In Search for Comparability: The PECUNIA Reference Unit Costs for Health and Social Care Services in Europe

Clarifying terminology and definitions in education services for mental health users: A disambiguation study

In the wake of the mental health crisis in children and adolescents, the coordination of education and mental health services has become a global priority. However, differing terminologies and classifications across sectors, hinder effective comparison. The classification in education focuses mainly on outputs like qualifications or throughputs like teaching programs. This proof-of-concept study tested the applicability of a standard classification of health services, the Description and Evaluation of Services and DirectoriEs (DESDE), to evaluate education services for mental health users in the context of Spain and The Netherlands. It was conducted alongside the PECUNIA project, that sought to develop methods for the assessment of mental health costs and outcomes in different sectors. The study followed an ontoterminology approach involving: 1) identification of services from a predefined list of 46 resource-use items, 2) disambiguation of identified services with the DESDE, and classifying them as accurate, ambiguous, vague or confuse; and 3) external validation by an expert panel. The analysis was conducted at the level of type of resource, target population and care provision. From the initial list, only ten of the resources could be categorized as services using DESDE, and not activities, interventions or professionals. Only four of them (8,65%) were accurate across all disambiguation categories. Experts were unaware of terminology problems in classification of service provision in the education sector. Classifications and glossaries can clarify service naming, description and costing allowing comparative effectiveness analysis and facilitating cross-sectoral planning. This should be grounded in common methodologies, tools, and units of analysis.

A novel set of Austrian reference unit costs for comprehensive societal perspectives consistent with latest European costing methods for economic evaluations

Decision making in public health often happens against the background of scarce resources. The systematic use of economic evaluations can be a main enabler in the alignment of public health goals with budgetary constraints. However, the lack of standardized methodology in terms of costing method and perspective are a critical barrier to the implementation of economic evaluations and the international comparability of results. We present a novel set of 22 reference unit costs (RUCs) optimized for cross-sectoral economic evaluations in Austria suitable for international comparability calculated using the standardized PECUNIA RUC Template. The common framework for costing and reporting, as well as the easy availability of the RUCs will reduce the burden on researchers and policy makers in future economic evaluations. The higher quality, accuracy, transparency and availability of economic evidence for policy design will help to improve the efficiency of public health-relevant healthcare decisions and make it easier for policy makers to bring funding arrangements and decision making across multiple sectors in line with Health-in-All-Policies goals.

Methodological challenges and potential solutions for economic evaluations of palliative and end-of-life care: A systematic review

BACKGROUND

Given the increasing demand for palliative and end-of-life care, along with the introduction of costly new treatments, there is a pressing need for robust evidence on value. However, comprehensive guidance is missing on methods for conducting economic evaluations in this field.

AIM

To identify and summarise existing information on methodological challenges and potential solutions/recommendations for economic evaluations of palliative and end-of-life care.

DESIGN

We conducted a systematic review of publications on methodological considerations for economic evaluations of adult palliative and end-of-life care as per our PROSPERO protocol CRD42020148160. Following initial searches, we conducted a two-stage screening process and quality appraisal. Information was thematically synthesised, coded, categorised into common themes and aligned with the items specified in the Consolidated Health Economic Evaluation Reporting Standards statement.

DATA SOURCES

The databases Medline, Embase, HTADatabase, NHSEED and grey literature were searched between 1 January 1999 and 5 June 2023.

RESULTS

Out of the initial 6502 studies, 81 were deemed eligible. Identified challenges could be grouped into nine themes: ambiguous and inaccurate patient identification, restricted generalisability due to poor geographic transferability of evidence, narrow costing perspective applied, difficulties defining comparators, consequences of applied time horizon, ambiguity in the selection of outcomes, challenged outcome measurement, non-standardised measurement and valuation of costs as well as challenges regarding a reliable preference-based outcome valuation.

CONCLUSION

Our review offers a comprehensive context-specific overview of methodological considerations for economic evaluations of palliative and end-of-life care. It also identifies the main knowledge gaps to help prioritise future methodological research specifically for this field.

The identification of economically relevant health and social care services for mental disorders in the PECUNIA project

BACKGROUND

Health economic research is still facing significant problems regarding the standardization and international comparability of health care services. As a result, comparative effectiveness studies and cost-effectiveness analyses are often not comparable. This study is part of the PECUNIA project, which aimed to improve the comparability of economic evaluations by developing instruments for the internationally standardized measurement and valuation of health care services for mental disorders. The aim of this study was to identify internationally relevant services in the health and social care sectors relevant for health economic studies for mental disorders.

