Issues in the incorporation of economic perspectives and evidence into Cochrane reviews

Lessons for the UK on implementation and evaluation of breastfeeding support: evidence syntheses and stakeholder engagement

Background

Breastfeeding impacts positively on multiple health outcomes, but < 50% of UK women breastfeed at 8 weeks. Women with long-term conditions face additional challenges in breastfeeding.

Objectives

To synthesise global and UK evidence to co-create an implementation and evaluation toolkit for cost-effective breastfeeding support in the NHS.

Design

Evidence syntheses with stakeholder engagement.

Review methods

Systematic reviews examined effectiveness of breastfeeding support for (1) healthy women and (2) women with long-term conditions using Cochrane Pregnancy and Childbirth Group methods. Mixed-methods systematic reviews synthesised process evaluations of effective breastfeeding support interventions for healthy women and experiences of receiving/providing support for breastfeeding women with long-term conditions. Cross-study synthesis integrated qualitative and quantitative findings. Systematic reviews synthesised evidence on the incremental costs and cost-effectiveness of breastfeeding support following National Institute for Health and Care Excellence guidance. All searches were conducted from May 2021 to October 2022. Stakeholder engagement and toolkit development comprised online discussions, a modified Delphi study, focus groups and four workshops. Participants were 23 stakeholders, 16 parents in the parents' panels, 15 women in the focus groups and 87 stakeholders who attended the workshops.

Results

We found considerably more interventions designed for healthy women (review 1) than aimed at women with long-term conditions (reviews 1 and 4); approximately half of the studies were targeted at groups at higher risk of poor breastfeeding outcomes, and the impact of support may be different in these populations. Despite this, studies from review 2 found that women perceived the provision of support as positive, important and needed. Studies from review 5 echoed a range of suggestions from participants regarding potential strategies to improve breastfeeding support, with the most widely reported being the need to acknowledge the role and influence of other sources of support (e.g. partners, family, friends, peers, external professionals, web-based resources) and involving these sources in the provision of breastfeeding support for women with long-term conditions. In reviews 3 and 6, there was uncertainty about the cost-effectiveness of breastfeeding support interventions due to the limited number of studies and lack of good-quality evidence.

Limitations

There was a lack of evidence for the effectiveness and cost-effectiveness of breastfeeding interventions in the UK. There was often insufficient information reported about intervention characteristics.

Conclusions

'Breastfeeding only' support probably reduces the number of women stopping any or exclusive breastfeeding. The evidence for 'breastfeeding plus' interventions is less consistent, but these may reduce the number of women stopping exclusive breastfeeding at 4-6 weeks and at 6 months. We found no evidence of differential intervention effects regarding mode of provision or provider. Cost-effectiveness is uncertain due to the lack of good-quality evidence. Key enablers of successful implementation were responsiveness and tailoring of interventions to both women's and supporters' needs. Breastfeeding support as delivered in the included studies probably has little to no effect on breastfeeding outcomes for women with long-term conditions. The mixed-methods synthesis and stakeholder work identified that existing interventions may not address the complex needs of these women. The main study output is a co-produced toolkit to guide implementation and evaluation of breastfeeding support services in the UK.

Future work

Evaluation of breastfeeding support for all women, particularly those at risk of poor breastfeeding outcomes (e.g. long-term conditions, deprivation). This could involve tailoring the toolkit to local contexts via implementation and effectiveness studies or using quality improvement studies.

Study registration

This study is registered as PROSPERO CRD42022337239, CRD42021229769 and CRD42022374509. The reviews of economic evidence were not registered; however, the review protocol can be accessed via the repository held by Queen's University Belfast Research Portal (https://pure.qub.ac.uk/).

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130995) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 20. See the NIHR Funding and Awards website for further award information.

Automated oxygen delivery for preterm infants with respiratory dysfunction

BACKGROUND

Many preterm infants require respiratory support to maintain an optimal level of oxygenation, as oxygen levels both below and above the optimal range are associated with adverse outcomes. Optimal titration of oxygen therapy for these infants presents a major challenge, especially in neonatal intensive care units (NICUs) with suboptimal staffing. Devices that offer automated oxygen delivery during respiratory support of neonates have been developed since the 1970s, and individual trials have evaluated their effectiveness.

OBJECTIVES

To assess the benefits and harms of automated oxygen delivery systems, embedded within a ventilator or oxygen delivery device, for preterm infants with respiratory dysfunction who require respiratory support or supplemental oxygen therapy.

