Including quality attributes in efficiency measures consistent with net benefit: Creating incentives for evidence based medicine in practice

Aligning opportunity cost and net benefit criteria: the health shadow price

Given constrained healthcare budgets and many competing demands, public health decision-making requires comparing the expected cost and health outcomes of alternative strategies and associated adoption and financing actions. Opportunity cost (comparing outcomes from the best alternative use of budgets or actions in decision making) and more recently net benefit criteria (relative valuing of effects at a threshold value less costs) have been key concepts and metrics applied toward making such decisions. In an ideal world, opportunity cost and net benefit criteria should be mutually supportive and consistent. However, that requires a threshold value to align net benefit with opportunity cost assessment. This perspective piece shows that using the health shadow price as the ICER threshold aligns net benefit and opportunity cost criteria for joint adoption and financing actions that arise when reimbursing any new strategy or technology under a constrained budget. For an investment strategy with ICER at the health shadow price Bc = 1/(1/n + 1/d-1/m), net benefit of reimbursing (adopting and financing) that strategy given an incremental cost-effectiveness ration (ICER) of actual displacement, d, in financing, is shown to be equivalent to that of the best alternative actions, the most cost-effective expansion of existing programs (ICER = n) funded by the contraction of the least cost-effective programs (ICER = m). Net benefit is correspondingly positive or negative if it is below or above this threshold. Implications are discussed for creating pathways to optimal public health decision-making with appropriate incentives for efficient displacement as well as for adoption actions and related research.

Globally optimal trial design and risk sharing arrangements are key to avoiding opportunity costs of delay and enabling equitable, feasible and effective global vaccine research and implementation in current or future pandemics

Global vaccination in the face of pandemics such as COVID-19 and new variants is a race against time. Avoiding the opportunity costs of delay and the associated health, social, and downstream economic impacts is a challenge and an imperative. Failures to address the global challenges posed by COVID-19 have become increasingly evident as waves of vaccine-evading mutations have emerged, facilitated by unequal vaccination coverage and diminishing immunity against new variants worldwide. To address these challenges, societal decision-makers (governments) and industry manufacturer interests must be better aligned for rapid, globally optimal trial design, ideally with research coverage, implementation, and accessibility of effective vaccines across joint research, implementation, and distribution cycles to address pandemic evolution in real time. Value of information (VoI) methods for optimal global trial design and risk-sharing arrangements align the research, distribution, and implementation interests and efforts globally to meet head-on the imperative of avoiding opportunity costs of delay and enabling consistent global solutions with maximizing local and global net benefits. They uniquely enable feasible early adoption of the most promising strategies in real time while the best globally translatable evidence is collected and interests are aligned for global distribution and implementation. Furthermore, these methods are generally shown to be imperative for feasible, fast, and optimal solutions across joint research, reimbursement, and regulatory processes for current and future pandemics and other global existential threats. Establishing pathways for globally optimal trial designs, risk-sharing agreements, and efficient translation to practice is urgent on many fronts.

Robust cross-country comparison of children meeting 24-HR movement guidelines: an odds solution for binary effect efficiency measures

Aim

International comparisons of public health measures relative to observed best practice are increasingly important for evaluating community health promotion strategies and policies such as meeting or not meeting public health guidelines. This study aimed to identify methods enabling robust evaluation with such binary effect measures at a population level.

Subject and methods

Conventional efficiency comparisons of binary effect proportions are problematic due to a lack of consistency with alternate framing of resulting relative risks. In this paper, we illustrate such inconsistent efficiency measures comparing the proportion of school age children (9–11 years) meeting or not meeting integrated movement guidelines (IMGs) across the 12 countries from the International Study of Childhood Obesity, Lifestyle and the Environment (ISCOLE) study. IMGs jointly consider physical activity, sleep and sedentary behaviours. An odds method is developed to enable consistent efficiency comparison with alternative framing of binary effects.

Results

A novel odds solution to relative risk problems arising with conventional efficiency comparison of binary effects with alternative framing is shown to provide consistent efficiency measures relative to best practice. Furthermore, this technical advancement is shown to extend to consistent indirect comparison and evidence translation.

