Economic evaluation and decision making in the UK

Considerations Around the Inclusion of Children and Young People's Time in Economic Evaluation: Findings from an International Delphi Study

BACKGROUND

People's time is a finite resource and a valuable input that ought to be considered in economic evaluations taking a broad, societal perspective. Yet, evaluations of interventions focusing on children and young people (CYP) rarely account for the opportunity cost of time in this population. As a key reason for this, health economists have pointed to uncertainty around when it is appropriate to include CYP time-related costs in an economic evaluation and highlighted the lack of clear guidance on the topic.

METHODS

With this in mind, we carried out a Delphi study to establish a list of relevant considerations for researchers to utilise whilst making decisions about whether and when to include CYP time in their economic evaluations. Delphi panellists were asked to propose and rate a set of possible considerations and provide additional thoughts on their ratings. Ratings were summarised using descriptive statistics, and text comments were interrogated through thematic analysis.

FINDINGS

A total of 73 panellists across 16 countries completed both rounds of a two-round Delphi study. Panellists' ratings showed that, when thinking about whether to include displaced CYP time in an economic evaluation, it is very important to consider whether: (1) inclusion would be in line with specified perspective(s) (median score: 9), (2) CYP's time may already be accounted for in other parts of the evaluation (median score: 8), (3) the amount of forgone time is substantial, either in absolute or relative terms (median score: 7) and (4) inclusion of CYP's time costs would be of interest to decision-makers (median score: 7). Respondents thought that considerations such as (1) whether inclusion would be of interest to the research community (median score: 6), (2) whether CYP's time displaced by receiving treatment is 'school' or 'play' time (median score: 5), and (3) whether CYP's are old enough for their time to be considered valuable (median score: 5) are moderately important. A range of views was offered to support beliefs and ratings, many of which were underpinned by compelling normative questions.

The reimbursement process in three national healthcare systems: variation in time to reimbursement of pembrolizumab for metastatic non-small cell lung cancer

In this article, we focus on the reimbursement process, and as an example, characterize the time to reimbursement of pembrolizumab, a PD-1 immune checkpoint inhibitor for treatment of metastatic NSCLC from publicly available websites, in three different healthcare systems: The National Institute for Health and Care Excellence (NICE) in the UK, the Pharmaceutical Benefits Advisory Committee (PBAC) in Australia, and the National Advisory Committee for the Basket of Health Services in Israel, all who have publicly funded health systems which include drug coverage. Our study found that there are substantial differences in time to reimbursement of pembrolizumab for the same conditions in different countries, with NICE and The National Advisory Committee for the Basket of Health Services in Israel approving one condition at the same time, Israel approving two conditions earlier than NICE, and PBAC lagging behind for every condition. These differences could be due to the differences in health policy systems and the many factors that affect reimbursement. Comparing the reimbursement process between different countries can highlight the challenges facing their health systems in early adoption of new treatments.

"Slow science" for 21st century healthcare: reinventing health service research that serves fast-paced, high-complexity care organisations

Purpose

The purpose of this paper is to argue for an improved conceptualisation of health service research, using Stengers' (2018) metaphor of “slow science” as a critical yardstick.

Design/methodology/approach

The paper is structured in three parts. It first reviews the field of health services research and the approaches that dominate it. It then considers the healthcare research approaches whose principles and methodologies are more aligned with “slow science” before presenting a description of a “slow science” project in which the authors are currently engaged.

Findings

Current approaches to health service research struggle to offer adequate resources for resolving frontline complexity, principally because they set more store by knowledge generalisation, disciplinary continuity and integrity and the consolidation of expertise, than by engaging with frontline complexity on its terms, negotiating issues with frontline staff and patients on their terms and framing findings and solutions in ways that key in to the in situ dynamics and complexities that define health service delivery.

Originality/value

There is a need to engage in a paradigm shift that engages health services as co-researchers, prioritising practical change and local involvement over knowledge production. Economics is a research field where the products are of natural appeal to powerful health service managers. A “slow science” approach adopted by the embedded Economist Program with its emphasis on pre-implementation, knowledge mobilisation and parallel site capacity development sets out how research can be flexibly produced to improve health services.

Embedding an economist in regional and rural health services to add value and reduce waste by improving local-level decision-making: protocol for the 'embedded Economist' program and evaluation

Background

Systematic approaches to the inclusion of economic evaluation in national healthcare decision-making are usual. It is less common for economic evaluation to be routinely undertaken at the ‘local-level’ (e.g. in a health service or hospital) despite the largest proportion of health care expenditure being determined at this service level and recognition by local health service decision makers of the need for capacity building in economic evaluation skills. This paper describes a novel program – the embedded Economist (eE) Program. The eE Program aims to increase local health service staff awareness of, and develop their capacity to access and apply, economic evaluation principles in decision making. The eE program evaluation is also described. The aim of the evaluation is to capture the contextual, procedural and relational aspects that assist and detract from the eE program aims; as well as the outcomes and impact from the specific eE projects.

Methods

The eE Program consists of a embedding a health economist in six health services and the provision of supported education in applied economic evaluation, provided via a community of practice and a university course. The embedded approach is grounded in co-production, embedded researchers and ‘slow science’. The sites, participants, and program design are described. The program evaluation includes qualitative data collection via surveys, semi-structured interviews, observations and field diaries. In order to share interim findings, data are collected and analysed prior, during and after implementation of the eE program, at each of the six health service sites. The surveys will be analysed by calculating frequencies and descriptive statistics. A thematic analysis will be conducted on interview, observation and filed diary data. The Framework to Assess the Impact from Translational health research (FAIT) is utilised to assess the overall impact of the eE Program.

Discussion

This program and evaluation will contribute to knowledge about how best to build capacity and skills in economic evaluation amongst decision-makers working in local-level health services. It will examine the extent to which participants are able to improve their ability to utilise evidence to inform decisions, avoid waste and improve the value of care delivery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06181-1.

Economic impact of clinical pharmaceutical activities in hospital wards: A systematic review

BACKGROUND

The positive impact of clinical pharmacy services (CPS) in improving clinical outcomes such as reduction of drug related problems is well demonstrated. Despite these results, the deployment of these activities is not systematically observed in the hospital setting.

OBJECTIVES

This systematic review first aimed to describe existing evidence regarding economic evaluation of ward-based CPS focusing on the entire treatment of a patient in a hospital setting. Secondly, the quality of economic evaluations of existing evidence was assessed.

METHODS

A comprehensive literature search was performed in PubMed/Medline, Science Direct and the NHS Economic Evaluation databases from January 2000 to March 2019. English or French language articles describing an economic evaluation of ward-based CPS on inpatients in hospital settings were included. Articles not describing a single study, dealing with a CPS not considering the entire medication regimen of the patient or presenting both inpatient and outpatient CPS were excluded. Selected articles were analyzed according to Drummond's check-list for assessing economic evaluations.

RESULTS

Forty-one studies were included. About one third were American publications. CPS implemented in ICU represented about half of the selected articles. Pharmacist-to-bed ratios varied according to countries and care unit type with the most favorable ratios in ICU and in American studies. Cost-avoidance was mostly used to express economic impact and ranged from €1579 to €3,089 328. Studies yielding the greater economic impact were conducted in the USA with implementation of full-time equivalents pharmacists or establishing of collaborative practice agreements. Only 6 articles dealt correctly with at least 7 of the 10 Drummond's checklist assessment criteria.

CONCLUSION

This review suggests that the existing evidence is not sufficient to conclude to a positive economic impact of CPS conducted according to clinical pharmacy guidelines. Funding resources, remuneration of clinical pharmacy activities and provision of standardized national clinical and economic databases appear to be essential evolutions to improve CPS development.