SEARCH METHODS

We searched CENTRAL, MEDLINE, CINAHL, and clinical trials databases without language or publication date restrictions on 23 January 2023. We also checked the reference lists of retrieved articles for other potentially eligible trials.

SELECTION CRITERIA

We included randomised controlled trials and randomised cross-over trials that compared automated oxygen delivery versus manual oxygen delivery, or that compared different automated oxygen delivery systems head-to-head, in preterm infants (born before 37 weeks' gestation).

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our main outcomes were time (%) in desired oxygen saturation (SpO2) range, all-cause in-hospital mortality by 36 weeks' postmenstrual age, severe retinopathy of prematurity (ROP), and neurodevelopmental outcomes at approximately two years' corrected age. We expressed our results using mean difference (MD), standardised mean difference (SMD), and risk ratio (RR) with 95% confidence intervals (CIs). We used GRADE to assess the certainty of evidence.

MAIN RESULTS

We included 18 studies (27 reports, 457 infants), of which 13 (339 infants) contributed data to meta-analyses. We identified 13 ongoing studies. We evaluated three comparisons: automated oxygen delivery versus routine manual oxygen delivery (16 studies), automated oxygen delivery versus enhanced manual oxygen delivery with increased staffing (three studies), and one automated system versus another (two studies). Most studies were at low risk of bias for blinding of personnel and outcome assessment, incomplete outcome data, and selective outcome reporting; and half of studies were at low risk of bias for random sequence generation and allocation concealment. However, most were at high risk of bias in an important domain specific to cross-over trials, as only two of 16 cross-over trials provided separate outcome data for each period of the intervention (before and after cross-over). Automated oxygen delivery versus routine manual oxygen delivery Automated delivery compared with routine manual oxygen delivery probably increases time (%) in the desired SpO2 range (MD 13.54%, 95% CI 11.69 to 15.39; I2 = 80%; 11 studies, 284 infants; moderate-certainty evidence). No studies assessed in-hospital mortality. Automated oxygen delivery compared to routine manual oxygen delivery may have little or no effect on risk of severe ROP (RR 0.24, 95% CI 0.03 to 1.94; 1 study, 39 infants; low-certainty evidence). No studies assessed neurodevelopmental outcomes. Automated oxygen delivery versus enhanced manual oxygen delivery There may be no clear difference in time (%) in the desired SpO2 range between infants who receive automated oxygen delivery and infants who receive manual oxygen delivery (MD 7.28%, 95% CI -1.63 to 16.19; I2 = 0%; 2 studies, 19 infants; low-certainty evidence). No studies assessed in-hospital mortality, severe ROP, or neurodevelopmental outcomes. Revised closed-loop automatic control algorithm (CLACfast) versus original closed-loop automatic control algorithm (CLACslow) CLACfast allowed up to 120 automated adjustments per hour, whereas CLACslow allowed up to 20 automated adjustments per hour. CLACfast may result in little or no difference in time (%) in the desired SpO2 range compared to CLACslow (MD 3.00%, 95% CI -3.99 to 9.99; 1 study, 19 infants; low-certainty evidence). No studies assessed in-hospital mortality, severe ROP, or neurodevelopmental outcomes. OxyGenie compared to CLiO2 Data from a single small study were presented as medians and interquartile ranges and were not suitable for meta-analysis.

AUTHORS' CONCLUSIONS

Automated oxygen delivery compared to routine manual oxygen delivery probably increases time in desired SpO2 ranges in preterm infants on respiratory support. However, it is unclear whether this translates into important clinical benefits. The evidence on clinical outcomes such as severe retinopathy of prematurity are of low certainty, with little or no differences between groups. There is insufficient evidence to reach any firm conclusions on the effectiveness of automated oxygen delivery compared to enhanced manual oxygen delivery or CLACfast compared to CLACslow. Future studies should include important short- and long-term clinical outcomes such as mortality, severe ROP, bronchopulmonary dysplasia/chronic lung disease, intraventricular haemorrhage, periventricular leukomalacia, patent ductus arteriosus, necrotising enterocolitis, and long-term neurodevelopmental outcomes. The ideal study design for this evaluation is a parallel-group randomised controlled trial. Studies should clearly describe staffing levels, especially in the manual arm, to enable an assessment of reproducibility according to resources in various settings. The data of the 13 ongoing studies, when made available, may change our conclusions, including the implications for practice and research.

