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

Discussing uncertainty and risk in primary care: recommendations of a multi-disciplinary panel regarding communication around prostate cancer screening.

BackgroundShared decision making improves value-concordant decision-making around prostate cancer screening (PrCS). Yet, PrCS discussions remain complex, challenging and often emotional for physicians and average-risk men.ObjectiveIn July 2011, the Centers for Disease Control and Prevention convened a multidisciplinary expert panel to identify priorities for funding agencies and development groups to promote evidence-based, value-concordant decisions between men at average risk for prostate cancer and their physicians.DesignTwo-day multidisciplinary expert panel in Atlanta, Georgia, with structured discussions and formal consensus processes.ParticipantsSixteen panelists represented diverse specialties (primary care, medical oncology, urology), disciplines (sociology, communication, medical education, clinical epidemiology) and market sectors (patient advocacy groups, Federal funding agencies, guideline-development organizations).Main measuresPanelists used guiding interactional and evaluation models to identify and rate strategies that might improve PrCS discussions and decisions for physicians, patients and health systems/society. Efficacy was defined as the likelihood of each strategy to impact outcomes. Effort was defined as the relative amount of effort to develop, implement and sustain the strategy. Each strategy was rated (1-7 scale; 7 = maximum) using group process software (ThinkTank(TM)). For each group, intervention strategies were grouped as financial/regulatory, educational, communication or attitudinal levers. For each strategy, barriers were identified.Key resultsHighly ranked strategies to improve value-concordant shared decision-making (SDM) included: changing outpatient clinic visit reimbursement to reward SDM; development of evidence-based, technology-assisted, point-of-service tools for physicians and patients; reframing confusing prostate cancer screening messages; providing pre-visit decision support interventions; utilizing electronic health records to promote benchmarking/best practices; providing additional training for physicians around value-concordant decision-making; and using re-accreditation to promote training.ConclusionsConference outcomes present an expert consensus of strategies likely to improve value-concordant prostate cancer screening decisions. In addition, the methodology used to obtain agreement provides a model of successful collaboration around this and future controversial cancer screening issues, which may be of interest to funding agencies, educators and policy makers

Methodological reflections on the evaluation of the implementation and adoption of national electronic health record systems

Copyright @ 2012, International Journal of Integrated Care (IJIC). This work is licensed under a (http://creativecommons.org/licenses/by/3.0) Creative Commons Attribution 3.0 Unported License.Introduction/purpose of presentation: Far-reaching policy commitments to information technology-centered transformations of healthcare systems have now been made in many countries. There is as yet little empirical evidence to justify such decisions, hence the need for rigorous independent evaluation of current implementation efforts. Such evaluations however pose a number of important challenges. This presentation has been designed as a part of a Panel based on our experience of evaluating the National Health Service’s (NHS) implementation of electronic health records (EHR) systems in hospitals throughout England. We discuss the methodological challenges encountered in planning and undertaking an evaluation of a program of this scale and reflect on why and how we adapted our evaluation approach—both conceptually and methodologically—in response to these challenges. Study design/population studied: Critical reflections on a multi-disciplinary and multi-facet independent evaluation of a national program to implement electronic health record systems into 12 ‘early wave’ NHS hospitals in England. Findings: Our initial plan was to employ a mixed methods longitudinal ‘before-during-after’ study design. We however found this unsustainable in the light of fluxes in policy, contractual issues and over-optimistic schedules for EHR deployments. More importantly, this research design failed adequately to address the core of multi-faceted evolving EHRs as understood by key stakeholders and as worked out in their distinct work settings. Thus conventional outcomes-centric evaluations may not easily scale-up when evaluating transformational programs and may indeed prove misleading. New assumptions concerning the implementation process of EHR need to be developed that recognize the constantly changing milieu of policy, product, projects and professions that are inherent to such national implementations. The approaches we subsequently developed substitute the positivist view that EHR initiatives are self-evident and self-contained interventions, which are amenable to traditional quantitative evaluations, to one that focuses on how they are understood by various stakeholders and made to work in specific contexts. These assumptions recast the role of evaluation towards an approach that explores and interprets processes of socio-technical change that surround EHR implementation and adoption as seen by multiple stakeholders. Conclusions and policy implications: There is likely to be an increase in politically-driven national programs of reform of healthcare based on information and communication technologies. Programs on such a scale are inherently complex with extended temporalities and extensive and dynamic sets of stakeholders. They are, in short, different and pose new evaluation challenges that previously formulated evaluation methods for health information systems cannot easily address. This calls for methodological innovation amongst research teams and their supporting bodies. We argue that evaluation of such system-wide transformation programs are likely to demand both breadth and depth of experience within a multidisciplinary research team, constant questioning of what is and what can be evaluated and how, and a particular way of working that emphasizes continuous dialogue and reflexivity. Making this transition is essential to enable evaluations that can usefully inform policy-making. Health policy experts urgently need to reassess the evaluation strategies they employ as they come to address national policies for system-wide transformation based on new electronic health infrastructures