METHODS

A systematic literature review on cost-of-illness studies and economic evaluations was conducted to identify relevant services, complemented by an additional grey literature search and a search of resource use measurement (RUM) questionnaires. A preliminary long-list of identified services was explored and reduced to a short-list by multiple consolidation rounds within the international research team and an external international expert survey in six European countries.

RESULTS

After duplicate removal, the systematic search yielded 15,218 hits. From these 295 potential services could be identified. The grey literature search led to 368 and the RUM search to 36 additional potential services. The consolidation process resulted in a preliminary list of 186 health and social care services which underwent an external expert survey. A final consolidation step led to a basic list of 56 services grouped into residential care, daycare, outpatient care, information for care, accessibility to care, and self-help and voluntary care.

CONCLUSIONS

The initial literature searches led to an extensive number of potential service items for health and social care. Many of these items turned out to be procedures, interventions or providing professionals rather than services and were removed from further analysis. The resulting list was used as a basis for typological coding, the development of RUM questionnaires and corresponding unit costs for international mental health economic studies in the PECUNIA project.

Viewpoint: Assessing the value of mental health treatments in Europe

One in eight individuals worldwide lives with a mental health disorder. For many European countries, the prevalence is even higher, with one in four people reporting mental health problems [1]. Three-quarters of all mental health disorders develop before age 25, with many presenting initially in undiagnosed forms already in the mid-teens and eventually manifesting as severe disorders and lasting into old age [2]. There is also growing evidence that mental health disorder symptoms cross diagnoses and people frequently have more than one mental health disorder [3].

Cost-Effectiveness of Inter-Professional Collaboration to Reduce Hospitalisations in Nursing Home Residents: Results from the German Interprof ACT Trial

Background

The German multi-centre cluster-randomised controlled trial interprof ACT investigated interventions to increase inter-professional collaboration between nursing home (NH) staff and local general practitioners to reduce hospitalisations and improve nursing homes residents' (NHRs) quality of life. The trial was funded by the German Health Care Innovation Fund.

Methods

Cost-effectiveness of interprof ACT interventions was evaluated and compared to current standard of care (SOC) over 12 months, including 622 NHRs in 34 NHs in Germany. Multiplying resource use of healthcare services with German-specific unit costs generated costs. Health outcome was measured in quality-adjusted life-years QALYs), utility by multiplying EQ-5D-5L values with German-specific utility weights. Incremental cost-effectiveness analysis used an intention-to-treat approach and scenario analyses (SAs). Net-benefit-regression and cost-effectiveness acceptability curves addressed uncertainty. A German healthcare insurance perspective was assumed.

Results

Base case results showed non-significant cost savings of 851.88€ and non-significant QALY loss of -0,056.

Discussion

Dependency levels at baseline were non-significantly higher in IG compared to control group (CG). Lack of baseline costing data eliminated possibility to evaluate changes in costs due to the interprof ACT measures for both groups.

Conclusion

Interprof ACT interventions are not cost-effective compared to current SOC.

Formal health care costs among older people in Ireland: methods and estimates using The Irish Longitudinal Study on Ageing (TILDA)

Background: Reliable data on health care costs in Ireland are essential to support planning and evaluation of services. New unit costs and high-quality utilisation data offer the opportunity to estimate individual-level costs for research and policy. Methods: Our main dataset was The Irish Longitudinal Study on Ageing (TILDA). We used participant interviews with those aged 55+ years in Wave 5 (2018) and all end-of-life interviews (EOLI) to February 2020. We weighted observations by age, sex and last year of life at the population level. We estimated total formal health care costs by combining reported usage in TILDA with unit costs (non-acute care) and public payer reimbursement data (acute hospital admissions, medications). All costs were adjusted for inflation to 2022, the year of analysis. We examined distribution of estimates across the population, and the composition of costs across categories of care, using descriptive statistics. We identified factors associated with total costs using generalised linear models. Results: There were 5,105 Wave 5 observations, equivalent at the population level to 1,207,660 people aged 55+ years and not in the last year of life, and 763 EOLI observations, equivalent to 28,466 people aged 55+ years in the last year of life. Mean formal health care costs in the weighted sample were EUR 8,053; EUR 6,624 not in the last year of life and EUR 68,654 in the last year of life. Overall, 90% of health care costs were accounted for by 20% of users. Multiple functional limitations and proximity to death were the largest predictors of costs. Other factors that were associated with outcome included educational attainment, entitlements to subsidised care and serious chronic diseases. Conclusions: Understanding the patterns of costs, and the factors associated with very high costs for some individuals, can inform efforts to improve patient experiences and optimise resource allocation.

