Evaluating Public Health Interventions: A Neglected Area in Health Technology Assessment

'Integrating Ethics and Equity with Economics and Effectiveness for newborn screening in the genomic age: A qualitative study protocol of stakeholder perspectives

BACKGROUND

Newborn bloodspot screening is a well-established population health initiative that detects serious, childhood-onset, treatable conditions to improve health outcomes. With genomic technologies advancing rapidly, many countries are actively discussing the introduction of genomic assays into newborn screening programs. While adding genomic testing to Australia's newborn screening program could improve outcomes for infants and families, it must be considered against potential harms, ethical, legal, equity and social implications, and economic and health system impacts. We must ask not only 'can' we use genomics to screen newborns?' but 'should we'?' and 'how much should health systems invest in genomic newborn screening?'.

METHODS

This study will use qualitative methods to explore understanding, priorities, concerns and expectations of genomic newborn screening among parents/carers, health professionals/scientists, and health policy makers across Australia. In-depth, semi-structured interviews will be held with 30-40 parents/carers recruited via hospital and community settings, 15-20 health professionals/scientists, and 10-15 health policy makers. Data will be analysed using inductive content analysis. The Sydney Children's Hospital Network Human Research Ethics Committee approved this study protocol [2023/ETH02371]. The Standards for Reporting Qualitative Research will guide study planning, conduct and reporting.

DISCUSSION

Few studies have engaged a diverse range of stakeholders to explore the implications of genomics in newborn screening in a culturally and genetically diverse population, nor in a health system underpinned by universal health care. As the first study within a multi-part research program, findings will be used to generate new knowledge on the risks and benefits and importance of ethical, legal, social and equity implications of genomic newborn screening from the perspective of key stakeholders. As such it will be the foundation on which child and family centered criteria can be developed to inform health technology assessments and drive efficient and effective policy decision-making on the implementation of genomics in newborn screening.

Moving from intervention management to disease management: a qualitative study exploring a systems approach to health technology assessment in Canada

OBJECTIVES

Health technology assessment (HTA) traditionally informs decision making for single health technologies, which could lead to ill-informed decisions, suboptimal care, and system inefficiencies. We explored opportunities for conceptualizing the decision space in HTA as a disease management question versus an intervention management question.

METHODS

Semistructured interviews were conducted between April 2022 and October 2022 with purposefully selected individuals from national and provincial HTA agencies and related organizations in Canada. We conducted manual line by line coding of data informed by our interview guide and sensitizing concepts from the literature. One author coded the data, and findings were independently verified by a second author who coded a subset of transcripts.

RESULTS

Twenty-four invitations were distributed, and eighteen individuals agreed to participate. A disease management approach to HTA was differentiated from traditional approaches as being disease-based, multi-interventional, and dynamic. There was general support for an explicit care pathway approach to HTA by informing discussions around patient choice and suboptimal care, creating a space where decision makers can collaborate on shared objectives, and in setting up a platform for open dialogue about managing high-cost and high-severity diseases. There are opportunities for a care pathway approach to be implemented that build on the strengths of the existing HTA system in Canada.

CONCLUSIONS

A disease management approach may enhance the impact of HTA by supporting dynamic decision making that could better inform a proactive, resilient, and sustainable healthcare system in Canada.

Adaptation and Utilization of a Postmarket Evaluation Model for Digital Contact Tracing Mobile Health Tools in the United States: Observational Cross-sectional Study

BACKGROUND

Case investigation and contact tracing are core public health activities used to interrupt disease transmission. These activities are traditionally conducted manually. During periods of high COVID-19 incidence, US health departments were unable to scale up case management staff to deliver effective and timely contact-tracing services. In response, digital contact tracing (DCT) apps for mobile phones were introduced to automate these activities. DCT apps detect when other DCT users are close enough to transmit COVID-19 and enable alerts to notify users of potential disease exposure. These apps were deployed quickly during the pandemic without an opportunity to conduct experiments to determine effectiveness. However, it is unclear whether these apps can effectively supplement understaffed manual contact tracers.

OBJECTIVE

The aims of this study were to (1) evaluate the effectiveness of COVID-19 DCT apps deployed in the United States during the COVID-19 pandemic and (2) determine if there is sufficient DCT adoption and interest in adoption to meet a minimum population use rate to be effective (56%). To assess uptake, interest and safe use covariates were derived from evaluating DCTs using the American Psychological Association App Evaluation Model (AEM) framework.

METHODS

We analyzed data from a nationally representative survey of US adults about their COVID-19-related behaviors and experiences. Survey respondents were divided into three segments: those who adopted a DCT app, those who are interested but did not adopt, and those not interested. Descriptive statistics were used to characterize factors of the three groups. Multivariable logistic regression models were used to analyze the characteristics of segments adopting and interested in DCT apps against AEM framework covariates.

