[Health promotion: a profitable investment? Economic efficiency of preventive interventions in Spain]

Methodological reviews of economic evaluations in health care: what do they target?

INTRODUCTION AND OBJECTIVES

An increasing number of published studies of economic evaluations of health technologies have been reviewed and summarized with different purposes, among them to facilitate decision-making processes. These reviews have covered different aspects of economic evaluations, using a variety of methodological approaches. The aim of this study is to analyze the methodological characteristics of the reviews of economic evaluations in health care, published during the period 1990-2010, to identify their main features and the potential missing elements. This may help to develop a common procedure for elaborating these kinds of reviews.

METHODS

We performed systematic searches in electronic databases (Scopus, Medline and PubMed) of methodological reviews published in English, period 1990-2010. We selected the articles whose main purpose was to review and assess the methodology applied in the economic evaluation studies. We classified the data according to the study objectives, period of the review, number of reviewed studies, methodological and non-methodological items assessed, medical specialty, type of disease and technology, databases used for the review and their main conclusions. We performed a descriptive statistical analysis and checked how generalizability issues were considered in the reviews.

RESULTS

We identified 76 methodological reviews, 42 published in the period 1990-2001 and 34 during 2002-2010. The items assessed most frequently (by 70% of the reviews) were perspective, type of economic study, uncertainty and discounting. The reviews also described the type of intervention and disease, funding sources, country in which the evaluation took place, type of journal and author's characteristics. Regarding the intertemporal comparison, higher frequencies were found in the second period for two key methodological items: the source of effectiveness data and the models used in the studies. However, the generalizability issues that apparently are creating a growing interest in the economic evaluation literature did not receive as much attention in the reviews of the second period. The remaining items showed similar frequencies in both periods.

CONCLUSIONS

Increasingly more reviews of economic evaluation studies aim to analyze the application of methodological principles, and offer summaries of papers classified by either diseases or health technologies. These reviews are useful for finding literature trends, aims of studies and possible deficiencies in the implementation of methods of specific health interventions. As no significant methodological improvement was clearly detected in the two periods analyzed, it would be convenient to pay more attention to the methodological aspects of the reviews.

[Working with our smoker patients in primary care. Analysis of cost-effectiveness]

OBJECTIVE

The aim of this work is to realize an economic evaluation of the smoking interventions in Primary Care (PC).

DESIGN

Cost-Effectiveness Analysis comparing two intervention strategies; intensive and brief.

SETTING

Patients in a general practitioner's list in a peri-urban Health Centre.

PARTICIPANTS

All the medical histories labelled as smokers; 235 and 37 in the group of brief and intensive intervention respectively.

INTERVENTIONS

The brief intervention (BI) was made in the context of consultation for another purpose (1-5 minutes). The intensive intervention (II) was exclusively for smoking consultation (10-15 minutes).

MAIN MEASUREMENTS

The effectiveness data are obtained by the evaluation of intervention for smokers, in a general practitioner's list, after 6 years. We employ direct sanitary costs. We exclude drugs, non- sanitary and indirect costs. We apply the valuation of incremental cost-effectiveness ratio (ICER) of the brief interventions, intensive and total (brief + intensive) to compare not taking part with each type of intervention and II with regard to BI and probabilistic analysis to treat the uncertainty.

RESULTS

The total cost per abstinent patient was 406,74 €: 129,83 € for BI and 1.034,99 € for I.I. ICER Total intervention = €498, 87/patient who stops smoking. ICER BI = €235, 32/patient who stops smoking. ICER II = €1.232, 85/patient who stops smoking. ICER II/BI = €7.772,25/patient who stops smoking.

CONCLUSIONS

Smoking interventions in PC are efficient. A proposal for smoking intervention in PC from an effective cost perspective could be an BI for smokers and an II on those who find more difficult to leave the habit.

[Economic evaluation of public health interventions]

The scarcity of resources available to meet the growing demand for healthcare services has increased interest in economic evaluation as a tool to inform resource allocation. The aim of economic evaluation is to compare various alternatives for action, in terms of their costs and effects on health, by using several techniques: cost minimization analysis, cost-effectiveness analysis, cost-utility analysis, and cost-benefit analysis. Irrespective of the methodology used, any assessment must include scope of the problem, selection of alternatives for comparison, explication of the perspective of analysis and the time horizon, measurement and evaluation of costs and health effects, presentation of results, and sensitivity analysis. In Spain, evaluation of currently ongoing preventive interventions, and adherence to the existing economic evaluation guidelines by researchers would be desirable.

