 82.44 ± 8.69 as compared with nonindustry funding studies (n = 11) with mean 72.22 ± 17.67. The overall mean QHES scores were found to be higher 79.06 ± 11.84, representing high quality (75–100) compared to CHEERS scores (%) 75.03 ± 11.21. The statistical pairwise comparison between CHEERS mean (75.03 ± 11.21) and QHES mean (79.06 ± 11.84) were not statistically significant (P = 0.10) whereas, QHES score showed higher means as compared to CHEERS. This study suggests the overall quality of the published literatures was relatively few high-quality health economic evaluation demonstrating the cost-effectiveness of drugs for postmenopausal osteoporosis, and the majority of the literature highlights that methodological shortcoming.
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Affiliation(s)
- Md Azharuddin
- Division of Pharmacology, Department of Pharmaceutical Medicine, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Mohammad Adil
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Rashid Ali Khan
- Division of Pharmacology, Department of Pharmaceutical Medicine, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
| | - Pinaki Ghosh
- Department of Pharmacology, Poona College of Pharmacy, Bharati Vidyapeeth, Pune, India
| | - Prem Kapur
- Department of Medicine, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi, India
| | - Manju Sharma
- Department of Pharmacology, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
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Merlo G, Page K, Zardo P, Graves N. Applying an Implementation Framework to the Use of Evidence from Economic Evaluations in Making Healthcare Decisions. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2019; 17:533-543. [PMID: 31049847 DOI: 10.1007/s40258-019-00477-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND AND OBJECTIVE There is a need for the application of theory in understanding the use of evidence from economic evaluations in healthcare decision making. The purpose of this study is to review the published literature on the use of evidence from economic evaluations for healthcare decision making and to map the findings to the Consolidated Framework for Implementation Research (CFIR). METHODS A systematic search strategy was used to identify studies investigating the factors that determine the use of evidence from economic evaluation in healthcare decision making. Barriers and facilitators identified in the included studies were mapped across the five CFIR domains, with the "intervention" referring to the use of economic evaluations in decision making. Gaps, inconsistencies and emergent relations were identified through the mapping process. RESULTS Fifty-three studies met eligibility criteria and were included in the review. The CFIR constructs associated with the Intervention Characteristics and those associated with the knowledge and beliefs of users of economic evaluations were widely cited in the identified barriers and facilitators. Other constructs from the CFIR had not been reported in the literature, such as 'organisational networks' and 'individual stage of change'. Most of the stages in the implementation process as described by the CFIR were reflected in the identified barriers and facilitators. DISCUSSION By categorising barriers and facilitators into domains, the CFIR provides a systematic approach to assess how these factors interact. Literature gaps in the literature regarding the use of economic evaluation in healthcare decision making were identified, specifically issues regarding organisational networks and the role of feedback. CONCLUSIONS Through mapping findings from studies of the use of evidence from economic evaluations in healthcare decision making, we present an implementation framework based on the CFIR for understanding the use of economic evaluations into practice.
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Affiliation(s)
- Gregory Merlo
- Queensland University of Technology, Institute of Health and Biomedical Innovation, 60 Musk Avenue, Kelvin Grove, Brisbane, QLD, 4059, Australia.
| | - Katie Page
- Queensland University of Technology, Institute of Health and Biomedical Innovation, 60 Musk Avenue, Kelvin Grove, Brisbane, QLD, 4059, Australia
| | - Pauline Zardo
- Faculty of Law, Queensland University of Technology, Brisbane, QLD, Australia
| | - Nicholas Graves
- Queensland University of Technology, Institute of Health and Biomedical Innovation, 60 Musk Avenue, Kelvin Grove, Brisbane, QLD, 4059, Australia
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Use of economic predictions to make formulary decisions. Am J Health Syst Pharm 2019; 76:S15-S20. [DOI: 10.1093/ajhp/zxy024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Raftery J, Hanney S, Greenhalgh T, Glover M, Blatch-Jones A. Models and applications for measuring the impact of health research: update of a systematic review for the Health Technology Assessment programme. Health Technol Assess 2018; 20:1-254. [PMID: 27767013 DOI: 10.3310/hta20760] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND This report reviews approaches and tools for measuring the impact of research programmes, building on, and extending, a 2007 review. OBJECTIVES (1) To identify the range of theoretical models and empirical approaches for measuring the impact of health research programmes; (2) to develop a taxonomy of models and approaches; (3) to summarise the evidence on the application and use of these models; and (4) to evaluate the different options for the Health Technology Assessment (HTA) programme. DATA SOURCES We searched databases including Ovid MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and The Cochrane Library from January 2005 to August 2014. REVIEW METHODS This narrative systematic literature review comprised an update, extension and analysis/discussion. We systematically searched eight databases, supplemented by personal knowledge, in August 2014 through to March 2015. RESULTS The literature on impact assessment has much expanded. The Payback Framework, with adaptations, remains the most widely used approach. It draws on different philosophical traditions, enhancing an underlying logic model with an interpretative case study element and attention to context. Besides the logic model, other ideal type approaches included constructionist, realist, critical and performative. Most models in practice drew pragmatically on elements of several ideal types. Monetisation of impact, an increasingly popular approach, shows a high return from research but relies heavily on assumptions about the extent to which health gains depend on research. Despite usually requiring systematic reviews before funding trials, the HTA programme does not routinely examine the impact of those trials on subsequent systematic reviews. The York/Patient-Centered Outcomes Research Institute and the Grading of Recommendations Assessment, Development and Evaluation toolkits provide ways of assessing such impact, but need to be evaluated. The literature, as reviewed here, provides very few instances of a randomised trial playing a major role in stopping the use of a new technology. The few trials funded by the HTA programme that may have played such a role were outliers. DISCUSSION The findings of this review support the continued use of the Payback Framework by the HTA programme. Changes in the structure of the NHS, the development of NHS England and changes in the National Institute for Health and Care Excellence's remit pose new challenges for identifying and meeting current and future research needs. Future assessments of the impact of the HTA programme will have to take account of wider changes, especially as the Research Excellence Framework (REF), which assesses the quality of universities' research, seems likely to continue to rely on case studies to measure impact. The HTA programme should consider how the format and selection of case studies might be improved to aid more systematic assessment. The selection of case studies, such as in the REF, but also more generally, tends to be biased towards high-impact rather than low-impact stories. Experience for other industries indicate that much can be learnt from the latter. The adoption of researchfish® (researchfish Ltd, Cambridge, UK) by most major UK research funders has implications for future assessments of impact. Although the routine capture of indexed research publications has merit, the degree to which researchfish will succeed in collecting other, non-indexed outputs and activities remains to be established. LIMITATIONS There were limitations in how far we could address challenges that faced us as we extended the focus beyond that of the 2007 review, and well beyond a narrow focus just on the HTA programme. CONCLUSIONS Research funders can benefit from continuing to monitor and evaluate the impacts of the studies they fund. They should also review the contribution of case studies and expand work on linking trials to meta-analyses and to guidelines. FUNDING The National Institute for Health Research HTA programme.