Making an economic argument for investment in global mental health: The case of conflict-affected refugees and displaced people

Mental health expenditure accounts for just 2.1% of total domestic governmental health expenditure per capita. There is an economic, as well as moral, imperative to invest more in mental health given the long-term adverse impacts of mental disorders. This paper focuses on how economic evidence can be used to support the case for action on global mental health, focusing on refugees and people displaced due to conflict. Refugees present almost unique challenges as some policy makers may be reluctant to divert scarce resources away from the domestic population to these population groups. A rapid systematic scoping review was also undertaken to identify economic evaluations of mental health-related interventions for refugees and displaced people and to look at how this evidence base can be strengthened. Only 11 economic evaluations focused on the mental health of refugees, asylum seekers and other displaced people were identified. All but two of these intervention studies potentially could be cost-effective, but only five studies reported cost per quality-adjusted life year gained, a metric allowing the economic case for investment in refugee mental health to be compared with any other health-focused intervention. There is a need for more consistent collection of data on quality of life and the longer-term impacts of intervention. The perspective adopted in economic evaluations may also need broadening to include intersectoral benefits beyond health, as well as identifying complementary benefits to host communities. More use can be also made of modelling, drawing on existing evidence on the effectiveness and resource requirements of interventions delivered in comparable settings to expand the current evidence base. The budgetary impact of any proposed strategy should be considered; modelling could also be used to look at how implementation might be adapted to contain costs and take account of local contextual factors.

Development of an Instrument for the Assessment of Health-Related Multi-sectoral Resource Use in Europe: The PECUNIA RUM

BACKGROUND

Measuring objective resource-use quantities is important for generating valid cost estimates in economic evaluations. In the absence of acknowledged guidelines, measurement methods are often chosen based on practicality rather than methodological evidence. Furthermore, few resource-use measurement (RUM) instruments focus on the measurement of resource use in multiple societal sectors and their development process is rarely described. Thorn and colleagues proposed a stepwise approach to the development of RUM instruments, which has been used for developing cost questionnaires for specific trials. However, it remains unclear how this approach can be translated into practice and whether it is applicable to the development of generic self-reported RUM instruments and instruments measuring resource use in multiple sectors. This study provides a detailed description of the practical application of this stepwise approach to the development of a multi-sectoral RUM instrument developed within the ProgrammE in Costing, resource use measurement and outcome valuation for Use in multi-sectoral National and International health economic evaluAtions (PECUNIA) project.

METHODS

For the development of the PECUNIA RUM, the methodological approach was based on best practice guidelines. The process included six steps, including the definition of the instrument attributes, identification of cost-driving elements in each sector, review of methodological literature and development of a harmonized cross-sectorial approach, development of questionnaire modules and their subsequent harmonization.

RESULTS

The selected development approach was, overall, applicable to the development of the PECUNIA RUM. However, due to the complexity of the development of a multi-sectoral RUM instrument, additional steps such as establishing a uniform methodological basis, harmonization of questionnaire modules and involvement of a broader range of stakeholders (healthcare professionals, sector-specific experts, health economists) were needed.

CONCLUSION

This is the first study that transparently describes the development process of a generic multi-sectoral RUM instrument in health economics and provides insights into the methodological aspects and overall validity of its development process.

Patterns of mental healthcare provision in rural areas: A demonstration study in Australia and Europe

INTRODUCTION

Mental healthcare systems are primarily designed to urban populations. However, the specific characteristics of rural areas require specific strategies, resource allocation, and indicators which fit their local conditions. This planning process requires comparison with other rural areas. This demonstration study aimed to describe and compare specialized rural adult mental health services in Australia, Norway, and Spain; and to demonstrate the readiness of the healthcare ecosystem approach and the DESDE-LTC mapping tool (Description and Evaluation of Services and Directories of Long Term Care) for comparing rural care between countries and across areas.

METHODS

The study described and classified the services using the DESDE-LTC. The analyses included context analysis, care availability, placement capacity, balance of care, and diversity of care. Additionally, readiness (Technology Readiness Levels - TRL) and impact analyses (Adoption Impact Ladder - AIL) were also assessed by two independent raters.

RESULTS

The findings demonstrated the usability of the healthcare ecosystem approach and the DESDE-LTC to map and identify differences and similarities in the pattern of care of highly divergent rural areas. Day care had a greater weight in the European pattern of care, while it was replaced by social outpatient care in Australian areas. In contrast, care coordination was more common in Australia, pointing to a more fragmented system that requires navigation services. The share between hospital and community residential care showed no differences between the two regions, but there were differences between catchment areas. The healthcare ecosystem approach showed a TRL 8 (the tool has been demonstrated in a real-world environment and it is ready for release and general use) and an AIL of 5 (the target public agencies provided resources for its completion). Two experts evaluated the readiness of the use of DESDE-LTC in their respective regional studies. All of them were classified using the TRL.

