Essays on healthcare priority setting for population health

Healthcare priority setting is a major concern in most countries because healthcare represents a large and increasing public expenditure. Yet, there is not well established procedure that is consistently used to support those responsible for priority setting decisions. This dissertation consists of a review of the literature and five independent essays on healthcare priority setting, focusing on the value of formal analysis to support local healthcare planners in allocating a fixed budget. This dissertation makes both an intellectual and a practical contribution. The intellectual contribution is a synthesis of both economics and decision analysis insights. The review of the literature shows that tools grounded in health economics currently fail to contribute to local healthcare priority setting decisions because they are not practical. At the same time, tools grounded in (multi-criteria) decision analysis fail to incorporate the methodological advances of health economics and are hence theoretically weak. My thesis contributes to closing this gap. The practical contribution is that I design, and test the value of, a process and of particular value functions that can be used by local healthcare planners within their limited resources

Beyond “make” or “buy”: evaluating value‐for‐money in public service delivery

Outsourcing of public services is under heightened scrutiny. Public managers are asked to conduct thorough “make or buy” assessments to help assure deliverability, affordability, and value for money of public services. The naivety of this request dramatically overlooks the subtlety and challenge faced by public managers. In this paper we connect a range of differently configured contractual agreements to underlying components of “value for money”, namely, the pursuit of economy, efficiency and effectiveness. We set out a framework consisting of conceptual models and the corresponding decision tree to allow comparison across alternative sourcing strategies, considering both the associated transaction costs and transaction benefits. We also use simulation methods to capture uncertainty while establishing the practicality of the framework. This study advocates for moving beyond the polarized ‘make or buy’ debate with more instrumental considerations of “how to buy” from the perspective of the public manager

Healthcare prioritisation at the local level: a socio-technical approach

Cost effectiveness analysis is a systematic tool to inform resource allocation decision in healthcare. There is extensive evidence, however, that the tool is difficult to apply in practice, particularly at the level of local health planners, because it is not accessible to those involved in the prioritisation process and not embeds assumptions which are felt to be unacceptable for ethical or other reasons. Pragmatic tools such as Program Budgeting and Marginal Analysis appear to be more suitable for supporting local decisions by engaging stakeholders in a deliberative process. Unlike cost-effectiveness analysis, however, these tools are hard to relate to widely accepted health economic principles. This paper presents a socio-technical approach which draws explicitly on health economic theory and in a practical and reproduceable way through an action research case study with a local healthcare planner of the English National Health Service. Through close and iterative work with those responsible for allocating resources we present a formal model to capture the objectives of the health planners, a communicative procedure and interactive elicitation methods to help key stakeholders to articulate their knowledge and values. The approach proved accessible and acceptable and has been used in making spending decisions

Effectiveness-implementation hybrid type 2 study evaluating an intervention to support ‘information work’ in dementia care: an implementation study protocol

Introduction Patients with long-term conditions consistently report a lack of information around services and support available to them. This unmet need for information is significant among people with dementia and family carers. A quality improvement intervention is being carried out to tackle this issue as part of a co-creation initiative in the North East of England (UK). The intervention consists of the dissemination (via the local Community Mental Health Services for Older People) of a leaflet about services available to people with dementia and their family carers in the study site. This protocol is reported in accordance with the Standards for Reporting Implementation Studies. Methods and analysis This effectiveness–implementation hybrid type 2 study aims at understanding (1) the unfolding and outcomes of the implementation strategy, (2) the outcomes of the intervention (for people with dementia and family carers, staff implementing the intervention and local service providers) and (3) the contribution of co-creation to the design and implementation of the intervention and its outcomes. The prospective theory of change of the intervention articulated by local stakeholders is used as a reference framework against which to assess the implementation and outcomes of the intervention. Evaluation data will be collected through in-depth interviews with people with dementia and family carers receiving the intervention, staff implementing the intervention and managers from local service providers. Referral data from local service providers will be collected to triangulate the interview data. A focus group with key stakeholders will support the sense-making of findings. The realist configuration of mechanism–context–outcome, operationalised using an information behaviour model, will inform data analysis and interpretation. Ethics and dissemination Ethical and research governance approvals have been obtained from the West Midlands—South Birmingham Research Ethics Committee. The results of the study will be submitted for publication in peer-reviewed journals and disseminated through conferences