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Affiliation(s)
- James Raftery
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton General Hospital, Southampton, UK
| | - Steve Hanney
- Health Economics Research Group (HERG), Institute of Environment, Health and Societies, Brunel University London, London, UK
| | - Trish Greenhalgh
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Matthew Glover
- Health Economics Research Group (HERG), Institute of Environment, Health and Societies, Brunel University London, London, UK
| | - Amanda Blatch-Jones
- Wessex Institute, Faculty of Medicine, University of Southampton, Southampton, UK
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Turner S, D'Lima D, Hudson E, Morris S, Sheringham J, Swart N, Fulop NJ. Evidence use in decision-making on introducing innovations: a systematic scoping review with stakeholder feedback. Implement Sci 2017; 12:145. [PMID: 29202772 PMCID: PMC5715650 DOI: 10.1186/s13012-017-0669-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 11/08/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A range of evidence informs decision-making on innovation in health care, including formal research findings, local data and professional opinion. However, cultural and organisational factors often prevent the translation of evidence for innovations into practice. In addition to the characteristics of evidence, it is known that processes at the individual level influence its impact on decision-making. Less is known about the ways in which processes at the professional, organisational and local system level shape evidence use and its role in decisions to adopt innovations. METHODS A systematic scoping review was used to review the health literature on innovations within acute and primary care and map processes at the professional, organisational and local system levels which influence how evidence informs decision-making on innovation. Stakeholder feedback on the themes identified was collected via focus groups to test and develop the findings. RESULTS Following database and manual searches, 31 studies reporting primary qualitative data met the inclusion criteria: 24 were of sufficient methodological quality to be included in the thematic analysis. Evidence use in decision-making on innovation is influenced by multi-level processes (professional, organisational, local system) and interactions across these levels. Preferences for evidence vary by professional group and health service setting. Organisations can shape professional behaviour by requiring particular forms of evidence to inform decision-making. Pan-regional organisations shape innovation decision-making at lower levels. Political processes at all levels shape the selection and use of evidence in decision-making. CONCLUSIONS The synthesis of results from primary qualitative studies found that evidence use in decision-making on innovation is influenced by processes at multiple levels. Interactions between different levels shape evidence use in decision-making (e.g. professional groups and organisations can use local systems to validate evidence and legitimise innovations, while local systems can tailor or frame evidence to influence activity at lower levels). Organisational leaders need to consider whether the environment in which decisions are made values diverse evidence and stakeholder perspectives. Further qualitative research on decision-making practices that highlights how and why different types of evidence come to count during decisions, and tracks the political aspects of decisions about innovation, is needed.
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Affiliation(s)
- Simon Turner
- Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK.
| | - Danielle D'Lima
- Department of Clinical, Educational and Health Psychology, UCL Centre for Behaviour Change, University College London, 1-19 Torrington Place, London, UK
| | - Emma Hudson
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, UK
| | - Jessica Sheringham
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, UK
| | - Nick Swart
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, UK
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, 1-19 Torrington Place, London, UK
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Coast J. A history that goes hand in hand: Reflections on the development of health economics and the role played by Social Science & Medicine, 1967-2017. Soc Sci Med 2017; 196:227-232. [PMID: 29132835 DOI: 10.1016/j.socscimed.2017.10.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 10/16/2017] [Accepted: 10/30/2017] [Indexed: 01/05/2023]
Affiliation(s)
- Joanna Coast
- Population Health Sciences, Bristol Medical School, University of Bristol, United Kingdom.
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Golmohamdi FR, Abbasi M, Karyani AK, Sari AA. Cost-Effectiveness of Zoledronic Acid to Prevent and Treat Postmenopausal Osteoporosis in Comparison with Routine Medical Treatment. Electron Physician 2016; 8:3434-3440. [PMID: 28163861 PMCID: PMC5279979 DOI: 10.19082/3434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 05/29/2016] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Fractures caused by osteoporosis are prevalent among elderly females, which reduce quality of life significantly. This study aimed at comparing cost-effectiveness of Zoledronic acid in preventing and treating post-menopause osteoporosis as compared with routine medical treatment. METHODS This cost-effectiveness study was carried out retrospectively from the Ministry of Health and insurance organizations perspective. Costs were evaluated based on the cost estimation of a sample of patients. Outcomes were obtained from a systematic review. The Cost-Effectiveness Ratio (CER) and incremental cost-effectiveness ratio (ICER) for outcome of femoral neck Bone Mineral Density (BMD), hip trochanter BMD, total hip BMD and lumbar spine BMD and cost-benefit of consuming Zoledronic Acid were calculated for fracture outcome obtained from reviewing hospital records. RESULTS The results and the ICER calculated for study outcomes indicated that one percent increase of BMD on femoral neck BMD requires further cost of $386. One percent increase of BMD on hip trochanter BMD requires further cost of $264. One percent increase of BMD on total hip BMD requires further cost of $388, one percent increase of BMD on lumbar spine BMD requires further cost of $347. The Cost Benefit Analysis (CBA) calculated for vertebral and hip fracture, non-vertebral fracture, any clinical fracture, and morphometric fracture for a 36-month period were about 0.82, 0.57, and 1.06, respectively. Vertebral and hip fractures, and non-vertebral fractures or any clinical fracture for a 12-month period were calculated as 1.14 and 0.64, respectively. In other words, Zoledronic acid consumption approach is a cheaper and better approach based on an economic assessment, and it can be considered as a dominant approach. CONCLUSION According to the cost-effectiveness of zoledronic acid in the prevention and treatment of osteoporosis in women, despite the costs, it is recommended that insurance coverage for the drug should be considered in the period after menopause and the benefits of this drug. This can reduce the costs imposed on the patients and also it can reduce the economic burden on the community, particularly as a result of the fracture.
