1
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Kopka CJ, Pugliese N, Brennan PN, Lazarus JV. We must address the MASLD awareness gap, improve educational quality and prepare for the digitally quantified self. Liver Int 2024; 44:2099-2101. [PMID: 39205464 DOI: 10.1111/liv.15951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/08/2024] [Accepted: 04/12/2024] [Indexed: 09/04/2024]
Affiliation(s)
- Christopher J Kopka
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Nicola Pugliese
- Division of Internal Medicine and Hepatology, Department of Gastroenterology, IRCCS Humanitas Research Hospital, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Paul N Brennan
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
- NHS Tayside, Ninewells Hospital and Medical School, Dundee, UK
- The Global NASH Council, Washington, DC, USA
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
- The Global NASH Council, Washington, DC, USA
- City University of New York Graduate School of Public Health and Health Policy (CUNY SPH), New York, New York, USA
- Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
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2
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Ammi M, Arpin E, Dedewanou FA, Allin S. Do expenditures on public health reduce preventable mortality in the long run? Evidence from the Canadian provinces. Soc Sci Med 2024; 345:116696. [PMID: 38377835 DOI: 10.1016/j.socscimed.2024.116696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 01/19/2024] [Accepted: 02/13/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND Investments in public health - prevention of illnesses, and promotion, surveillance, and protection of population health - may improve population health, however, effects may only be observed over a long period of time. OBJECTIVE To investigate the potential long-run relationship between expenditures on public health and avoidable mortality from preventable causes. METHODS We focused on the country spending the most on public health in the OECD, Canada. We constructed a longitudinal dataset on mortality, health care expenditures and socio-demographic information covering years 1979-2017 for the ten Canadian provinces. We estimated error correction models for panel data to disentangle short-from long-run relationships between expenditures on public health and avoidable mortality from preventable causes. We further explored some specific causes of mortality to understand potential drivers. For comparison, we also estimated the short-run relationship between curative expenditures and avoidable mortality from treatable causes. RESULTS We find evidence of a long-run relationship between expenditures on public health and preventable mortality, and no consistent short-run associations between these two variables. Findings suggest that a 1% increase in expenditures on public health could lead to 0.22% decrease in preventable mortality. Reductions in preventable mortality are greater for males (-0.29%) compared to females (-0.09%). These results are robust to different specifications. Reductions in some cancer and cardiovascular deaths are among the probable drivers of this overall decrease. By contrast, we do not find evidence of a consistent short-run relationship between curative expenditures and treatable mortality, except for males. CONCLUSION This study supports the argument that expenditures on public health reap health benefits primarily in the long run, which, in this case, represents a reduction in avoidable mortality from preventable causes. Reducing public health expenditures on the premise that they have no immediate measurable benefits might thus harm population health outcomes in the long run.
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Affiliation(s)
- Mehdi Ammi
- School of Public Policy and Administration, Carleton University, Richcraft Hall, 1125 Colonel By Dr, Ottawa, ON, K1S 5B6, Canada; Centre for the Business and Economics of Health, University of Queensland, Sir Llew Edwards Building, St Lucia, QLD, 4072, Australia.
| | - Emmanuelle Arpin
- Institute of Health Policy Management and Evaluation, University of Toronto, 155 College St 4th Floor, Toronto, ON, M5T 3M6, Canada
| | - F Antoine Dedewanou
- School of Public Policy and Administration, Carleton University, Richcraft Hall, 1125 Colonel By Dr, Ottawa, ON, K1S 5B6, Canada
| | - Sara Allin
- Institute of Health Policy Management and Evaluation, University of Toronto, 155 College St 4th Floor, Toronto, ON, M5T 3M6, Canada
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3
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Gloria MAJ, Thavorncharoensap M, Chaikledkaew U, Youngkong S, Thakkinstian A, Chaiyakunapruk N, Ochalek J, Culyer AJ. Systematic review of the impact of health care expenditure on health outcome measures: implications for cost-effectiveness thresholds. Expert Rev Pharmacoecon Outcomes Res 2024; 24:203-215. [PMID: 38112068 DOI: 10.1080/14737167.2023.2296562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/14/2023] [Indexed: 12/20/2023]
Abstract
OBJECTIVE Empirical estimates of the impact of healthcare expenditure on health outcome measures may inform the cost-effectiveness threshold (CET) for guiding funding decisions. This study aims to systematically review studies that estimated this, summarize and compare the estimates by country income level. METHODS We searched PubMed, Scopus, York Research database, and [anonymized] for Reviews and Dissemination database from inception to 1 August 2023. For inclusion, a study had to be an original article, estimating the impact of healthcare expenditure on health outcome measures at a country level, and presented estimates, in terms of cost per quality-adjusted life year (QALY) or disability-adjusted life year (DALY). RESULTS We included 18 studies with 385 estimates. The median (range) estimates were PPP$ 11,224 (PPP$ 223 - PPP$ 288,816) per QALY gained and PPP$ 5,963 (PPP$ 71 - PPP$ 165,629) per DALY averted. As ratios of Gross Domestic Product per capita (GDPPC), these estimates were 0.376 (0.041-182.840) and 0.318 (0.004-37.315) times of GDPPC, respectively. CONCLUSIONS The commonly used CET of GDPPC seems to be too high for all countries, but especially low-to-middle-income countries where the potential health losses from misallocation of the same money are greater. REGISTRATION The review protocol was published and registered in PROSPERO (CRD42020147276).
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Affiliation(s)
- Mac Ardy Junio Gloria
- Mahidol University Health Technology Assessment Graduate Program, Mahidol University, Bangkok, Thailand
- Department of Clinical, Social and Administrative Pharmacy, College of Pharmacy, University of the Philippines Manila, Manila, Philippines
| | - Montarat Thavorncharoensap
- Mahidol University Health Technology Assessment Graduate Program, Mahidol University, Bangkok, Thailand
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Usa Chaikledkaew
- Mahidol University Health Technology Assessment Graduate Program, Mahidol University, Bangkok, Thailand
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Sitaporn Youngkong
- Mahidol University Health Technology Assessment Graduate Program, Mahidol University, Bangkok, Thailand
- Social and Administrative Pharmacy Division, Department of Pharmacy, Faculty of Pharmacy, Mahidol University, Bangkok, Thailand
| | - Ammarin Thakkinstian
- Mahidol University Health Technology Assessment Graduate Program, Mahidol University, Bangkok, Thailand
- Department of Clinical Epidemiology and Biostatistics, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT, USA
- IDEAS Center, Veterans Affairs Salt Lake City Healthcare System, Salt Lake City, UT, USA
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4
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Al-Janabi H, Williams I, Powell M. Is the NHS underfunded? Three approaches to answering the question. J R Soc Med 2023; 116:409-412. [PMID: 38059823 PMCID: PMC10850869 DOI: 10.1177/01410768231214340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023] Open
Affiliation(s)
- Hareth Al-Janabi
- Health Economics Unit, Institute of Applied Health Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Iestyn Williams
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham B15 2TT, UK
| | - Martin Powell
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham B15 2TT, UK
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5
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Gibson E, Ollendorf DA, Simoens S, Bloom DE, Martinón-Torres F, Salisbury D, Severens JL, Toumi M, Molnar D, Meszaros K, Sohn WY, Begum N. Rule of Prevention: a potential framework to evaluate preventive interventions for rare diseases. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2023; 11:2239557. [PMID: 37583879 PMCID: PMC10424616 DOI: 10.1080/20016689.2023.2239557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 06/19/2023] [Accepted: 07/18/2023] [Indexed: 08/17/2023]
Abstract
Background: The benefits of preventive interventions lack comprehensive evaluation in standard health technology assessments (HTA), particularly for rare and transmissible diseases. Objective: To identify possible considerations for future HTA using analogies between the treatment and prevention of rare diseases. Study design: An Expert panel meeting assessed whether one HTA assessment framework can be applied to assess both rare disease treatments and preventive interventions. Experts also evaluated the range of value elements currently included in HTAs and their applicability to rare, transmissible, and/or preventable diseases. Results: A broad range of value should be considered when assessing rare, transmissible disease prevention. Although standard HTA can be applied to transmissible diseases, the risk of local outbreaks and the need for large-scale prevention programs suggest a modified assessment framework, capable of incorporating prevention-specific value elements in HTAs. A 'Rule of Prevention' framework was proposed to allow broader value considerations anchored to severity, equity, and prevention benefits in decision-making for preventive interventions for rare transmissible diseases. Conclusion: The proposed prevention framework introduces an explicit initial approach to consistently assess rare transmissible diseases, and to incorporate the broader value of preventive interventions compared with treatment.