Health Risk Assessment Indicators for the Left-Behind Elderly in Rural China: A Delphi Study

In China, many young and middle-aged rural residents move to urban areas each year. The rural elderly are left behind. The number of the rural left-behind elderly is increasing with urbanization, but it is unclear which indicators can be used to assess their health condition. The health risk assessment index system was developed to improve the health level of the rural left-behind elderly. A two-round web-based Delphi process was used to organize the recommendations from fifteen Chinese experts in geriatrics, health management, social psychology who participated in this study. Meaningfulness, importance, modifiability, and comprehensive value of the health risk assessment indicators in the index system were evaluated. The effective recovery rates of the two-round Delphi were 86.67% and 92.31%, respectively. The judgement coefficient and the authority coefficient were 0.87 and 0.82, respectively. The expert familiarity was 0.76. Ultimately, the health risk assessment index system for the rural left-behind elderly consisted of five first-level indicators, thirteen second-level indicators, and sixty-six third-level indicators. The final indicators can be used to evaluate the health of the rural left-behind elderly and provide the basis for additional health risk interventions.

Understanding the global measurement of willingness to pay in health

Objective: To understand the different methodologies used to elicit willingness to pay for health and the value of a statistical life year through surveys. Methodology: A systematic review of the literature was undertaken to identify studies using surveys to estimate either willingness to pay for health or the value of a statistical life year. Each study was reviewed and the study setting, sample size, sample description, survey administration (online or face to face), survey methodology, and results were extracted. The results of the studies were then compared to any published national guidelines of cost-effectiveness thresholds to determine their accuracy. Results: Eighteen studies were included in the review with 15 classified as willingness to pay and 3 value of a statistical life. The included studies covered Asia (n = 6), Europe (n = 4), the Middle East (n = 1), and North America (n = 5), with one study taking a global perspective. There were substantial differences in both the methodologies and the estimates of both willingness to pay and value of a statistical life between the different studies. Conclusion: Different methods used to elicit willingness to pay and the value of a statistical life year resulted in a wide range of estimates.

A Systematic Review of Utility Score Assessments in the Breast Surgery Cost-Analysis Literature

BACKGROUND

Surgery for breast cancer can have significant impact on patient quality-of-life. Cost-utility analysis provides a way to analyze the economic impact of a surgical procedure with the change in a patient's quality of life. Utility scores are used in these analyses to quantify the impact on quality of life. We undertook a systematic review of the literature on breast cancer surgical procedures to compile a repository of utility scores and to assess gaps in the current literature.

METHODS

Following PRISMA guidelines, a systematic review was performed for studies reporting utility scores for breast surgery and breast reconstruction. The health states and utility scores were extracted and grouped into seven procedural categories based on oncologic and reconstructive methods. Mean utility score and ranges were calculated and reported for each procedural category.

RESULTS

Nineteen articles met the inclusion criteria assessing 118 health states. Most utility scores were obtained from healthcare professionals. Breast-conserving therapy yielded the highest mean utility score at 0.79, whereas mastectomy yielded a mean utility score of 0.75. Among reconstruction health states, implant reconstruction had a lower score than autologous reconstruction (0.64 implant vs. latissimus dorsi 0.69 and TRAM/DIEP 0.71). No utility scores were found associated with oncoplasty or nipple-sparing mastectomy procedures.

CONCLUSIONS

A reliable body of utility scores is important in enabling future cost-utility and value-based analysis comparisons for breast surgical oncology. Additional work is needed to obtain health state assessments from the patient perspective, as well as assessment of more modern surgical and reconstructive approaches.

Developing outcome, process and balancing measures for an emergency department longitudinal patient monitoring system using a modified Delphi

BACKGROUND

Early warning score systems have been widely recommended for use to detect clinical deterioration in patients. The Irish National Emergency Medicine Programme has developed and piloted an emergency department specific early warning score system. The objective of this study was to develop a consensus among frontline healthcare staff, quality and safety staff and health systems researchers regarding evaluation measures for an early warning score system in the Emergency Department.

METHODS

Participatory action research including a modified Delphi consensus building technique with frontline hospital staff, quality and safety staff, health systems researchers, local and national emergency medicine stakeholders was the method employed in this study. In Stage One, a workshop was held with the participatory action research team including frontline hospital staff, quality and safety staff and health systems researchers to gather suggestions regarding the evaluation measures. In Stage Two, an electronic modified-Delphi study was undertaken with a panel consisting of the workshop participants, key local and national emergency medicine stakeholders. Descriptive statistics were used to summarise the characteristics of the panellists who completed the questionnaires in each round. The mean Likert rating, standard deviation and 95% bias-corrected bootstrapped confidence interval for each variable was calculated. Bonferroni corrections were applied to take account of multiple testing. Data were analysed using Stata 14.0 SE.

RESULTS

Using the Institute for Healthcare Improvement framework, 12 process, outcome and balancing metrics for measuring the effectiveness of an ED-specific early warning score system were developed.

CONCLUSION

There are currently no published measures for evaluating the effectiveness of an ED early warning score system. It was possible in this study to develop a suite of evaluation measures using a modified Delphi consensus approach. Using the collective expertise of frontline hospital staff, quality and safety staff and health systems researchers to develop and categorise the initial set of potential measures was an innovative and unique element of this study.

Does Selecting Covariates Using Factor Analysis in Mapping Algorithms Improve Predictive Accuracy? A Case of Predicting EQ-5D-5L and SF-6D Utilities from the Women's Health Questionnaire

BACKGROUND

In addition to theoretical justifications, many statistical methods have been used for selecting covariates to include in algorithms mapping nonutility measures onto utilities. However, it is not clear whether using exploratory factor analysis (EFA) as one such method improves the predictive ability of these algorithms.

OBJECTIVE

This question is addressed within the context of mapping a non-utility-based outcome, the core 23-item Women's Health Questionnaire (WHQ-23), onto two utility instruments: five-level EuroQol five-dimensional questionnaire (EQ-5D-5L) and the six-dimensional health state short form (derived from short form 36 health survey) (SF-6D).

METHODS

Data on all three outcomes were collected from 455 women from the Australian general population participating in a study assessing attitudes toward in vitro fertilization. Statistical methods for selecting covariates included stepwise regression (SW), including all covariates (Include all), multivariable fractional polynomial (MFP), and EFA. The predictive accuracy of 108 regression models was assessed using five criteria: mean absolute error, root mean squared error, correlation, distribution of predicted utilities, and proportion of predictions with absolute errors of less than 0.0.5. Validation of "primary" models was carried out on random samples of the in vitro fertilization study.

RESULTS

The best results for EQ-5D-5L and SF-6D predictions were obtained from models using SW, "Include all," and MFP covariate-selection approaches. Root mean squared error (0.0762-0.1434) and mean absolute error (0.0590-0.0924) estimates for these models were within the range of published estimates. EFA was outperformed by other covariate-selection methods.

CONCLUSIONS

It is possible to predict valid utilities from the WHQ-23 using regression methods based on SW, "Include all," and MFP covariate-selection techniques.

Suitability of the Epworth Sleepiness Scale (ESS) for Economic Evaluation: An Assessment of Its Convergent and Discriminant Validity

OBJECTIVE

To assess the suitability for use within economic evaluation of a widely used sleep-related instrument (the Epworth Sleepiness Scale [ESS]) by examining its convergent and discriminant validity with two widely used generic preference-based instruments (Short-Form 36 [SF-36] and the Assessment of Quality of Life 4 dimensions [AQoL-4D]).

METHODS

Data from a cross-section of 2,236 community-dwelling Australian men were analyzed. Convergent validity was investigated using Spearman's correlation, intraclass correlation, and modified Bland-Altman plots, while discriminant validity was examined using Kruskal Wallis tests.

RESULTS

All instruments showed good discriminant validity. The ESS was weakly correlated to the Short Form 6 dimension, or SF-6D (derived from the SF-36) and AQoL-4D utilities (r = 0.20 and r = 0.19, respectively). Correlations between ESS and SF-36/AQoL-4D dimensions measuring the same construct were all in the hypothesized directions but also weak (range of absolute r = 0.00 to 0.18). The level of agreement between the ESS and AQoL-4D was the weakest, followed by that between the ESS and SF-6D. Moderate convergent validity was seen between the utilities.