Community Guide Methods for Systematic Reviews of Economic Evidence

INTRODUCTION

Community Guide systematic economic reviews provide information on the cost, economic benefit, cost-benefit, and cost-effectiveness of public health interventions recommended by the Community Preventive Services Task Force on the basis of evidence of effectiveness. The number and variety of economic evaluation studies in public health have grown substantially over time, contributing to methodologic challenges that required updates to the methods for Community Guide systematic economic reviews. This paper describes these updated methods.

METHODS

The 9-step Community Guide economic review process includes prioritization of topic, creation of a coordination team, conceptualization of review, literature search, screening studies for inclusion, abstraction of studies, analysis of results, translation of evidence to Community Preventive Services Task Force economic findings, and dissemination of findings and evidence gaps. The methods applied in each of these steps are reported in this paper.

RESULTS

Two published Community Guide reviews, tailored pharmacy-based interventions to improve adherence to medications for cardiovascular disease and permanent supportive housing with housing first to prevent homelessness, are used to illustrate the application of the updated methods. The Community Preventive Services Task Force reached a finding of cost-effectiveness for the first intervention and a finding of favorable cost-benefit for the second on the basis of results from the economic reviews.

CONCLUSIONS

The updated Community Guide economic systematic review methods provide transparency and improve the reliability of estimates that are used to derive a Community Preventive Services Task Force economic finding. This may in turn augment the utility of Community Guide economic reviews for communities making decisions about allocating limited resources to effective programs.

Strengthening women's empowerment and gender equality in fragile contexts towards peaceful and inclusive societies: A systematic review and meta-analysis

Background

Across the globe, gender disparities still exist with regard to equitable access to resources, participation in decision-making processes, and gender and sexual-based violence. This is particularly true in fragile and conflict-affected settings, where women and girls are affected by both fragility and conflict in unique ways. While women have been acknowledged as key actors in peace processes and post-conflict reconstruction (e.g., through the United Nations Security Council Resolution 1325 and the Women, Peace and Security Agenda) evidence on the effectiveness of gender-specific and gender-transformative interventions to improve women's empowerment in fragile and conflict-affected states and situations (FCAS) remains understudied.

Objectives

The purpose of this review was to synthesize the body of evidence around gender-specific and gender-transformative interventions aimed at improving women's empowerment in fragile and conflict-affected settings with high levels of gender inequality. We also aimed to identify barriers and facilitators that could affect the effectiveness of these interventions and to provide implications for policy, practice and research designs within the field of transitional aid.

Methods

We searched for and screened over 100,000 experimental and quasi-experimental studies focused on FCAS at the individual and community levels. We used standard methodological procedures outlined by the Campbell Collaboration for the data collection and analysis, including quantitative and qualitative analyses, and completed the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology to assess the certainty around each body of evidence.

Results

We identified 104 impact evaluations (75% randomised controlled trials) assessing the effects of 14 different types of interventions in FCAS. About 28% of included studies were assessed as having a high risk of bias (45% among quasi-experimental designs). Interventions supporting women's empowerment and gender equality in FCAS produced positive effects on the outcomes related to the primary focus of the intervention. There are no significant negative effects of any included interventions. However, we observe smaller effects on behavioural outcomes further along the causal chain of empowerment. Qualitative syntheses indicated that gender norms and practices are potential barriers to intervention effectiveness, while working with local powers and institutions can facilitate the uptake and legitimacy of interventions.

Conclusions

We observe gaps of rigorous evidence in certain regions (notably MENA and Latin America) and in interventions specifically targeting women as actors of peacebuilding. Gender norms and practices are important elements to consider in programme design and implementation to maximise potential benefits: focusing on empowerment only might not be enough in the absence of targeting the restrictive gender norms and practices that may undermine intervention effectiveness. Lastly, programme designers and implementation should consider explicitly targeting specific empowerment outcomes, promoting social capital and exchange, and tailoring the intervention components to the desired empowerment-related outcomes.

Meta-analysis of economic evaluation studies: data harmonisation and methodological issues

BACKGROUND

In the context of ever-growing health expenditure and limited resources, economic evaluations aid in making evidence-informed policy decisions. Cost-utility analysis (CUA) is often used, and CUA data synthesis is also desirable, but methodological issues are challenged. Hence, we aim to provide a step-by-step process to prepare the CUA data for meta-analysis.