Conclusion

Robust methods for international cross-country comparison of binary effect measures such as meeting or not meeting guidelines are identified with a novel odds ratio method. This novel solution is particularly important for health promotion evaluation of IMGs given the need for consistent comparison in evaluating practice evidence of what works now and consistent evidence translation of treatment effects as and when they emerge.

Multiple effects health economic evaluation of the Ahead of The Game Study for mental health promotion in sporting club communities

BACKGROUND

This study evaluates the Ahead Of The Game (AOTG) mental health promotion strategy for adolescent males relative to usual practice in team based sporting club community settings, allowing for joint incremental effects across 13 dimensions and 5 domains alongside intervention implementation costs.

METHODS

Analysis is undertaken between matched communities with difference in differences analysis of joint multiple pre-post effect changes alongside implementation costs employing radar plots in cost-disutility space. A robust bootstrapping method allowed including all observed change in effect data from 343 AOTG and 273 control arm participants across 13 effect dimensions.

RESULTS

Triangulation across joint evidence shows mean incremental effects favoured AOTG in all dimensions (10/13 significantly at 5% level) and in simple aggregation to each of five pre-specified 5 domains (each significant at < 1% level) and global measures (significant at 0.001% level), while mean AOTG implementation costs were conservatively estimated as $37.47 per participant.

CONCLUSION

The AOTG strategy was found to represent an effective mental health promotion strategy across all domains and globally with associated significant potential for downstream health system cost savings to offset against modest implementation costs. Evaluation methods extend conventional cost-effectiveness analysis to enable robust joint presentation and triangulation under uncertainty of multiple effect dimensions alongside costs.

TRIAL REGISTRATION

ANZCTR, ACTRN12617000709347 . Registered 17th May 2017.

Professional judgement in clinical practice (part 3): A better alternative to strong evidence-based medicine

Parts 1 and 2 in this series of three articles have shown that and how strong evidence-based medicine has neither a coherent theoretical foundation nor creditable application to clinical practice. Because of its core commitment to the discredited positivist tradition it holds both a false concept of scientific knowledge and misunderstandings concerning clinical decision-making. Strong EBM continues attempts to use flawed adjustments to recover from the unsalvageable base view. Paper three argues that a promising solution is at hand if we can manage several modes of inclusion. A modified original, moderate version of EBM continues though usually overshadowed. As definitively laid out by Sackett in the 1990s, clinical decision making is intended to be person-centered, recognizing and integrating multiple modes of evidence and knowledge that have been marginalized: professional experience, illness narratives, and individual patients' values and preferences. Complementary resources are at hand: interpretative understanding and practice, such as philosophical anthropology, hermeneutical phenomenology, complexity theory, and phronetic practices respond to the major problems and open new possibilities. Phronesis is especially important in regard to public decision making. Within part 3 an additional tone necessarily occurs. While most of papers 1, 2, and 3 are written in the classical mode of contrasting the theoretical-logical and empirical evidence offered by contending positions bearing on the decision making and judgement in clinical practice, a shift occurs when considerations move beyond what is possible for clinical practitioners to accomplish. A different, discontinuous level of power operates in the trans-personal realm of instrumental policy, insurance, and hospital management practices. In this social-economic-political-ethical realm what happens in clinical practice today increasingly becomes a matter of what is "done unto" clinical practitioners, of what hampers their professional action and thus care of individual patients and clients.

Effectiveness of quality incentive payments in general practice (EQuIP-GP): a study protocol for a cluster-randomised trial of an outcomes-based funding model in Australian general practice to improve patient care

BACKGROUND

There is international interest in whether improved primary care, in particular for patients with chronic or complex conditions, can lead to decreased use of health resources and whether financial incentives help achieve this goal. This trial (EQuIP-GP) will investigate whether a funding model based upon targeted, continuous quality incentive payments for Australian general practices increases relational continuity of care, and lessens health-service utilisation, for high-risk patients and children.