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Affiliation(s)
- Fateme Rostami Golmohamdi
- M.Sc. in Health Economics, Department of Health Research Center, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Mahnaz Abbasi
- Associate Professor of Rheumatology, Metabolic Disease Research Center, Qazvin University of Medical Sciences, Qazvin, Iran
| | - Ali Kazemi Karyani
- Ph.D. Student in Health Economics, Department of Public Health, School of Public Health, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Ali Akbari Sari
- Ph.D. of Health Policy, Professor, Department of Health Management and Economics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
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John-Baptiste A, Schapira MM, Cravens C, Chambers JD, Neumann PJ, Siegel J, Lawrence W. The Role of Decision Models in Health Care Policy: A Case Study. Med Decis Making 2016; 36:666-79. [PMID: 27225487 DOI: 10.1177/0272989x16646732] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 03/26/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND In 2009, the Centers for Medicare and Medicaid Services (CMS) underwent a National Coverage Determination on computed tomography colonography (CTC) to screen for colorectal cancer. The Cancer Intervention & Surveillance Network developed decision models to inform this decision. The purpose of our study was to investigate the role of models in this decision. METHODS We performed a descriptive case study. We conducted semistructured telephone interviews with members of the CMS coverage and analysis group (CAG) and Medicare Coverage and Analysis Advisory Committee (MEDCAC) panelists. Informed by previously published literature, we developed a coding scheme to analyze interview transcripts, MEDCAC meeting transcripts, and the final CMS decision memo. RESULTS Four members of the CAG and 8 MEDCAC panelists were interviewed. The total number of codes across all study documents was 772. We found evidence that decision makers believed in the adequacy of models to inform decision making. In interview transcripts, the code Models Are Adequate to Inform was more frequent than the code Models Are Inadequate to Inform (47 times v. 5). Discussion of model conceptualization dominated the MEDCAC meeting (Model Conceptualization assigned 113 times) and was frequently discussed during interviews (Model Conceptualization assigned 84 times). We also found evidence that the models helped to focus the policy discussion. Across study documents, the codes Focus on Cost, Focus on Clinical-Health Impact, and Focus on Inadequacy of Evidence Base were assigned 99, 98, and 97 times, respectively. CONCLUSIONS Decision makers involved in the CTC decision believed in the adequacy of models to inform coverage decisions. The model played a role in focusing the CTC coverage policy discussion.
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Affiliation(s)
- Ava John-Baptiste
- Center for Outcomes and Evidence, Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, MD, USA (AJ-B, CC, JS, WL),Departments of Anesthesia & Perioperative Medicine, Epidemiology & Biostatistics, Interfaculty Program in Public Health, Schulich School of Medicine & Dentistry, The University of Western Ontario, London, Ontario, Canada (AJ-B),Centre for Medical Evidence, Decision Integrity, Clinical Impact (MEDICI), London, Ontario, Canada (AJ-B),Lawson Health Research Institute, London, Ontario, Canada (AJ-B),Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA (AJ-B, JDC, PJN)
| | - Marilyn M Schapira
- Perelman School of Medicine, University of Pennsylvania, PA, USA (MMS),Center for Health Equity & Research Program, Philadelphia VA Medical Center, PA, USA (MMS)
| | - Catherine Cravens
- Center for Outcomes and Evidence, Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, MD, USA (AJ-B, CC, JS, WL)
| | - James D Chambers
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA (AJ-B, JDC, PJN)
| | - Peter J Neumann
- Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA (AJ-B, JDC, PJN)
| | - Joanna Siegel
- Center for Outcomes and Evidence, Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, MD, USA (AJ-B, CC, JS, WL)
| | - William Lawrence
- Center for Outcomes and Evidence, Agency for Healthcare Research and Quality, Department of Health and Human Services, Rockville, MD, USA (AJ-B, CC, JS, WL)
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Burke N. Management of Hospital Formularies in Ontario: Challenges within a Local Health Integration Network. Can J Hosp Pharm 2016; 69:187-93. [PMID: 27402997 PMCID: PMC4924938 DOI: 10.4212/cjhp.v69i3.1554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Expenditures on drugs dispensed and administered to patients in Canadian hospitals have been estimated at $2.4 billion per year. Pharmacy and therapeutics (P&T) committees play a key role in the evaluation and management of drug therapies in this setting. Hospitals differ with respect to the composition of these committees, their members' expertise, and the processes used for making formulary decisions. OBJECTIVES To examine the current processes for formulary drug review from the perspective of P&T committees and their individual members, and to examine the needs and preferences of these stakeholders related to evidence review and potential collaborative drug review processes within a large Local Health Integration Network (LHIN) in Ontario. METHODS Twenty-three sites within 10 hospital corporations in LHIN 4 (Hamilton Niagara Haldimand Brant) were recruited. A 2-part questionnaire was developed and pretested for clarity and comprehensiveness. The institution profile section of the questionnaire was to be completed by pharmacy directors and the P&T section by committee members. RESULTS Ten pharmacy directors and 28 committee members representing 10 P&T committees responded. A mean of 6.4 new drug requests were reviewed annually by each P&T committee. Across the LHIN, the workload associated with reviewing submissions for new drugs to be added to the formulary represented 0.84 full-time equivalent. The quality of clinical evidence in the drug submissions was rated more favourably than the quality of economic evidence; furthermore, the use of economic evidence was limited by a lack of health economics expertise within the committees. A centralized review process for the LHIN was perceived as beneficial to improve efficiency, the quality of review, and standardization, and also to reduce costs. CONCLUSIONS Across the Hamilton Niagara Haldimand Brant LHIN, considerable time and resources are spent on the review of potential new drugs for addition to the hospitals' formularies. A standardized formulary review process, with greater use of provincial and national drug reviews, would likely benefit all LHINs.
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Affiliation(s)
- Natasha Burke
- Natasha Burke, MSc, is with McMaster University and St Joseph’s Health-care Hamilton (Programs for Assessment of Technology in Health [PATH]), Hamilton, Ontario
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O'Mahony JF, Normand C. HIQA's CEA of Breast Screening: Pragmatic Policy Recommendations are Welcome, but ACERs Reported as ICERs are Not. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2015; 18:941-945. [PMID: 26686777 DOI: 10.1016/j.jval.2015.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/05/2015] [Accepted: 08/12/2015] [Indexed: 06/05/2023]
Abstract
The Health Information and Quality Authority (HIQA) is Ireland's statutory cost-effectiveness analysis (CEA) agency. It recently published a CEA of screening strategies for women at elevated risk of breast cancer. Although the strategies recommended by HIQA exceed Ireland's cost-effectiveness threshold, they can reasonably be welcomed as a pragmatic response to constraints on disinvestment and are expected to improve screening cost-effectiveness. What is not welcome, however, is HIQA's reporting of average cost-effectiveness ratios (ACERs) as incremental cost-effectiveness ratios (ICERs). The distinction between ACERs and ICERs is well understood in CEA, as is the fact that ICERs not ACERs are the appropriate metric to determine cost-effectiveness. This article critiques HIQA's reporting, considering the implications for the particular case of breast cancer screening and the broader context of consistency of and confidence in CEA as a guide to resource allocation in Ireland. The reporting of ACERs as ICERs is unlikely to be of any great significance in the particular case of screening women at elevated risk of breast cancer, given likely constraints on disinvestment. Despite this, ICERs still need to be reported correctly. If thresholds are exceeded in certain cases, then it is important that decision makers appreciate by how much. More generally, using ACERs in some cases and ICERs in others raises concerns that methods are being applied inconsistently, which risks compromising confidence in CEA in Ireland. As Ireland's statutory CEA authority, HIQA has a special onus of responsibility to ensure established methods are applied correctly.