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Affiliation(s)
| | - Daniel A. Ollendorf
- Institute for Clinical Research and Health Policy Studies (ICRHPS), Center for the Evaluation of Value and Risk in Health (CEVR), Tufts Medical Center, Boston, MA, USA
| | - Steven Simoens
- Clinical Pharmacology and Pharmacotherapy, KU Leuven, Leuven, Belgium
| | - David E Bloom
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Federico Martinón-Torres
- Department of Pediatrics, Translational Pediatrics and Infectious Diseases, Pediatrics Department, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
- Genetics, Vaccines and Infections Research Group (GENVIP), Instituto de Investigación Sanitaria de Santiago, University of Santiago, Santiago de Compostela, Spain
- Centro de Investigación Biomédica En Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España
| | - David Salisbury
- Royal Institute of International Affairs, Chatham House, London, UK
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6
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Rae M. Public health cuts hit the poorest hardest. BMJ 2022; 379:o2706. [PMID: 36368724 DOI: 10.1136/bmj.o2706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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7
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Stokes J, Bower P, Guthrie B, Mercer SW, Rice N, Ryan AM, Sutton M. Cuts to local government spending, multimorbidity and health-related quality of life: A longitudinal ecological study in England. THE LANCET REGIONAL HEALTH. EUROPE 2022; 19:100436. [PMID: 36039277 PMCID: PMC9417904 DOI: 10.1016/j.lanepe.2022.100436] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Population health has stagnated or is declining in many high-income countries. We analysed whether nationally administered austerity cuts in England were associated with prevalence of multimorbidity (individuals with two or more long-term conditions) and health-related quality of life. METHODS We conducted an observational, longitudinal study on 147 local authorities in England. We examined associations of changes in spending over time (2009/10-2017/18), in total and by budget line, with (i) prevalence of multimorbidity, 2+ conditions (2011/12-2017/18), and (ii) health-related quality of life (EQ-5D-5L) score (2012/13-2016/17). We estimated linear, log-log regression models, incorporating local authority fixed-effects, time-varying demographic and socio-economic confounders, and time trends. FINDINGS All local authorities experienced real spending cuts, varying from 42% (Barking and Dagenham) to 0·3% (Sefton). A 1% cut in per capita total service expenditure was associated with a 0·10% (95% CI 0·03 to 0·16) increase in prevalence of multimorbidity. We found no association (0·003%; 95% CI -0·01 to 0·01) with health-related quality of life. By budget line, after controlling for other spending, a 1% cut in public health expenditure was associated with a 0·15% (95% CI 0·11 to 0·20) increase in prevalence of multimorbidity, and a 1% cut in adult social care expenditure was associated with a 0·01% (95% CI 0·002 to 0·02) decrease in average health-related quality of life. INTERPRETATION Fiscal austerity is associated with worse multimorbidity and health-related quality of life. Policymakers should consider the potential health consequences of local government expenditure cuts and knock-on effects for health systems. FUNDING Medical Research Council.
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Affiliation(s)
- Jonathan Stokes
- Centre for Primary Care & Health Services Research, University of Manchester, Oxford Road, Manchester M13 9PL, England
| | - Peter Bower
- Centre for Primary Care & Health Services Research, University of Manchester, Oxford Road, Manchester M13 9PL, England
| | - Bruce Guthrie
- Usher Institute of Population Health Sciences and Informatics, Old Medical School, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, Scotland
| | - Stewart W. Mercer
- Usher Institute of Population Health Sciences and Informatics, Old Medical School, University of Edinburgh, Teviot Place, Edinburgh EH8 9AG, Scotland
| | - Nigel Rice
- Department of Economics and Related Studies and Centre for Health Economics, University of York, Heslington, York YO10 5DD, England
| | - Andrew M. Ryan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Matt Sutton
- Centre for Primary Care & Health Services Research, University of Manchester, Oxford Road, Manchester M13 9PL, England
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8
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Yu HB, Han BJ, Cao HJ. Prevention of Radiodermatitis With Topical Chinese Herbal Medicine: A Systematic Review and Meta-Analysis. Front Pharmacol 2022; 13:819733. [PMID: 35814240 PMCID: PMC9257048 DOI: 10.3389/fphar.2022.819733] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 05/09/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives: Topical Chinese herbal medicine (TCHM) is widely used to prevent radiodermatitis in patients who receive radiation therapy in China. However, evidence regarding its efficacy remains limited. The purpose of the review is to evaluate the effects of TCHM in preventing radiodermatitis. Methods: The protocol of this review was registered in PROSPERO (CRD42020220620). Relevant clinical trials were identified (from January 1, 2010, to April 24, 2022) through 11 electronic databases, including PubMed, SpringerLink, Proquest, the Cochrane Central Register of Controlled Trials, Scopus, the ProQuest Dissertation & Theses Global, PsycINFO, Applied Social Sciences Index and Abstracts, the Chinese National Knowledge Infrastructure Databases, Wangfang Data Knowledge Service Platform, and the Chongqing VIP Chinese Science and Technology Periodical Database. The quality of the included trials was assessed through a risk of bias assessment using Version 2 of the Cochrane risk-of-bias tool (RoB 2.0). We included RCTs that compared TCHM single used or as adjunctive treatment with routine drugs, conventional therapy, or placebo for cancer patients who are about to start radiation therapy and do not possess any type of dermatitis or skin lesions at that time. Primary outcomes of interest were the incidence of radiodermatitis and the grade of radiodermatitis according to the RTOG (Radiation Therapy Oncology Group). Secondary outcomes included the recovery time of skin and mucosa, the occurrence time of radiodermatitis, the radiation dose, quality of life, and adverse events. Data were summarized using risk ratio (RR) calculations and 95% confidence intervals (CI) for binary outcomes or mean difference (MD) with 95% CI for continuous outcomes. Certainty of the evidence was assessed according to the GRADE criteria. Results: In this review, 38 randomized controlled trials (RCTs) were included. Risk of bias assessment through RoB 2.0 showed that two studies were rated as low risk, two studies were rated as high risk, and the rest were rated as having some concerns. Compared with routine drugs, TCHM may have an advantage in reducing RTOG grading (RR = 0.46, 95%CI 0.35–0.60), decreasing the recovery time of radiodermatitis (MD = −2.35, 95%CI 3.58 to −1.12 days), delaying the occurrence of radiodermatitis (MD = 2.36, 95%CI 1.74–2.98), and improving the quality of life of patients (RR = 1.46, 95%CI 1.03–2.06). Compared with conventional therapy, TCHM may also have an advantage in decreasing the grade of RTOG (RR = 0.28, 95%CI 0.21–0.38). Conclusion: Current low evidence revealed that TCHM may have better efficacy in the prevention of radiodermatitis; however, more high-quality RCTs are still warranted to testify this conclusion. Systematic Review Registration: (https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020220620), identifier (PROSPERO 2020 CRD42020220620).