METHODS

We will use a mixed methods approach incorporating a two-arm pragmatic cluster randomised control trial with nested qualitative case studies. We aim to recruit 36 general practices from Practice-Based Research Networks (PBRN) covering urban and regional areas of Australia, randomised into intervention and control groups. Control practices will provide usual care while intervention practices will be supported to implement a new service model incorporating incentives for relational continuity and timely access to appointments. Patients will comprise three groups: older (over 65 years); 18-65 years with chronic and/or complex conditions; and those aged less than 16 years with increased risk of hospitalisation. The funding model includes financial incentives to general practitioners (GPs) for providing longer consultations, same day access and timely follow-up after hospitalisation to enrolled patients. The payments are proportional to expected health system savings associated with improved quality of GP care. An outreach facilitator will work with practices to help incorporate the incentive model into usual work. The main outcome measure is relational continuity of care (Primary Care Assessment Tool short-form survey), with secondary outcomes including health-related quality of life and health service use (hospitalisations, emergency presentations, GP and specialist services in the community, medicine prescriptions and targeted pathology and imaging ordering). Outcomes will be initially evaluated over a period of 12 months, with ongoing data collection for 5 years.

DISCUSSION

The trial will provide robust evidence on a novel approach to providing continuous incentives for improving quality of general practice care, which can be compared to block payment incentives awarded at target quality levels of pay-for-performance, both within Australia and also internationally.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12618000105246. Registered on 23 January 2018.

Aligning policy objectives and payment design in palliative care

BACKGROUND

Payment models for palliative care vary across nations, with few adopting contemporary payments designs that apply to other parts of the health system.

AIM

To propose optimal payment arrangements for palliative care.

APPROACH

Review of relevant literature on funding mechanisms in health care generally and palliative care in particular.

RESULTS

Payment models for palliative care should move toward activity-based funding using an agreed classification, be uncapped funding with performance monitoring, and make explicit use of performance metrics and reporting.

CONCLUSIONS

If palliative care is to become a universally accessible service, new approaches to funding, based on the experience of funding reforms in other parts of the health system, need to be adopted.

Hospital diagnostic aggregation and risk-adjusted quality

OBJECTIVE

To demonstrate the importance of diagnostic aggregation when assessing hospitals.

DATA SOURCES

Patient data from the Victorian Admitted Episodes Database (VAED), 1999/2000 to 2004/2005. Financial statements from public hospitals, 2002/2003 to 2004/2005.

STUDY DESIGN

Risk-adjusted quality computed for each hospital using two aggregation levels. Each is then used to estimate the relationship between hospital efficiency and quality using two-stage DEA/Tobit model by Wilson and Simar (2006).

DATA COLLECTION

Selected variables from the VAED were obtained from the Department of Health in Victoria, then linked anonymously with financial statements.

PRINCIPAL FINDINGS

Hospital quality and, in some cases, its relationship with efficiency differs depending on aggregations.

CONCLUSIONS

Patient risk adjustment should be conducted using more than one aggregation level whenever possible.

Better informing decision making with multiple outcomes cost-effectiveness analysis under uncertainty in cost-disutility space

INTRODUCTION

Comparing multiple, diverse outcomes with cost-effectiveness analysis (CEA) is important, yet challenging in areas like palliative care where domains are unamenable to integration with survival. Generic multi-attribute utility values exclude important domains and non-health outcomes, while partial analyses-where outcomes are considered separately, with their joint relationship under uncertainty ignored-lead to incorrect inference regarding preferred strategies.

OBJECTIVE

The objective of this paper is to consider whether such decision making can be better informed with alternative presentation and summary measures, extending methods previously shown to have advantages in multiple strategy comparison.

METHODS

Multiple outcomes CEA of a home-based palliative care model (PEACH) relative to usual care is undertaken in cost disutility (CDU) space and compared with analysis on the cost-effectiveness plane. Summary measures developed for comparing strategies across potential threshold values for multiple outcomes include: expected net loss (ENL) planes quantifying differences in expected net benefit; the ENL contour identifying preferred strategies minimising ENL and their expected value of perfect information; and cost-effectiveness acceptability planes showing probability of strategies minimising ENL.