CONCLUSIONS

The lack of convergent validity between the ESS and the preference-based instruments shows that sleep-related constructs are not captured by the latter. The ESS has, however, demonstrated good discriminant validity comparable to that of the AQoL-4D and the SF-36/SF-6D and would therefore be equally useful for measuring subgroup differences within economic evaluation. We therefore recommend using the ESS within cost-effectiveness analysis as a complement to preference-based instruments in order to capture sleep-specific constructs not measured by the latter.

Development of Methods for the Mapping of Utilities Using Mixture Models: Mapping the AQLQ-S to the EQ-5D-5L and the HUI3 in Patients with Asthma

BACKGROUND

Studies have shown that methods based on mixture models work well when mapping clinical to preference-based methods.

OBJECTIVES

To develop these methods in different ways and to compare performance in a case study.

METHODS

Data from 856 patients with asthma allowed mapping between the Asthma Quality of Life Questionnaire and both the five-level EuroQol five-dimensional questionnaire (EQ-5D-5L) and the health utilities index mark 3 (HUI3). Adjusted limited dependent variable mixture models and beta-based mixture models were estimated. Optional inclusion of the gap between full health and the next value as well as a mass point at the next feasible value were explored.

RESULTS

In all cases, model specifications formally modeling the gap between full health and the next feasible value were an improvement on those that did not. Mapping to the HUI3 required more components in the mixture models than did mapping to the EQ-5D-5L because of its uneven distribution. The optimal beta-based mixture models mapping to the HUI3 included a probability mass at the utility value adjacent to full health. This is not the case when estimating the EQ-5D-5L, because of the low proportion of observations at this point.

CONCLUSIONS

Beta-based mixture models marginally outperformed adjusted limited dependent variable mixture models with the same number of components in this data set. Nevertheless, they require a larger number of parameters and longer estimation time. Both mixture model types closely fit both EQ-5D-5L and HUI data. Standard mapping approaches typically lead to biased estimates of health gain. The mixture model approaches exhibit no such bias. Both can be used with confidence in applied cost-effectiveness studies. Future mapping studies in other disease areas should consider similar methods.

PRIORITIES FOR HEALTH ECONOMIC METHODOLOGICAL RESEARCH: RESULTS OF AN EXPERT CONSULTATION

BACKGROUND

The importance of economic evaluation in decision making is growing with increasing budgetary pressures on health systems. Diverse economic evidence is available for a range of interventions across national contexts within Europe, but little attention has been given to identifying evidence gaps that, if filled, could contribute to more efficient allocation of resources. One objective of the Research Agenda for Health Economic Evaluation project is to determine the most important methodological evidence gaps for the ten highest burden conditions in the European Union (EU), and to suggest ways of filling these gaps.

METHODS

The highest burden conditions in the EU by Disability Adjusted Life Years were determined using the Global Burden of Disease study. Clinical interventions were identified for each condition based on published guidelines, and economic evaluations indexed in MEDLINE were mapped to each intervention. A panel of public health and health economics experts discussed the evidence during a workshop and identified evidence gaps.

RESULTS

The literature analysis contributed to identifying cross-cutting methodological and technical issues, which were considered by the expert panel to derive methodological research priorities.

CONCLUSIONS

The panel suggests a research agenda for health economics which incorporates the use of real-world evidence in the assessment of new and existing interventions; increased understanding of cost-effectiveness according to patient characteristics beyond the "-omics" approach to inform both investment and disinvestment decisions; methods for assessment of complex interventions; improved cross-talk between economic evaluations from health and other sectors; early health technology assessment; and standardized, transferable approaches to economic modeling.

HEALTH TECHNOLOGY DISINVESTMENT WORLDWIDE: OVERVIEW OF PROGRAMS AND POSSIBLE DETERMINANTS

Objectives:In the past decade, there has been a growing interest in health technology disinvestment. A disinvestment process should involve all relevant stakeholders to identify and deliver the most effective, safe, and cost-effective healthcare interventions. The aim of the present study was to describe the state of the art of health technology disinvestment around the world and to identify parameters that could be associated with the implementation of disinvestment programs.

Methods:A systematic review of the literature was performed from database inception to November 2014, together with the collection of original data on socio-economic indicators from forty countries.

Results:Overall, 1,456 records (1,199 from electronic databases and 257 from other sources) were initially retrieved. After analyzing 172 full text articles, 38 papers describing fifteen disinvestment programs/experiences in eight countries were included. The majority (12/15) of disinvestment programs began after 2006. As expected, these programs were more common in developed countries, 63 percent of which had a Beveridge model healthcare system. The univariate analysis showed that countries with disinvestment programs had a significantly higher level of Human Development Index, Gross Domestic Product per capita, public expenditure on health and social services, life expectancy at birth and a lower level of infant mortality rate, and of perceived corruption. The existence of HTA agencies in the country was a strong predictor (p= .034) for the development of disinvestment programs.

Conclusions:The most significant variables in the univariate analysis were connected by a common factor, potentially related to the overall development stage of the country.

INFLUENCE OF HEALTH TECHNOLOGY ASSESSMENT AND ITS MEASUREMENT

Objectives: The aim of this study was to obtain information on methods used to measure health technology assessment (HTA) influence, decisions that were influenced, and outcomes linked to HTA.

Methods: Electronic databases were used to locate studies in which HTA influence had been demonstrated. Inclusion criteria were studies that reliably reported consideration by decision makers of HTA findings; comparative studies of technology use before and after HTA; and details of changes in policy, health outcomes, or research that could be credibly linked to an HTA.

Results: Fifty-one studies were selected for review. Settings were national (24), regional (12), both national and regional (3) hospitals (9), and multinational (3). The most common approach to appraisal of influence was review of policy or administrative decisions following HTA recommendations (51 percent). Eighteen studies (35 percent) reported interview or survey findings, thirteen (26 percent) reviewed administrative data, and six considered the influence of primary studies. Of 142 decisions informed by HTA, the most common types were on routine clinical practice (67 percent of studies), coverage (63 percent), and program operation (37 percent). The most frequent indications of HTA influence were on decisions related to resource allocation (59 percent), change in practice pattern (31 percent), and incorporation of HTA details in reference material (18 percent). Few publications assessed the contribution of HTA to changing patient outcomes.

Conclusions: The literature on HTA influence remains limited, with little on longer term effects on practice and outcomes. The reviewed publications indicated how HTA is being used in different settings and approaches to measuring its influence that might be more widely applied, such as surveys and monitoring administrative data.

Mapping Between the Sydney Asthma Quality of Life Questionnaire (AQLQ-S) and Five Multi-Attribute Utility Instruments (MAUIs)

PURPOSE

Economic evaluation of health services commonly requires information regarding health-state utilities. Sometimes this information is not available but non-utility measures of quality of life may have been collected from which the required utilities can be estimated. This paper examines the possibility of mapping a non-utility-based outcome, the Sydney Asthma Quality of Life Questionnaire (AQLQ-S), onto five multi-attribute utility instruments: Assessment of Quality of Life 8 Dimensions (AQoL-8D), EuroQoL 5 Dimensions 5-Level (EQ-5D-5L), Health Utilities Index Mark 3 (HUI3), 15 Dimensions (15D), and the Short-Form 6 Dimensions (SF-6D).

METHODS

Data for 856 individuals with asthma were obtained from a large Multi-Instrument Comparison (MIC) survey. Four statistical techniques were employed to estimate utilities from the AQLQ-S. The predictive accuracy of 180 regression models was assessed using six criteria: mean absolute error (MAE), root mean squared error (RMSE), correlation, distribution of predicted utilities, distribution of residuals, and proportion of predictions with absolute errors <0.0.5. Validation of initial 'primary' models was carried out on a random sample of the MIC data.