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9
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May P, Normand C, Matthews S, Kenny RA, Romero-Ortuno R, Tysinger B. Projecting future health and service use among older people in Ireland: an overview of a dynamic microsimulation model in The Irish Longitudinal Study on Ageing (TILDA). HRB Open Res 2022; 5:21. [PMID: 36262382 PMCID: PMC9554695 DOI: 10.12688/hrbopenres.13525.2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2022] [Indexed: 10/14/2023] Open
Abstract
Background: Demographic ageing is a population health success story but poses unprecedented policy challenges in the 21st century. Policymakers must prepare health systems, economies and societies for these challenges. Policy choices can be usefully informed by models that evaluate outcomes and trade-offs in advance under different scenarios. Methods: We developed a dynamic demographic-economic microsimulation model for the population aged 50 and over in Ireland: the Irish Future Older Adults Model (IFOAM). Our principal dataset was The Irish Longitudinal Study on Ageing (TILDA). We employed first-order Markovian competing risks models to estimate transition probabilities of TILDA participants to different outcomes: diagnosis of serious diseases, functional limitations, risk-modifying behaviours, health care use and mortality. We combined transition probabilities with the characteristics of the stock population to estimate biennial changes in outcome state. Results: IFOAM projections estimated large annual increases in total deaths, in the number of people living and dying with serious illness and functional impairment, and in demand for hospital care between 2018 and 2040. The most important driver of these increases is the rising absolute number of older people in Ireland as the population ages. The increasing proportion of older old and oldest old citizens is projected to increase the average prevalence of chronic conditions and functional limitations. We deemed internal validity to be good but lacked external benchmarks for validation and corroboration of most outcomes. Conclusion: We have developed and validated a microsimulation model that projects health and related outcomes among older people in Ireland. Future research should address identified policy questions. The model enhances the capacity of researchers and policymakers to quantitatively forecast health and economic dynamics among older people in Ireland, to evaluate ex ante policy responses to these dynamics, and to collaborate internationally on global challenges associated with demographic ageing.
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Affiliation(s)
- Peter May
- Centre for Health Policy and Management, Trinity College Dublin, 3-4 Foster Place, Dublin, D2, Ireland
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Pearse Street, Dublin, D2, Ireland
| | - Charles Normand
- Centre for Health Policy and Management, Trinity College Dublin, 3-4 Foster Place, Dublin, D2, Ireland
- Cicely Saunders Institute, King's College London, Denmark Hill, London, SE1 1UL, UK
| | - Soraya Matthews
- Centre for Health Policy and Management, Trinity College Dublin, 3-4 Foster Place, Dublin, D2, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Pearse Street, Dublin, D2, Ireland
| | - Roman Romero-Ortuno
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Pearse Street, Dublin, D2, Ireland
- Global Brain Health Institute, Trinity College Dublin, Lloyd Institute, Dublin, D2, Ireland
| | - Bryan Tysinger
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, 90007, USA
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10
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Rae M, Carruthers J. The future of public health. Br J Hosp Med (Lond) 2022; 83:1-3. [DOI: 10.12968/hmed.2022.0228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article considers the strong public health response to the COVID-19 pandemic, while recognising that the system must be strengthened moving forwards. It provides an overview of the challenges facing public health today including widening social inequalities, increasingly squeezed health and social care budgets, changes to the public health landscape, and recovery from COVID-19.
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Affiliation(s)
| | - Jamie Carruthers
- Leicester Medical School, College of Life Sciences, University of Leicester, Leicester, UK
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11
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Skarda I, Asaria M, Cookson R. Evaluating childhood policy impacts on lifetime health, wellbeing and inequality: Lifecourse distributional economic evaluation. Soc Sci Med 2022; 302:114960. [PMID: 35477060 DOI: 10.1016/j.socscimed.2022.114960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 03/04/2022] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Abstract
We introduce and illustrate a new framework for distributional economic evaluation of childhood policies that takes a broad and long view of the impacts on health, wellbeing and inequality from a cross-sectoral whole-lifetime perspective. Total lifetime benefits and public cost savings are estimated using lifecourse microsimulation of diverse health, social and economic outcomes for each individual in a general population birth cohort from birth to death. Cost-effectiveness analysis, policy targeting analysis and distributional analysis of inequality impacts are then conducted using an index of lifetime wellbeing that allow comparisons of both value-for-money (efficiency) and distributional impact (equity) from a cross-sectoral lifetime perspective. We illustrate how this framework can be applied in practice by re-evaluating a training programme in England for parents of children at risk of conduct disorder. Our illustration uses a simple index of lifetime wellbeing based on health-related quality of life and consumption, but other indices could be used based on other kinds of outcomes data such as life satisfaction or multidimensional quality of life. We create the detailed underpinning data needed to apply the framework by using a previously published meta-analysis of randomised controlled trials to estimate the short-term effects and a previously published lifecourse microsimulation model to extrapolate the long-term effects.
