Health economic decision-making: a comparison between UK and Spain

Towards a conceptual framework for the prevention of gambling-related harms: Findings from a scoping review

The global gambling sector has grown significantly over recent years due to liberal deregulation and digital transformation. Likewise, concerns around gambling-related harms-experienced by individuals, their families, their local communities or societies-have also developed, with growing calls that they should be addressed by a public health approach. A public health approach towards gambling-related harms requires a multifaceted strategy, comprising initiatives promoting health protection, harm minimization and health surveillance across different strata of society. However, there is little research exploring how a public health approach to gambling-related harms can learn from similar approaches to other potentially harmful but legal sectors such as the alcohol sector, the tobacco sector, and the high in fat, salt and sugar product sector. Therefore, this paper presents a conceptual framework that was developed following a scoping review of public health approaches towards the above sectors. Specifically, we synthesize strategies from each sector to develop an overarching set of public health goals and strategies which-when interlinked and incorporated with a socio-ecological model-can be deployed by a range of stakeholders, including academics and treatment providers, to minimise gambling-related harms. We demonstrate the significance of the conceptual framework by highlighting its use in mapping initiatives as well as unifying stakeholders towards the minimization of gambling-related harms, and the protection of communities and societies alike.

AOTMiT reimbursement recommendations compared to other HTA agencies

Our objective was to compare AOTMiT (Polish: Agencja Oceny Technologii Medycznych i Taryfikacji) recommendations to other HTA (Health Technology Assessment) agencies for newly registered drugs and new registration indications issued by the European Medicines Agency between 2014 and 2019. The study aims to assess the consistency and justifications of AOTMiT recommendations compared to that of other HTA agencies in 11 countries. A total of 2494 reimbursement recommendations published by 12 HTA agencies for 464 medicinal products and 525 indications were analyzed. Our analysis confirmed that the Polish AOTMiT agency seems to bear the closest resemblance to the corresponding HTA agencies from Canada (CADTH) and New Zealand (PHARMAC), when it comes to the outcome of HTA recommendations (positive or negative). Poland had a general scheme for justifying recommendations, similar to that of Ireland-four aspects (i.e., clinical efficacy, safety profile, cost-effectiveness, and impact on the payer's budget) are important for Poland when formulating the final decision. Compared to other countries, Poland shows a noticeably different pattern of justifying reimbursement recommendations, as revealed primarily in terms of budget impact and somewhat less so for cost-effectiveness rationales.

Reimbursement decision-making system in Poland systematically compared to other countries

Introduction: Our objective was to analyze and compare systematically and structurally reimbursement systems in Poland and other countries. Methods: The systems were selected based on recommendations issued by the Polish Agency for Health Technology Assessment and Tariffication (AHTAPol), which explicitly referred to other countries and agencies). Consequently, apart from Poland, the countries included in the analysis were England, Scotland, Wales, Ireland, France, Netherlands, Germany, Norway, Sweden, Canada, Australia and New Zealand. Relevant information and data were collected through a systematic search of PubMed (Medline), Embase and The Cochrane Library as well as competent authority websites and grey literature sources. Results and discussion: In most of the countries, the submission of a reimbursement application is initiated by a pharmaceutical company, and only a few countries allow it before a product is approved for marketing. All of the agencies analyzed are independent and some have regulatory function of reimbursement decision making body. A key criterion differentiating the various agencies in terms of HTA is the cost-effectiveness threshold. Most of the countries have specific mechanisms to improve access to expensive specialty drugs, including cancer drugs and those used for rare diseases. Reimbursement systems often lack consistency in appreciating the same stages, leading to heterogeneous decision-making processes. The analysis of recommendations issued in different countries for the same medicinal product will allow a better understanding of the relations between the reimbursement system, HTA assessment, stakeholders involvement and decision on reimbursement of innovative drugs.

