176 research outputs found
The NICE Cost-Effectiveness Threshold: What it is and What that Means
The National Institute for Health and Clinical Excellence (NICE) has been using a cost-effectiveness threshold range between £20 000 and £30 000 for over 7 years. What the cost-effectiveness threshold represents, what the appropriate
level is for NICE to use, and what the other factors are that NICE should consider have all been the subject of much discussion. In this article, we briefly review hese questions, provide a critical assessment of NICE’s utilization of the incremental cost-effectiveness ratio (ICER) threshold to inform its guidance, and suggest ways in which NICE’s utilization of the ICER threshold could be
developed to promote the efficient use of health service resources.
We conclude that it is feasible and probably desirable to operate an explicit single threshold rather than the current range; the threshold should be seen as a
threshold at which ‘other’ criteria beyond the ICER itself are taken into account; interventions with a large budgetary impact may need to be subject to a lower
threshold as they are likely to displace more than the marginal activities; reimbursement at the threshold transfers the full value of an innovation to the
manufacturer. Positive decisions above the threshold on the grounds of innovation reduce population health; the value of the threshold should be reconsidered regularly to
ensure that it captures the impact of changes in efficiency and budget over time; the use of equity weights to sustain a positive recommendation when the ICER is
above the threshold requires knowledge of the equity characteristics of those patients who bear the opportunity cost. Given the barriers to obtaining this knowledge and knowledge about the characteristics of typical beneficiaries of UK NHS care, caution is warranted before accepting claims from special pleaders; uncertainty in the evidence base should not be used to justify a positive recommendation when the ICER is above the threshold. The development of a programme of disinvestment guidance would enable NICE and the NHS to be more confident that the net health benefit of the Technology Appraisal Programme is
positive
HTA – algorithm or process? Comment on ‘Expanded HTA: enhancing fairness and legitimacy’
Daniels, Porteny and Urrutia et al make a good case for the idea that that public decisions ought to be made not
only “in the light of ” evidence but also “on the basis of ” budget impact, financial protection and equity. Health
technology assessment (HTA) should, they say, be accordingly expanded to consider matters additional to safety
and cost-effectiveness. They also complain that most HTA reports fail to develop ethical arguments and generally
do not even mention ethical issues. This comment argues that some of these defects are more apparent than real and
are not inherent in HTA – as distinct from being common characteristics found in poorly conducted HTAs. More
generally, HTA does not need “extension” since (1) ethical issues are already embedded in HTA processes, not least in
their scoping phases, and (2) HTA processes are already sufficiently flexible to accommodate evidence about a wide
range of factors, and will not need fundamental change in order to accommodate the new forms of decision-relevant
evidence about distributional impact and financial protection that are now starting to emerge. HTA and related
techniques are there to support decision-makers who have authority to make decisions. Analysts like us are there to
support and advise them (and not to assume the responsibilities for which they, and not we, are accountable). The
required quality in HTA then becomes its effectiveness as a means of addressing the issues of concern to decisionmakers. What is also required is adherence by competent analysts to a standard template of good analytical practice.
The competencies include not merely those of the usual disciplines (particularly biostatistics, cognitive psychology,
health economics, epidemiology, and ethics) but also the imaginative and interpersonal skills for exploring the “real”
question behind the decision-maker’s brief (actual or postulated) and eliciting the social values that necessarily
pervade the entire analysis. The product of such exploration defines the authoritative scope of an HTA
Social and ethical criteria for prioritizing patients: a survey of students and health professionals in Portugal
O estudo quali-quantitativo explora
o dilema ético da microalocação dos recursos da
saúde. Objetiva identificar e comparar a opinião
de dois grupos da sociedade portuguesa - estudantes
e profissionais de saúde sobre a importância
das características pessoais dos pacientes no momento
de os priorizar e se as escolhas se explicam
por referenciais bioéticos de caráter utilitaristas ou
deontológicos. Os dados foram recolhidos através
de um questionário aplicado a uma amostra de
180 estudantes universitários e 60 profissionais de
saúde. Os respondentes perante hipotéticos cená-
rios de emergência clínica tiveram de escolher de
entre dois pacientes (distinguidos por idade, sexo,
responsabilidade social, situação económica e laboral,
comportamentos lesivos da saúde e registo
criminal) quem tratar e justificar a escolha. Foram
usados testes estatísticos de associação para
comparar as respostas dos dois grupos e análise
de conteúdo para categorizar as justificações. Os
resultados sugerem a existência de diferenças nas
escolhas dos dois grupos, com os profissionais de
saúde a revelarem aceitar menos a utilização de
critérios sociais em contexto de escassez e coexistência
de critérios utilitaristas e deontológicos,
com predomínio da eficiência por parte dos profissionais
de saúde e da equidade por parte dos
estudantesThis qualitative/quantitative study examines
the ethical dilemma of microallocation of
health resources. It seeks to identify and compare
the opinion of two groups in Portuguese society
– students and health professionals – on the importance
of personal characteristics of patients at
the moment of prioritizing them and if the choices
can be explained by bioethical references of a
utilitarian or deontological nature. Data were
collected by means of a questionnaire administered
to a sample of 180 students and 60 health
professionals. Faced with hypothetical emergency
scenarios, the respondents had to choose between
two patients (distinguished by: age, gender, social
responsibility, economic and employment
situation, harmful health behaviors and criminal
record), duly selecting who to treat and then
justifying their choice. The results suggest the existence
of differences in choices between the two
groups, with health professionals revealing they
are less prepared to accept the use of social criteria
in a context of scarce resources and co-existence
of utilitarian and deontological criteria, with a
predominance of efficiency on the part of health
professionals and equity on the part of students.info:eu-repo/semantics/publishedVersio
Cost-Effectiveness of Docetaxel and Paclitaxel for Adjuvant Treatment of Early Breast Cancer: Adaptation of a Model-Based Economic Evaluation From the United Kingdom to South Africa
Objectives
Transferability of economic evaluations to low- and middle-income countries through adaptation of models is important; however, several methodological and practical challenges remain. Given its significant costs and the quality-of-life burden to patients, adjuvant treatment of early breast cancer was identified as a priority intervention by the South African National Department of Health. This study assessed the cost-effectiveness of docetaxel and paclitaxel-containing chemotherapy regimens (taxanes) compared with standard (non-taxane) treatments.