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Affiliation(s)
- Ieva Skarda
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK.
| | - Miqdad Asaria
- Department of Health Policy, Cowdray House, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK
| | - Richard Cookson
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK
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12
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Sajid IM, Frost K, Paul AK. 'Diagnostic downshift': clinical and system consequences of extrapolating secondary care testing tactics to primary care. BMJ Evid Based Med 2022; 27:141-148. [PMID: 34099498 DOI: 10.1136/bmjebm-2020-111629] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/09/2021] [Indexed: 12/21/2022]
Abstract
Numerous drivers push specialist diagnostic approaches down to primary care ('diagnostic downshift'), intuitively welcomed by clinicians and patients. However, primary care's different population and processes result in under-recognised, unintended consequences. Testing performs poorer in primary care, with indication creep due to earlier, more undifferentiated presentation and reduced accuracy due to spectrum bias and the 'false-positive paradox'. In low-prevalence settings, tests without near-100% specificity have their useful yield eclipsed by greater incidental or false-positive findings. Ensuing cascades and multiplier effects can generate clinician workload, patient anxiety, further low-value tests, referrals, treatments and a potentially nocebic population 'disease' burden of unclear benefit. Increased diagnostics earlier in pathways can burden patients and stretch general practice (GP) workloads, inducing downstream service utilisation and unintended 'market failure' effects. Evidence is tenuous for reducing secondary care referrals, providing patient reassurance or meaningfully improving clinical outcomes. Subsequently, inflated investment in per capita testing, at a lower level in a healthcare system, may deliver diminishing or even negative economic returns. Test cost poorly represents 'value', neglecting under-recognised downstream consequences, which must be balanced against therapeutic yield. With lower positive predictive values, more tests are required per true diagnosis and cost-effectiveness is rarely robust. With fixed secondary care capacity, novel primary care testing is an added cost pressure, rarely reducing hospital activity. GP testing strategies require real-world evaluation, in primary care populations, of all downstream consequences. Test formularies should be scrutinised in view of the setting of care, with interventions to focus rational testing towards those with higher pretest probabilities, while improving interpretation and communication of results.
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Affiliation(s)
- Imran Mohammed Sajid
- NHS West London Clinical Commissioning Group, London, UK
- University of Global Health Equity, Kigali, Rwanda
| | - Kathleen Frost
- NHS Central London Clinical Commissioning Group, London, UK
| | - Ash K Paul
- NHS South West London Health and Care Partnership STP, London, UK
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13
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May P, Normand C, Matthews S, Kenny RA, Romero-Ortuno R, Tysinger B. Projecting future health and service use among older people in Ireland: an overview of a dynamic microsimulation model in The Irish Longitudinal Study on Ageing (TILDA). HRB Open Res 2022; 5:21. [PMID: 36262382 PMCID: PMC9554695 DOI: 10.12688/hrbopenres.13525.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Demographic ageing is a population health success story but poses unprecedented policy challenges in the 21st century. Policymakers must prepare health systems, economies and societies for these challenges. Policy choices can be usefully informed by models that evaluate outcomes and trade-offs in advance under different scenarios. Methods:
We developed a dynamic demographic-economic microsimulation model for the population aged 50 and over in Ireland: the Irish Future Older Adults Model (IFOAM). Our principal dataset was The Irish Longitudinal Study on Ageing (TILDA). We employed first-order Markovian competing risks models to estimate transition probabilities of TILDA participants to different outcomes: diagnosis of serious diseases, functional limitations, risk-modifying behaviours, health care use and mortality. We combined transition probabilities with the characteristics of the stock population to estimate biennial changes in outcome state.
Results: IFOAM projections estimated large annual increases in total deaths, in the number of people living and dying with serious illness and functional impairment, and in demand for hospital care between 2018 and 2040. The most important driver of these increases is the rising absolute number of older people in Ireland as the population ages. The increasing proportion of older old and oldest old citizens is projected to increase the average prevalence of chronic conditions and functional limitations. We deemed internal validity to be good but lacked external benchmarks for validation and corroboration of most outcomes. Conclusion:
We have developed and validated a microsimulation model that predicts future health and related outcomes among older people in Ireland. Future research should address identified policy questions. The model enhances the capacity of researchers and policymakers to quantitatively forecast future health and economic dynamics among older people in Ireland, to evaluate ex ante policy responses to these dynamics, and to collaborate internationally on global challenges associated with demographic ageing.
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Affiliation(s)
- Peter May
- Centre for Health Policy and Management, Trinity College Dublin, 3-4 Foster Place, Dublin, D2, Ireland
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Pearse Street, Dublin, D2, Ireland
| | - Charles Normand
- Centre for Health Policy and Management, Trinity College Dublin, 3-4 Foster Place, Dublin, D2, Ireland
- Cicely Saunders Institute, King's College London, Denmark Hill, London, SE1 1UL, UK
| | - Soraya Matthews
- Centre for Health Policy and Management, Trinity College Dublin, 3-4 Foster Place, Dublin, D2, Ireland
| | - Rose Anne Kenny
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Pearse Street, Dublin, D2, Ireland
| | - Roman Romero-Ortuno
- The Irish Longitudinal Study on Ageing, Trinity College Dublin, Pearse Street, Dublin, D2, Ireland
- Global Brain Health Institute, Trinity College Dublin, Lloyd Institute, Dublin, D2, Ireland
| | - Bryan Tysinger
- Leonard D. Schaeffer Center for Health Policy and Economics, University of Southern California, Los Angeles, CA, 90007, USA
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14
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Zamora B, Towse A. The cost-per-QALY threshold in England: Identifying structural uncertainty in the estimates. FRONTIERS IN HEALTH SERVICES 2022; 2:936774. [PMID: 36925841 PMCID: PMC10012707 DOI: 10.3389/frhs.2022.936774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 12/09/2022] [Indexed: 01/21/2023]
Abstract
Introduction There are increasing numbers of estimates of opportunity cost to inform the setting of thresholds as ceiling cost-per-quality-adjusted life year (QALY) ratios. To understand their ability to inform policy making, we need to understand the degree of uncertainty surrounding these estimates. In particular, do estimates provide sufficient certainty that the current policy "rules" or "benchmarks" need revision? Does the degree of uncertainty around those estimates mean that further evidence generation is required? Methods We analyse uncertainty and methods from three papers that focus on the use of data from the NHS in England to estimate opportunity cost. All estimate the impact of expenditure on mortality in cross-sectional regression analyses and then translate the mortality elasticities into cost-per-QALY thresholds using the same assumptions. All three discuss structural uncertainty around the regression analysis, and report parameter uncertainty derived from their estimated standard errors. However, only the initial, seminal, paper explores the structural uncertainty involved in moving from the regression analysis to a threshold. We discuss the elements of structural uncertainty arising from the assumptions that underpin the translation of elasticities to thresholds and seek to quantify the importance of some of the effects. Results We find several sets of plausible structural assumptions that would place the threshold estimates from these studies within the current National Institute for Health and Care Excellence (NICE) range of £20,000 to £30,000 per QALY. Heterogeneity, an additional source of uncertainty from variability, is also discussed and reported. Discussion Lastly, we discuss how decision uncertainty around the threshold could be reduced, setting out what sort of additional research is required, notably in improving estimates of disease burden and of the impact of health expenditure on quality of life. Given the likely value to policy makers of this research it should be a priority for health system research funding.