DISCUSSION

In conclusion, this study strongly supports gathering data on the provision of care in rural areas using standardized methods to inform rural service planning. It provides information on context and service availability, capacity and balance of care that may improve, directly or through subsequent analyses, the management and planning of services in rural areas.

International comparability of reference unit costs of education services: when harmonizing methodology is not enough (PECUNIA project)

BACKGROUND

Health problems can lead to costs in the education sector. However, these costs are rarely incorporated in health economic evaluations due to the lack of reference unit costs (RUCs), cost per unit of service, of education services and of validated methods to obtain them. In this study, a standardized unit cost calculation tool developed in the PECUNIA project, the PECUNIA RUC Template for services, was applied to calculate the RUCs of selected education services in five European countries.

METHODS

The RUCs of special education services and of educational therapy were calculated using the information collected via an exploratory gray literature search and contact with service providers.

RESULTS

The RUCs of special education services ranged from €55 to €189 per school day. The RUCs of educational therapy ranged from €6 to €25 per contact and from €5 to €35 per day. Variation was observed in the type of input data and measurement unit, among other.

DISCUSSION

The tool helped reduce variability in the RUCs related to costing methodology and gain insights into other aspects that contribute to the variability (e.g. data availability). Further research and efforts to generate high quality input data are required to reduce the variability of the RUCs.

Unit Costs in Health Economic Evaluations: Quo Vadis, Austria?

Evidence-informed healthcare decision-making relies on high quality data inputs, including robust unit costs, which in many countries are not readily available. The objective of the Department of Health Economics' Unit Cost Online Database, developed based on systematic reviews of Austrian costing studies, is to make conducting economic evaluations from healthcare and societal perspectives more feasible with publicly available unit cost information in Austria. This article aims to describe trends in unit cost data sources and reporting using this comprehensive database as a case study to encourage relevant national and international methodological discussions. Database analysis and synthesis included publication/study characteristics and costing reporting details in line with the Consolidated Health Economic Evaluation Reporting Standards (CHEERS 2022) with the year of the database launch as the cut-off point to assess how the methods have developed over time. Forty-two full economic evaluations and 278 unit costs were analyzed (2004-2016: 34 studies/232 unit costs, 2017-2022: 8 studies/46 unit costs). Although the reporting quality of costing details including the study perspective, unit cost sources and years has improved since 2017, the unit cost estimates and sources remained heterogeneous in Austria. While methodologically standardized national-level unit costs would be the gold standard, a systematically collated list of unit costs is a first step towards supporting health economic evaluations nationally.

Magnitude of terminological bias in international health services research: a disambiguation analysis in mental health

AIMS

Health services research (HSR) is affected by a widespread problem related to service terminology including non-commensurability (using different units of analysis for comparisons) and terminological unclarity due to ambiguity and vagueness of terms. The aim of this study was to identify the magnitude of the terminological bias in health and social services research and health economics by applying an international classification system.

METHODS

This study, that was part of the PECUNIA project, followed an ontoterminology approach (disambiguation of technical and scientific terms using a taxonomy and a glossary of terms). A listing of 56 types of health and social services relevant for mental health was compiled from a systematic review of the literature and feedback provided by 29 experts in six European countries. The disambiguation of terms was performed using an ontology-based classification of services (Description and Evaluation of Services and DirectoriEs - DESDE), and its glossary of terms. The analysis focused on the commensurability and the clarity of definitions according to the reference classification system. Interrater reliability was analysed using κ.

RESULTS

The disambiguation revealed that only 13 terms (23%) of the 56 services selected were accurate. Six terms (11%) were confusing as they did not correspond to services as defined in the reference classification system (non-commensurability bias), 27 (48%) did not include a clear definition of the target population for which the service was intended, and the definition of types of services was unclear in 59% of the terms: 15 were ambiguous and 11 vague. The κ analyses were significant for agreements in unit of analysis and assignment of DESDE codes and very high in definition of target population.

CONCLUSIONS

Service terminology is a source of systematic bias in health service research, and certainly in mental healthcare. The magnitude of the problem is substantial. This finding has major implications for the international comparability of resource use in health economics, quality and equality research. The approach presented in this paper contributes to minimise differentiation between services by taking into account key features such as target population, care setting, main activities and type and number of professionals among others. This approach also contributes to support financial incentives for effective health promotion and disease prevention. A detailed analysis of services in terms of cost measurement for economic evaluations reveals the necessity and usefulness of defining services using a coding system and taxonomical criteria rather than by 'text-based descriptions'.