The use of quality-adjusted life-years in the economic evaluation of health technologies in Spain: a review of the 1990-2009 literature

OBJECTIVE

To appraise economic evaluations of health technologies that included quality-adjusted life-years (QALYs) as an outcome measure conducted over the past 20 years in Spain.

METHODS

A systematic review of the literature was conducted. Economic evaluations that included QALYs as an outcome measure, conducted in Spain and published between January 1990 and December 2009 were identified. Primary and gray literature sources were reviewed.

RESULTS

A total of 60 articles and 4 health technology assessment reports were included. Key findings were 1) the vast majority of articles (77.1%) referred to therapeutic interventions; 2) 63.2% dealt with pharmaceutical products and much fewer with preventive strategies, medical devices, or diagnostic interventions; 3) most evaluations referred to cardiovascular- (19.8%), respiratory- (16.3%), and cancer- (13.0%) related processes; 4) 80.3% were based on a theoretical model, most commonly Markov models (71.4%); 5) 67.3% adopted the National Health System perspective; 6) information on the methods used to describe the health states was given in 45.1% of studies; 7) 40.3% used the EuroQoL-5D to elicit preferences, whereas 66.1% gave no details on the methods applied to determine patients' choices; 8) it was possible to state who completed the questionnaires in only 17.7% of studies; 9) 77.1% of the interventions assessed were below the €30,000/QALY suggested affordable threshold in Spain.

CONCLUSIONS

An increasing number of economic evaluations using QALYs had been conducted. Most of them relied on theoretical models. Several methodological issues remain unsolved. Great disparity exists regarding the reporting of the methods used to determine health states and utility values.

Burden of disease and economic evaluation of healthcare interventions: are we investigating what really matters?

Background

The allocation of limited available healthcare resources demands an agreed rational allocation principle and the consequent priority setting. We assessed the association between economic evaluations of healthcare interventions published in Spain (1983-2008) and the disease burden in the population.

Methods

Electronic databases (e.g., PubMed/MEDLINE, SCOPUS, ISI Web of Knowledge, CRD, IME, IBECS) and reports from health technology assessment agencies were systematically reviewed. For each article, multiple variables were recorded such as: year and journal of publication, type of study, health intervention targetted, perspective of analysis, type of costs and sources of information, first author's affiliation, explicit recommendations aimed at decision-making, and the main disease cause to which the intervention was addressed. The following disease burden measures were calculated: years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life years (DALYs), and mortality by cause. Correlation and linear regression models were fitted.

Results

Four hundred and seventy-seven economic evaluations were identified. Cardiovascular diseases (15.7%), infectious diseases (15.3%), malignant neoplasms (13.2%), and neuropsychiatric diseases (9.6%) were the conditions most commonly addressed. Accidents and injuries, congenital anomalies, oral conditions, nutritional deficiencies and other neoplasms were the categories with a lowest number of studies (0.6% for each of them). For the main disease categories (n = 20), a correlation was seen with: mortality 0.67 (p = 0.001), DALYs 0.63 (p = 0.003), YLLs 0.54 (p = 0.014), and YLDs 0.51 (p = 0.018). By disease sub-categories (n = 51), the correlations were generally low and non statistically significant.

Conclusions

Examining discrepancies between economic evaluations in particular diseases and the overall burden of disease helps shed light on whether there are potentially over- and under-investigated areas. The approach taken could help policy-makers understand whether resources for economic evaluation are being allocated by using summary measures of population health.

[Health in all policies. Is the economic depression a time of opportunities? SESPAS Report 2010]

El diseño coste-efectivo y equitativo de la política de salud implica abordar los determinantes sociales de la salud y tomar conciencia del impacto de las políticas no sanitarias. Para ello se requieren cambios estructurales en las formas de organización de las instituciones, que han de favorecer la gobernanza en red. La inercia institucional, las deficiencias en los mecanismos de coordinación y cooperación entre sectores, niveles de gobierno y agentes, los intereses económicos y las pautas culturales que mantienen el paradigma biomédico, o la falta de colaboración entre expertos, profesionales y autoridades sanitarias, actúan como factores de ralentización, pero pueden contrarrestarse con voluntad política y con el conocimiento que proporcionan las experiencias propias y ajenas. La coyuntura actual derivada de las recientes crisis de salud pública, y particularmente de la última crisis económica, ofrece una oportunidad excepcional para introducir cambios en la planificación de las acciones orientadas a mejorar la salud.