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Affiliation(s)
- James F O'Mahony
- The Centre of Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland.
| | - Charles Normand
- The Centre of Health Policy and Management, School of Medicine, Trinity College Dublin, Dublin, Ireland
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15
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Niven DJ, Mrklas KJ, Holodinsky JK, Straus SE, Hemmelgarn BR, Jeffs LP, Stelfox HT. Towards understanding the de-adoption of low-value clinical practices: a scoping review. BMC Med 2015; 13:255. [PMID: 26444862 PMCID: PMC4596285 DOI: 10.1186/s12916-015-0488-z] [Citation(s) in RCA: 206] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 09/15/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Low-value clinical practices are common in healthcare, yet the optimal approach to de-adopting these practices is unknown. The objective of this study was to systematically review the literature on de-adoption, document current terminology and frameworks, map the literature to a proposed framework, identify gaps in our understanding of de-adoption, and identify opportunities for additional research. METHODS MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, the Cochrane Database of Abstracts and Reviews of Effects, and CINAHL Plus were searched from 1 January 1990 to 5 March 2014. Additional citations were identified from bibliographies of included citations, relevant websites, the PubMed 'related articles' function, and contacting experts in implementation science. English-language citations that referred to de-adoption of clinical practices in adults with medical, surgical, or psychiatric illnesses were included. Citation selection and data extraction were performed independently and in duplicate. RESULTS From 26,608 citations, 109 were included in the final review. Most citations (65%) were original research with the majority (59%) published since 2010. There were 43 unique terms referring to the process of de-adoption-the most frequently cited was "disinvest" (39% of citations). The focus of most citations was evaluating the outcomes of de-adoption (50%), followed by identifying low-value practices (47%), and/or facilitating de-adoption (40%). The prevalence of low-value practices ranged from 16% to 46%, with two studies each identifying more than 100 low-value practices. Most articles cited randomized clinical trials (41%) that demonstrate harm (73%) and/or lack of efficacy (63%) as the reason to de-adopt an existing clinical practice. Eleven citations described 13 frameworks to guide the de-adoption process, from which we developed a model for facilitating de-adoption. Active change interventions were associated with the greatest likelihood of de-adoption. CONCLUSIONS This review identified a large body of literature that describes current approaches and challenges to de-adoption of low-value clinical practices. Additional research is needed to determine an ideal strategy for identifying low-value practices, and facilitating and sustaining de-adoption. In the meantime, this study proposes a model that providers and decision-makers can use to guide efforts to de-adopt ineffective and harmful practices.
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Affiliation(s)
- Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, T1Y 6J4, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Kelly J Mrklas
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Jessalyn K Holodinsky
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, M5B 1T8, Canada.
| | - Brenda R Hemmelgarn
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada. .,Department of Medicine, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
| | - Lianne P Jeffs
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, M5B 1T8, Canada.
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, T1Y 6J4, Canada. .,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada. .,Department of Medicine, University of Calgary, Calgary, Alberta, T2N 4Z6, Canada.
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Merlo G, Page K, Ratcliffe J, Halton K, Graves N. Bridging the gap: exploring the barriers to using economic evidence in healthcare decision making and strategies for improving uptake. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2015; 13:303-309. [PMID: 25288052 DOI: 10.1007/s40258-014-0132-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Evidence from economic evaluations is often not used to inform healthcare policy despite being well regarded by policy makers and physicians. This article employs the accessibility and acceptability framework to review the barriers to using evidence from economic evaluation in healthcare policy and the strategies used to overcome these barriers. Economic evaluations are often inaccessible to policymakers due to the absence of relevant economic evaluations, the time and cost required to conduct and interpret economic evaluations, and lack of expertise to evaluate quality and interpret results. Consistently reported factors that limit the translation of findings from economic evaluations into healthcare policy include poor quality of research informing economic evaluations, assumptions used in economic modelling, conflicts of interest, difficulties in transferring resources between sectors, negative attitudes to healthcare rationing, and the absence of equity considerations. Strategies to overcome these barriers have been suggested in the literature, including training, structured abstract databases, rapid evaluation, reporting checklists for journals, and considering factors other than cost effectiveness in economic evaluations, such as equity or budget impact. The factors that prevent or encourage decision makers to use evidence from economic evaluations have been identified, but the relative importance of these factors to decision makers is uncertain.