METHODS

Data harmonisation methods were constructed specifically considering CUA methodology, including inconsistent reports, economic parameters, heterogeneity (i.e., country's income, time horizon, perspective, modelling approaches, currency, willingness to pay). An incremental net benefit (INB) and its variance were estimated and pooled across studies using a basic meta-analysis by COMER.

RESULTS

Five scenarios show how to obtain INB and variance with various reported data: Study reports the mean and variance (Scenario 1) or 95% confidence interval (Scenario 2) of ΔC, ΔE, and ICER for INB/variance calculations. Scenario 3: ΔC, ΔE, and variances are available, but not for the ICER; a Monte Carlo was used to simulate ΔC and ΔE data, variance and covariance can be then estimated leading INB calculation. Scenario-4: Only the CE plane was available, ΔC and ΔE data can be extracted; means of ΔC, ΔE, and variance/covariance can be estimated accordingly, leading to INB/variance estimates. Scenario-5: Only mean cost/outcomes and ICER are available but not for variance and the CE-plane. A variance INB can be borrowed from other studies which are similar characteristics, including country income, ICERs, intervention-comparator, time period, country region, and model type and inputs (i.e., discounting, time horizon).

CONCLUSION

Out data harmonisation and meta-analytic methods should be useful for researchers for the synthesis of economic evidence to aid policymakers in decision making.

PROTOCOL: Strengthening women's empowerment and gender equality in fragile contexts towards peaceful and inclusive societies: A systematic review and meta-analysis

This review builds on 3ie's (international initiative for impact evaluation) evidence gap map (EGM) of the impact evaluation and systematic review (SR) evidence base of interventions aiming to promote peaceful and inclusive societies in fragile contexts. The EGM identified a cluster of studies evaluating gender equality-focused behaviour change communication programmes and raised interest in investigating the evidence base for understanding the role of women more broadly as agents of change in developing peaceful and inclusive societies. Building on the cluster of evidence identified in the EGM, our review will increase generalisability of findings from single studies and focus on interventions across a broad range of geographical locations, settings and populations, types of implementations and outcomes. We will also address (when possible) the identified gaps in literature regarding metaanalysis in conflict-affected contexts. As such, we propose the following objectives: (1) The primary objective of this review is to identify, assess and synthesise evidence on the effect of gender specific and gender transformative interventions within the context of the four pillars of United Nations Security Council Resolution (UNSCR) 1325 on women's empowerment and gender equality in Fragile and Conflict Affected States/Situations (FCAS). The SR will facilitate the use of evidence in informing policy and practice decisions within the field of transition aid, particularly as it relates to gender focused programming. (2) Our second objective is to assess how these interventions contribute to inclusive and sustainable peace in conflict affected situations. We will compare the effectiveness of these different types of interventions through the lenses of their ecological level, types of impact on women's empowerment, local context of gender inequality and conflict. To achieve these objectives we aim to answer the following questions: (1) What are the impacts of gender transformative and specific interventions on women's empowerment and gender equality in FCAS? (2) What are the effects of these interventions on sustainable peace? (3) To what extent do effects vary by population group, ecological level and types of interventions? (4) What are contextual barriers to and facilitators of intervention effectiveness?

When complexity matters: a step-by-step guide to incorporating a complexity perspective in guideline development for public health and health system interventions

BACKGROUND

Guidelines on public health and health system interventions often involve considerations beyond effectiveness and safety to account for the impact that these interventions have on the wider systems in which they are implemented. This paper describes how a complexity perspective may be adopted in guideline development to facilitate a more nuanced consideration of a range of factors pertinent to decisions regarding public health and health system interventions. These factors include acceptability and feasibility, and societal, economic, and equity and equality implications of interventions.

MAIN MESSAGE

A 5-step process describes how to incorporate a complexity perspective in guideline development with examples to illustrate each step. The steps include: (i) guideline scoping, (ii) formulating questions, (iii) retrieving and synthesising evidence, (iv) assessing the evidence, and (v) developing recommendations. Guideline scoping using stakeholder consultations, complexity features, evidence mapping, logic modelling, and explicit decision criteria is emphasised as a key step that informs all subsequent steps.

CONCLUSIONS

Through explicit consideration of a range of factors and enhanced understanding of the specific circumstances in which interventions work, a complexity perspective can yield guidelines with better informed recommendations and facilitate local adaptation and implementation. Further work will need to look into the methods of collecting and assessing different types of evidence beyond effectiveness and develop procedural guidance for prioritising across a range of decision criteria.