Preventing type 2 diabetes: systematic review of studies of cost-effectiveness of lifestyle programmes and metformin, with and without screening, for pre-diabetes

Objective Explore the cost-effectiveness of lifestyle interventions and metformin in reducing subsequent incidence of type 2 diabetes, both alone and in combination with a screening programme to identify high-risk individuals. Design Systematic review of economic evaluations. Data sources and eligibility criteria Database searches (Embase, Medline, PreMedline, NHS EED) and citation tracking identified economic evaluations of lifestyle interventions or metformin alone or in combination with screening programmes in people at high risk of developing diabetes. The International Society for Pharmaco-economics and Outcomes Research’s Questionnaire to Assess Relevance and Credibility of Modelling Studies for Informing Healthcare Decision Making was used to assess study quality. Results 27 studies were included; all had evaluated lifestyle interventions and 12 also evaluated metformin. Primary studies exhibited considerable heterogeneity in definitions of pre-diabetes and intensity and duration of lifestyle programmes. Lifestyle programmes and metformin appeared to be cost effective in preventing diabetes in high-risk individuals (median incremental cost-effectiveness ratios of £7490/quality-adjusted life-year (QALY) and £8428/QALY, respectively) but economic estimates varied widely between studies. Intervention-only programmes were in general more cost effective than programmes that also included a screening component. The longer the period evaluated, the more cost-effective interventions appeared. In the few studies that evaluated other economic considerations, budget impact of prevention programmes was moderate (0.13%–0.2% of total healthcare budget), financial payoffs were delayed (by 9–14 years) and impact on incident cases of diabetes was limited (0.1%–1.6% reduction). There was insufficient evidence to answer the question of (1) whether lifestyle programmes are more cost effective than metformin or (2) whether low-intensity lifestyle interventions are more cost effective than the more intensive lifestyle programmes that were tested in trials. Conclusions The economics of preventing diabetes are complex. There is some evidence that diabetes prevention programmes are cost effective, but the evidence base to date provides few clear answers regarding design of prevention programmes because of differences in denominator populations, definitions, interventions and modelling assumption

Social Outcomes Contracting (SOC) in Social Programmes and Public Services: A Mixed-Methods Systematic Review Protocol