Coupled economic-ecological models for ecosystem-based fishery management: Exploration of trade-offs between model complexity and management needs

Ecosystem based fishery management has moved beyond rhetorical statements calling for a more holistic approach to resource management, to implementing decisions on resource use that are compatible with goals of maintaining ecosystem health and resilience. Coupled economic-ecological models are a primary tool for informing these decisions. Recognizing the importance of these models, the International Council for the Exploration of the Seas (ICES) formed a Study Group on Integration of Economics, Stock Assessment and Fisheries Management (SGIMM) to explore alternative modelling approaches that bring the multiple disciplines of economics, ecology, and stock assessment into integrated ecosystem models. The theme session was designed to be an extension of a series of workshops and theme sessions organized by the SGIMM, but highlighted the economic component of coupled models. Although economic and ecological systems are inherently complex, models are abstractions of these systems incorporating varying levels of complexity depending on available data and the management issues to be addressed. The objective of this special session was to assess the pros and cons of increasing model complexity to incorporate linkages between ecosystem components and processes. While more complex ecosystem models may provide greater insight into how management decisions and human actions propagate through the ecosystem and impact the value of ecosystem services, the resources and information required to develop and parameterize them is greater and these models tend to require trade-offs such as the inability to quantify uncertainty or model human behaviour as accurately as can be done with models of individual fisheries. The theme session was organized as a moderated panel format representing a progression of economic-ecological models from less to increasingly complex. The panel was selected to represent a range of models from fully integrated, highly detailed and dynamic economic-ecological models such as Atlantis to models that may be less detailed or not fully dynamic or integrated. The special session focused primarily on management issues that are of a longer term strategic nature such as the implications of climate change, fundamental regime change, or the role of forage species in an ecosystem. Each panellist provided an overview of their model including the management questions the model was designed to address, the data and time requirements, as well as any lessons learned. The panellist presentations were followed by an open discussion among the panellists and the audience. The abstracts for each of the panellist presentation are provided below followed by a summary of the issues raised during the moderated discussion sessio

The moderating influence of device characteristics and usage on user acceptance of smart mobile devices

This study seeks to develop a comprehensive model of consumer acceptance in the context of Smart Mobile Device (SMDs). This paper proposes an adaptation of the Technology Acceptance Model (TAM) and the Unified Theory of Acceptance and Use of Technology (UTAUT2) model that can be employed to explain and predict the acceptance of SMDs. Also included in the model are a number of external and new moderating variables that can be used to explain user intentions and subsequent usage behaviour. The model holds that Activity-based Usage and Device Characteristics are posited to moderate the impact of the constructs empirically validated in the UTAUT2 model. Through an important cluster of antecedents the proposed model aims to enhance our understanding of consumer motivations for using SMDs and aid efforts to promote the adoption and diffusion of these devices

A National Dialogue on Health Information Technology and Privacy

Increasingly, government leaders recognize that solving the complex problems facing America today will require more than simply keeping citizens informed. Meeting challenges like rising health care costs, climate change and energy independence requires increased level of collaboration. Traditionally, government agencies have operated in silos -- separated not only from citizens, but from each other, as well. Nevertheless, some have begun to reach across and outside of government to access the collective brainpower of organizations, stakeholders and individuals.The National Dialogue on Health Information Technology and Privacy was one such initiative. It was conceived by leaders in government who sought to demonstrate that it is not only possible, but beneficial and economical, to engage openly and broadly on an issue that is both national in scope and deeply relevant to the everyday lives of citizens. The results of this first-of-its-kind online event are captured in this report, together with important lessons learned along the way.This report served as a call to action. On his first full day in office, President Obama put government on notice that this new, more collaborative model can no longer be confined to the efforts of early adopters. He called upon every executive department and agency to "harness new technology" and make government "transparent, participatory, and collaborative." Government is quickly transitioning to a new generation of managers and leaders, for whom online collaboration is not a new frontier but a fact of everyday life. We owe it to them -- and the citizens we serve -- to recognize and embrace the myriad tools available to fulfill the promise of good government in the 21st Century.Key FindingsThe Panel recommended that the Administration give stakeholders the opportunity to further participate in the discussion of heath IT and privacy through broader outreach and by helping the public to understand the value of a person-centered view of healthcare information technology

