A computer-guided quality improvement tool for primary health care: cost-effectiveness analysis based on TORPEDO trial data

Health economic evaluation of preventive digital public health interventions using decision-analytic modelling: a systematized review

BACKGROUND

Digital public health (DiPH) provides novel approaches for prevention, potentially leading to long-term health benefits in resource-limited health systems. However, cost-effectiveness of DiPH interventions is unclear. This systematized review investigates the use of decision-analytic modelling in health economic evaluations of DiPH primary prevention and health promotion interventions, focusing on intervention's design, methods used, results, and reporting quality.

METHODS

PubMed, CINAHL, and Web of Science were searched for studies of decision-analytic economic evaluations of digital interventions in primary prevention or health promotion, published up to June 2022. Intervention characteristics and selected items were extracted based on the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). Incremental cost-effectiveness ratios (ICERs) were then extracted and price-adjusted to compare the economic evaluation results. Finally, the included studies' reporting quality was assessed by building a score using CHEERS.

RESULTS

The database search (including search update) produced 2,273 hits. After removing duplicates, 1,434 titles and abstracts were screened. Of the 89 studies meeting the full-text search criteria, 14 were ultimately reviewed. The most common targets were physical activity (five studies) and weight loss (four). Digital applications include text messages, web-based inventions, app-based interventions, e-learning devices, and the promotion of smartphone apps. The mean ICER of the 12 studies using quality-adjusted life years (QALYs) is €20,955 per QALY (min. - €3,949; max. €114,211). The mean of reported CHEERS items per study is 81% (min. 59%; max. 91%).

CONCLUSIONS

This review only includes primary prevention and health promotion, and thus excludes other DiPH fields (e.g. secondary prevention). It also focuses on decision-analytic models, excluding study-based economic evaluations. Standard methods of economic evaluation could be adapted more to the specifics of DiPH by measuring the effectiveness of more current technologies through alternative methods, incorporating a societal perspective, and more clearly defining comparators. Nevertheless, the review demonstrates using common thresholds that the new field of DiPH shows potential for cost-effective preventive interventions.

Utilisation of government-subsidised chronic disease management plans and cardiovascular care in Australian general practices

Background

Government-subsidised general practice management plans (GPMPs) facilitate chronic disease management; however, impact on cardiovascular disease (CVD) is unknown. We aimed to determine utilisation and impact of GPMPs for people with or at elevated risk of CVD.

Methods

Secondary analysis of baseline data from the CONNECT randomised controlled trial linked to Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) claims. Multivariate regression examining the association of GPMP receipt and review with: (1) ≥ 1 MBS-subsidised allied health visit in the previous 24 months; (2) adherence to dual cardioprotective medication (≥ 80% of days covered with a dispensed PBS prescription); and (3) meeting recommended LDL-cholesterol and blood pressure (BP) targets concurrently.

Results

Overall, 905 trial participants from 24 primary health care services consented to data linkage. Participants with a GPMP (46.6%, 422/905) were older (69.4 vs 66.0 years), had lower education (32.3% vs 24.7% high school or lower), lower household income (27.5% vs 17.0% in lowest bracket), and more comorbidities, particularly diabetes (42.2% vs 17.6%) compared to those without a GPMP. After adjustment, a GPMP was strongly associated with allied health visits (odds ratio (OR) 14.80, 95% CI: 9.08–24.11) but not higher medication adherence rates (OR 0.82, 95% CI: 0.52–1.29) nor meeting combined LDL and BP targets (OR 1.31, 95% CI: 0.72–2.38). Minor differences in significant covariates were noted in models using GPMP review versus GPMP initiation.

Conclusions

In people with or at elevated risk of CVD, GPMPs are under-utilised overall. They are targeting high-needs populations and facilitate allied health access, but are not associated with improved CVD risk management, which represents an opportunity for enhancing their value in supporting guideline-recommended care.

Design, effectiveness, and economic outcomes of contemporary chronic disease clinical decision support systems: a systematic review and meta-analysis

Objectives

Electronic health record-based clinical decision support (CDS) has the potential to improve health outcomes. This systematic review investigates the design, effectiveness, and economic outcomes of CDS targeting several common chronic diseases.

Material and Methods

We conducted a search in PubMed (Medline), EBSCOHOST (CINAHL, APA PsychInfo, EconLit), and Web of Science. We limited the search to studies from 2011 to 2021. Studies were included if the CDS was electronic health record-based and targeted one or more of the following chronic diseases: cardiovascular disease, diabetes, chronic kidney disease, hypertension, and hypercholesterolemia. Studies with effectiveness or economic outcomes were considered for inclusion, and a meta-analysis was conducted.