RESULTS

Best results were obtained with non-linear models that included a quadratic term for the AQLQ-S score along with demographic variables. The four statistical techniques predicted models that performed differently when assessed by the six criteria; however, the best results, for both the estimation and validation samples, were obtained using a generalised linear model (GLM estimator).

CONCLUSIONS

It is possible to predict valid utilities from the AQLQ-S using regression methods. We recommend GLM models for this exercise.

The Use of Economic Evidence to Inform Drug Pricing Decisions in Jordan

BACKGROUND

Drug pricing is an example of a priority setting in a developing country with official requirements for the use of cost-effectiveness (CE) evidence.

OBJECTIVE

To describe the role of economic evidence in drug pricing decisions in Jordan.

METHODS

A prospective review of all applications submitted between November 2013 and May 2015 to the Jordan Food and Drug Association's drug pricing committee was carried out. All applications that involved requests for CE evidence were reviewed. Details on the type of study, the extent, and whether the evidence submitted was part of the formal deliberations were extracted and summarized.

RESULTS

The committee reviewed a total of 1608 drug pricing applications over the period of the study. CE evidence was requested in only 11 applications. The submitted evidence was of limited use to the committee due to concerns about quality, relevance of studies, and lack of pharmacoeconomic expertise. There were also no clear rules describing how CE would inform pricing decisions.

CONCLUSIONS

Limited local data and health economic experience were the main barriers to the use of economic evidence in drug pricing decisions in Jordan. In addition, there are no official rules describing the elements and process by which the CE evidence would inform drug pricing decisions. This study summarized accumulated observations for the current use of economic evaluations and evidence-based decision making in Jordan. Recommendations have been proposed to applicants and key decision makers to enhance the role of economic evidence in influencing health policies and evidence-based decision making across priority settings.

An economic cost analysis of emergency department key performance indicators in Ireland

OBJECTIVES

High quality data is fundamental to using key performance indicators (KPIs) for performance monitoring. However, the resources required to collect high quality data are often significant and should usually be targeted at high priority areas. As part of a study of 11 emergency department (ED) KPIs in Ireland, the primary objective of this study was to estimate the relative cost of collecting the additional minimum data set (MDS) elements for those 11 KPIs.

METHODS

An economic cost analysis focused on 12 EDs in the Republic of Ireland. The resource use data were obtained using two separate focus group interviews. The number of available MDS elements was obtained from a sample of 100 patient records per KPI per participating ED. Unit costs for all resource use were taken at the midpoint of the relevant staff salary scales.

RESULTS

An ED would need to spend an estimated additional &OV0556;3561 per month on average to capture all the MDS elements relevant to the 11 KPIs investigated. The additional cost ranges from 14.8 to 39.2%; this range is 13.9-32.3% for small EDs, whereas the range for medium EDs is 11.7-40%. Regional EDs have a higher additional estimated cost to capture all the relevant MDS elements (&OV0556;3907), compared with urban EDs (&OV0556;3353).

CONCLUSION

The additional cost of data collection, contingent on that already collected, required to capture all the relevant MDS elements for the KPIs examined, ranges from 14.8 to 39.2% per KPI, with variation identified between regional and urban hospitals.

A Systematic Review of the State of Economic Evaluation for Health Care in India

BACKGROUND AND OBJECTIVE

Economic evaluations are one of the important tools in policy making for rational allocation of resources. Given the very low public investment in the health sector in India, it is critical that resources are used wisely on interventions proven to yield best results. Hence, we undertook this study to assess the extent and quality of evidence for economic evaluation of health-care interventions and programmes in India.

METHODS

A comprehensive search was conducted to search for published full economic evaluations pertaining to India and addressing a health-related intervention or programme. PubMed, Scopus, Embase, ScienceDirect, and York CRD database and websites of important research agencies were identified to search for economic evaluations published from January 1980 to the middle of November 2014. Two researchers independently assessed the quality of the studies based on Drummond and modelling checklist.

RESULTS

Out of a total of 5013 articles enlisted after literature search, a total of 104 met the inclusion criteria for this systematic review. The majority of these papers were cost-effectiveness studies (64%), led by a clinician or public-health professional (77%), using decision analysis-based methods (59%), published in an international journal (80%) and addressing communicable diseases (58%). In addition, 42% were funded by an international funding agency or UN/bilateral aid agency, and 30% focussed on pharmaceuticals. The average quality score of these full economic evaluations was 65.1%. The major limitation was the inability to address uncertainties involved in modelling as only about one-third of the studies assessed modelling structural uncertainties (33%), or ran sub-group analyses to account for heterogeneity (36.5%) or analysed methodological uncertainty (32%).

CONCLUSION

The existing literature on economic evaluations in India is inadequate to feed into sound policy making. There is an urgent need to generate awareness within the government of how economic evaluation can inform and benefit policy making, and at the same time build capacity of health-care professionals in understanding the economic principles of health-care delivery system.

Caveat emptor NICE: biased use of cost-effectiveness is inefficient and inequitable

Concern with the threshold applied in cost-effectiveness analyses by bodies such as NICE distracts attention from their biased use of the principle. The bias results from the prior requirement that an intervention be effective (usually 'clinically effective') before its cost-effectiveness is considered. The underlying justification for the use of cost-effectiveness as a criterion, whatever the threshold adopted, is that decisions in a resource-constrained system have opportunity costs. Their existence rules out any restriction to those interventions that are 'incrementally cost-effective' at a chosen threshold and requires acceptance of those that are 'decrementally cost-effective' at the same threshold. Interventions that fall under the linear ICER line in the South-West quadrant of the cost-effectiveness plane are cost-effective because they create net health benefits, as do those in the North-East quadrant. If there is objection to the fact that they are cost-effective by reducing effectiveness as well as costs, it is possible to reject them, but only on policy grounds other than their failure to be cost-effective. Having established this, the paper considers and seeks to counter the arguments based on these other grounds. Most notably these include those proposing a different threshold in the South-West quadrant from the North-East one, i.e. propose a 'kinked ICER'. Another undesirable consequence of the biased use of cost-effectiveness is the failure to stimulate innovations that would increase overall health gain by being less effective in the condition concerned, but generate more benefits elsewhere. NICE can only reward innovations that cost more.

Sample Size Estimation for Non-Inferiority Trials: Frequentist Approach versus Decision Theory Approach

BACKGROUND

Non-inferiority trials are performed when the main therapeutic effect of the new therapy is expected to be not unacceptably worse than that of the standard therapy, and the new therapy is expected to have advantages over the standard therapy in costs or other (health) consequences. These advantages however are not included in the classic frequentist approach of sample size calculation for non-inferiority trials. In contrast, the decision theory approach of sample size calculation does include these factors. The objective of this study is to compare the conceptual and practical aspects of the frequentist approach and decision theory approach of sample size calculation for non-inferiority trials, thereby demonstrating that the decision theory approach is more appropriate for sample size calculation of non-inferiority trials.

METHODS

The frequentist approach and decision theory approach of sample size calculation for non-inferiority trials are compared and applied to a case of a non-inferiority trial on individually tailored duration of elastic compression stocking therapy compared to two years elastic compression stocking therapy for the prevention of post thrombotic syndrome after deep vein thrombosis.

RESULTS

The two approaches differ substantially in conceptual background, analytical approach, and input requirements. The sample size calculated according to the frequentist approach yielded 788 patients, using a power of 80% and a one-sided significance level of 5%. The decision theory approach indicated that the optimal sample size was 500 patients, with a net value of €92 million.

CONCLUSIONS

This study demonstrates and explains the differences between the classic frequentist approach and the decision theory approach of sample size calculation for non-inferiority trials. We argue that the decision theory approach of sample size estimation is most suitable for sample size calculation of non-inferiority trials.