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Affiliation(s)
- Bernarda Zamora
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Adrian Towse
- Office of Health Economics, London, United Kingdom
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15
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Ammi M, Arpin E, Allin S. Interpreting forty-three-year trends of expenditures on public health in Canada: Long-run trends, temporal periods, and data differences. Health Policy 2021; 125:1557-1564. [PMID: 34670685 DOI: 10.1016/j.healthpol.2021.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 09/28/2021] [Accepted: 10/04/2021] [Indexed: 10/20/2022]
Abstract
The COVID-19 pandemic has raised concerns around public health (PH) investments. Among OECD countries, Canada devotes one of the largest shares of total health expenditures to PH. Examining retrospectively PH spending growth over a very long period may hold lessons on how to reach this high share. Further, different historical periods can be used to understand how macroeconomic conditions affect PH spending growth. Using forty-three years of data, we examine real PH spending growth per capita, comparatively between thirteen Canadian jurisdictions and with other key publicly funded healthcare sectors (physicians, hospitals, and pharmaceuticals), as well as by four periods defined by macroeconomic conditions. We find a five-fold increase on average in PH spending since 1975, a growth above physicians and hospitals, but below pharmaceuticals. However, there is substantial variation in PH growth between periods and across the country. Because concerns have been raised over PH spending data in other OECD countries, we explore differences between spending estimates reported by the national agency and ten provincial budgetary estimates, and find the former is larger. The magnitude of the difference varies between jurisdictions but not much over time. Although these differences do not challenge the presence of growth in PH spending, they show that the growth may be below that of hospitals. A better categorization of PH financing data is warranted.
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Affiliation(s)
- Mehdi Ammi
- School of Public Policy and Administration, Carleton University, Richcraft Hall, 1125 Colonel By Dr, Ottawa, ON K1S 5B6, Canada; Centre for the Business and Economics of Health, University of Queensland, Sir Llew Edwards Building, St Lucia QLD 4072, Australia.
| | - Emmanuelle Arpin
- Institute of Health Policy Management and Evaluation, University of Toronto, 155 College St 4th Floor, Toronto, ON M5T 3M6, Canada
| | - Sara Allin
- Institute of Health Policy Management and Evaluation, University of Toronto, 155 College St 4th Floor, Toronto, ON M5T 3M6, Canada
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16
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Dambha-Miller H, Simpson G, Akyea RK, Hounkpatin H, Morrison L, Gibson J, Stokes J, Islam N, Chapman A, Stuart B, Zaccardi F, Zlatev Z, Jones K, Roderick P, Boniface M, Santer M, Farmer A. The development and validation of population clusters for integrating health and social care: A protocol for a mixed-methods study in Multiple Long-Term Conditions (Cluster-AIM) (Preprint). JMIR Res Protoc 2021; 11:e34405. [PMID: 35708751 PMCID: PMC9247810 DOI: 10.2196/34405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 03/18/2022] [Accepted: 04/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Multiple long-term health conditions (multimorbidity) (MLTC-M) are increasingly prevalent and associated with high rates of morbidity, mortality, and health care expenditure. Strategies to address this have primarily focused on the biological aspects of disease, but MLTC-M also result from and are associated with additional psychosocial, economic, and environmental barriers. A shift toward more personalized, holistic, and integrated care could be effective. This could be made more efficient by identifying groups of populations based on their health and social needs. In turn, these will contribute to evidence-based solutions supporting delivery of interventions tailored to address the needs pertinent to each cluster. Evidence is needed on how to generate clusters based on health and social needs and quantify the impact of clusters on long-term health and costs. Objective We intend to develop and validate population clusters that consider determinants of health and social care needs for people with MLTC-M using data-driven machine learning (ML) methods compared to expert-driven approaches within primary care national databases, followed by evaluation of cluster trajectories and their association with health outcomes and costs. Methods The mixed methods program of work with parallel work streams include the following: (1) qualitative semistructured interview studies exploring patient, caregiver, and professional views on clinical and socioeconomic factors influencing experiences of living with or seeking care in MLTC-M; (2) modified Delphi with relevant stakeholders to generate variables on health and social (wider) determinants and to examine the feasibility of including these variables within existing primary care databases; and (3) cohort study with expert-driven segmentation, alongside data-driven algorithms. Outputs will be compared, clusters characterized, and trajectories over time examined to quantify associations with mortality, additional long-term conditions, worsening frailty, disease severity, and 10-year health and social care costs. Results The study will commence in October 2021 and is expected to be completed by October 2023. Conclusions By studying MLTC-M clusters, we will assess how more personalized care can be developed, how accurate costs can be provided, and how to better understand the personal and medical profiles and environment of individuals within each cluster. Integrated care that considers “whole persons” and their environment is essential in addressing the complex, diverse, and individual needs of people living with MLTC-M. International Registered Report Identifier (IRRID) PRR1-10.2196/34405
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Affiliation(s)
| | - Glenn Simpson
- Primary Care Research Centre, Southampton, United Kingdom
| | - Ralph K Akyea
- University of Nottingham, Nottingham, United Kingdom
| | | | | | - Jon Gibson
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | - Jonathan Stokes
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | | | - Adriane Chapman
- Electronic and Computer Science Centre for Health Technologies, University of Southampton, Southampton, United Kingdom
| | - Beth Stuart
- Primary Care Research Centre, Southampton, United Kingdom
| | - Francesco Zaccardi
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - Zlatko Zlatev
- Electronic and Computer Science Centre for Health Technologies, University of Southampton, Southampton, United Kingdom
| | - Karen Jones
- Centre for the Study of Health, Science and Environment, University of Kent, Kent, United Kingdom
| | - Paul Roderick
- Public Health, University of Southampton, Southampton, United Kingdom
| | - Michael Boniface
- Electronic and Computer Science Centre for Health Technologies, University of Southampton, Southampton, United Kingdom
| | - Miriam Santer
- Primary Care Research Centre, Southampton, United Kingdom
| | - Andrew Farmer
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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17
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Martin S, Longo F, Lomas J, Claxton K. Causal impact of social care, public health and healthcare expenditure on mortality in England: cross-sectional evidence for 2013/2014. BMJ Open 2021; 11:e046417. [PMID: 34654700 PMCID: PMC8559090 DOI: 10.1136/bmjopen-2020-046417] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES The first objective is to estimate the joint impact of social care, public health and healthcare expenditure on mortality in England. The second objective is to use these results to estimate the impact of spending constraints in 2010/2011-2014/2015 on total mortality. METHODS The impact of social care, healthcare and public health expenditure on mortality is analysed by applying the two-stage least squares method to local authority data for 2013/2014. Next, we compare the growth in healthcare and social care expenditure pre-2010 and post-2010. We use the difference between these growth rates and the responsiveness of mortality to changes in expenditure taken from the 2013/2014 cross-sectional analysis to estimate the additional mortality generated by post-2010 spending constraints. RESULTS Our most conservative results suggest that (1) a 1% increase in healthcare expenditure reduces mortality by 0.532%; (2) a 1% increase in social care expenditure reduces mortality by 0.336%; and (3) a 1% increase in local public health spending reduces mortality by 0.019%. Using the first two of these elasticities and data on the change in spending growth between 2001/2002-2009/2010 and 2010/2011-2014/2015, we find that there were 57 550 (CI 3075 to 111 955) more deaths in the latter period than would have been observed had spending growth during this period matched that in 2001/2002-2009/2010. CONCLUSIONS All three forms of public healthcare-related expenditure save lives and there is evidence that additional social care expenditure is more than twice as productive as additional healthcare expenditure. Our results are consistent with the hypothesis that the slowdown in the rate of improvement in life expectancy in England and Wales since 2010 is attributable to spending constraints in the healthcare and social care sectors.