The crime, mental health, and economic impacts of prearrest diversion of people with mental health problems: A systematic review

BACKGROUND

Prearrest diversion strategies are being adopted across the Western world, enabling the police to identify and divert people suspected of having mental disorder towards health and community services rather than the criminal justice system.

AIMS

To quantify longer-term criminal justice and mental health outcomes after prearrest diversion of people with suspected mental disorder and consider economic correlates.

METHODS

A systematic review of published literature on longer term outcomes after prearrest diversion.

RESULTS

Only two quasi-experimental studies, with four independent samples, could be included. Findings for criminal and mental health outcomes were inconclusive, but potential for adverse outcomes was identified. Ten studies with cost data suggested that prearrest diversion can lead to overall cost savings.

CONCLUSIONS

There is still inadequate evidence on which to base prearrest diversion programmes. Although some benefits have been identified by the review, so have possible harms. Future research and funding strategies must build in high-quality, systematic evaluation of outcomes before implementing a theoretically attractive strategy more widely.

Systematic review: economic evaluations of HCV screening in the direct-acting antivirals era

BACKGROUND

The World Health Organization estimated that 90% of the infected people need to be diagnosed and 80% need to be treated to reach the aim of hepatitis C virus (HCV) elimination by 2030. For this reason, all possible strategies to detect and treat HCV-infected people need to be carefully evaluated to implement the best one.

AIM

To review and synthesise the economic evaluations of HCV screening programs conducted in the era of direct-acting antiviral agents regimens.

METHODS

A systematic literature review was conducted until April 2018 to provide information on the costs and effectiveness of HCV screenings in direct-acting antiviral agents era. A critical assessment of the quality of economic evaluations retrieved was conducted.

RESULTS

The literature search identified 716 references; 17 of them assessed cost and effectiveness of screening programs and antiviral treatments in different populations: general population (n = 7), drug users (n = 5), high-risk populations (n = 4) and other populations (n = 3). The HCV screening and direct-acting antiviral agents treatment appear to be good value for money, both in general and high-risk populations, if a cost per quality adjusted life years of $50 000 is set as willingness to pay threshold. Some studies showed the value of including lower stage of fibrosis in the treatment selection criteria.

CONCLUSIONS

Several HCV screening strategies plus direct-acting antiviral agents treatments resulted cost-effectiveness in different populations. However, there is still need of country and population-specific evaluations within the different HCV screening and treatment strategies available, in order to assess their cost-effectiveness and sustainability and fully support an evidence-informed policy for HCV elimination.

Systematic reviews of health economic evaluations: A structured analysis of characteristics and methods applied

INTRODUCTION

The number of systematic reviews of health economic evaluations (SR-HEs) is increasing. We aimed at providing a detailed overview of the characteristics and applied methods in recently published SR-HEs.

METHODS

We searched MEDLINE (03/2017) for SR-HEs published since 2015 using validated search filters. We included studies that performed a systematic review of full economic evaluations and searched at least one electronic database. We extracted data in a standardized, beforehand piloted form that was deduced from the items of the PRISMA and CHEERS checklists. Data were extracted by one reviewer, and a 10% random sample was verified by a second. We prepared descriptive statistical measures to describe the SR-HEs.

RESULTS

We included 202 SR-HEs. We identified similarities especially in the methods for information retrieval. Study selection, data extraction, and assessment of quality and transferability were frequently not reported or performed without taking measures to reduce errors (eg, independent study selection). A wide range of different tools was applied for critical appraisal. Moreover, the reporting of included economic evaluations and the synthesis of their results showed strong variations.

CONCLUSIONS

Overall, we identified few common features in the applied methods for SR-HEs. The information retrieval processes are largely standardized, but many studies did not use validated search filters. For the other systematic review steps, the methodological approaches varied. In particular, important challenges seem to be the methodological quality and transferability assessment as well as presentation and (quantitative) synthesis of results. Efforts are needed for increasing standardization, quality of applied methods, and reporting of SR-HEs.