Methodological variation in economic evaluations conducted in low- and middle-income countries: information for reference case development

Information generated from economic evaluation is increasingly being used to inform health resource allocation decisions globally, including in low- and middle- income countries. However, a crucial consideration for users of the information at a policy level, e.g. funding agencies, is whether the studies are comparable, provide sufficient detail to inform policy decision making, and incorporate inputs from data sources that are reliable and relevant to the context. This review was conducted to inform a methodological standardisation workstream at the Bill and Melinda Gates Foundation (BMGF) and assesses BMGF-funded cost-per-DALY economic evaluations in four programme areas (malaria, tuberculosis, HIV/AIDS and vaccines) in terms of variation in methodology, use of evidence, and quality of reporting. The findings suggest that there is room for improvement in the three areas of assessment, and support the case for the introduction of a standardised methodology or reference case by the BMGF. The findings are also instructive for all institutions that fund economic evaluations in LMICs and who have a desire to improve the ability of economic evaluations to inform resource allocation decisions.

Economic evaluation of prostate cancer screening: a systematic review

ABSTRACT 

This review, based on published papers, aims to describe the costs of prostate cancer screening and to examine whether prostate cancer screening is cost effective. The estimated cost per cancer detected ranged from €1299 in The Netherlands to US$44,355 in the USA. The estimated cost per life-year saved ranged from US$3000 to US$729,000, while the cost per quality-adjusted life year (QALY) was AU$291,817 and Can$371,100. The most appropriate data for economic evaluation of prostate cancer screening should be the cost per QALY gained. The estimated costs per QALY gained by prostate cancer screening were significantly higher than the cost–effectiveness threshold, suggesting that even when based on favorable randomized controlled trials in younger age groups, prostate cancer screening is still not cost effective.

Trends and issues in oncology costs

Approximately 18% of US gross domestic product is spent on healthcare and 5% of that is for cancer care. With rapidly increasing oncologic drug prices, growth in cancer spending will likely far outpace overall healthcare spending growth. Developing cost-saving strategies is imperative, but economizing must not compromise patients' well-being. Providing quality care at the most economical price is the main aim. This article summarizes trends in rising cancer costs, and reviews cost-management strategies, including those proposed in the Affordable Care Act. Many programs economize by correcting inefficiencies, preventing therapeutic failures and eliminating errors. Process improvement is important, but in oncology, medications substantially drive costs. Identifying the most effective and economical treatments requires cost-effectiveness research. At the current pace, the US payers cannot continue to afford increasing costs for cancer treatments. Research on maximizing patient outcomes for reasonable costs is essential. More analyses of quality of life assessment and cost-effectiveness can support future decisions about cancer care.

Study protocol for valuing EQ-5D-3L and EORTC-8D health states in a representative population sample in Sri Lanka

BACKGROUND

Economic evaluations to inform decisions about allocation of health resources are scarce in Low and Middle Income Countries, including in Sri Lanka. This is in part due to a lack of country-specific utility weights, which are necessary to derive appropriate Quality Adjusted Life Years. The EQ-5D-3 L, a generic multi-attribute instrument (MAUI), is most widely used to measure and value health states in high income countries; nevertheless, the sensitivity of generic MAUIs has been criticised in some conditions such as cancer. This article describes a protocol to produce both a generic EQ-5D-3 L and cancer specific EORTC-8D utility index in Sri Lanka.

METHOD

EQ-5D-3 L and EORTC-8D health states will be valued using the Time Trade-Off technique, by a representative population sample (n = 780 invited) identified using stratified multi-stage cluster sampling with probability proportionate to size method. Households will be randomly selected within 30 clusters across four districts; one adult (≥ 18 years) within each household will be selected using the Kish grid method.Data will be collected via face-to-face interview, with a Time Trade-Off board employed as a visual aid. Of the 243 EQ-5D-3 L and 81,290 EORTC-8D health states, 196 and 84 respectively will be directly valued. In EQ-5D-3 L, all health states that combine level 3 on mobility with either level 1 on usual activities or self-care were excluded. Each participant will first complete the EQ-5D-3 L, rank and value 14 EQ-5D-3 L states (plus the worst health state and "immediate death"), and then rank and value seven EORTC-8D states (plus "immediate death"). Participant demographic and health characteristics will be also collected.Regression models will be fitted to estimate utility indices for EQ-5D-3 L and EORTC-8D health states for Sri Lanka. The dependent variable will be the utility value. Different specifications of independent variables will be derived from the ordinal EQ-5D-3 L to test for the best-fitting model.

DISCUSSION

In Sri Lanka, a LMIC health state valuation will have to be carried out using face to face interview instead of online methods. The proposed study will provide the first country-specific health state valuations for Sri Lanka, and one of the first valuations to be completed in a South Asian Country.

Value of research and value of development in early assessments of new medical technologies

OBJECTIVES

In early stages of development of new medical technologies, there are conceptually separate but related societal decisions to be made concerning adoption, further development (i.e., technical improvement), and research (i.e., clinical trials) of new technologies. This article presents a framework to simultaneously support these three decisions from a societal perspective. The framework is applied to the 70-gene signature, a gene-expression profile for breast cancer, deciding which patients should receive adjuvant systemic therapy after surgery. The "original" signature performed on fresh frozen tissue (70G-FFT) could be further developed to a paraffin-based signature (70G-PAR) to reduce test failures.

METHODS

A Markov decision model comparing the "current" guideline Adjuvant Online (AO), 70G-FFT, and 70G-PAR was used to simulate 20-year costs and outcomes in a hypothetical cohort in The Netherlands. The 70G-PAR strategy was based on projected data from a comparable technology. Incremental net monetary benefits were calculated to support the adoption decision. Expected net benefit of development for the population and expected net benefit of sampling were calculated to support the development and research decision.

RESULTS

The 70G-PAR had the highest net monetary benefit, followed by the 70G-FFT. The population expected net benefit of development amounted to €91 million over 20 years (assuming €250 development costs per patient receiving the test). The expected net benefit of sampling amounted to €61 million for the optimal trial (n = 4000).

CONCLUSIONS

We presented a framework to simultaneously support adoption, development, and research decisions in early stages of medical technology development. In this case, the results indicate that there is value in both further development of 70G-FFT into 70G-PAR and further research.

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

OBJECTIVE

This review examines the impact of economic evaluation in informing national or local policies within both jurisdictions. We focus on the factors that have made the economic evaluation evolves differently in both settings.

AREAS OF AGREEMENT

Economic evaluation facilitates decision-making regarding the efficiency of interventions. The existence of national or local bodies regulating the process has contributed to increasing its use in decision-making and the development of its methods.

AREAS OF CONTROVERSY

Cost-effectiveness approach is based on the assumption of health maximization subject to a budget constraint. Decision-makers are not only interested in health maximization alone. This may result in policy-makers failing to consider economic evaluations into their allocation decisions. AREAS TO DEVELOP RESEARCH: Methods that incorporate wider decision-makers goals (mainly local) and research to study the real impact of economic evaluation in terms of improved efficiency and equity are particularly required.

Scenario drafting to anticipate future developments in technology assessment

BACKGROUND

Health Technology Assessment (HTA) information, and in particular cost-effectiveness data is needed to guide decisions, preferably already in early stages of technological development. However, at that moment there is usually a high degree of uncertainty, because evidence is limited and different development paths are still possible. We developed a multi-parameter framework to assess dynamic aspects of a technology -still in development-, by means of scenario drafting to determine the effects, costs and cost-effectiveness of possible future diffusion patterns. Secondly, we explored the value of this method on the case of the clinical implementation of the 70-gene signature for breast cancer, a gene expression profile for selecting patients who will benefit most from chemotherapy.

METHODS

To incorporate process-uncertainty, ten possible scenarios regarding the introduction of the 70-gene signature were drafted with European experts. Out of 5 most likely scenarios, 3 drivers of diffusion (non-compliance, technical failure, and uptake) were quantitatively integrated in a decision-analytical model. For these scenarios, the cost-effectiveness of the 70-gene signature expressed in Incremental Cost-Effectiveness Ratios (ICERs) was compared to clinical guidelines, calculated from the past (2005) until the future (2020).