Results

The review included 76 studies with effectiveness outcomes and 9 with economic outcomes. Of the effectiveness studies, 63% described a positive outcome that favored the CDS intervention group. However, meta-analysis demonstrated that effect sizes were heterogenous and small, with limited clinical and statistical significance. Of the economic studies, most full economic evaluations (n = 5) used a modeled analysis approach. Cost-effectiveness of CDS varied widely between studies, with an estimated incremental cost-effectiveness ratio ranging between USD$2192 to USD$151 955 per QALY.

Conclusion

We summarize contemporary chronic disease CDS designs and evaluation results. The effectiveness and cost-effectiveness results for CDS interventions are highly heterogeneous, likely due to differences in implementation context and evaluation methodology. Improved quality of reporting, particularly from modeled economic evaluations, would assist decision makers to better interpret and utilize results from these primary research studies.

Registration

PROSPERO (CRD42020203716)

Economic evaluations of audit and feedback interventions: a systematic review

BACKGROUND

The effectiveness of audit and feedback (A&F) interventions to improve compliance to healthcare guidelines is supported by randomised controlled trials (RCTs) and meta-analyses of RCTs. However, there is currently a knowledge gap on their cost-effectiveness.

OBJECTIVE

We aimed to assess whether A&F interventions targeting improvements in compliance to recommended care are economically favourable.

METHODS

We conducted a systematic review including experimental, observational and simulation-based economic evaluation studies of A&F interventions targeting healthcare providers. Comparators were a 'do nothing' strategy, or any other intervention not involving A&F or involving a subset of A&F intervention components. We searched MEDLINE, CINAHL, CENTRAL, Econlit, EMBASE, Health Technology Assessment Database, MEDLINE, NHS Economic Evaluation Database, ABI/INFORM, Web of Science, ProQuest and websites of healthcare quality associations to December 2021. Outcomes were incremental cost-effectiveness ratios, incremental cost-utility ratios, incremental net benefit and incremental cost-benefit ratios. Pairs of reviewers independently selected eligible studies and extracted relevant data. Reporting quality was evaluated using CHEERS (Consolidated Health Economic Evaluation Reporting Standards). Results were synthesised using permutation matrices for all studies and predefined subgroups.

RESULTS

Of 13 221 unique citations, 35 studies met our inclusion criteria. The A&F intervention was dominant (ie, at least as effective with lower cost) in 7 studies, potentially cost-effective in 26 and was dominated (ie, the same or less effectiveness and higher costs) in 2 studies. A&F interventions were more likely to be economically favourable in studies based on health outcomes rather than compliance to recommended practice, considering medical costs in addition to intervention costs, published since 2010, and with high reporting quality.

DISCUSSION

Results suggest that A&F interventions may have a high potential to be cost-effective. However, as is common in systematic reviews of economic evaluations, publication bias could have led to an overestimation of their economic value.

The role of Primary Health Networks in cardiovascular disease prevention: A qualitative interview study

BACKGROUND

Since the inception of PHNs in Australia, their role in implementing chronic disease prevention activities in general practice has been unclear. This study aimed to qualitatively explore the views of PHN staff on the role of PHNs in promoting prevention, with a focus on cardiovascular disease (CVD) prevention.

METHODS

Content analysis of PHN Needs Assessments was conducted to inform interview questions. Twenty-nine semi-structured interviews were conducted with 32 PHN staff, between June and December 2020, in varied roles across 18 PHNs in all Australian states and territories. Transcribed audio recordings were thematically coded, using the Framework Analysis method to ensure rigour.

RESULTS

We identified three main themes: (a) Informal prevention: All respondents agreed the role of PHNs in prevention was indirect and, for the most part, outside the formal remit of PHN Key Performance Indicators (KPIs.) Prevention activities were conducted in partnership with external stakeholders, professional development and quality improvement programs, and PHN-funded data extraction and analysis software for general practice. (b) Constrained by financial incentives: Most interviewees felt the role of PHNs in prevention was contingent on the financial drivers provided by the Commonwealth government, such as Medicare funding and national quality improvement programs. (c) Shaped through competing priorities: The role of PHNs in prevention is a function of competing priorities. There was strong agreement amongst participants that the myriad competing priorities from government and local needs assessments impeded prevention activities.

CONCLUSIONS

PHNs are well-positioned to foster prevention activities in general practice. However, we found that PHNs role in prevention activities was informal, constrained by financial incentives and shaped through competing priorities. Prevention can be improved through a more explicit prevention focus at the Commonwealth government level. To optimise the role of PHNs, therefore, requires prioritising prevention, aligning it with KPIs and supporting stakeholders like general practice.