The value of clinical information : an economic approach to research priority setting.

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Budget Allocation and the Revealed Social Rate of Time Preference for Health

Appropriate decisions based on cost-effectiveness evaluations of health care technologies depend upon the cost-effectiveness threshold and its rate of growth as well as some social rate of time preference for health. The concept of the cost-effectiveness threshold, social rate of time preference for consumption and social opportunity cost of capital are briefly explored before the question of how a social rate of time preference for health might be established is addressed. A more traditional approach to this problem is outlined before a social decision making approach is developed which demonstrates that social time preference for health is revealed through the budget allocations made by a socially legitimate higher authority. The relationship between the social time preference rate for health, the growth rate of the cost-effectiveness threshold and the rate at which the higher authority can borrow or invest is then examined. We establish that the social time preference rate for health is implied by the budget allocation and the health production functions in each period. As such, the social time preference rate for health depends not on the social time preference rate for consumption or growth in the consumption value of health but on growth in the cost-effectiveness threshold and the rate at which the higher authority can save or borrow between periods. The implications for discounting and the policies of bodies such as NICE are then discussed

Does public long-term care expenditure improve care-related quality of life in England?

Public long-term care (LTC) systems are common across Organisation for Economic Co-operation and Development countries and they provide services to support people experiencing difficulties with their activities of daily living. This study investigates the marginal effect of changes in public LTC expenditure on care-related quality of life (CRQoL) in England. The public LTC programme for people aged 18 or older in England is called Adult Social Care (ASC) and it is provided and managed by local authorities. We collect data on outcomes and characteristics of public ASC users, and on public ASC expenditure and characteristics of local authorities across England in 2017/18. We employ an instrumental variable approach using conditionally exogenous elements of the public funding system to estimate the effect of public ASC expenditure on users’ CRQoL. Our findings show that increasing public ASC expenditure by £1,000 per user generates 0.0031 additional CRQoL. These results suggest that public ASC is effective in increasing users’ quality of life but only to a relatively small extent. Combined with other findings on the effect of LTC expenditure on mortality, this study can inform policy makers in the UK and around the world about whether social care provides good value for money

Country-level cost-effectiveness thresholds : initial estimates and the need for further research

Objectives: Cost-effectiveness analysis (CEA) can guide policymakers in resource allocation decisions. CEA assesses whether the health gains offered by an intervention are large enough relative to any additional costs to warrant adoption. Where there are constraints on the healthcare system’s budget or ability to increase expenditures, additional costs imposed by interventions have an ‘opportunity cost’ in terms of the health foregone as other interventions cannot be provided. Cost-effectiveness thresholds (CETs) are typically used to assess whether an intervention is worthwhile and should reflect health opportunity cost. However, CETs used by some decision makers - such as the World Health Organization (WHO) suggested CETs of 1-3 times gross domestic product per capita (GDP pc) - do not. This study estimates CETs based on opportunity cost for a wide range of countries. Methods: We estimate CETs based upon recent empirical estimates of opportunity cost (from the English NHS), estimates of the relationship between country GDP pc and the value of a statistical life, and a series of explicit assumptions. Results: CETs for Malawi (the lowest income country in the world), Cambodia (borderline low/low-middle income), El Salvador (borderline low-middle/upper-middle) and Kazakhstan (borderline high-middle/high) are estimated to be $3-116 (1-51$44-518 (4-51%), $422-1,967 (11-51$4,485-8,018 (32-59%); respectively. Conclusions: To date opportunity cost-based CETs for low/middle income countries have not been available. Although uncertainty exists in the underlying assumptions, these estimates can provide a useful input to inform resource allocation decisions and suggest that routinely used CETs have been too high

Cost per DALY averted thresholds for low- and middle-income countries : evidence from cross country data

Low- and middle-income countries (LMICs) face difficult decisions about which health care interventions are worthwhile given existing constraints on health care expenditure. Decisions require some assessment of the health opportunity costs of proposed investments, i.e., a ‘supply side’ cost-effectiveness threshold (CET) that represents the likely health effects of changes in health care expenditure.  This paper provides a framework for generating country-level CETs using existing published estimates of the mortality effect of health expenditure. Two different estimation strategies are used (Bokhari et al (2007) and Moreno-Serra and Smith (2015)) and, where possible, estimation is extended to include other measures of mortality, survival and disability outcomes, reflecting the demographic and other characteristics of each LMIC. The results suggest that CETs representing likely health opportunity costs tend to be below the lower bound suggested by WHO of 1x GDP per capita. Hence, many previous and existing recommendations about which interventions are cost-effective that are based on the WHO threshold are likely to do more harm than good

Is extending eligibility for Adult Social Care better than investing more in existing users in England? Cross-sectional evidence for multiple financial years