RESULTS

In 2005 the ICER was €1,9 million/quality-adjusted-life-year (QALY), meaning that the 70-gene signature was not yet cost-effective compared to the current clinical guideline. The ICER for the 70-gene signature improved over time with a range of €1,9 million to €26,145 in 2010 and €1,9 million to €11,123/QALY in 2020 depending on the separate scenario used. From 2010, the 70-gene signature should be cost-effective, based on the combined scenario. The uptake-scenario had strongest influence on the cost-effectiveness.

CONCLUSIONS

When optimal diffusion of a technology is sought, incorporating process-uncertainty by means of scenario drafting into a decision model may reveal unanticipated developments and can demonstrate a range of possible cost-effectiveness outcomes. The effect of scenarios give additional information on the speed with cost effectiveness might be reached and thus provide a more realistic picture for policy makers, opinion leaders and manufacturers.

Economic evaluation of vaccination: capturing the full benefits, with an application to human papillomavirus

Vaccination has been among the greatest contributors to the past century's dramatic improvements in health and life expectancy. Recent advances in vaccinology have resulted in new vaccines that will likely lead to substantial future health gains. However, the high cost of these new vaccines, such as the human papillomavirus (HPV) vaccine, poses an obstacle to their widespread adoption in many countries. Economic evaluation can help to determine if investment in vaccine introduction is worthwhile. However, existing economic evaluations usually focus on a narrow set of vaccination-mediated benefits-most notably avoided medical-care costs-and fail to account for several categories of potentially important gains. We consider three sources of such benefit and discuss them with respect to HPV vaccination: (i) outcome-related productivity gains, (ii) behaviour-related productivity gains, and (iii) externalities. We also highlight that HPV vaccination protects against more than just cervical cancer and that these other health gains should be taken into account. Failing to account for these broader benefits of HPV vaccination could result in substantial underestimation of the value of HPV vaccination, thereby leading to ill-founded decisions regarding its introduction into national immunization programmes.

Haemophilia prophylaxis: how can we justify the costs?

Severe haemophilia results in increased mortality and poorer quality of life. Factor prophylaxis leads to a more normal life, but is very costly; most of the cost is due to the high cost of replacement factor. Despite its high cost, factor prophylaxis has been adopted throughout the developed world--even in different health care systems. We argue that there are at least five possible reasons why societies may value factor prophylaxis despite its cost: (i) it is directed towards an inherited disease, (ii) the treatment is largely directed towards children, (iii) the disease is rare and the overall cost to society is small, (iv) the treatment is preventative, and v) the high cost is largely the result of providing safe products. In an era of rising health care costs, there is a strong research agenda to establish the factors that determine the value of expensive therapies for rare diseases like haemophilia.

Contribution of imaging to cancer care costs

Health care costs in the United States are increasing faster than the gross domestic product (GDP), and the growth rate of costs related to diagnostic imaging exceeds those of overall health care expenditures. Here we show that the contribution of imaging to cancer care costs pales in comparison to those of other key cost components, such as cancer drugs. Specifically, we estimate that (18)F-FDG PET or PET/CT accounted for approximately 1.5% of overall Medicare cancer care costs in 2009. Moreover, we propose that the appropriate use of (18)F-FDG PET or PET/CT could reduce the costs of cancer care. Because the U.S. health care system is complex and because it is difficult to find accurate data elsewhere, most cost and use assessments are based on published data from the U.S. Centers for Medicare & Medicaid Services.

Cost-effectiveness of involving nurse specialists for adult patients with urinary incontinence in primary care compared to care-as-usual: an economic evaluation alongside a pragmatic randomized controlled trial

AIMS

To determine the 12-month, societal cost-effectiveness of involving urinary incontinence (UI) nurse specialists in primary care compared to care-as-usual by general practitioners (GPs).

METHODS

From 2005 until 2008 an economic evaluation was performed alongside a pragmatic multicenter randomized controlled trial comparing UI patients receiving care by nurse specialists with patients receiving care-as-usual by GPs in the Netherlands. One hundred eighty-six adult patients with stress, urgency, or mixed UI were randomly allocated to the intervention and 198 to care-as-usual; they were followed for 1 year. Main outcome measures were Quality Adjusted Life Year (QALY(societal) ) based on societal preferences for health outcomes (EuroQol-5D), QALY(patient) based on patient preferences for health outcomes (EuroQol VAS), and Incontinence Severity weighted Life Year (ISLY) based on patient-reported severity and impact of UI (ICIQ-UI SF). Health care resource use, patient and family costs, and productivity costs were assessed. Data were collected by three monthly questionnaires. Incremental cost-effectiveness ratios were calculated. Uncertainty was assessed using bootstrap simulation, and the expected value of perfect information was calculated (EVPI).

RESULTS

Compared to care-as-usual, nurse specialist involvement costs € 16,742/QALY(societal) gained. Both QALY(patient) and ISLY yield slightly more favorable cost-effectiveness results. At a threshold of € 40,000/QALY(societal,) the probability that the intervention is cost-effective is 58%. The EVPI amounts to € 78 million.

CONCLUSIONS

Based on these results, we recommend adopting the nurse specialist intervention in primary care, while conducting more research through careful monitoring of the effectiveness and costs of the intervention in routine practice.

Assessment of pharmacoeconomic evaluations submitted for reimbursement in Korea

OBJECTIVE

To assess the quality of pharmacoeconomic evaluations (PEs) submitted with new drug applications for reimbursement and to investigate the role of PEs for coverage decisions in Korea.

METHODS

Forty-seven PEs that were submitted by pharmaceutical companies for coverage decisions between June 2005 and December 2009 were included in this study. To assess their appropriateness with regard to the PE guidelines, we used the Health Insurance Review and Assessment services (HIRA) checklist consisting of 20 items based on the PE guidelines. We also evaluated the results for coverage decisions, as "recommended," "recommended with restricted use," or "not recommended," based on the incremental cost-effectiveness ratio and the range of uncertainty.

RESULTS

On average, 14 of the 20 items on the HIRA checklist were fulfilled (70.9%, range 35.0%-100%). The compliance rate for the following items was above 70%: presentation of perspectives and evaluation methods, a sufficient time horizon, and appropriateness of comparators and health outcomes. The compliance rate for the following items was below 70%: omission of objectives for the study, inappropriate target population, unclear selection process for effectiveness and cost, inappropriate cost estimation, insufficient justification of generalizability, and description of study limitations. The range of incremental cost-effectiveness ratios per quality-adjusted life-years of PEs from a societal perspective varied from dominant to 59K USD (n = 13): it consisted of dominant to 28K USD for "recommended" submissions (n = 6), 8K to 20K USD for "recommended with restricted use" submissions (n = 4), and 13K to 59K for "not recommended" ones (n = 3).

CONCLUSIONS

Our study showed that most PEs in this study have reached an adequate level for coverage decisions. Overall barriers associated with a lack of relevant evidence could account for the low compliance rate with specific items in the PE guidelines. PEs with good quality submitted for coverage decisions have played an important role for selecting cost-effective drugs.

Comparing cancer mortality and GDP health expenditure in England and Wales with other major developed countries from 1979 to 2006

BACKGROUND

Cancer and gross-domestic-product on health expenditure (GDPHE) are critical issues for major developed countries (MDC). Each country's economic input, GDPHE 1980-2005 is contrasted with clinical outputs, cancer mortality rates (CMRs), to compare their efficiency and effectiveness in reducing CMR.

METHODS

World Health Organization's CMR data for baseline years (1979-1981) are compared with 2004-2006 by sex and age. The χ(2)-tests are used to determine differences between MDC. Efficiency is analysed by calculating a ratio of average GDPHE to reduced CMR over the period.