Economic evaluations of electronic health interventions for people with age-related cognitive impairment and their caregivers: A systematic review

OBJECTS

Dementia has physical, social and economic impacts, causing considerable distress for people with age-related cognitive impairment (PWACI) and their caregivers. Electronic health (e-health) interventions can provide convenient education to improve the coping competence of caregivers and have become an important approach to supporting them. Understanding the economic evidence of e-health interventions will facilitate the decision making and implementation of integrating e-health into routine health services. The present review aimed to appraise economic evidence related to e-health interventions for PWACI and their caregivers.

METHODS

We systematically searched multiple cross-disciplinary databases from inception to February 28, 2023. Two reviewers independently selected the trials, assessed the quality, and checked the data. A descriptive-analytical narrative method was used to analyze the review findings.

RESULTS

Thirteen studies were analyzed, including 12 randomized controlled trials and one quasi-experimental study. All included studies were conducted in developed countries. The included studies reported limited economic information. There were six cost-effectiveness analysis, five cost-consequence analysis and one partial economic evaluation. The included studies were heterogeneous, and varied in quality. The results demonstrated that e-health multicomponent interventions can reduce the cost of health service utilization in short term (10-104 weeks).

CONCLUSIONS

Few studies calculated the incremental cost-effectiveness ratio to evaluate the cost-effectiveness of e-health interventions. Preliminary evidence indicates that e-health interventions can reduce the cost of health service utilization in the short term, but the cost-effectiveness of e-health interventions hasn't been identified. More robust evidence is needed to clarify the value of e-health interventions for PWACI and their caregivers.

Commissioning [Integrated] Care in England: An Analysis of the Current Decision Context

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Valuing the AD-5D Dementia Utility Instrument: An Estimation of a General Population Tariff

OBJECTIVE

This paper reports on the valuation of quality-of-life states in the Alzheimer's Disease Five Dimensions (AD-5D) instrument in a representative sample of the general population in Australia using the discrete-choice experiment with duration (DCE_TTO) elicitation technique.

METHOD

A DCE with 200 choice sets of two quality-of-life (QoL) state-duration combinations blocked into 20 survey versions, with ten choice sets in each version, was designed and administered online to a sample representative of the Australian population. Two additional choice sets comprising internal consistency and dominance checks were included in each survey version. A range of model specifications investigating preferences with respect to duration and interactions between AD-5D dimension levels were estimated. Utility weights were developed, with estimated coefficients transformed to the 0 (being dead) to 1 (full health) scale, suitable for the calculation of quality-adjusted life-year (QALY) weights for use in economic evaluation.

RESULTS

In total, 1999 respondents completed the choice experiment. Overall, respondents were slightly better educated and had higher annual incomes than the Australian general population. The estimation results from different specifications and models were broadly consistent with the monotonic nature of the AD-5D: utility increased with increased life expectancy and decreased as the severity level for each dimension worsened. A utility value set was generated for the calculation of utilities for all QoL states defined by the AD-5D descriptive system.

CONCLUSION

The DCE-based utility value set is now available to use to generate QALYs for the economic evaluation of treatments and interventions targeting people with dementia and/or their family caregivers.

Does the use of health technology assessment have an impact on the utilisation of health care resources? Evidence from two European countries

OBJECTIVES

A centralised approach to health technology assessment (HTA) may facilitate optimal use of HTA resources. A regional approach may increase the chances of local implementation of recommendations. This study aimed to compare assessment procedures in England (centralised HTA approach) with Spain (regional HTA approach) discussing key challenges and opportunities from both approaches.

METHODS

We compared technology assessments of anticancer medicines in the two jurisdictions from 2008 to 2015. To assess the implementation of HTA recommendations, we assessed trends in medicine usage using regression methods. We used IQVIA data, from 2011 to 2016, for a sample of 11 medicines. We used CatSalut data from Catalonia to assess the implementation of local recommendations.