RESULTS

An insufficient percentage of the population adopted or was interested in DCTs to achieve our minimum national target effectiveness rate (56%). A total of 17.4% (n=490) of the study population reported adopting a DCT app, 24.7% (n=697) reported interest, and 58.0% (n=1637) were not interested. Younger, high-income, and uninsured individuals were more likely to adopt a DCT app. In contrast, people in fair to poor health were interested in DCT apps but did not adopt them. App adoption was positively associated with visiting friends and family outside the home (odds ratio [OR] 1.63, 95% CI 1.28-2.09), not wearing masks (OR 0.52, 95% CI 0.38-0.71), and adopters thinking they have or had COVID-19 (OR 1.60, 95% CI 1.21-2.12).

CONCLUSIONS

Overall, a small percentage of the population adopted DCT apps. These apps may not be effective in protecting adopters' friends and family from their maskless contacts outside the home given low adoption rates. The public health community should account for safe use behavioral factors in future public health contact-tracing app design. The AEM framework was useful in developing a study design to evaluate DCT effectiveness and safety.

The Public Health Value of Coding Surgery in South Africa Using the International Classification of Health Interventions

BACKGROUND

The lack of a national intervention coding system and the current intervention coding in South Africa through the use of multiple billing and coding systems does not support quality intervention data collection and patient outcomes reporting for general surgery. This presents difficulties in the understanding of the different types of general surgical interventions performed in hospitals, the associated resources, risks, complications, outcomes reporting, public healthcare delivery, and determination of barriers to care. This study illustrates the use of accurate data on health interventions in South Africa's acute care general surgery coding to assist in improved resource allocation, using the new WHO International Classification of Health Interventions (ICHI). ICHI has over 8000 codes and consists of three axes: Target (the entity on which the Action is carried out), Action (a deed performed by an actor to a target), and Means (the processes and methods by which the Action is carried out). A key benefit of ICHI is that it can be used collectively with the International Classification of Diseases (ICD) and the International Classification of Functioning, Disability and Health (ICF).

OBJECTIVES

to evaluate the suitability of ICHI for general surgery interventions by coding intervention descriptions to ICHI codes; to identify gaps in the ICHI system; and to provide a rationale for ICHI to be a nationally regulated system.

METHODS

This study adopted a retrospective, descriptive design; in total, 3000 in-patient intervention data files, captured in an electronic database from April 2013 to August 2019 at three academic hospitals in Johannesburg, were extracted randomly, and coded using ICHI. Quantitative data analysis techniques were utilized to assess the overall degree of match between ICHI codes and the intervention descriptions.

RESULTS

Of the 3000 patient case entries that were coded, there was an agreement of 67.6% of the coded data amongst the three coders, leaving a variability of 32.4%. The variability was largely due to the coders' experience and the quality of healthcare documentation.

CONCLUSIONS

ICHI has the ability to cater for the broad range of general surgery interventions, thus indicating that ICHI is suitable for general surgery coding.

Evaluating cost benefits from a heat health warning system in Adelaide, South Australia

OBJECTIVE

To examine the cost benefits of a heat health warning system (HHWS) in South Australia.

METHODS

Information from key agencies was used to estimate the costs associated with the South Australian HHWS, including for three targeted public health interventions. Health cost savings were estimated based on previously reported HHWS-attributable reductions in hospital and emergency department (ED) admissions and ambulance callouts.

RESULTS

The estimated cost for a one-week activation of the HHWS was AU$593,000. Activation costs compare favourably with the potential costs averted through HHWS-attributable reductions in hospital admissions and ambulance callouts with an estimated benefit-cost ratio of 2.0-3.3.

CONCLUSIONS

On the basis of estimated cost benefit, the South Australian HHWS is a no-regret public health response to heatwaves. Implications for public health: As global temperatures rise there are likely to be significant health impacts from more frequent and intense heatwaves. This study indicates that HHWSs incorporating targeted supports for vulnerable groups are likely to be cost-effective public health interventions.

Expectations for the Development of Health Technology Assessment in Brazil

The implementation of health technology assessment (HTA) in emerging countries depends on the characteristics of the health care system and the needs of public health care. The objective of this survey was to investigate experts' expectations for the development of HTA in Brazil and to derive measures to strengthen the impact of HTA in Brazil on health care decisions. Based on a scoping literature review, a questionnaire was developed proposing eight theses for seven domains of HTA: (i) capacity building, (ii) public involvement, (iii) role of cost-effectiveness analysis (CEA), (iv) institutional framework, (v) scope of HTA studies, (vi) methodology of HTA, and (vii) HTA as the basis for jurisdiction. Thirty experts responded in full to the survey and agreed to five of the eight theses proposed. Experts suggested several measures to promote HTA within the scope of each domain, thus addressing capacity building related to HTA, availability, and reliability of population data, and legal endowment of the HTA system. Finally, HTA processes in Brazil should also address public health issues (e.g., appraisal of interventions directed at chronic diseases).