RESULTS

Inputs: All the countries GDPHE grew substantially. For the United Kingdom this reached 9.3%, which is below the MDC average (10%). Outputs: CMR fell substantially (>20%) in six of the ten countries. The male average (15-74 years) CMR in England and Wales had been third highest but by 2004-2006 was sixth, a 31% reduction, which was significantly greater than seven other countries. Initially England and Wales female average CMR was the highest of all countries and is now the second highest. There were significantly greater reductions for the 55-64 and 65-74 years old than in seven and four countries, respectively. GDPHE reduced CMR ratios--the average GDPHE:reduced CMR ratio of England and Wales was 1:120, greater than all MDC and double that in four countries.

CONCLUSION

Comparing GDPHE input with CMR output showed that relatively the NHS achieved more with proportionately less than other MDC.

A comparison of the superficial inferior epigastric artery flap and deep inferior epigastric perforator flap in postmastectomy reconstruction: A cost-effectiveness analysis

PURPOSE

To perform a cost-effectiveness analysis comparing the superficial inferior epigastric artery (SIEA) and deep inferior epigastric perforator (DIEP) flaps in postmastectomy reconstruction.

METHODS

A decision analytic model with seven clinically important health outcomes (health states) was used, incorporating the Ontario Ministry of Health's perspective. Direct medical costs were estimated from a university-based hospital. The utilities of each health state converted into quality-adjusted life years (QALYs) were obtained from previously published data. Health state probabilities were computed from a systematic literature review. Analyses yielded SIEA and DIEP expected costs and QALYs allowing calculation of the incremental cost-utility ratio (ICUR). One-way sensitivity analyses were conducted under five plausible scenarios, assessing result robustness.

RESULTS

Five SIEA and 27 DIEP studies were identified. The baseline SIEA expected cost was slightly higher than that for the DIEP ($16,107 versus $16,095), with slightly higher QALYs (33.14 years versus 32.98 years), giving an ICUR of $77/QALY. Taking into account conversions from SIEA to DIEP, the ICUR increased to $4,480/QALY. Sensitivity analysis gave ICURs ranging from $2,614/QALY to 'dominant', all consistent with the adoption of the SIEA over the DIEP.

CONCLUSION

The best available evidence suggests the SIEA is a cost-effective procedure. However, given the high SIEA to DIEP conversion rates and small marginal differences in cost and effectiveness, the ICUR may be sensitive to minor changes in costs or QALYs. The 'truth' can only be obtained from a randomized, controlled trial comparing both techniques side by side, simultaneously capturing the costs of the competing interventions.

Comparing the USA, UK and 17 Western countries' efficiency and effectiveness in reducing mortality

OBJECTIVES

To test the hypothesis that the USA healthcare system was superior to the NHS and 17 other Western countries in reducing feasible mortality rates over the period 1979-2005.

DESIGN

Economic inputs into healthcare, GDP health expenditure (GDPHE) were compared with clinical outputs, i.e. total 'adult' (15-74 years) and 'older' (55-74 years) mortality rates based upon three-year average mortality rates for 1979-81 vs. 2003-2005. A cost-effective ratio was calculated by dividing average GDPHE into reduced mortality rates over the period.

SETTING

Nineteen Western countries' mortality rates compared between 1979-2005.

PARTICIPANTS

Mortality of people by age and gender.

MAIN OUTCOME MEASURES

A cost-effective ratio to measure efficiency and effectiveness of healthcare systems in reducing mortality rates. Chi-square tested any differences between the USA, UK and other Western countries.

RESULTS

INPUT

The USA had the highest current and average GDPHE; the UK was 10th highest but joint 16th overall, still below the Western countries' average. Output: Every country's mortality rate fell substantially; but 15 countries reduced their mortality rates significantly more than the US, while UK 'adult' and 'older' mortality rates fell significantly more than 12 other countries. Cost-effectiveness: The USA GDPHE: mortality rate ratio was 1:205 for 'adults' and 1:515 for 'older' people, 16 Western countries having bigger ratios than the US; the UK had second greatest ratios at 1:593 and 1:1595, respectively. The UK ratios were >20% larger than 14 other countries.

CONCLUSIONS

In cost-effective terms, i.e. economic input versus clinical output, the USA healthcare system was one of the least cost-effective in reducing mortality rates whereas the UK was one of the most cost-effective over the period.

Value and cancer care: toward an equitable future

Health care expenses in the United States are increasing inexorably. At the current rate of growth, it is anticipated that 20% of the gross national product will consist of health-related expenditures within the next decade. Cancer is the second leading cause of death in the United States, and it is increasing in prevalence because of the aging of the population and the limited number of successful prevention strategies. As the biological characteristics of cancer come into sharper focus, targeted therapies are being developed that offer the promise of increased clinical benefit with fewer toxicities than are associated with conventional treatment. Although spectacular successes are infrequent with this approach, to date, the majority of targeted therapies are modestly effective at best, and extremely costly. This observation suggests that a broadly acceptable definition of value in a cancer therapeutic agent is not at hand, but is sorely needed from the vantage points of the patient and society. A corollary issue of enormous import is how to equitably distribute the health care dollar in the service of achieving the greatest good for the greatest number. Although cancer is responsible for only 5% of the health care budget, its cost is increasing and it can be viewed as paradigmatic when contemplating the problem of equity in health care. Here, a number of concepts are discussed that focus on this goal and its implications for the cancer patient and society at large.

Markov Models in health care

ABSTRACT Markov Chains provide support for problems involving decision on uncertainties through a continuous period of time. The greater availability and access to processing power through computers allow that these models can be used more often to represent clinical structures. Markov models consider the patients in a discrete state of health, and the events represent the transition from one state to another. The possibility of modeling repetitive events and time dependence of probabilities and utilities associated permits a more accurate representation of the evaluated clinical structure. These templates can be used for economic evaluation in health care taking into account the evaluation of costs and clinical outcomes, especially for evaluation of chronic diseases. This article provides a review of the use of modeling within the clinical context and the advantages of the possibility of including time for this type of study.

Ethical and value issues in insurance coverage for cancer treatment

Many new cancer drugs provide only limited benefits, but at very great cost, for example, $200,000-$300,000 per quality-adjusted life year produced. By most standards of value or cost-effectiveness, this does not represent good value. I first review several of the causes of this value failure, including monopoly patents, prohibitions on Medicare's negotiating on drug prices, health insurance protecting patients from costs, and financial incentives of physicians to use these drugs. Besides value or cost-effectiveness, the other principal aim in health care resource allocation should be equity among the population served. I examine several equity considerations-priority to the worse off, aggregation and special priority to life extension, and the rule of rescue-and argue that none justifies greater priority for cancer treatment on the grounds of equity. Finally, I conclude by noting two recent policy changes that are in the wrong direction for achieving value in cancer care, and suggesting some small steps that could take us in the right direction.

Cost-effectiveness research on preventive interventions: a survey of the publications in 2008

BACKGROUND

In recent years the literature regarding the cost-effectiveness of disease prevention and health promotion has grown exponentially. Aim of this study is to investigate: (i) how many and what type of economic evaluations have been published in 2008, (ii) the diseases or health problems World Health Organization International Classification of Diseases 10 chapters the economic evaluations of preventive interventions focus on, in relation to the global burden of disease and (iii) the cost-effectiveness of these interventions.

METHODS

Literature study of economic evaluations on preventive interventions in PubMed and Scopus.

RESULTS

In 2008, 232 economic evaluations of preventive interventions have been published. Of these studies, 75% (n = 175) used costs per (Quality Adjusted) Life Year [(QA)LY] gained as outcome measure. Most economic evaluations focus on the prevention of infectious diseases (31.5%, n = 73) and cancers (21%, n = 49) Infectious diseases are responsible for the highest global burden of disease (19.8%), followed by mental and behavioural disorders (11.7%). Of the included economic evaluations, 80% remained below a threshold of €50 000 and 60% below €20 000 per (QA)LY.

