The policy context

Test-retest reliability of the EQ-5D-5L and the reworded QOLIBRI-OS in the general population of Italy, the Netherlands, and the United Kingdom

PURPOSE

To assess the test-retest reliability of the EQ-5D-5L and the reworded Quality of Life After Traumatic Brain Injury Overall Scale (QOLIBRI-OS) for the general population of Italy, the Netherlands, and the United Kingdom (UK).

METHODS

The sample contains 1864 members of the general population (aged 18-75 years) of Italy, the Netherlands, and the UK who completed a web-based questionnaire at two consecutive time points. The survey included items on gender, age, level of education, occupational status, household annual income, chronic health status, and the EQ-5D-5L and reworded QOLIBRI-OS instrument. Test-retest reliability of the EQ-5D-5L dimensions, EQ-5D-5L summary index, EQ VAS, reworded QOLIBRI-OS dimensions and reworded QOLIBRI-OS level sum score was examined by Gwet's Agreement Coefficient (Gwet's AC) and Intraclass Correlation Coefficient (ICC).

RESULTS

Gwet's AC ranged from 0.64 to 0.97 for EQ-5D-5L dimensions. The ICC ranged from 0.73 to 0.84 for the EQ-5D-5L summary index and 0.61 to 0.68 for EQ VAS in the three countries. Gwet's AC ranged from 0.35 to 0.55 for reworded QOLIBRI-OS dimensions in the three countries. The ICC ranged from 0.69 to 0.77 for reworded QOLIBRI-OS level sum score.

CONCLUSION

Test-retest reliability of the EQ-5D-5L administered via a web-based questionnaire was substantial to almost perfect for the EQ-5D-5L dimensions, good for EQ-5D-5L summary index, and moderate for the EQ VAS. However, test-retest reliability was less satisfactory for the reworded QOLIBRI-OS. This indicates that the web-based EQ-5D-5L is a reliable instrument for the general population, but further research of the reworded QOLIBRI-OS is required.

Fit for purpose? Introducing a rational priority setting approach into a community care setting

Purpose - Program budgeting and marginal analysis (PBMA) is a priority setting approach that assists decision makers with allocating resources. Previous PBMA work establishes its efficacy and indicates that contextual factors complicate priority setting, which can hamper PBMA effectiveness. The purpose of this paper is to gain qualitative insight into PBMA effectiveness. Design/methodology/approach - A Canadian case study of PBMA implementation. Data consist of decision-maker interviews pre (n=20), post year-1 (n=12) and post year-2 (n=9) of PBMA to examine perceptions of baseline priority setting practice vis-à-vis desired practice, and perceptions of PBMA usability and acceptability. Findings - Fit emerged as a key theme in determining PBMA effectiveness. Fit herein refers to being of suitable quality and form to meet the intended purposes and needs of the end-users, and includes desirability, acceptability, and usability dimensions. Results confirm decision-maker desire for rational approaches like PBMA. However, most participants indicated that the timing of the exercise and the form in which PBMA was applied were not well-suited for this case study. Participant acceptance of and buy-in to PBMA changed during the study: a leadership change, limited organizational commitment, and concerns with organizational capacity were key barriers to PBMA adoption and thereby effectiveness. Practical implications - These findings suggest that a potential way-forward includes adding a contextual readiness/capacity assessment stage to PBMA, recognizing organizational complexity, and considering incremental adoption of PBMA's approach. Originality/value - These insights help us to better understand and work with priority setting conditions to advance evidence-informed decision making.

The pharmacoeconomics of pneumococcal conjugate vaccines in Latin America

Streptococcus pneumoniae continues to be the most important causative agent of invasive bacterial infections in children and is the most common cause of vaccine-preventable deaths in children less than 5 years of age. Due to some conditions in the Latin America region, economic assessments of pneumococcal conjugate vaccines (PCVs) have unique characteristics. First, distribution of S. pneumoniae serotypes, and thus coverage by vaccines that incorporate certain serotypes, varies within the region and compared with other parts of the world. Second, the mortality rate of pneumococcal infections in developing countries is significantly higher than in the US and Europe. Third, the economies of the Latin American region are very different from those of developed countries. For these reasons, the Pan American Health Organization (PAHO) is promoting the need for economic valuation studies of the impact of pneumococcal vaccines Latin America. Given the importance of pneumonia in the burden of pneumococcal disease in Latin America, the number of pneumonia cases prevented by the vaccine has a large impact on the economic valuation of PCVs, due to a strong correlation with numbers of deaths averted, quality-adjusted life-years (QALYs) gained or disability-adjusted life-years (DALYs) avoided. In terms of cost, analysis of impact on acute otitis media (short-term) and sequelae (long-term) show a significant and important expenditure avoided by vaccination. Cost-effectiveness is significantly modified by vaccine cost, mortality due to pneumonia, vaccine efficacy/effectiveness and herd immunity. Finally the validity of certain assumptions based on the uncertainty of the data should be considered in economic assessments of new PCVs. These include assumptions related to the impact on otitis media, estimates of efficacy/effectiveness based on measured antibody levels and the extrapolation to PCV10 and PCV13 of previous experience with PCV7.