Integrating Behavioral Health & Primary Care in New Hampshire: A Path Forward to Sustainable Practice & Payment Transformation

New Hampshire residents face challenges with behavioral and physical health conditions and the interplay between them. National studies show the costs and the burden of illness from behavioral health conditions and co-occurring chronic health conditions that are not adequately treated in either primary care or behavioral health settings. Bringing primary health and behavioral health care together in integrated care settings can improve outcomes for both behavioral and physical health conditions. Primary care integrated behavioral health works in conjunction with specialty behavioral health providers, expanding capacity, improving access, and jointly managing the care of patients with higher levels of acuity In its work to improve the health of NH residents and create effective and cost-effective systems of care, the NH Citizens Health Initiative (Initiative) created the NH Behavioral Health Integration Learning Collaborative (BHI Learning Collaborative) in November of 2015, as a project of its Accountable Care Learning Network (NHACLN). Bringing together more than 60 organizations, including providers of all types and sizes, all of the state’s community mental health centers, all of the major private and public insurers, and government and other stakeholders, the BHI Learning Collaborative built on earlier work of a NHACLN Workgroup focused on improving care for depression and co-occurring chronic illness. The BHI Learning Collaborative design is based on the core NHACLN philosophy of “shared data and shared learning” and the importance of transparency and open conversation across all stakeholder groups. The first year of the BHI Learning Collaborative programming included shared learning on evidence-based practice for integrated behavioral health in primary care, shared data from the NH Comprehensive Healthcare Information System (NHCHIS), and work to develop sustainable payment models to replace inadequate Fee-for-Service (FFS) revenues. Provider members joined either a Project Implementation Track working on quality improvement projects to improve their levels of integration or a Listen and Learn Track for those just learning about Behavioral Health Integration (BHI). Providers in the Project Implementation Track completed a self-assessment of levels of BHI in their practice settings and committed to submit EHR-based clinical process and outcomes data to track performance on specified measures. All providers received access to unblinded NHACLN Primary Care and Behavioral Health attributed claims data from the NHCHIS for provider organizations in the NH BHI Learning Collaborative. Following up on prior work focused on developing a sustainable model for integrating care for depression and co-occurring chronic illness in primary care settings, the BHI Learning Collaborative engaged consulting experts and participants in understanding challenges in Health Information Technology and Exchange (HIT/HIE), privacy and confidentiality, and workforce adequacy. The BHI Learning Collaborative identified a sustainable payment model for integrated care of depression in primary care. In the process of vetting the payment model, the BHI Learning Collaborative also identified and explored challenges in payment for Substance Use Disorder Screening, Brief Intervention and Referral to Treatment (SBIRT). New Hampshire’s residents will benefit from a health care system where primary care and behavioral health are integrated to support the care of the whole person. New Hampshire’s current opiate epidemic accentuates the need for better screening for behavioral health issues, prevention, and treatment referral integrated into primary care. New Hampshire providers and payers are poised to move towards greater integration of behavioral health and primary care and the Initiative looks forward to continuing to support progress in supporting a path to sustainable integrated behavioral and primary care

Care Management of Patients With Complex Health Care Needs

Explores how patients' complexity of healthcare needs, vulnerability, and age affect the cost and quality of their health care. Examines the potential for care management to improve quality of care and reduce costs, elements of success, and challenges

Using Intermediary Structures to Support Families: An International Comparison of Practice in Child Protection

Responses to child maltreatment can be conceptualized as a continuum, ranging from a welfare-oriented approach on one end, to a legalistic emphasis at the other end. By shifting attention to structures existing at the welfare end of the continuum, this paper endeavours to look beyond the approaches of investigation and legal processing, currently emphasized in Ontario’s approach to child welfare. This paper examines how intermediary structures and roles in various international settings are constructed to offer support to families and children. Intermediary judicial and professional roles found in European child welfare systems will be discussed. In addition, the paper will examine the roles and structures found in Ontario’s child welfare system that resemble those of an intermediary nature found in Europe. It is hoped that readers can use these cross-cultural comparisons to clarify the rationale behind choices, stimulate awareness of alternative views, and rethink some of the emphases and methods that dominate the child welfare system in Ontario