The WHO-INTEGRATE evidence to decision framework version 1.0: integrating WHO norms and values and a complexity perspective

INTRODUCTION

Evidence-to-decision (EtD) frameworks intend to ensure that all criteria of relevance to a health decision are systematically considered. This paper, part of a series commissioned by the WHO, reports on the development of an EtD framework that is rooted in WHO norms and values, reflective of the changing global health landscape, and suitable for a range of interventions and complexity features. We also sought to assess the value of this framework to decision-makers at global and national levels, and to facilitate uptake through suggestions on how to prioritise criteria and methods to collect evidence.

METHODS

In an iterative, principles-based approach, we developed the framework structure from WHO norms and values. Preliminary criteria were derived from key documents and supplemented with comprehensive subcriteria obtained through an overview of systematic reviews of criteria employed in health decision-making. We assessed to what extent the framework can accommodate features of complexity, and conducted key informant interviews among WHO guideline developers. Suggestions on methods were drawn from the literature and expert consultation.

RESULTS

The new WHO-INTEGRATE (INTEGRATe Evidence) framework comprises six substantive criteria-balance of health benefits and harms, human rights and sociocultural acceptability, health equity, equality and non-discrimination, societal implications, financial and economic considerations, and feasibility and health system considerations-and the meta-criterion quality of evidence. It is intended to facilitate a structured process of reflection and discussion in a problem-specific and context-specific manner from the start of a guideline development or other health decision-making process. For each criterion, the framework offers a definition, subcriteria and example questions; it also suggests relevant primary research and evidence synthesis methods and approaches to assessing quality of evidence.

CONCLUSION

The framework is deliberately labelled version 1.0. We expect further modifications based on focus group discussions in four countries, example applications and input across concerned disciplines.

Cost-Effectiveness through the Dental-Health FRAMM Guideline for Caries Prevention among 12- to 15-Year-Olds in Sweden

Since 2008, FRAMM has been a guideline for caries prevention for all 3- to 15-year-olds in the Västra Götaland Region in Sweden and a predominant part is school-based fluoride varnish applications for all 12- to 15-year-olds. The aims were to evaluate dental health-economic data among 12- to 15-year-olds, based on the approximal caries prevalence at the age of 12, and to evaluate cost-effectiveness. Caries data for 13,490 adolescents born in 1993 who did not take part and 11,321 adolescents born in 1998 who followed this guideline were extracted from dental records. Those with no dentin and/or enamel caries lesions and/or fillings on the approximal surfaces were pooled into the “low” subgroup, those with 1–3 into the “moderate” subgroup and those with ≥4 into the “high” subgroup. The results revealed that the low subgroup had a low approximal caries increment compared with the moderate and high subgroups during the 4-year study period. In all groups, there were statistically significant differences between those who took part in the guideline and those who did not. The analysis of cost-effectiveness revealed the lowest incremental cost-effectiveness ratio (ICER) for the high subgroup for decayed and/or filled approximal surfaces (DFSa) and approximal enamel lesions together and the highest ICER for the low subgroup for DFSa alone. To conclude, the FRAMM Guideline reduced the caries increment for adolescents with low, moderate and high approximal caries prevalence. The subgroup with the most favourable cost-effectiveness comprised those with a high caries prevalence at the age of 12.

Cost-effectiveness of spinal manipulation, exercise, and self-management for spinal pain using an individual participant data meta-analysis approach: a study protocol

Background

Spinal pain is a common and disabling condition with considerable socioeconomic burden. Spine pain management in the United States has gathered increased scrutiny amidst concerns of overutilization of costly and potentially harmful interventions and diagnostic tests. Conservative interventions such as spinal manipulation, exercise and self-management may provide value for the care of spinal pain, but little is known regarding the cost-effectiveness of these interventions in the U.S. Our primary objective for this project is to estimate the incremental cost-effectiveness of spinal manipulation, exercise therapy, and self-management for spinal pain using an individual patient data meta-analysis approach.

Methods/design

We will estimate the incremental cost-effectiveness of spinal manipulation, exercise therapy, and self-management using cost and clinical outcome data collected in eight randomized clinical trials performed in the U.S. Cost-effectiveness will be assessed from both societal and healthcare perspectives using QALYs, pain intensity, and disability as effectiveness measures. The eight randomized clinical trials used similar methods and included different combinations of spinal manipulation, exercise therapy, or self-management for spinal pain. They also collected similar clinical outcome, healthcare utilization, and work productivity data. A two-stage approach to individual patient data meta-analysis will be conducted.