The problem with health measurement

In this review we discuss health measurement with a focus on psychometric methods and methodology. In particular, we examine some of the key issues currently facing the use of clinician and patient rating scales to measure the health outcomes of disease and treatment. We present three key facts and flag one crucial problem. First, the numbers generated by scales are increasingly used as the measurements of the central dependent variables upon which clinical decisions are frequently made. The rising profile of rating scales has significant implications for scale construction, evaluation, and selection, as well as for interpreting studies. Second, rating scale science is well established. Therefore, it is important to learn the lessons from those who have built and established the science over the last century. Finally, the goal of a rating scale is to measure. As such, over the last half century, developments in rating scale (psychometric) methods have caused a refocus in the way we should be measuring health. In particular, newer methods have significant clinical advantages over traditional approaches. These should be seriously considered for inclusion in everyday practice. This leads us to the central problem with health measurement, which is that we cannot currently be sure what most rating scales are measuring. This is because the methods we have in place to ensure the validity of rating scales fall short of what is actually required. We expand on this point, and provide some potential routes forward to help address this important problem.

The science behind quality-of-life measurement: a primer for plastic surgeons

Plastic surgeons perform a wide range of surgical procedures that have diverse clinical goals and complex effects on patients' lives. In recent years, quality-of-life outcomes have become increasingly important to clinical practice and plastic surgery research. It is important, therefore, that plastic surgeons understand the scientific issues surrounding the appropriate development and use of questionnaires that measure quality of life; they may then directly shape how new measures are developed and used, and define the future of outcome measurement in plastic surgery.

Addressing efficiency: economic evaluation and the agenda for CAM researchers

Considerations of efficiency are increasingly part of the broad agenda for evidence-based practice in conventional medicine. The findings of applied economic evaluations are often combined with other forms of evidence to assist clinical and wider resource decisions. It follows that as complementary and alternative medicine (CAM) strives for further integration into conventional health services, it might also be subjected to such scrutiny. In preparation for this, this paper provides a basic yet critical introduction to applied economic evaluation; the types of techniques used, their broad strengths and weaknesses, related ethical and moral debate and, in particular, specific issues concerning their application to CAM. Readers will decide for themselves whether they might be supportive of, or opposed to, economic evaluation and under what circumstances. Nevertheless, a wide-ranging agenda for research on economic evaluation and CAM is presented and some basic methodological and design issues--including place specificities and sensitivities--are highlighted.

Cost-utility analysis of vagus nerve stimulators for adults with medically refractory epilepsy

INTRODUCTION

The cost-utility of vagus nerve stimulator (VNS) devices for medically refractory epilepsy has yet to be estimated.

METHODS

Using a meta-analysis of randomised controlled trials of VNS, we estimate that six people require implantation in order for one person to experience a 50% reduction in seizure frequency. Costs averted from improved epilepsy control were ascertained from published literature. Values for health states were obtained from a series of 42 seizure clinic attenders using time trade-off techniques and the EQ-5D health status instrument. The cost per quality adjusted life year gained was estimated and the values obtained were tested in a sensitivity analysis.

RESULTS

Improved epilepsy control averted, on average, 745 pounds sterling health care costs per annum. People with epilepsy had great difficulty performing the time trade-off experiment, but those who managed to complete the task valued a 50% reduction in their own seizure frequency at 0.285 units. For a programme of six implants, the baseline model estimated the cost per quality adjusted life year gained at 28,849 pounds sterling. The most favourable estimate was equal to 4785 pounds sterling per quality adjusted life year gained, assuming that the number needed to treat was similar to published series in which one response was obtained for every three implants. The least favourable estimate was equal to 63,000 pounds sterling per quality adjusted life year gained, when EQ-5D utility values were used. The cost per quality adjusted life year gained was not sensitive to changes in length of stay, nor complication rates, but was significantly influenced by cost of device and device battery life expectancy.

CONCLUSION

There is not a strong economic argument against a programme of VNS implantation, although care should be taken to try and identify and treat those most likely to benefit.

Setting priorities and allocating resources in health regions: lessons from a project evaluating program budgeting and marginal analysis (PBMA)

BACKGROUND

Program budgeting and marginal analysis (PBMA) is a framework for setting priorities in health care, used internationally over the last 25 years in Britain, Australia and New Zealand. However, the framework has undergone limited evaluation, and insight into how such evaluation should even take place is not found in the literature.

METHODS

Seven PBMA case studies were conducted in three Canadian health regions to examine the feasibility of applying the PBMA framework. Structured follow-up surveys with the users of the framework were carried out following the priority setting exercises.

