Are life-extending treatments for terminal illnesses a special case? Exploring choices and societal viewpoints

Criteria used by the National Institute for Health and Care Excellence (NICE) to assess life-extending, end-of-life (EoL) treatments imply that health gains from such treatments are valued more than other health gains. Despite claims that the policy is supported by societal values, evidence from preference elicitation studies is mixed and in-depth research has shown there are different societal viewpoints. Few studies elicit preferences for policies directly or combine different approaches to understand preferences.Survey questions were designed to investigate support for NICE EoL guidance at national and regional levels. These ‘Decision Rule’ and ‘Treatment Choice’ questions were administered to an online sample of 1496 UK respondents in May 2014. The same respondents answered questions designed to elicit their agreement with three viewpoints (previously identified and described) in relation to provision of EoL treatments for terminally ill patients. We report the findings of these choice questions and examine how they relate to each other and respondents' viewpoints.The Decision Rule questions described three policies: DA – a standard ‘value for money’ test, applied to all health technologies; DB – giving special consideration to all treatments for terminal illnesses; and DC – giving special consideration to specific categories of treatments for terminal illnesses e.g. life extension (as in NICE EoL guidance) or those that improve quality-of-life (QoL). Three Treatment Choices were presented: TA – improving QoL for patients with a non-terminal illness; TB – extending life for EoL patients; and TC – improving QoL at the EoL.DC received most support (45%) with most respondents giving special consideration to EoL only when treatments improved QoL. The most commonly preferred treatment choices were TA (51%) and TC (43%). Overall, this study challenges claims about public support for NICE's EoL guidance and the focus on life extension at EoL and substantiates existing evidence of plurality in societal values

Cost-Effectiveness Thresholds in Global Health: Taking a Multisectoral Perspective.

Good health is a function of a range of biological, environmental, behavioral, and social factors. The consumption of quality health care services is therefore only a part of how good health is produced. Although few would argue with this, the economic framework used to allocate resources to optimize population health is applied in a way that constrains the analyst and the decision maker to health care services. This approach risks missing two critical issues: 1) multiple sectors contribute to health gain and 2) the goods and services produced by the health sector can have multiple benefits besides health. We illustrate how present cost-effectiveness thresholds could result in health losses, particularly when considering health-producing interventions in other sectors or public health interventions with multisectoral outcomes. We then propose a potentially more optimal second best approach, the so-called cofinancing approach, in which the health payer could redistribute part of its budget to other sectors, where specific nonhealth interventions achieved a health gain more efficiently than the health sector's marginal productivity (opportunity cost). Likewise, other sectors would determine how much to contribute toward such an intervention, given the current marginal productivity of their budgets. Further research is certainly required to test and validate different measurement approaches and to assess the efficiency gains from cofinancing after deducting the transaction costs that would come with such cross-sectoral coordination

Healthcare queueing models.

Healthcare systems differ intrinsically from manufacturing systems. As such, they require a distinct modeling approach. In this article, we show how to construct a queueing model of a general class of healthcare systems. We develop new expressions to assess the impact of service outages and use the resulting model to approximate patient flow times and to evaluate a number of practical applications. We illustrate the devastating impact of service interruptions on patient flow times and show the potential gains obtained by pooling hospital resources. In addition, we present an optimization model to determine the optimal number of patients to be treated during a service session.Operations research; Health care evaluation mechanisms; Organizational efficiency; Management decision support systems; Time management; Queueing theory;