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Affiliation(s)
- Stephen Martin
- Department of Economics and Related Studies, University of York, York, UK
| | | | - James Lomas
- Centre for Health Economics, University of York, York, UK
| | - Karl Claxton
- Centre for Health Economics & Department of Economics, University of York, York, UK
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18
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Sharp A, Jain V, Alimi Y, Bausch DG. Policy and planning for large epidemics and pandemics - challenges and lessons learned from COVID-19. Curr Opin Infect Dis 2021; 34:393-400. [PMID: 34342301 PMCID: PMC8452318 DOI: 10.1097/qco.0000000000000778] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The COVID-19 pandemic is a global catastrophe that has led to untold suffering and death. Many previously identified policy challenges in planning for large epidemics and pandemics have been brought to the fore, and new ones have emerged. Here, we review key policy challenges and lessons learned from the COVID-19 pandemic in order to be better prepared for the future. RECENT FINDINGS The most important challenges facing policymakers include financing outbreak preparedness and response in a complex political environment with limited resources, coordinating response efforts among a growing and diverse range of national and international actors, accurately assessing national outbreak preparedness, addressing the shortfall in the global health workforce, building surge capacity of both human and material resources, balancing investments in public health and curative services, building capacity for outbreak-related research and development, and reinforcing measures for infection prevention and control. SUMMARY In recent years, numerous epidemics and pandemics have caused not only considerable loss of life, but billions of dollars of economic loss. The COVID-19 pandemic served as a wake-up call and led to the implementation of relevant policies and countermeasures. Nevertheless, many questions remain and much work to be done. Wise policies and approaches for outbreak control exist but will require the political will to implement them.
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Affiliation(s)
- Ashley Sharp
- UK Public Health Rapid Support Team, Public Health England/London School of Hygiene & Tropical Medicine
| | - Vageesh Jain
- Institute for Global Health, University College London, London, UK
| | - Yewande Alimi
- Africa Centres for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Daniel G. Bausch
- UK Public Health Rapid Support Team, Public Health England/London School of Hygiene & Tropical Medicine
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19
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Alexiou A, Fahy K, Mason K, Bennett D, Brown H, Bambra C, Taylor-Robinson D, Barr B. Local government funding and life expectancy in England: a longitudinal ecological study. LANCET PUBLIC HEALTH 2021; 6:e641-e647. [PMID: 34265265 PMCID: PMC8390384 DOI: 10.1016/s2468-2667(21)00110-9] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 03/24/2021] [Accepted: 05/04/2021] [Indexed: 12/13/2022]
Abstract
Background Since 2010, large reductions in funding for local government services have been introduced in England. These reductions in funding have potentially led to reduced provision of health-promoting public services. We aimed to investigate whether areas that showed a greater decline in funding also had more adverse trends in life expectancy and premature mortality. Methods In this longitudinal ecological study, we linked annual data from the Ministry of Housing, Communities, and Local Government on local government revenue expenditure and financing to 147 upper-tier local authorities in England between 2013 and 2017 with data from Public Health England, on male and female life expectancy at birth, male and female life expectancy at age 65 years, and premature (younger than 75 years) all-cause mortality rate for male and female individuals. Local authorities were excluded if their populations were too small or if changes in boundaries meant consistent data were not available. Using multivariable fixed-effects panel regression models, and controlling for local socioeconomic conditions, we estimated whether changes in local funding from 2013 were associated with changes in life expectancy and premature mortality. We included a set of alternative model specifications to test the robustness of our findings. Findings Between 2013 and 2017, mean per-capita central funding to local governments decreased by 33% or £168 per person (range –£385 to £1). Each £100 reduction in annual per person funding was associated over the study period 2013–17 with an average decrease in life expectancy at birth of 1·3 months (95% CI 0·7–1·9) for male individuals and 1·2 months (0·7–1·7) for female individuals; for life expectancy at age 65 years, the results show a decrease of 0·8 months (0·3–1·3) for male individuals and 1·1 months (0·7–1·5) for female individuals. Funding reductions were greater in more deprived areas and these areas had the worst changes in life expectancy. We estimated that cuts in funding were associated with an increase in the gap in life expectancy between the most and least deprived quintiles by 3% for men and 4% for women. Overall reductions in funding during this period were associated with an additional 9600 deaths in people younger than 75 years in England (3800–15 400), an increase of 1·25%. Interpretation Our findings indicate that cuts in funding for local government might in part explain adverse trends in life expectancy. Given that more deprived areas showed greater reductions in funding, our analysis suggests that inequalities have widened. Since the pandemic, strategies to address these adverse trends in life expectancy and reduce health inequalities could prioritise reinvestment in funding for local government services, particularly within the most deprived areas of England. Funding National Institute for Health Research (NIHR) School for Public Health Research, NIHR Applied Research Collaboration North East and North Cumbria, NIHR Applied Research Collaboration North West Coast and Medical Research Council.
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Affiliation(s)
- Alexandros Alexiou
- Department of Public Health, Policy, and Systems, University of Liverpool, Liverpool, UK.
| | - Katie Fahy
- Department of Public Health, Policy, and Systems, University of Liverpool, Liverpool, UK
| | - Kate Mason
- Department of Public Health, Policy, and Systems, University of Liverpool, Liverpool, UK
| | - Davara Bennett
- Department of Public Health, Policy, and Systems, University of Liverpool, Liverpool, UK
| | - Heather Brown
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Clare Bambra
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - David Taylor-Robinson
- Department of Public Health, Policy, and Systems, University of Liverpool, Liverpool, UK
| | - Benjamin Barr
- Department of Public Health, Policy, and Systems, University of Liverpool, Liverpool, UK
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20
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Walker S, Fox A, Altunkaya J, Colbourn T, Drummond M, Griffin S, Gutacker N, Revill P, Sculpher M. Program Evaluation of Population- and System-Level Policies: Evidence for Decision Making. Med Decis Making 2021; 42:17-27. [PMID: 34041992 DOI: 10.1177/0272989x211016427] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Policy evaluations often focus on ex post estimation of causal effects on short-term surrogate outcomes. The value of such information is limited for decision making, as the failure to reflect policy-relevant outcomes and disregard for opportunity costs prohibits the assessment of value for money. Further, these evaluations do not always consider all relevant evidence, other courses of action, or decision uncertainty. METHODS In this article, we explore how policy evaluation could better meet the needs of decision making. We begin by defining the evidence required to inform decision making. We then conduct a literature review of challenges in evaluating policies. Finally, we highlight potential methods available to help address these challenges. RESULTS The evidence required to inform decision making includes the impacts on the policy-relevant outcomes, the costs and associated opportunity costs, and the consequences of uncertainty. Challenges in evaluating health policies are described using 8 categories: 1) valuation space; 2) comparators; 3) time of evaluation; 4) mechanisms of action; 5) effects; 6) resources, constraints, and opportunity costs; 7) fidelity, adaptation, and level of implementation; and 8) generalizability and external validity. Methods from a broad set of disciplines are available to improve policy evaluation, relating to causal inference, decision-analytic modeling, theory of change, realist evaluation, and structured expert elicitation. LIMITATIONS The targeted review may not identify all possible challenges, and the methods covered are not exhaustive. CONCLUSIONS Evaluations should provide appropriate evidence to inform decision making. There are challenges in evaluating policies, but methods from multiple disciplines are available to address these challenges. IMPLICATIONS Evaluators need to carefully consider the decision being informed, the necessary evidence to inform it, and the appropriate methods.[Box: see text].