CONCLUSION

This study shows that many economic evaluations of preventive interventions use a generic outcome measure. This adds to the comparability of different studies on the cost-effectiveness of prevention. Although the focus of published economic evaluations in general corresponds well with those diseases that cause a large share of the world's burden of disease, mental and behavioural diseases and diseases of the respiratory system remain underrepresented. Finally, it appears that the vast majority of published economic evaluations of preventive measures show favourable cost-effectiveness levels.

18FDG-PET-CT in the follow-up of non-small cell lung cancer patients after radical radiotherapy with or without chemotherapy: an economic evaluation

BACKGROUND

The optimal follow-up strategy of non-small cell lung cancer (NSCLC) patients after curative intent therapy is still not established. In a recent prospective study with 100 patients, we showed that a FDG-PET-CT 3 months after radiotherapy (RT) could identify progression amenable for curative treatment in 2% (95% confidence interval (CI): 1-7%) of patients, who were all asymptomatic. Here, we report on the economic evaluation of this study.

PATIENTS AND METHODS

A decision-analytic Markov model was developed in which the long-term cost-effectiveness of 3 follow-up strategies was modelled with different imaging methods 3 months after therapy: a PET-CT scan; a chest CT scan; and conventional follow-up with a chest X-ray. A probabilistic sensitivity analysis was performed to account for uncertainty. Because the results of the prospective study indicated that the advantage seems to be confined to asymptomatic patients, we additionally examined a strategy where a PET-CT was applied only in the subgroup of asymptomatic patients. Cost-effectiveness of the different follow-up strategies was expressed in incremental cost-effectiveness ratios (ICERs), calculating the incremental costs per quality adjusted life year (QALY) gained.

RESULTS

Both PET-CT- and CT-based follow-up were more costly but also more effective than conventional follow-up. CT-based follow-up was only slightly more effective than conventional follow-up, resulting in an incremental cost-effectiveness ratio (ICER) of euro 264.033 per QALY gained. For PET-CT-based follow-up, the ICER was euro 69.086 per QALY gained compared to conventional follow-up. The strategy in which a PET-CT was only performed in the asymptomatic subgroup resulted in an ICER of euro 42.265 per QALY gained as opposed to conventional follow-up. With this strategy, given a ceiling ratio of euro 80.000, PET-CT-based follow-up had the highest probability of being cost-effective (73%).

CONCLUSIONS

This economic evaluation shows that a PET-CT scan 3 months after (chemo)radiotherapy with curative intent is a potentially cost-effective follow-up method, and is more cost-effective than CT alone. Applying a PET-CT scan only in asymptomatic patients is probably as effective and more cost-effective. It is worthwhile to perform additional research to reduce uncertainty regarding the decision concerning imaging in the follow-up of NSCLC.

The generalist disciplines in American medicine one hundred years following the Flexner Report: a case study of unintended consequences and some proposals for post-Flexnerian reform

Abraham Flexner's analysis of U.S. medical education at the turn of the 20th century transformed the processes of student selection and instruction, the roles and responsibilities of faculty members, and the provision of resources to support medical education. Flexner's report also led to the nearly universal adoption of the academic medical center as the focal point of medical school teaching, research, and clinical activities. In this article, the authors describe the effects of the dissemination of this model and how the subsequent introduction of public funding for research and patient care transformed academic health centers and altered the composition of the physician workforce, resulting in the proliferation of specialties. They also describe how these workforce changes, along with the evolution of health care financing during the late 20th century, have led to a system that affords the most scientifically advanced and potentially efficacious care in the world, yet so profoundly fails to ensure affordability and equitable access and quality, that the system is no longer sustainable. The authors propose that both health care system reform and medical education reform are needed now to restore economic viability and moral integrity, and that a key element of this process will be to rebalance the generalist and specialist composition of the physician workforce. They conclude by suggesting that post-Flexnerian reform of medical education should include broadening the scope of criteria used to select medical students and reshaping the curriculum to address the evolving needs of patient care during the 21st century.

Relationships among self-management, patient perceptions of care, and health economic outcomes for decision-making and clinical practice in type 2 diabetes

OBJECTIVES

Type 2 diabetes (T2D) treatment involves complex interactions between biological, psychological, and behavioral factors of care, requiring multifaceted efforts in clinical practice and disease management to reduce health and economic burdens. We aimed to quantify correlations among these factors and characterize their level of inclusion in economic analyses that are part of informed medical decision-making.

METHODS

A comprehensive, stepwise systematic literature review was performed on published articles dated 1993 to 2008 using medical subject heading and keyword searches in electronic reference libraries. Data were collected using standardized techniques and were analyzed descriptively.

RESULTS

A total of 97 articles fulfilling all inclusion criteria were reviewed, including 16 on economic models (17% of articles). Most studies were retrospective (41 of 97; 42%) and from managed care perspectives (66%). Oral antidiabetic drugs were a central focus, appearing in 83% of studies. Patient behaviors, particularly medication adherence and persistence in real-world settings, are well researched (n=65) and may influence diabetes outcomes, cardiovascular risk, mortality rates, and treatment-specific resource use (e.g., hospitalizations) and costs (<or=$3400 annually per patient). Nevertheless, they are absent from current economic models.

CONCLUSIONS

Strong correlations exist between patient behaviors, perspectives of care, health outcomes, and costs in T2D. Enhancing their inclusion in pharmacoeconomic modeling, notably the influence on clinical effectiveness of variation in self-management between treatments, should ultimately lead to more accurate estimates of comparative cost-effectiveness, and thereby improve value-based resource allocation and patient access to appropriate therapy.

Cost-effectiveness of ruling out deep venous thrombosis in primary care versus care as usual

BACKGROUND

Referral for ultrasound testing in all patients suspected of DVT is inefficient, because 80-90% have no DVT.

OBJECTIVE

To assess the incremental cost-effectiveness of a diagnostic strategy to select patients at first presentation in primary care based on a point of care D-dimer test combined with a clinical decision rule (AMUSE strategy), compared with hospital-based strategies.

PATIENTS/METHODS

A Markov-type cost-effectiveness model with a societal perspective and a 5-year time horizon was used to compare the AMUSE strategy with hospital-based strategies. Data were derived from the AMUSE study (2005-2007), the literature, and a direct survey of costs (2005-2007).

RESULTS OF BASE-CASE ANALYSIS

Adherence to the AMUSE strategy on average results in savings of euro138 ($185) per patient at the expense of a very small health loss (0.002 QALYs) compared with the best hospital strategy. The iCER is euro55 753($74 848). The cost-effectiveness acceptability curves show that the AMUSE strategy has the highest probability of being cost-effective.

RESULTS OF SENSITIVITY ANALYSIS

Results are sensitive to decreases in sensitivity of the diagnostic strategy, but are not sensitive to increase in age (range 30-80), the costs for health states, and events.

CONCLUSION

A diagnostic management strategy based on a clinical decision rule and a point of care D-dimer assay to exclude DVT in primary care is not only safe, but also cost-effective as compared with hospital-based strategies.

Applying Programme Budgeting Marginal Analysis in the health sector: 12 years of experience

The Pharmaceutical Management Agency in New Zealand, PHARMAC, was established in 1993 at a time when growth in pharmaceutical expenditure was very high and arguably unsustainable. PHARMAC was charged with finding new and effective ways to manage expenditure growth, while also obtaining the best health outcomes for the New Zealand population. In order to help achieve this goal, PHARMAC has used Programme Budgeting Marginal Analysis. The use of Programme Budgeting Marginal Analysis, together with a capped budget and tools to generate savings, has significantly contributed to PHARMAC achieving its objective. However, there are implications of using Programme Budgeting Marginal Analysis with a capped budget. In particular, a different approach is required when undertaking and using cost-utility analysis (focused strongly on relative cost-effectiveness), and the opportunity cost of poor decisions is magnified significantly. As the demand on pharmaceutical expenditure continues to rise, the opportunity cost of not having a capped budget and tools for controlling pharmaceutical subsidies will only increase.