RESULTS

Conventional analysis suggests PEACH is cost-effective when the threshold value per additional day at home (𝕜1) exceeds $1,068 or dominated by usual care when only the proportion of home deaths is considered. In contrast, neither alternative dominate in CDU space where cost and outcomes are jointly considered, with the optimal strategy depending on threshold values. For example, PEACH minimises ENL when 𝕜1=$2,000 and 𝕜2=$2,000 (threshold value for dying at home), with a 51.6% chance of PEACH being cost-effective.

CONCLUSION

Comparison in CDU space and associated summary measures have distinct advantages to multiple domain comparisons, aiding transparent and robust joint comparison of costs and multiple effects under uncertainty across potential threshold values for effect, better informing net benefit assessment and related reimbursement and research decisions.

Kinky thresholds revisited: opportunity costs differ in the NE and SW quadrants

Historically, a kinked threshold line on the cost-effectiveness plane at the origin was suggested due to differences in willingness to pay (WTP) for health gain with trade-offs in the north-east (NE) quadrant versus willingness to accept (WTA) cost reductions for health loss with trade-offs in the south-west (SW) quadrant. Empirically, WTA is greater than WTP for equivalent units of health, a finding supported by loss aversion under prospect theory. More recently, appropriate threshold values for health effects have been shown to require an endogenous consideration of the opportunity cost of alternative actions in budget-constrained health systems, but also allocative and displacement inefficiency observed in health system practice. Allocative and displacement inefficiency arise in health systems where the least cost-effective program in contraction has a higher incremental cost-effectiveness ratio (ICER = m) than the most cost-effective program in expansion (ICER = n) and displaced services (ICER = d), respectively. The health shadow price derived by Pekarsky, [Formula: see text] reflects the opportunity cost of best alternative adoption and financing actions in reimbursing new technology with expected incremental costs and net effect allowing for allocative (n < m), and displacement, inefficiency (d < m). This provides an appropriate threshold value for the NE quadrant. In this paper, I show that for trade-offs in the SW quadrant, where new strategies have lower expected net cost while lower expected net effect than current practice, the opportunity cost is contraction of the least cost-effective program, with threshold ICER m. That is, in the SW quadrant, the cost reduction per unit of decreased effect should be compared with the appropriate opportunity cost, best alternative generation of funding. Consequently, appropriate consideration of opportunity cost produces a kink in the threshold at the origin, with the health shadow price in the NE quadrant and ICER of the least cost-effective program in contraction (m) in the SW quadrant having the same general shape as that previously suggested by WTP versus WTA. The extent of this kink depends on the degree of allocative and displacement inefficiency, with no kink in the threshold line strictly only appropriate with complete allocative and displacement efficiency, that is n = d = m.

Can the real opportunity cost stand up: displaced services, the straw man outside the room

In current literature, displaced services have been suggested to provide a basis for determining a threshold value for the effects of a new technology as part of a reimbursement process when budgets are fixed. We critically examine the conditions under which displaced services would represent an economically meaningful threshold value. We first show that if we assume that the least cost-effective services are displaced to finance a new technology, then the incremental cost-effectiveness ratio (ICER) of the displaced services (d) only coincides with that related to the opportunity cost of adopting that new technology, the ICER of the most cost-effective service in expansion (n), under highly restrictive conditions-namely, complete allocative efficiency in existing provision of health care interventions. More generally, reimbursement of new technology with a fixed budget comprises two actions; adoption and financing through displacement and the effect of reimbursement is the net effect of these two actions. In order for the reimbursement process to be a pathway to allocative efficiency within a fixed budget, the net effect of the strategy of reimbursement is compared with the most cost-effective alternative strategy for reimbursement: optimal reallocation, the health gain maximizing expansion of existing services financed by the health loss minimizing contraction. The shadow price of the health effects of a new technology, βc = (1/n + 1/d - 1/m)(-1), accounts for both imperfect displacement (the ICER of the displaced service, d < m, the ICER of the least cost-effective of the existing services in contraction) and the allocative inefficiency (n < m) characteristic of health systems.