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Affiliation(s)
- Gregory Merlo
- Centre of Research Excellence in Reducing Healthcare Associated Infections (CRE-RHAI), Institute of Health and Biomedical Innovation, Queensland University of Technology (QUT), Brisbane, Australia,
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Hollingworth W, Rooshenas L, Busby J, Hine CE, Badrinath P, Whiting PF, Moore THM, Owen-Smith A, Sterne JAC, Jones HE, Beynon C, Donovan JL. Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03130] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundNHS expenditure has stagnated since the economic crisis of 2007, resulting in financial pressures. One response is for policy-makers to regulate use of existing health-care technologies and disinvest from inefficiently used health technologies. A key challenge to disinvestment is to identify existing health technologies with uncertain cost-effectiveness.ObjectivesWe aimed to explore if geographical variation in procedure rates is a marker of clinical uncertainty and might be used by local commissioners to identify procedures that are potential candidates for disinvestment. We also explore obstacles and solutions to local commissioners achieving disinvestment, and patient and clinician perspectives on regulating access to procedures.MethodsWe used Hospital Episode Statistics to measure geographical variation in procedure rates from 2007/8 to 2011/12. Expected procedure numbers for each primary care trust (PCT) were calculated adjusting for proxies of need. Random effects Poisson regression quantified the residual inter-PCT procedure rate variability. We benchmarked local procedure rates in two PCTs against national rates. We conducted rapid systematic reviews of two high-use procedures selected by the PCTs [carpal tunnel release (CTR) and laser capsulotomy], searching bibliographical databases to identify systematic reviews and randomised controlled trials (RCTs). We conducted non-participant overt observations of commissioning meetings and semistructured interviews with stakeholders about disinvestment in general and with clinicians and patients about one disinvestment case study. Transcripts were analysed thematically using constant comparison methods derived from grounded theory.ResultsThere was large inter-PCT variability in procedure rates for many common NHS procedures. Variation in procedure rates was highest where the diffusion or discontinuance was rapidly evolving and where substitute procedures were available, suggesting that variation is a proxy for clinical uncertainty about appropriate use. In both PCTs we identified procedures where high local use might represent an opportunity for disinvestment. However, there were barriers to achieving disinvestment in both procedure case studies. RCTs comparing CTR with conservative care indicated that surgery was clinically effective and cost-effective on average but provided limited evidence on patient subgroups to inform commissioning criteria and achieve savings. We found no RCTs of laser capsulotomy. The apparently high rate of capsulotomy was probably due to the coding inaccuracy; some savings might be achieved by greater use of outpatient procedures. Commissioning meetings were dominated by new funding requests. Benchmarking did not appear to be routinely carried out because of capacity issues and concerns about data reliability. Perceived barriers to disinvestment included lack of collaboration, central support and tools for disinvestment. Clinicians felt threshold criteria had little impact on their practice and that prior approval systems would not be cost-effective. Most patients were unaware of rationing.ConclusionsPolicy-makers could use geographical variation as a starting point to identify procedures where health technology reassessment or RCTs might be needed to inform policy. Commissioners can use benchmarking to identify procedures with high local use, possibly indicating overtreatment. However, coding inconsistency and limited evidence are major barriers to achieving disinvestment through benchmarking. Increased central support for commissioners to tackle disinvestment is needed, including tools, accurate data and relevant evidence. Early engagement with patients and clinicians is essential for successful local disinvestment.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
| | - Leila Rooshenas
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - John Busby
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | | | | | - Theresa HM Moore
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Amanda Owen-Smith
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Jonathan AC Sterne
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Hayley E Jones
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | | | - Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Rooshenas L, Owen-Smith A, Hollingworth W, Badrinath P, Beynon C, Donovan JL. “I won't call it rationing…”: An ethnographic study of healthcare disinvestment in theory and practice. Soc Sci Med 2015; 128:273-81. [DOI: 10.1016/j.socscimed.2015.01.020] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Ghojazadeh M, Hajebrahimi S, Azami-Aghdash S, Pournaghi Azar F, Keshavarz M, Naghavi-Behzad M, Hazrati H. Medical students' attitudes on and experiences with evidence-based medicine: a qualitative study. J Eval Clin Pract 2014; 20:779-85. [PMID: 25039542 DOI: 10.1111/jep.12191] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/06/2014] [Indexed: 01/02/2023]
Abstract
RATIONALE, AIMS AND OBJECTIVES This qualitative study was designed to determine the attitudes towards and experiences of medical students on evidence-based medicine (EBM). METHODS The study was conducted using the phenomenological method. Medical students' attitudes about and experiences with evidence-based medicine were determined through semi-structured interviews. Forty senior medical students were chosen by purposive sampling from medical sciences students of Tabriz University and Shahid Beheshti University. The context of interviews was analysed using the content analysis method. RESULTS Medical students' attitudes and experiences were ascertained through four main questions, and their answers were divided in to 12 categories and 31 subcategories. According to the subjects of the study, two basic concepts that they understood about EBM were its being up to date and requiring research skills. To the question what is necessary for EBM, the students' answers were summarized as follows: access to information, teamwork and faculty members who could provide modeling and organizational support. Students reported having used EBM for problem solving, thinking and self-confidence. On the other hand, lack of equipment and facilities, human factors and organizational factors were considered the main barriers to EBM use. CONCLUSION According to the results of this study, providing suitable conditions and appropriate planning to address identified barriers and encouraging students can promote EBM practice. Also, more extensive EBM integration in medical curricula and clinical settings by leading faculty members would prompt medical students to use EBM in their daily practice.
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Affiliation(s)
- Morteza Ghojazadeh
- Liver and Gastrointestinal Disease Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
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Prioritising public health guidance topics in the National Institute for Health and Care Excellence using the Analytic Hierarchy Process. Public Health 2014; 128:896-903. [PMID: 25369354 DOI: 10.1016/j.puhe.2014.07.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2013] [Revised: 05/21/2014] [Accepted: 07/04/2014] [Indexed: 11/23/2022]
Abstract
OBJECTIVES The Centre for Public Health (CPH), at the United Kingdom's National Institute for Health and Care Excellence (NICE) is responsible for producing national guidance relating to the promotion of good health and the prevention and treatment of disease. Given the challenges of developing guidance in this area, choosing the most appropriate topics for further study is of fundamental importance. This paper explores the current prioritisation process and describes how the Analytic Hierarchy Process (AHP), a multi criteria decision analysis (MCDA) technique, might be used to do so. STUDY DESIGN A proposed approach is outlined, which was tested in a proof of concept pilot. This consisted of eight participants with experience of related NICE committees building scores for each topic together in a 'decision conference' setting. METHODS Criteria were identified and subsequently weighted to indicate the relative importance of each. Participants then collaboratively estimated the performance of each topic on each criterion. RESULTS Total scores for each topic were calculated, which could be ranked and used as the basis for better informed discussion for prioritising topics to recommend to the Minister for future guidance. Sensitivity analyses of the dataset found it to be robust. CONCLUSIONS Choosing the right topics for guidance at the earliest possible time is of fundamental importance to public health guidance, and judgement is likely to play an important part in doing so. MCDA techniques offer a potentially useful approach to structuring the problem in a rational and transparent way. NICE should consider carefully whether such an approach might be worth pursuing in the future.
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Hodgetts K, Hiller JE, Street JM, Carter D, Braunack-Mayer AJ, Watt AM, Moss JR, Elshaug AG. Disinvestment policy and the public funding of assisted reproductive technologies: outcomes of deliberative engagements with three key stakeholder groups. BMC Health Serv Res 2014; 14:204. [PMID: 24885716 PMCID: PMC4016640 DOI: 10.1186/1472-6963-14-204] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 04/25/2014] [Indexed: 11/10/2022] Open
Abstract
Background Measures to improve the quality and sustainability of healthcare practice and provision have become a policy concern. In addition, the involvement of stakeholders in health policy decision-making has been advocated, as complex questions arise around the structure of funding arrangements in a context of limited resources. Using a case study of assisted reproductive technologies (ART), deliberative engagements with a range of stakeholder groups were held on the topic of how best to structure the distribution of Australian public funding in this domain. Methods Deliberative engagements were carried out with groups of ART consumers, clinicians and community members. The forums were informed by a systematic review of ART treatment safety and effectiveness (focusing, in particular, on maternal age and number of treatment cycles), as well as by international policy comparisons, and ethical and cost analyses. Forum discussions were transcribed and subject to thematic analysis. Results Each forum demonstrated stakeholders’ capacity to understand concepts of choice under resource scarcity and disinvestment, and to countenance options for ART funding not always aligned with their interests. Deliberations in each engagement identified concerns around ‘equity’ and ‘patient responsibility’, culminating in a broad preference for (potential) ART subsidy restrictions to be based upon individual factors rather than maternal age or number of treatment cycles. Community participants were open to restrictions based upon measures of body mass index (BMI) and smoking status, while consumers and clinicians saw support to improve these factors as part of an ART treatment program, as distinct from a funding criterion. All groups advocated continued patient co-payments, with measures in place to provide treatment access to those unable to pay (namely, equity of access). Conclusions Deliberations yielded qualitative, socially-negotiated evidence required to inform ethical, accountable policy decisions in the specific area of ART and health care more broadly. Notably, reductionist, deterministic characterizations of stakeholder ‘self-interest’ proved unfounded as each group sought to prioritise universal values (in particular, ‘equity’ and ‘responsibility’) over specific, within-group concerns. Our results - from an emotive case study in ART - highlight that evidence-informed disinvestment decision-making is feasible, and potentially less controversial than often presumed.