Discussion

This project capitalizes on a unique opportunity to combine clinical and economic data collected in a several clinical trials that used similar methods. The findings will provide important information on the value of spinal manipulation, exercise therapy, and self-management for spinal pain management in the U.S.

Disparities in model-based cost-effectiveness analyses of tuberculosis diagnosis: A systematic review

Background

Structural approach disparities were minimally addressed in past systematic reviews of model-based cost-effectiveness analyses addressing Tuberculosis management strategies. This review aimed to identify the structural approach disparities in model-based cost-effectiveness analysis studies addressing Tuberculosis diagnosis and describe potential hazards caused by those disparities.

Methods

A systematic search to identify studies published before October 2015 was performed in five electronic databases. After removal of duplication, studies’ titles and abstracts were screened based on predetermined criteria. The full texts of potentially relevant studies were subsequently screened and excluded when they did not address active pulmonary Tuberculosis diagnosis. Quality of the studies was assessed using the “Philips’ checklist.” Various data regarding general information, cost-effectiveness results, and disease modeling were extracted using standardized data extraction forms. Data pertaining to models’ structural approaches were compared and analyzed qualitatively for their applicability in various study settings, as well as their potential influence on main outcomes and cost-effectiveness conclusion.

Results

A total of 27 studies were included in the review. Most studies utilized a static model, which could underestimate the cost-effectiveness of the diagnostic tools strategies, due to the omission of indirect diagnosis effects, i.e. transmission reduction. A few structural assumption disparities were found in the dynamic models. Extensive disparities were found in the static models, consisting of varying structural assumptions regarding treatment outcomes, clinical diagnosis and empirical treatment, inpatient discharge decision, and re-diagnosis of false negative patients.

Conclusion

In cost-effectiveness analysis studies addressing active pulmonary Tuberculosis diagnosis, models showed numerous disparities in their structural approaches. Several structural approaches could be inapplicable in certain settings. Furthermore, they could contribute to under- or overestimation of the cost-effectiveness of the diagnosis tools or strategies. They could thus lead to ambiguities and difficulties when interpreting a study result. A set of recommendations is proposed to manage issues related to these structural disparities.

Childhood vaccination communication outcomes unpacked and organized in a taxonomy to facilitate core outcome establishment

OBJECTIVES

We present a comprehensive taxonomy of outcomes for childhood vaccination communication interventions. Adding to our earlier map of trial outcomes, we aimed to (1) identify relevant outcomes not measured in trials, (2) identify outcomes from stakeholder focus groups, and (3) organize outcomes into a taxonomy.

STUDY DESIGN AND SETTING

We identified additional outcomes from nonvaccination health communication literature and through parent and health care professional focus groups. We organized outcomes into the taxonomy through iterative discussion and informed by organizational principles established by leaders in core outcome research.

RESULTS

The taxonomy includes three overarching core areas, divided into eight domains and then into outcomes. Core area one is psychosocial impact, including the domains "knowledge or understanding," "attitudes or beliefs," and "decision-making." Core area two is health impact, covering "vaccination status and behaviors" and "health status and well-being." Core area three is community, social, or health system impact, containing "intervention design and implementation," "community participation," and "resource use."

CONCLUSION

To our knowledge, this taxonomy is the first attempt to conceptualize the range of potential outcomes for vaccination communication. It can be used by researchers selecting outcomes for complex communication interventions. We will also present the taxonomy to stakeholders to establish core outcome domains.

How to prepare a systematic review of economic evaluations for informing evidence-based healthcare decisions: a five-step approach (part 1/3)

INTRODUCTION

Systematic reviews of economic evaluations are useful for synthesizing economic evidence about health interventions and for informing evidence-based decisions. Areas covered: As there is no detailed description of the methods for performing a systematic review of economic evidence, this paper aims to provide an overview of state-of-the-art methodology. This is laid out in a 5-step approach, as follows: step 1) initiating a systematic review; step 2) identifying (full) economic evaluations; step 3) data extraction, risk of bias and transferability assessment; step 4) reporting results; step 5) discussion and interpretation of findings. Expert commentary: The paper aims to help inexperienced reviewers and clinical practice guideline developers, but also to be a resource for experts in the field who want to check on current methodological developments.