RESULTS

In England, 66 assessments were undertaken by the National Institute for Health and Care Excellence (NICE), using a standardised methodology. In Spain, there were 79 reports undertaken by a range of bodies using a shared process and coordinated through the GENESIS collaboration; the assessment methods used varied substantially. Overall, the recommendations in the two jurisdictions were similar. Regression analyses indicate that where there is a positive recommendation by HTA bodies, the usage of the medicine responds most strongly (p < 0.001) in Catalonia (4.892), followed by England (3.120) and Spain (1.693).

CONCLUSIONS

This study suggests that medicine utilisation does respond to the positive recommendations of HTA bodies. However, if HTA capacity is organised primarily regionally, considerable effort may be required in coordination, to ensure consistent and rigorous assessments and adequate implementation of HTA findings.

Economic Evaluation for Pricing and Reimbursement of New Drugs in Spain: Fable or Desideratum?

BACKGROUND

The economic evaluation of healthcare technologies has become in many countries a basic tool for reimbursement, pricing and purchasing decisions.

OBJECTIVE

The objective of this article is to examine the institutional, legal, and political factors that have impeded the application of economic evaluation and the criterion of efficiency in the process of pricing and reimbursement of new medicines in Spain.

METHODS

Narrative description of the current institutional framework for the use of economic evaluation in pricing and reimbursement in Spain, legal and policy framework in the field of evaluation of new medicines, and stakeholder initiatives and policies related to the use of economic evaluation outside of the pricing and reimbursement process.

RESULTS

Spain has an institutional framework created and established over the last years that could have facilitated a formal use of economic evaluation in the process of pricing and reimbursement. Nevertheless, the real use of economic evaluation at the central or regional level is still unknown, although application of the efficiency criterion, linking to cost-effectiveness, has been clearly required by Spanish laws and regulations at the national level. We highlight a certain degree of moral hazard from the central government that is not directly responsible for the budget impact of reimbursement and pricing decisions. There are currently a number of ongoing initiatives in the field of economic evaluation by various agents, but they remain uncoordinated.

CONCLUSIONS

Poor governance at the highest level of decision making is the main reason for the lack of interest in economic evaluation. A profound political change, supported by transparency and accountability, is required before the criterion of efficiency can be fully considered in the process of pricing and reimbursement of new medicines in Spain.

Economic evaluations in community aged care: a systematic review

Background

This paper reports the methods and findings from a systematic review of economic evaluations conducted in the community aged care sector between 2000 and 2016.

Methods

Online databases searched were PubMed, Medline, Scopus, and web of science, CINAHL and informit. Studies were included if they 1) were full economic evaluations that compared both the costs and outcomes of two or more interventions 2) in study population of people aged 65 years and over 3) dependent older people living in the community 4) alternatives being compared were care models or service delivery interventions in the community aged care sector (a group of programs that have been established as a support system to allow older people to remain living in their own homes for as long as possible, as an alternative to institutional or residential care) and 5) published in the English language between 2000 and November 2016.

Results

Eleven studies reporting upon economic evaluations of service delivery interventions in community aged care were identified; the majority of which were undertaken in Europe. Critical appraisal of the identified studies highlighted the methodological rigour in these evaluations.

Conclusion

This systematic review highlights the paucity of economic evaluation studies conducted to date in the community aged care sector. The findings highlight the importance of cost utility analysis methodology as it allows for a uniform outcome measure, that facilitates the comparison of different interventions. In addition, multi-attribute utility measures that represent those quality of life domains that are most important to older people should be used and attention must be paid to the inclusion of informal care costs and outcomes as this is a key resource in community aged care service delivery.

New insights into the burden and costs of multiple sclerosis in Europe: Results for Spain

INTRODUCTION

In order to estimate the value of interventions in multiple sclerosis (MS) where lifetime costs and outcomes cannot be observed, outcome data have to be combined with costs. This requires that cost data be regularly updated.

OBJECTIVES AND METHODS

This study is part of a cross-sectional retrospective study in 16 countries collecting data on resource consumption, work capacity, health-related quality of life (HRQoL) and prevalent symptoms for patients with MS. Descriptive analyses are presented by level of severity, from the societal perspective, in EUR 2015.