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Affiliation(s)
- Simon Walker
- Centre for Health Economics, University of York, York, UK
| | - Aimee Fox
- Adelphi Values, Bollington, Cheshire, UK
| | - James Altunkaya
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | - Mike Drummond
- Centre for Health Economics, University of York, York, UK
| | - Susan Griffin
- Centre for Health Economics, University of York, York, UK
| | - Nils Gutacker
- Centre for Health Economics, University of York, York, UK
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, UK
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21
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Anderson M, Pitchforth E, Asaria M, Brayne C, Casadei B, Charlesworth A, Coulter A, Franklin BD, Donaldson C, Drummond M, Dunnell K, Foster M, Hussey R, Johnson P, Johnston-Webber C, Knapp M, Lavery G, Longley M, Clark JM, Majeed A, McKee M, Newton JN, O'Neill C, Raine R, Richards M, Sheikh A, Smith P, Street A, Taylor D, Watt RG, Whyte M, Woods M, McGuire A, Mossialos E. LSE-Lancet Commission on the future of the NHS: re-laying the foundations for an equitable and efficient health and care service after COVID-19. Lancet 2021; 397:1915-1978. [PMID: 33965070 DOI: 10.1016/s0140-6736(21)00232-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 12/10/2020] [Accepted: 01/07/2021] [Indexed: 02/06/2023]
Affiliation(s)
- Michael Anderson
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Emma Pitchforth
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Miqdad Asaria
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Carol Brayne
- Cambridge Public Health, University of Cambridge, Cambridge, UK
| | - Barbara Casadei
- Radcliffe Department of Medicine, BHF Centre of Research Excellence, NIHR Biomedical Research Centre, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Anita Charlesworth
- The Health Foundation, London, UK; College of Social Sciences, Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Angela Coulter
- Green Templeton College, University of Oxford, Oxford, UK; Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Bryony Dean Franklin
- UCL School of Pharmacy, University College London, London, UK; NIHR Imperial Patient Safety Translational Research Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Cam Donaldson
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | | | | | - Margaret Foster
- National Health Service Wales Shared Services Partnership, Cardiff, UK
| | | | | | | | - Martin Knapp
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Gavin Lavery
- Belfast Health and Social Care Trust, Belfast, UK
| | - Marcus Longley
- Welsh Institute for Health and Social Care, University of South Wales, Pontypridd, UK
| | | | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Martin McKee
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Ciaran O'Neill
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Rosalind Raine
- Department of Applied Health Research, University College London, London, UK
| | - Mike Richards
- Department of Health Policy, London School of Economics and Political Science, London, UK; The Health Foundation, London, UK
| | - Aziz Sheikh
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Peter Smith
- Centre for Health Economics, University of York, York, UK; Centre for Health Economics and Policy Innovation, Imperial College London, London, UK
| | - Andrew Street
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - David Taylor
- UCL School of Pharmacy, University College London, London, UK
| | - Richard G Watt
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Moira Whyte
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Michael Woods
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Alistair McGuire
- Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Elias Mossialos
- Department of Health Policy, London School of Economics and Political Science, London, UK; Institute of Global Health Innovation, Imperial College London, London, UK.
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22
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Roscoe S, Pryce R, Buykx P, Gavens L, Meier PS. Is disinvestment from alcohol and drug treatment services associated with treatment access, completions and related harm? An analysis of English expenditure and outcomes data. Drug Alcohol Rev 2021; 41:54-61. [PMID: 33960031 DOI: 10.1111/dar.13307] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 04/21/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The positive impact of substance use treatment is well-evidenced but there has been substantial disinvestment from publicly funded treatment services in England since 2013/2014. This paper examines whether this disinvestment from adult alcohol and drug treatment provision was associated with changes in treatment and health outcomes, including: treatment access, successful completions from treatment, alcohol-specific hospital admissions, alcohol-specific mortality and drug-related deaths. METHODS Annual administrative data from 2013/2014 to 2018/2019 was matched at local government level and multi-level time series analysis using linear mixed-effect modelling conducted for 151 upper-tier local authorities in England. RESULTS Between 2013/2014 and 2018/2019, £212.2 million was disinvested from alcohol and drug treatment services, representing a 27% decrease. Concurrently, 11% fewer people accessed, and 21% fewer successfully completed, treatment. On average, controlling for other potential explanatory factors, a £10 000 disinvestment from alcohol and drug treatment services was associated with reductions in all treatment outcomes, including 0.3 fewer adults in treatment (95% confidence interval 0.16-0.45) and 0.21 fewer adults successfully completing treatment (95% % confidence interval 0.12-0.29). A £10 000 disinvestment from alcohol treatment was not significantly associated with changes in alcohol-specific hospital admissions or mortality, nor was disinvestment from drug treatment associated with the rate of drug-related deaths. DISCUSSION AND CONCLUSIONS Local authority spending cuts to alcohol and drug treatment services in England were associated with fewer people accessing and successfully completing alcohol and drug treatment but were not associated with changes in related hospital admissions and deaths.
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Affiliation(s)
- Suzie Roscoe
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Robert Pryce
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Penny Buykx
- School of Humanities and Social Science, University of Newcastle, Newcastle, Australia
| | - Lucy Gavens
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Petra S Meier
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK
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23
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Soares MO, Sculpher MJ, Claxton K. Authors' Response to: "Health Opportunity Costs and Expert Elicitation: A Comment on Soares et al." by Sampson, Firth, and Towse. Med Decis Making 2021; 41:258-260. [PMID: 33629616 PMCID: PMC7985852 DOI: 10.1177/0272989x20987222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Marta O Soares
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Mark J Sculpher
- Centre for Health Economics, University of York, York, Yorkshire, UK
| | - Karl Claxton
- Centre for Health Economics, University of York, York, Yorkshire, UK.,Department of Economics and Related Studies, University of York, York, Yorkshire, UK
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24
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Paulden M, McCabe C. Modifying NICE's Approach to Equity Weighting. PHARMACOECONOMICS 2021; 39:147-160. [PMID: 33517512 DOI: 10.1007/s40273-020-00988-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/12/2020] [Indexed: 06/12/2023]
Abstract
The UK's National Institute for Health and Care Excellence (NICE) recently launched a consultation on the methods it uses to evaluate new health technologies, and has highlighted the issue of how 'modifiers', including equity weights, should be incorporated into its processes. The practice of applying equity weights to specific population subgroups, as a means for increasing the effective cost-effectiveness threshold for some new health technologies, is well established in health technology assessment. It is also the subject of extensive discussion in the academic literature. In this paper, we demonstrate that NICE's current approach to equity weighting has the effect of reducing both population health and equity-weighted population health, a fundamental problem that appears to place NICE in contravention of its principles and obligations. We consider two potential methods for modifying NICE's current approach to address this problem. We also consider the merits of NICE abandoning its current approach to equity weighting and adopting a standard 'net benefit' approach in its place. We find that adopting a standard 'net benefit' approach is the most desirable option, as it provides for the most transparency while avoiding specific issues that arise when attempting to modify NICE's current approach. Regardless of the approach NICE uses for equity weighting, we find that protecting the health of National Health Service patients requires that some new technologies be evaluated using an effective cost-effectiveness threshold lower than the 'supply-side' cost-effectiveness threshold. This poses a particular challenge for NICE, given its obligations under the 2019 'Voluntary Scheme' between the UK pharmaceutical industry, the National Health Service, and the UK Government. We conclude by making some recommendations as to how NICE can move forward with the use of 'modifiers' in its decision making.