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Affiliation(s)
| | | | | | | | | | | | | | - Adam G Elshaug
- Menzies Centre for Health Policy, Sydney School of Public Health, Sydney Medical School, The University of Sydney, Coppleson Building D02, Sydney, NSW 2006, Australia.
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Jommi C, Costa E, Michelon A, Pisacane M, Scroccaro G. Multi-tier drugs assessment in a decentralised health care system. The Italian case-study. Health Policy 2013; 112:241-7. [DOI: 10.1016/j.healthpol.2013.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 06/02/2013] [Accepted: 06/05/2013] [Indexed: 10/26/2022]
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Hodgetts K, Elshaug AG, Hiller JE. What counts and how to count it: Physicians’ constructions of evidence in a disinvestment context. Soc Sci Med 2012; 75:2191-9. [DOI: 10.1016/j.socscimed.2012.08.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 07/27/2012] [Accepted: 08/17/2012] [Indexed: 12/01/2022]
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Robinson S, Dickinson H, Freeman T, Rumbold B, Williams I. Structures and processes for priority-setting by health-care funders: a national survey of primary care trusts in England. Health Serv Manage Res 2012; 25:113-20. [DOI: 10.1258/hsmr.2012.012007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Although explicit priority-setting is advocated in the health services literature and supported by the policies of many governments, relatively little is known about the extent and ways in which this is carried out at local decision-making levels. Our objective was to undertake a survey of local resource allocaters in the English National Health Services in order to map and explore current priority-setting activity. A national survey was sent to Directors of Commissioning in English Primary Care Trusts (PCTs). The survey was designed to provide a picture of the types of priority-setting activities and techniques that are in place and offer some assessment of their perceived effectiveness. There is variation in the scale, aims and methods of priority-setting functions across PCTs. A perceived strength of priority-setting processes is in relation to the use of particular tools and/or development of formal processes that are felt to increase transparency. Perceived weaknesses tended to lie in the inability to sufficiently engage with a range of stakeholders. Although a number of formal priority-setting processes have been developed, there are a series of remaining challenges such as ensuring priority-setting goes beyond the margins and is embedded in budget management, and the development of disinvestment as well as investment strategies. Furthermore, if we are genuinely interested in a more explicit approach to priority-setting, then fostering a more inclusive and transparent process will be required.
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Affiliation(s)
- Suzanne Robinson
- University of Birmingham – Health Services Management Centre, Birmingham, UK
| | - Helen Dickinson
- University of Birmingham – Health Services Management Centre, Birmingham, UK
| | - Tim Freeman
- University of Birmingham – Health Services Management Centre, Birmingham, UK
| | | | - Iestyn Williams
- University of Birmingham – Health Services Management Centre, Birmingham, UK
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Robinson S, Williams I, Dickinson H, Freeman T, Rumbold B. Priority-setting and rationing in healthcare: evidence from the English experience. Soc Sci Med 2012; 75:2386-93. [PMID: 23083894 DOI: 10.1016/j.socscimed.2012.09.014] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2012] [Revised: 09/05/2012] [Accepted: 09/11/2012] [Indexed: 11/19/2022]
Abstract
In a context of ever increasing demand, the recent economic downturn has placed further pressure on decision-makers to effectively target healthcare resources. Over recent years there has been a push to develop more explicit evidence-based priority-setting processes, which aim to be transparent and inclusive in their approach and a number of analytical tools and sources of evidence have been developed and utilised at national and local levels. This paper reports findings from a qualitative research study which investigated local priority-setting activity across five English Primary Care Trusts, between March and November 2012. Findings demonstrate the dual aims of local decision-making processes: to improve the overall effectiveness of priority-setting (i.e. reaching 'correct' resource allocation decisions); and to increase the acceptability of priority-setting processes for those involved in both decision-making and implementation. Respondents considered priority-setting processes to be compartmentalised and peripheral to resource planning and allocation. Further progress was required with regard to disinvestment and service redesign with respondents noting difficulty in implementing decisions. While local priority-setters had begun to develop more explicit processes, public awareness and input remained limited. The leadership behaviours required to navigate the political complexities of working within and across organisations with differing incentives systems and cultures remained similarly underdeveloped.
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Affiliation(s)
- Suzanne Robinson
- School of Public Health, Faculty of Health Sciences, Curtin University Building 400-315, GPO Box U1987, Perth, WA 6845, Australia.
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Abstract
OBJECTIVE This review examines the impact of economic evaluation in informing national or local policies within both jurisdictions. We focus on the factors that have made the economic evaluation evolves differently in both settings. AREAS OF AGREEMENT Economic evaluation facilitates decision-making regarding the efficiency of interventions. The existence of national or local bodies regulating the process has contributed to increasing its use in decision-making and the development of its methods. AREAS OF CONTROVERSY Cost-effectiveness approach is based on the assumption of health maximization subject to a budget constraint. Decision-makers are not only interested in health maximization alone. This may result in policy-makers failing to consider economic evaluations into their allocation decisions. AREAS TO DEVELOP RESEARCH: Methods that incorporate wider decision-makers goals (mainly local) and research to study the real impact of economic evaluation in terms of improved efficiency and equity are particularly required.