A Methodological Approach for Measuring the Impact of HTA

There is a lack of evidence concerning the link between HTA and outcomes in terms of health improvements. This work proposes a framework for assessing the impact of HTA. This impact assessment is a necessary step in then better understanding the value for money of HTA bodies. We emphasis that this is still a work in progress. iDSI has developed a theory of change-based framework in order to evaluate the impact the iDSI has on institutional strengthening – leading to ‘better decisions’ for ‘better health’. This framework recognises that there is a complex translation process between better decisions and better health dependent on many assumptions about local factors and systems, including linkage between decisions and budgets, delivery, implementation, and data accuracy. Work has been undertaken over the last 6 months developing a methodological approach for measuring the impact of health technology assessment (HTA). Two case studies are used to illustrate the approach. At the core of impact assessment is a requirement to link causes and effects, to explain ‘how’ and ‘why’ and to identify – and thus improve or adapt – mechanisms leading to impact. Policy makers also want to know ‘to what extent’ or ‘the magnitude of impact’. The framework developed adopts an economic approach nested in theory of change as a means of both quantifying the magnitude of impact (utilising economic models) as well as explaining why and how impact happens (drawing on theory based approaches) in order to reinforce learning as to how to improve our response and optimise the use of HTA to have the greatest impact in a given context. This should also enable us to capture and explain wider impact – perhaps more intangible aspects which cannot be easily quantified. This may also possibly increase policy-makers’ ‘buy-in’

Opportunities for improving the efficiency of paediatric HIV treatment programmes

Objectives: To conduct two economic analyses addressing whether to: routinely monitor HIV-infected children on antiretroviral therapy (ART) clinically or with laboratory tests; continue or stop cotrimoxazole prophylaxis when children become stabilized on ART. Design and methods: The ARROW randomized trial investigated alternative strategies to deliver paediatric ART and cotrimoxazole prophylaxis in 1206 Ugandan/Zimbabwean children. Incremental cost-effectiveness and value of implementation analyses were undertaken. Scenario analyses investigated whether laboratory monitoring (CD4 tests for efficacy monitoring; haematology/biochemistry for toxicity) could be tailored and targeted to be delivered cost-effectively. Cotrimoxazole use was examined in malaria-endemic and non-endemic settings. Results: Using all trial data, clinical monitoring delivered similar health outcomes to routine laboratory monitoring, but at a reduced cost, so was cost-effective. Continuing cotrimoxazole improved health outcomes at reduced costs. Restricting routine CD4+ monitoring to after 52 weeks following ART initiation and removing toxicity testing was associated with an incremental cost-effectiveness ratio of $6084 per quality-adjusted life-year (QALY) across all age groups, but was much lower for older children (12+ years at initiation; incremental cost-effectiveness ratio =$769/QALY). Committing resources to improve cotrimoxazole implementation appears cost-effective. A healthcare system that could pay $600/QALY should be willing to spend up to$12.0 per patient-year to ensure continued provision of cotrimoxazole. Conclusion: Clinically driven monitoring of ART is cost-effective in most circumstances. Routine laboratory monitoring is generally not cost-effective at current prices, except possibly CD4 testing amongst adolescents initiating ART. Committing resources to ensure continued provision of cotrimoxazole in health facilities is more likely to represent an efficient use of resources

Monitoring targeting performance when decentralized allocation to the poor are unobserved

National antipoverty programs often rely heavily on provincial governments. The center targets poor provinces in the hope that they will reach their own poor. Without successful intraprovincial targeting, however, even dramatic redistribution from rich to poor provinces can have little impact on poverty nationally. However, data for assessing performance at provincial level are often far from ideal. Can a centralized government monitor the performance of decentralized social programs in reaching the poor when their benefit incidence is unobserved? The author shows that the poverty map and the corresponding spending allocation across geographic areas allow one to identify the latent differences in mean allocations to the poor versus the nonpoor. The national measure of targeting performance is also subgroup-decomposable. The author uses an application to an antipoverty program in Argentina (Trabajar II) to assess performance in reaching the poor and the measure the relative contributions to the program's performance - before and after reforms - of the center's provincial reallocation and decentralized targeting. Funding and program design changes led to large gains for the poor, although with diverse performance across provinces. Program funding and design choices by the central government can greatly affect the targeting performance of decentralized social programs. The allocation to a province should depend on how successful it is at reaching the poor with the extra resources, rather than how poor it is. Design choices should provide incentives for provincial governments to target resources to the poor . Finding feasible ways to monitor their performance and adjust ventral government's efforts accordingly are then crucial to better outcomes for poor people.Services&Transfers to Poor,Health Economics&Finance,Poverty Monitoring&Analysis,Poverty Reduction Strategies,Poverty Impact Evaluation,Safety Nets and Transfers,Poverty Monitoring&Analysis,Poverty Reduction Strategies,Services&Transfers to Poor,Rural Poverty Reduction