Background: Across a range of policy areas and geographies, governments and philanthropists are increasingly looking to adopt a social outcomes contracting (SOC) approach. Under this model, an agreement is made that a provider of services must achieve specific, measurable social and/or environmental outcomes and payments are only made when these outcomes have been achieved. Despite this growing interest, there is currently a paucity of evidence in relation to the tangible improvement in outcomes associated with the implementation of these approaches. Although promising, evidence suggests that there are risks (especially around managing perverse incentives).[1] The growing interest in SOC has been accompanied by research of specific programmes, policy domains or geographies, but there has not been a systematic attempt to synthetise this emerging evidence. To address this gap, this systematic review aims to surface the best evidence on when and where effects have been associated with SOC.  Methods: This mixed-methods systematic review protocol has been prepared using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol (PRISMA-P) guidelines (Additional File 2) (Shamseer et al., 2010). The review aims to consult policymakers throughout the evidence synthesis process, by adopting a user-involved research process. This will include the establishment and involvement of a Policy Advisory Group (PAG). The PAG will consist of a large, diverse, international group of policy makers who are or have been actively involved in funding and shaping social outcomes contracts (Additional File 3). The following electronic databases will be searched: ABI/INFORM Global, Applied Social Sciences Index & Abstracts (ASSIA), Scopus, International Bibliography of the Social Sciences (IBSS), PAIS Index, PolicyFile Index, Proquest Dissertations and Theses, ProQuest Social Science, Social Services Abstracts, Web of Science, Worldwide Political Science Abstracts and PsycINFO. We will also conduct a comprehensive search of grey literature sources. Studies will be imported into Covidence and screened (after de-duplication) independently by two reviewers, using explicit inclusion/exclusion criteria. We will conduct risk of bias and quality assessment using recommended tools and we will extract data using a pre-piloted, standardised data extraction form. If meta-synthesis cannot be conducted for the effectiveness component, we will carry out a descriptive narrative synthesis of the quantitative evidence, categorised by type of intervention, type of outcome/s, population characteristics and/or policy sector. The qualitative studies will be synthesised using thematic content analysis (Thomas and Harden 2008). If possible, we will also analyse the available economic data to understand the costs and benefits associated with SOC. Finally, we will conduct a cross-study synthesis, which will involve bringing together the findings from the effectiveness review, economic review and qualitative review. We recognise that the proposed conventional effectiveness review method may lead to inconclusive or partial findings given the complexity of the intervention, the likely degree of heterogeneity and the under-developed evidence base. We see a traditional systematic review as an important foundation to describe the evidence landscape. We will use this formal review as a starting point and then explore more contextually rooted review work in future. Discussion: We will use the systematic review findings to produce accessible and reliable empirical insights on whether, when, and where (and if possible, how) SOC approaches deliver improved impact when compared to more conventional funding arrangements. The outputs will support policymakers to make informed decisions in relation to commissioning and funding approaches. Systematic   review   registration: This   systematic review was registered with the International Prospective Register of Systematic Reviews (PROSPERO), on 20th November 2020 and was last updated on 21 January 2021: (registration number PROSPERO CRD42020215207). [1] A perverse incentive in an outcomes-based contract is an incentive that has unintended and undesirable results. For instance, a poorly designed welfare-to-work scheme could create incentives for service providers to prioritise clients who are easier to help and to ‘park’ those who are harder to assist (NAO 2015)

Gains in QALYs vs DALYs averted: the troubling implications of using residual life expectancy

This note explores the difference between QALYs gained and DALYs averted in estimates of health benefits from interventions, where DALYs are estimated using local life expectancy tables. I assume that disability weights in the DALYs framework correspond to quality adjustment weights in QALYs, that there is no age weighting and that both frameworks use the same discounting methodology. I find that for the same intervention, health benefit measured as a reduction in DALYs is always smaller than the same benefit measured as a gain in QALYs. The higher the age of deaths prevented by the intervention, and the lower the quality of life in the years of life gained, the bigger the difference between DALYs and QALYs. The difference is reduced when benefits are discounted. I show that the difference can lead to a different ranking in cost-effectiveness league tables based on DALYs averted compared to gains in QALYs. I conclude that the use of the DALY framework based on local life expectancy tables might be appropriate for estimating the total burden of disease, but leads to troubling results if used for cost-effectiveness analysis. The use of a fixed reference age would avoid those implications, but might not be a reasonable assumption for estimating the total burden of disease

Intertemporal tradeoffs priced in interest rates and amounts: a study of method variance

In intertemporal choice experiments people usually choose between smaller-sooner and larger-later amounts of money. That is, they make tradeoffs in terms of nominal amounts. Yet the factor governing intertemporal tradeoffs in the marketplace is usually the interest rate. In this study, we tested whether two major phenomena that occur when trading off nominal amounts, excessive discounting and the hyperbolic-interval effect, would also occur when trade-offs are made in terms of interest rates. They don’t. In a large-scale (N=1,960) internet study of Spanish consumers who made intertemporal tradeoffs for money, tradeoffs described in terms of nominal amounts induced high discount rates and a considerable hyperbolic-interval effect (replicating earlier studies). However, when they were described as both amounts and interest rates, discount rates were much lower, and there was no effect for how finely the interval was partitioned. When the tradeoffs were described as interest rates only, discount rates were even lower, and the hyperbolic-interval effect was reversed. Thus, some of the most-cited results in intertemporal choice research are unique to a specific way of eliciting discount rates