RESULTS

A total of 462 patients (mean age 43 years) participated in Spain; 96% were below retirement age and of these, 45% were employed. Employment was related to disability, and MS affected productivity at work for 72% of those working. Overall, 92% and 64% of patients experienced fatigue and cognitive difficulties as a problem, respectively. Mean utility and total annual costs were estimated at 0.772 and €20,600 at Expanded Disability Status Scale (EDSS) 0-3, 0.486 and €48,500 at EDSS 4-6.5 and 0.182 and €68,700 at EDSS 7-9, respectively. The mean cost of a relapse was €2050.

CONCLUSION

This study illustrates the burden of MS on Spanish patients and provides current data that are important for development of health policies.

Emotions and scope effects in the monetary valuation of health

This study presents evidence on the role of emotions in the monetary evaluation of health technologies, namely, drug-eluting stents (DES) in our case. It is shown that subjects who are very afraid of having to undergo an angioplasty are: (a) less sensitive to the size of the risk reduction provided by DES and (b) willing to pay more. The lack of scope sensitivity questions the normative validity of the responses of highly emotional subjects. We provide evidence of this effect using what we call the cognitive-emotional random utility model and the responses of a face-to-face, computer-assisted personal interview survey conducted in a representative sample of the Spanish general population (n = 1663).

Using health technology assessment to assess the value of new medicines: results of a systematic review and expert consultation across eight European countries

BACKGROUND

Although health technology assessment (HTA) systems base their decision making process either on economic evaluations or comparative clinical benefit assessment, a central aim of recent approaches to value measurement, including value based assessment and pricing, points towards the incorporation of supplementary evidence and criteria that capture additional dimensions of value.

OBJECTIVE

To study the practices, processes and policies of value-assessment for new medicines across eight European countries and the role of HTA beyond economic evaluation and clinical benefit assessment.

METHODS

A systematic (peer review and grey) literature review was conducted using an analytical framework examining: (1) 'Responsibilities and structure of HTA agencies'; (2) 'Evidence and evaluation criteria considered in HTAs'; (3) 'Methods and techniques applied in HTAs'; and (4) 'Outcomes and implementation of HTAs'. Study countries were France, Germany, England, Sweden, Italy, Netherlands, Poland and Spain. Evidence from the literature was validated and updated through two rounds of feedback involving primary data collection from national experts.

RESULTS

All countries assess similar types of evidence; however, the specific criteria/endpoints used, their level of provision and requirement, and the way they are incorporated (e.g. explicitly vs. implicitly) varies across countries, with their relative importance remaining generally unknown. Incorporation of additional 'social value judgements' (beyond clinical benefit assessment) and economic evaluation could help explain heterogeneity in coverage recommendations and decision-making.

CONCLUSION

More comprehensive and systematic assessment procedures characterised by increased transparency, in terms of selection of evaluation criteria, their importance and intensity of use, could lead to more rational evidence-based decision-making, possibly improving efficiency in resource allocation, while also raising public confidence and fairness.

A review of cost-effectiveness evaluations as part of national health technology assessments of biologic DMARDs in the treatment of rheumatoid arthritis

Rheumatoid arthritis (RA) is an autoimmune chronic disease which is associated with an increasing disability in patients and high socioeconomic burden. Given the large number of economic evaluations considered by national health technology assessments (HTAs), this review attempts to clarify whether results from biologic disease-modifying antirheumatic drugs (DMARDs) economic evaluations form the basis of official recommendation by national HTA agencies in Australia, Canada, Scotland and England. The results show that evidence of cost-effectiveness was not equally perceived by decision makers and did not have equal weightage in defining the official listing of biologic DMARDs for the treatment of RA. As it has been demonstrated in previous studies, major barriers exist for the integration of cost-effectiveness and cost-utility results with national HTA activity. In fact, as shown in this review, even when such analysis are available, cost-minimization and comparative effectiveness studies seemed to be preferred by some HTA agencies as tools to inform allocation of healthcare resources.