RESULTS

The PBMA framework was feasibly implemented in three regionalized contexts and was generally viewed favorably by managers and clinicians who participated in the case studies. Numerous methodological lessons were learned and it was found that successful implementation hinges on organizational context. An empirically derived model describing PBMA is outlined and put forth as an evaluation framework for future exercises.

CONCLUSIONS

Comparisons to the health care management literature indicate that the derived PBMA model is a novel addition to this broader literature. Overall, managers in health organizations internationally would be well-served to consider PBMA to aid regional decision-making processes, but should do so with explicit consideration of the context in which such activity is to occur.

Economic evaluation of healthcare--is it important to us?

Economic evaluation is now an accepted method for the appraisal of healthcare programmes. Although it is used widely in medicine, its use in the field of dentistry is only just beginning to achieve popularity. Economic evaluation in dentistry is likely to become increasingly important in the future and this paper aims to introduce the basics of the technique as well as describing some of the dental settings in which it is currently being used.

Certified nurse-midwives' knowledge of reimbursement issues

A recent survey examined the impact of reimbursement policies and admitting privileges on the ability of certified nurse-midwives (CNMs) to practice and maintain an income. Many CNMs reported deficits in their knowledge about reimbursement issues. The responses to the survey indicated that service directors either do not view this information as important to their leadership role, have delegated their authority to someone else, or do not have authority over this information. Education program directors may need to examine their curricular content to determine if students are being provided adequate information to better value and understand this data.

Programme budgeting revisited: special reference to people with learning disabilities

The recent reorganization of community care in the UK removed many of the perverse incentives identified in the previous system. However, the organization of care for many people is still divided across several agencies in the public and independent sectors. As purchasing and providing agencies in both the National Health Service and local authority personal social services attempt to coordinate policy objectives and the means to achieve them, the total resources available and their allocation across different care groups and among people in the same care groups from a consistent focus of attention. The principles and practice of programme budgeting provide important lessons for planning and monitoring expenditure. This paper rehearses such principles in the specialized area of policies for people with learning disabilities and draws on the experience of mapping expenditure on relevant services in a survey over 10 local authorities in England.

Medical technology assessment and the role of economic evaluation in health care

The growth in health care expenditure over the last few decades has necessitated the introduction of priority setting and decision making based on the results of critical evaluation. Medical technology assessment (MTA) is a valuable tool to assist policy makers in controlling existing and new medical technologies. Medical technology assessment and the role of economic evaluation as part of MTA are described, and various techniques of economic evaluation are discussed.

Economics, public health and health care purchasing: reinventing the wheel?

In this paper, a framework for using economics in health care priority setting is outlined. This framework is known as programme budgeting and marginal analysis (PBMA). Programme budgeting involves an assessment of how health care resources are currently distributed amongst programmes and within programmes. Such data can be used along with other information on local needs to decide on the main areas of change in service delivery. As resources are fixed, areas of change requiring more resources will be funded from service reductions within the same programme or within another programme. Candidates for more resources should be compared with each other and with candidates for service reduction to determine whether and what changes should go ahead. This involves 'marginal analysis' of costs and benefits of the candidates. In the paper, the problems with implementing this approach are outlined and the contribution of the other papers in the volume described.

Marginal analysis in practice: an alternative to needs assessment for contracting health care

Prioritising health care services on the basis of total needs can lead to inefficient use of resources. A better option is to determine priorities by marginal analysis, which examines the effects of altering the existing balance of expenditure between health care programmes. Resources to support investment are released from disinvestments-that is, the strategy is resource neutral. Thus an increase in total health benefits is achieved independent of any gains that may result from increased spending on health. In 1989 the Welsh Health Planning Forum identified 10 health gain areas, outlining within each one where further investment was likely to produce health gains and where disinvestment might be considered. All Welsh districts then attempted, with varying degrees of success, to produce a resource neutral strategy. Mid Glamorgan further explored the possibility of using marginal analysis in producing its strategy and influencing its policy for contracting. Working groups for most health gain areas each proposed 10 programmes for investment and a further 10 for disinvestment, which were then evaluated by a core evaluation team. In the case of maternal and child health the team dropped 10 of the 20 proposals. The remainder were considered by the health authority, which dropped a further proposal. Nine of the original 20 proposals thus formally became policy for 1995.

Shopping for health: purchasing health services through contracts

The 1993 New Zealand health service reforms were based on the purported efficiencies of the purchaser/provider split. Purchasers are required to contract for services that will maintain, improve and restore the health of the populations they serve. The purchasing role, which requires the development of contracting skills as well as the setting of strategic directions and priorities, is new and as yet poorly developed. This paper describes the role of purchasing agents in setting priorities, the different approaches that are being taken to contracting for services and some of the problems that have arisen in the first year of contracting. It explores the trade-off that is evident between the potential for improving efficiency through contestable contracting and the need to minimise transaction costs associated with the contracting process. The purchasers' accountability to the public and the Minister is analysed in the broader political context of the purchasers' role in shaping a public health service and improving the health of the population.