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Stafinski T, Menon D, Marshall D, Caulfield T. Societal values in the allocation of healthcare resources: is it all about the health gain? PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2012; 4:207-25. [PMID: 21815706 DOI: 10.2165/11588880-000000000-00000] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Over the past decade, public distrust in unavoidable value-laden decisions on the allocation of resources to new health technologies has grown. In response, healthcare organizations have made considerable efforts to improve their acceptability by increasing transparency in decision-making processes. However, the social value judgments (distributive preferences of the public) embedded in them have yet to be defined. While the need to explicate such judgments has become widely recognized, the most appropriate approach to accomplishing this remains unclear. The aims of this review were to identify factors around which distributive preferences of the public have been sought, create a list of social values proposed or used in current resource allocation decision-making processes for new health technologies, and review approaches to eliciting such values from the general public. Social values proposed or used in making resource allocation decisions for new health technologies were identified through three approaches: (i) a comprehensive review of published, peer-reviewed, empirical studies of public preferences for the distribution of healthcare; (ii) an analysis of non-technical factors or social value statements considered by technology funding decision-making processes in Canada and abroad; and (iii) a review of appeals to funding decisions on grounds in part related to social value judgments. A total of 34 empirical studies, 10 technology funding decision-making processes, and 12 appeals to decisions were identified and reviewed. The key factors/patient characteristics addressed through policy statements and around which distributive preferences of the public have been sought included severity of illness, immediate need, age (and its relationship to lifetime health), health gain (amount and final outcome/health state), personal responsibility for illness, caregiving responsibilities, and number of patients who could benefit (rarity). Empirical studies typically examined the importance of these factors in isolation. Therefore, the extent to which preferences around one factor may be modified in the presence of others is still unclear. Research that seeks to clarify interactions among factors by asking the public to weigh several of them at once is needed to ensure the relevance of elicited preferences to real-world technology funding decisions.
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Affiliation(s)
- Tania Stafinski
- School of Public Health, University of Alberta, Edmonton, AB, Canada.
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Erntoft S. Pharmaceutical priority setting and the use of health economic evaluations: a systematic literature review. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2011; 14:587-599. [PMID: 21669384 DOI: 10.1016/j.jval.2010.10.036] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Revised: 06/16/2010] [Accepted: 10/14/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVES To investigate which factors and criteria are used in priority setting of pharmaceuticals, in what contexts health economic evaluations are used, and barriers to the use of health economic evaluations at micro, meso, and macro health-care levels. METHODS The search for empirical articles was based on the MeSH index (Medical Substance Heading), including the search terms "economic evaluation," "cost-effectiveness analysis," "cost-utility analysis," "cost-benefit analysis," "pharmacoeconomic," AND "drug cost(s)," AND "eligibility determination," AND "decision-making," AND "rationing," AND formulary. The following databases were searched: PubMed, EconLit, Cochrane, Web of Science, CINAHL, and PsycINFO. More than 3100 studies were identified, 31 of which were included in this review. RESULTS The use of health economic evaluations at all three health-care levels was investigated in three countries (United States [US], United Kingdom [UK], and Sweden). Postal and telephone survey methods dominated (n = 17) followed by interviews (n = 13), document analysis (n = 10), and observations of group deliberations (n = 9). The cost-effectiveness criterion was most important at the macro level. A number of contextual uses of health economic evaluations were identified, including importantly the legitimizing of decisions, structuring the priority-setting process, and requesting additional budgets to finance expensive pharmaceuticals. CONCLUSION Factors that seem to support the increased use of health economic evaluations are well-developed frameworks for evaluations, the presence of health economic skills, and an explicit priority-setting process. Differences in how economic evaluations are used at macro, meso, and micro levels are attributed to differences in the preconditions at each level.
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Affiliation(s)
- Sandra Erntoft
- Department of Business Administration, Lund University, Lund, Sweden
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Stafinski T, Menon D, Philippon DJ, McCabe C. Health technology funding decision-making processes around the world: the same, yet different. PHARMACOECONOMICS 2011; 29:475-95. [PMID: 21568357 DOI: 10.2165/11586420-000000000-00000] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
All healthcare systems routinely make resource allocation decisions that trade off potential health gains to different patient populations. However, when such trade-offs relate to the introduction of new, promising health technologies, perceived 'winners' and 'losers' are more apparent. In recent years, public scrutiny over such decisions has intensified, raising the need to better understand how they are currently made and how they might be improved. The objective of this paper is to critically review and compare current processes for making health technology funding decisions at the regional, state/provincial and national level in 20 countries. A comprehensive search for published, peer-reviewed and grey literature describing actual national, state/provincial and regional/institutional technology decision-making processes was conducted. Information was extracted by two independent reviewers and tabulated to facilitate qualitative comparative analyses. To identify strengths and weaknesses of processes identified, websites of corresponding organizations were searched for commissioned reviews/evaluations, which were subsequently analysed using standard qualitative methods. A total of 21 national, four provincial/state and six regional/institutional-level processes were found. Although information on each one varied, they could be grouped into four sequential categories: (i) identification of the decision problem; (ii) information inputs; (iii) elements of the decision-making process; and (iv) public accountability and decision implementation. While information requirements of all processes appeared substantial and decision-making factors comprehensive, the way in which they were utilized was often unclear, as were approaches used to incorporate social values or equity arguments into decisions. A comprehensive inventory of approaches to implementing the four main components of all technology funding decision-making processes was compiled, from which areas for future work or research aimed at improving the acceptability of decisions were identified. They include the explication of decision criteria and social values underpinning processes.
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Affiliation(s)
- Tania Stafinski
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada.
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Alsultan MS. The role of pharmacoeconomics in formulary decision making in different hospitals in Riyadh, Saudi Arabia. Saudi Pharm J 2011; 19:51-6. [PMID: 23960742 PMCID: PMC3744944 DOI: 10.1016/j.jsps.2010.10.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2010] [Accepted: 09/25/2010] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To assess the trend of using pharmacoeconomic information by Pharmacy and Therapeutics (P&T) committees when making formulary decisions. DESIGN A cross-sectional study conducted in 2007, using structured survey questionnaires which were distributed to members of the P&T committees in 11 different hospitals in Riyadh, Saudi Arabia. RESULTS A total of 100 survey questionnaires were sent to head of pharmacy departments of 11 different hospitals in Riyadh, Saudi Arabia. Out of these, 48 questionnaires were completed and returned. Of the total respondents participated in the study, 64.58% were medical doctors and 16.66% were pharmacists and 75% of the respondents said they have applied pharmacoeconomic evaluations in their decision making process. More than 80% of the respondents perceived that they had a fair knowledge of pharmacoeconomics. Approximately 80% of respondents expressed some degree of agreement that pharmacoeconomics should be applied as a decision making tool. The majority of decision-makers (95%) expressed the interest in attending workshops on pharmacoeconomics. CONCLUSION The study showed that pharmacoeconomics can play an important role in the P&T committee formulary decisions. However, more education to health care professionals and to hospital administrators should be conducted to facilitate the use of such a tool. Also, hospitals should recruit health care professionals with pharmacoeconomic expertise to manage limited health resources in the best way available.