Objectives Publicly funded adult social care (ASC) in England aims to improve quality of life through the provision of services for individuals with care needs due to physical and/or mental impairment or illness. Access to these services, however, is often restricted to contain public expenditure. With a fast-growing care need, information on whether extending eligibility is good value for money becomes policy-relevant.Primary and secondary outcome measures This study investigates the effect of extending ASC eligibility on user care-related quality of life (CRQoL), a policy-relevant measure of quality of life.Design We use English cross-sectional survey data from 2017/2018 to 2019/2020 on users receiving publicly funded long-term support including domiciliary and other community-based social care, as well as residential and nursing care from local authorities responsible for ASC. We employ the two-stage least square method to estimate the impact of ASC expenditure on CRQoL at various levels of ASC expenditure in each financial year. This includes the CRQoL effect of increasing expenditure from zero to some level, which captures the effect of extending ASC eligibility to new users.Results We find that publicly funded ASC improves the CRQoL of both existing and newly eligible users, although the latter are likely to experience greater CRQoL gains. Moreover, from 2017/2018 to 2019/2020, spending as much as an average user for a newly eligible user costs between £54 224 and £77 778 per social care-quality-adjusted life year (SC-QALY) gained. These results are statistically significant at the 5% level. Compared with this finding, increasing expenditure for an existing user has always a higher cost per SC-QALY gained.Conclusions Extending ASC eligibility to new users is likely to be more cost-effective compared with using the same resources to increase expenditure for existing users

Expected health benefits of additional evidence : Principles, methods and applications. A white paper for the Patient-Centered Outcomes Research Institute (PCORI).

The purpose of this research is to illustrate: i) the principles of what assessments are required when considering the need for additional evidence and the priority of proposed research; and ii) how these assessments might be informed by quantitative analysis based on standard methods of systematic review and meta-analysis. We briefly outline the principles of what type of assessments are needed when considering research prioritization and commissioning. These are more fully examined through the integration of the principles of value of information analysis with the type of meta-analysis commonly conducted in systematic review and its application to four topics or case studies. The case studies were selected to cover a number of contexts in which these assessments are likely to be required and include: where the primary endpoint in existing studies capture key aspects of outcome; where it can be linked to other important aspects of outcome; when different ‘weights’ might be used to reflect the relevance and quality of different studies and when more than two alternative interventions need to be compared. Throughout, we distinguish the value of additional evidence and the value of implementing the findings from existing research. We also show how the value of additional evidence and the need for further research depends on the clinical difference in key aspects of outcome that would need to be demonstrated before clinical practice ‘should’ or is likely to change. We also consider whether the expected health benefits of additional evidence are sufficient to regard a particular research proposal as potentially worthwhile and whether it should it be prioritized over other research topics that could have been commissioned with the same resources. We also set out the implications of this type of analysis for research design, including whether randomised design is likely to be needed, the most appropriate scale of future research and the sequence in which different types of study might be undertaken. The report demonstrates how making best use of the results of standard meta-analysis can directly inform the questions posed in research prioritisation and commissioning. In principle, this type of analysis could become part of the routine reporting of the findings of systematic review. In addition, it is sufficiently general to be relevant across a range of different types of health care systems, whether or not formal cost effectiveness analysis is explicitly used as part of the decision making process

Country-level cost-effectiveness thresholds : initial estimates and the need for further research.

Healthcare systems in low- and middle-income countries (LMICs) face considerable population healthcare needs with markedly fewer resources than those in developed countries. The way in which available resources are allocated across competing priorities is crucial in affecting how much health is generated overall, who receives healthcare interventions and who goes without. Cost effectiveness analysis (CEA) is one tool that can assist policy-makers in resource allocation. The central concern in CEA is whether the health gains offered by an intervention are large enough relative to its costs to warrant adoption. This requires some notion of the value that must be realized by an intervention, which is most frequently represented using a cost-effectiveness threshold (CET). CETs should be based on estimates of the forgone benefit associated with alternative priorities which consequently cannot be implemented as a result of the commitment of resources to an alternative. For most health care systems these opportunity costs fall predominantly on health as a result of fixed budgets or constraints on health systems’ abilities to increase expenditures. However,many CEAs to inform decisions in LMICs have used as pirational expressions of value, such as the World Health Organization’s (WHO) recommended CETs (of 1-3 times GDP per capita in a country)which are not based upon opportunity costs. In contrast, we estimate CETs for a number of countries based upon recent empirical estimates of foregone benefit (from the English NHS) and international income elasticities of the value of health. The resulting CETs are much lower than those previously posited by WHO. There is no intention to provide definitive CETs; rather, the study is intended to provoke further research in this area of crucial policy importance and outlines how more robust estimates of CETs could be generated

Coverage with evidence development, only in research, risk sharing or patient access scheme? : A framework for coverage decisions

Until recently, purchasers’ options regarding whether to pay for the use of technologies have been binary in nature: a treatment is covered or not covered. However, policies have emerged which expand the options - for example, linking coverage to evidence development, an option increasingly used for new treatments with limited/uncertain evidence. There has been little effort to reconcile the features of technologies with the available options in a way that reflects purchasers’ ranges of authorit