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Affiliation(s)
- Mike Paulden
- School of Public Health, University of Alberta, 3-300 ECHA, 11405 87 Ave NW, Edmonton, AB, T6G 1C9, Canada.
| | - Christopher McCabe
- Institute of Health Economics, 1200 10405 Jasper Avenue, Edmonton, AB, T5J 3N4, Canada
- Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, 8440 112 St. NW, Edmonton, AB, T6G 2R7, Canada
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25
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Stokes J, Guthrie B, Mercer SW, Rice N, Sutton M. Multimorbidity combinations, costs of hospital care and potentially preventable emergency admissions in England: A cohort study. PLoS Med 2021; 18:e1003514. [PMID: 33439870 PMCID: PMC7815339 DOI: 10.1371/journal.pmed.1003514] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/19/2021] [Accepted: 01/05/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Patients with multimorbidities have the greatest healthcare needs and generate the highest expenditure in the health system. There is an increasing focus on identifying specific disease combinations for addressing poor outcomes. Existing research has identified a small number of prevalent "clusters" in the general population, but the limited number examined might oversimplify the problem and these may not be the ones associated with important outcomes. Combinations with the highest (potentially preventable) secondary care costs may reveal priority targets for intervention or prevention. We aimed to examine the potential of defining multimorbidity clusters for impacting secondary care costs. METHODS AND FINDINGS We used national, Hospital Episode Statistics, data from all hospital admissions in England from 2017/2018 (cohort of over 8 million patients) and defined multimorbidity based on ICD-10 codes for 28 chronic conditions (we backfilled conditions from 2009/2010 to address potential undercoding). We identified the combinations of multimorbidity which contributed to the highest total current and previous 5-year costs of secondary care and costs of potentially preventable emergency hospital admissions in aggregate and per patient. We examined the distribution of costs across unique disease combinations to test the potential of the cluster approach for targeting interventions at high costs. We then estimated the overlap between the unique combinations to test potential of the cluster approach for targeting prevention of accumulated disease. We examined variability in the ranks and distributions across age (over/under 65) and deprivation (area level, deciles) subgroups and sensitivity to considering a smaller number of diseases. There were 8,440,133 unique patients in our sample, over 4 million (53.1%) were female, and over 3 million (37.7%) were aged over 65 years. No clear "high cost" combinations of multimorbidity emerged as possible targets for intervention. Over 2 million (31.6%) patients had 63,124 unique combinations of multimorbidity, each contributing a small fraction (maximum 3.2%) to current-year or 5-year secondary care costs. Highest total cost combinations tended to have fewer conditions (dyads/triads, most including hypertension) affecting a relatively large population. This contrasted with the combinations that generated the highest cost for individual patients, which were complex sets of many (6+) conditions affecting fewer persons. However, all combinations containing chronic kidney disease and hypertension, or diabetes and hypertension, made up a significant proportion of total secondary care costs, and all combinations containing chronic heart failure, chronic kidney disease, and hypertension had the highest proportion of preventable emergency admission costs, which might offer priority targets for prevention of disease accumulation. The results varied little between age and deprivation subgroups and sensitivity analyses. Key limitations include availability of data only from hospitals and reliance on hospital coding of health conditions. CONCLUSIONS Our findings indicate that there are no clear multimorbidity combinations for a cluster-targeted intervention approach to reduce secondary care costs. The role of risk-stratification and focus on individual high-cost patients with interventions is particularly questionable for this aim. However, if aetiology is favourable for preventing further disease, the cluster approach might be useful for targeting disease prevention efforts with potential for cost-savings in secondary care.
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Affiliation(s)
- Jonathan Stokes
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, United Kingdom
| | - Bruce Guthrie
- Usher Institute, The University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Stewart W. Mercer
- Usher Institute, The University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Nigel Rice
- Department of Economics and Related Studies and Centre for Health Economics, University of York, York, United Kingdom
| | - Matt Sutton
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, United Kingdom
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26
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Martin S, Lomas J, Claxton K. Is an ounce of prevention worth a pound of cure? A cross-sectional study of the impact of English public health grant on mortality and morbidity. BMJ Open 2020; 10:e036411. [PMID: 33039987 PMCID: PMC7549458 DOI: 10.1136/bmjopen-2019-036411] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 07/25/2020] [Accepted: 08/17/2020] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES The UK government is proposing to cease cutting the local authority public health grant by reallocating part of the treatment budget to preventative activity. This study examines whether this proposal is evidenced based and, in particular, whether these resources are best reallocated to prevention, or whether this expenditure would generate more health gains if used for treatment. METHODS Instrumental variable regression methods are applied to English local authority data on mortality, healthcare and public health expenditure to estimate the responsiveness of mortality to variations in healthcare and public health expenditure in 2013/14. Using a well-established method, these mortality results are converted to a quality-adjusted life year (QALY) basis, and this facilitates the estimation of the cost per QALY for both National Health Service (NHS) healthcare and local public health expenditure. RESULTS Saving lives and improving the quality of life requires resources. Our estimates suggest that each additional QALY costs about £3800 from the local public health budget, and that each additional QALY from the NHS budget costs about £13 500. These estimates can be used to calculate the number of QALYs generated by a budget boost. If we err on the side of caution and use the most conservative estimates that we have, then an additional £1 billion spent on public health will generate 206 398 QALYs (95% CI 36 591 to 3 76 205 QALYs), and an additional £1 billion spent on healthcare will generate 67 060 QALYs (95% CI 21 487 to 112 633 QALYs). CONCLUSIONS Additional public health expenditure is very productive of health and is more productive than additional NHS expenditure. However, both types of expenditure are more productive of health than the norms used by National Institute for Health and Care Excellence (£20 000-£30 000 per QALY) to judge whether new therapeutic technologies are suitable for adoption by the NHS.
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Affiliation(s)
- Stephen Martin
- Department of Economics and Related Studies, University of York, York, UK
| | - James Lomas
- Centre for Health Economics, University of York, York, UK
| | - Karl Claxton
- Department of Economics and Related Studies, and Centre for Health Economics, University of York, York, UK
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