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Affiliation(s)
- Mohammed S. Alsultan
- Pharmacoeconomic and Outcomes Research Unit, Department of Clinical Pharmacy, College of Pharmacy, King Saud University, P.O. Box 2487, Riyadh 11451, Saudi Arabia
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Abraham J. Partial progress: governing the pharmaceutical industry and the NHS, 1948-2008. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2009; 34:931-977. [PMID: 20018987 DOI: 10.1215/03616878-2009-032] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Coinciding with sixty years of the U.K. National Health Service (NHS), this article reviews the neglected area of the governance of the pharmaceutical industry and the NHS. It traces the relationships between the pharmaceutical industry, the state, and the NHS from the creation of the health service to the present, as they have grappled with the overlapping challenges of pharmaceutical safety, efficacy, cost-effectiveness, pricing, promotion, and advertising. The article draws on the concepts of "corporate bias" and "regulatory capture" from political theory, and "counter-vailing powers" and "clinical autonomy" in medical sociology, while also introducing the new concepts of "assimilated allies" and "pharmaceuticalization" in order to synthesize a theoretical framework capable of longitudinal empirical analysis of pharmaceutical governance. The analysis identifies areas in which the governance of pharmaceuticals and the NHS has contributed to progress in health care since 1948. However, it is argued that that progress has been slow, restricted, and vulnerable to misdirection due to the enormous and unrivaled influence afforded to the pharmaceutical industry in policy developments. Countervailing influences against such corporate bias have often been limited and subject to destabilization by the industry's assimilated allies either within the state or in the embrace of pharmaceuticalization and consumerism.
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Rovithis D. Health economic evaluation: in need of more analytical rigor or more practical relevance? Expert Rev Pharmacoecon Outcomes Res 2009; 9:107-10. [PMID: 19402796 DOI: 10.1586/erp.09.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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[Hazards, tactics and constraints of evaluation of health care in low income countries]. C R Biol 2008; 331:1007-15. [PMID: 19027702 DOI: 10.1016/j.crvi.2008.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Unless a large, new, financial contribution comes from the international community, health indicators are far from good in low income countries. However, even if health financing is still insufficient, better health care in these countries could be produced with their present resources. It requires an improvement in the health system performance, as well as efficacy and efficiency of health programs. As a tool, evaluation allows one firstly to check this performance and efficiency, and then to assess the impact of different programs. This article is organising in three sections. The first presents the different (economic, ethical and social) stakes of an evaluation system. The second section describes its methods and the third analyses its constraints.
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Galani C, Rutten FFH. Self-reported healthcare decision-makers' attitudes towards economic evaluations of medical technologies. Curr Med Res Opin 2008; 24:3049-58. [PMID: 18826747 DOI: 10.1185/03007990802442695] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Increasing costs have generated concern among governments and healthcare providers who have realized the need for cost containment measures and more efficient resource utilization. Health economics is one potential source of information that can make healthcare more efficient. SCOPE This review article summarizes the published literature on self-reported attitudes of healthcare decision-makers towards economic evaluations of medical technologies and examines the extent to which economic evaluations are used in health policy decisions. METHODS A systematic literature review of published English language studies was conducted using MEDLINE, EMBASE, and HEED from January 1995 to December 2007. FINDINGS Fifty-five articles investigated the use of economic evaluations on three levels of decision-making: central, local, and physician level. Results indicate the use of economic evaluation information increased from limited/minor to moderate use. The influence of economic evaluations increased with the level of centralization of healthcare system. Barriers to use health economics research varied across levels and included health economics research-related barriers such as timely availability, lack of credibility, insufficient methodological quality and decision-context-related barriers including limited decision makers' knowledge, inflexibility in healthcare budgets and variability among healthcare organizations. CONCLUSIONS For consistent policy-making it is important that similar recommendations for cost-effective interventions and programs are developed at all levels and that implementation is promoted by incorporating the appropriate incentives in healthcare provision.
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Affiliation(s)
- Carmen Galani
- Institute for Medical Technology Assessment, Erasmus MC, Rotterdam,The Netherlands.
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Wranik D. Using economic evidence as a support tool for policy decisions: Herculean or Sisyphean effort? Expert Rev Pharmacoecon Outcomes Res 2008; 8:329-32. [PMID: 20528338 DOI: 10.1586/14737167.8.4.329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Dominika Wranik
- School of Public Administration, Dalhousie University, Halifax, Nova Scotia B3H3J5, Canada.
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Use of economic evaluation in local health care decision-making in England: a qualitative investigation. Health Policy 2008; 89:261-70. [PMID: 18657336 DOI: 10.1016/j.healthpol.2008.06.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Revised: 06/11/2008] [Accepted: 06/11/2008] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To explore decision-making and the use of economic evaluation at the local health care decision-making level in England (UK). METHODS Data collection was over a 16-month period (January 2003 to April 2004). Data collection comprised 29 in-depth interviews with a range of decision makers, 13 observations of decision-making meetings, and analysis of documents produced at meetings. A constant comparative approach was used to identify broad themes and sub-themes arising from the data. Data were analysed using Microsoft Word. RESULTS National Institute for Health and Clinical Excellence (NICE) guidance provides the main way in which economic evaluation is used at a local level in the UK, although following NICE guidance is often regarded as detrimental to pursuing local priorities. Other than through NICE, economic evaluation is not considered at the local level; we found no evidence for use at the meeting group (by individuals). Although decision makers appear to understand notions of scarcity, with some also referring to value for money, the process of decision-making departs from these principles in practice. Disinvestment decisions are not made nor are decisions weighted against pre-defined criteria. Options appraisal is conducted, but it does not embody the principles of economic evaluation, since options are not considered in terms of their costs and benefits and opportunity cost is not accounted for. There appear to be two reasons why economic evaluation is not used at the local level: (1) the nature of management decisions concerned with the employment of extra staff and new equipment, rather than the choice of medicines or specific interventions usually assessed in published economic evaluation; (2) lack of awareness of the economic evaluation approach to decision-making. These two factors point to a lack of freedom in decision-making at the local level and a lack of understanding of how priority setting can be achieved in practice. CONCLUSION A more detailed and rigorous approach to prioritisation at the local level is required. Whilst, PCTs have been given greater responsibility for priority setting, they lack the necessary power and understanding of the ways in which long term solutions to problems in health care can be achieved. Economics can be a valuable asset to priority setting and has already filtered into the jargon used by decision makers. Whilst most concepts are understood, the leap to adopting these concepts into the practice of decision-making needs to be made.
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A systematic review of the use of economic evaluation in local decision-making. Health Policy 2008; 86:129-41. [DOI: 10.1016/j.healthpol.2007.11.010] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2007] [Revised: 11/21/2007] [Accepted: 11/25/2007] [Indexed: 11/21/2022]
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