Evidence-based public policy making for medicines across countries: findings and implications for the future

Aim: Global expenditure on medicines is rising up to 6% per year driven by increasing prevalence of non-communicable diseases (NCDs) and new premium priced medicines for cancer, orphan diseases and other complex areas. This is difficult to sustain without reforms. Methods: Extensive narrative review of published papers and contextualizing the findings to provide future guidance. Results: New models are being introduced to improve the managed entry of new medicines including managed entry agreements, fair pricing approaches and monitoring prescribing against agreed guidance. Multiple measures have also successfully been introduced to improve the prescribing of established medicines. This includes encouraging greater prescribing of generics and biosimilars versus originators and patented medicines in a class to conserve resources without compromising care. In addition, reducing inappropriate antibiotic utilization. Typically, multiple measures are the most effective. Conclusion: Multiple measures will be needed to attain and retain universal healthcare.

Systems thinking in health technology assessment: a scoping review

OBJECTIVE

Our objective was to assess how, and to what extent, a systems-level perspective is considered in decision-making processes for health interventions by illustrating how studies define the boundaries of the system in their analyses and by defining the decision-making context in which a systems-level perspective is undertaken.

METHOD

We conducted a scoping review following the Joanna Briggs Institute methodology. MEDLINE, EMBASE, Cochrane Library, and EconLit were searched and key search concepts included decision making, system, and integration. Studies were classified according to an interpretation of the "system" of analysis used in each study based on a four-level model of the health system (patient, care team, organization, and/or policy environment) and using categories (based on intervention type and system impacts considered) to describe the decision-making context.

RESULTS

A total of 2,664 articles were identified and 29 were included for analysis. Most studies (16/29; 55%) considered multiple levels of the health system (i.e., patient, care team, organization, environment) in their analysis and assessed multiple classes of interventions versus a single class of intervention (e.g., pharmaceuticals, screening programs). Approximately half (15/29; 52%) of the studies assessed the influence of policy options on the system as a whole, and the other half assessed the impact of interventions on other phases of the disease pathway or life trajectory (14/29; 48%).

CONCLUSIONS

We found that systems thinking is not common in areas where health technology assessments (HTAs) are typically conducted. Against this background, our study demonstrates the need for future conceptualizations and interpretations of systems thinking in HTA.

Coding Public Health Interventions for Health Technology Assessments: A Pilot Experience With WHO's International Classification of Health Interventions (ICHI)

Introduction: An important requirement for successful public health interventions is a standardized classification in order to make these health technologies comparable in all contexts and recognized by all parties. The WHO International Classification of Health Interventions (ICHI), including an integrated public health component, has been developed to propose such an international standard.

Methods: To test (a) the translation of public health interventions to ICHI codes and (b) the technical handling and general coding in public health, we used a set of public health interventions from a recent cross-sectional survey among Health Technology Assessment professionals.

Results: Our study showed that handling of the ICHI interface is stable, that there is a need for specificity and adequate detail of intervention descriptions and desired outcomes to code adequately with ICHI and that the professional background of the coder, as well as his/her sex might influence the selection of codes.

Conclusion: International Classification of Health Interventions provides a good coverage of public health interventions. However, the broader character of system wide interventions, often involving a variety of institutions and stakeholders, may present a challenge to the application of ICHI coding. Based on this experience, we would tailor future surveys more specifically to the needs of the classification and we advise training for health professionals before coding with ICHI. Standards of reporting will likely strengthen insights about the efficiency of primary prevention interventions and thus benefit long-term health of populations and structured HTA reporting process.

Evaluations of public health interventions produced by health technology assessment agencies: A mapping review and analysis by type and evidence content

OBJECTIVES

Health technology assessments (HTAs) have been suggested as a strategy to bridge the evidence-to-policy gap in public health. It is unclear to what extent HTAs have been prepared to assist decisions to implement public health interventions (PHIs). We aimed to describe the experience of HTA agencies by mapping, classifying, and analyzing the evidence content of HTAs of PHIs.

METHODS

We systematically searched databases of 35 HTA agencies from 18 countries for evaluations of PHIs between 2008-2018. Interventions were classified using the International Classification of Health Interventions and the evidence content analysed with the INAHTA Product-Type-mark checklist.

RESULTS

Only 1010 (9%) of HTAs were on PHIs. 500 (50%) publications targeted Body Systems and Functions, 302 (30%) Health-related Behaviours, 137 (14%) the Environment and 44 (4%) Activities and Participation Domains. Out of 734 publications perused, few met the criteria of full-HTAs (71;10%) or mini-HTAs (110;15%). Most were rapid reviews (420;57%). 72% of all reports came from only 6 countries.

CONCLUSION

HTAs on PHIs were uncommon relative to clinical interventions. HTAs on population-based PHIs were less comprehensive in quality and rigor of the evidence. Countries with more resources and mature HTA-systems had done the most evaluations. Exploring the experiences of forerunners could help overcome barriers to evaluations of PHIs and exploit the full potential of HTAs to promote evidence-based public health.