Mind the Gap! A Multilevel Analysis of Factors Related to Variation in Published Cost-Effectiveness Estimates within and between Countries

Background. Published cost-effectiveness estimates can vary considerably, both within and between countries. Despite extensive discussion, little is known empirically about factors relating to these variations. Objectives. To use multilevel statistical modeling to integrate cost-effectiveness estimates from published economic evaluations to investigate potential causes of variation. Methods. Cost-effectiveness studies of statins for cardiovascular disease prevention were identified by systematic review. Estimates of incremental costs and effects were extracted from reported base case, sensitivity, and subgroup analyses, with estimates grouped in studies and in countries. Three bivariate models were developed: a cross-classified model to accommodate data from multinational studies, a hierarchical model with multinational data allocated to a single category at country level, and a hierarchical model excluding multinational data. Covariates at different levels were drawn from a long list of factors suggested in the literature. Results. We found 67 studies reporting 2094 cost-effectiveness estimates relating to 23 countries (6 studies reporting for more than 1 country). Data and study-level covariates included patient characteristics, intervention and comparator cost, and some study methods (e.g., discount rates and time horizon). After adjusting for these factors, the proportion of variation attributable to countries was negligible in the cross-classified model but moderate in the hierarchical models (14%−19% of total variance). Country-level variables that improved the fit of the hierarchical models included measures of income and health care finance, health care resources, and population risks. Conclusions. Our analysis suggested that variability in published cost-effectiveness estimates is related more to differences in study methods than to differences in national context. Multinational studies were associated with much lower country-level variation than single-country studies. These findings are for a single clinical question and may be atypical.

Comparative efficiency research (COMER): meta-analysis of cost-effectiveness studies

BACKGROUND

The aim of this study was to create a new meta-analysis method for cost-effectiveness studies using comparative efficiency research (COMER).

METHODS

We built a new score named total incremental net benefit (TINB), with inverse variance weighting of incremental net benefits (INB). This permits determination of whether an alternative is cost-effective, given a specific threshold (TINB > 0 test). Before validation of the model, the structure of dependence between costs and quality-adjusted life years (QoL) was analysed using copula distributions. The goodness-of-fit of a Spanish prospective observational study (n = 498) was analysed using the Independent, Gaussian, T, Gumbel, Clayton, Frank and Placket copulas. Validation was carried out by simulating a copula distribution with log-normal distribution for costs and gamma distribution for disutilities. Hypothetical cohorts were created by varying the sample size (n: 15-500) and assuming three scenarios (1-cost-effective; 2-non-cost-effective; 3-dominant). The COMER result was compared to the theoretical result according to the incremental cost-effectiveness ratio (ICER) and the INB, assuming a margin of error of 2,000 and 500 monetary units, respectively.

RESULTS

The Frank copula with positive dependence (-0.4279) showed a goodness-of-fit sufficient to represent costs and QoL (p-values 0.524 and 0.808). The theoretical INB was within the 95% confidence interval of the TINB, based on 15 individuals with a probability > 80% for scenarios 1 and 2, and > 90% for scenario 3. The TINB > 0 test with 15 individuals showed p-values of 0.0105 (SD: 0.0411) for scenario 1, 0.613 (SD: 0.265) for scenario 2 and < 0.0001 for scenario 3.

CONCLUSIONS

COMER is a valid tool for combining cost-effectiveness studies and may be of use to health decision makers.

Can aging in place be cost effective? A systematic review

PURPOSE OF THE STUDY

To systematically review cost, cost-minimization and cost-effectiveness studies for assisted living technologies (ALTs) that specifically enable older people to 'age in place' and highlight what further research is needed to inform decisions regarding aging in place.

DESIGN

People aged 65+ and their live-in carers (where applicable), using an ALT to age in place at home opposed to a community-dwelling arrangement.

METHODS

Studies were identified using a predefined search strategy on two key economic and cost evaluation databases NHS EED, HEED. Studies were assessed using methods recommended by the Campbell and Cochrane Economic Methods Group and presented in a narrative synthesis style.

RESULTS

Eight eligible studies were identified from North America spread over a diverse geographical range. The majority of studies reported the ALT intervention group as having lower resource use costs than the control group; though the low methodological quality and heterogeneity of the individual costs and outcomes reported across studies must be considered.

IMPLICATIONS

The studies suggest that in some cases ALTs may reduce costs, though little data were identified and what there were was of poor quality. Methods to capture quality of life gains were not used, therefore potential effects on health and wellbeing may be missed. Further research is required using newer developments such as the capabilities approach. High quality studies assessing the cost-effectiveness of ALTs for ageing in place are required before robust conclusion on their use can be drawn.