Methods
A cost-utility analysis was undertaken based on a UK 6-health-state Markov model adapted for South Africa using the Mullins checklist. The analysis assumed a 35-year time horizon. The model was populated with clinical effectiveness data (hazard ratios, recurrence rates, and adverse events) using direct comparisons from clinical trials. Resource use patterns and unit costs for estimating cost parameters (drugs, diagnostics, consumables, personnel) were obtained from South Africa. Uncertainty was assessed using probabilistic and deterministic sensitivity analyses.
Results
The incremental cost per patient for the docetaxel regimen compared with standard treatment was R6774. The incremental quality-adjusted life years (QALYs) were 0.24, generating an incremental cost-effectiveness ratio of R28430 per QALY. The cost of the paclitaxel regimen compared with standard treatment was estimated as −R578 and −R1512, producing an additional 0.03 and 0.025 QALYs, based on 2 trials. Paclitaxel, therefore, appears to be a dominant intervention. The base case results were robust to all sensitivity analyses.
Conclusions
Based on the adapted model, docetaxel and paclitaxel are predicted to be cost-effective as adjuvant treatment for early breast cancer in South Africa
SUPPORT Tools for evidence-informed health Policymaking (STP) 14: Organising and using policy dialogues to support evidence-informed policymaking
This article is part of a series written for people responsible for making decisions about health policies and programmes and for those who support these decision makers
From little things, big things grow: a local approach to system-wide maternity services reform in the absence of definitive evidence
For nearly two decades calls have been made to expand the role of midwives within maternity services in Australia. Although some progress has been made, it has been slow and, at system-wide level, limited. There are many barriers that prevent the expansion of midwifery-led services in Australia including funding arrangements for midwifery care, a lack of political will and resistance from powerful medical interest groups. The ongoing debate that exists about the evidence for the safety of midwifery-led care, particularly for the intrapartum phase, is likely to be an important reason why policy-makers are reluctant to implement system-wide reforms of maternity services
Socioeconomic patterns in the use of public and private health services and equity in health care
<p>Abstract</p> <p>Background</p> <p>Several studies in wealthy countries suggest that utilization of GP and hospital services, after adjusting for health care need, is equitable or pro-poor, whereas specialist care tends to favour the better off. Horizontal equity in these studies has not been evaluated appropriately, since the use of healthcare services is analysed without distinguishing between public and private services. The purpose of this study is to estimate the relation between socioeconomic position and health services use to determine whether the findings are compatible with the attainment of horizontal equity: equal use of public healthcare services for equal need.</p> <p>Methods</p> <p>Data from a sample of 18,837 Spanish subjects were analysed to calculate the percentage of use of public and private general practitioner (GP), specialist and hospital care according to three indicators of socioeconomic position: educational level, social class and income. The percentage ratio was used to estimate the magnitude of the relation between each measure of socioeconomic position and the use of each health service.</p> <p>Results</p> <p>After adjusting for age, sex and number of chronic diseases, a gradient was observed in the magnitude of the percentage ratio for public GP visits and hospitalisation: persons in the lowest socioeconomic position were 61–88% more likely to visit public GPs and 39–57% more likely to use public hospitalisation than those in the highest socioeconomic position. In general, the percentage ratio did not show significant socioeconomic differences in the use of public sector specialists. The magnitude of the percentage ratio in the use of the three private services also showed a socioeconomic gradient, but in exactly the opposite direction of the gradient observed in the public services.</p> <p>Conclusion</p> <p>These findings show inequity in GP visits and hospitalisations, favouring the lower socioeconomic groups, and equity in the use of the specialist physician. These inequities could represent an overuse of public healthcare services or could be due to the fact that persons in high socioeconomic positions choose to use private health services.</p
A model to prioritize access to elective surgery on the basis of clinical urgency and waiting time
<p>Abstract</p> <p>Background</p> <p>Prioritization of waiting lists for elective surgery represents a major issue in public systems in view of the fact that patients often suffer from consequences of long waiting times. In addition, administrative and standardized data on waiting lists are generally lacking in Italy, where no detailed national reports are available. This is true although since 2002 the National Government has defined implicit Urgency-Related Groups (URGs) associated with Maximum Time Before Treatment (MTBT), similar to the Australian classification. The aim of this paper is to propose a model to manage waiting lists and prioritize admissions to elective surgery.</p> <p>Methods</p> <p>In 2001, the Italian Ministry of Health funded the Surgical Waiting List Info System (SWALIS) project, with the aim of experimenting solutions for managing elective surgery waiting lists. The project was split into two phases. In the first project phase, ten surgical units in the largest hospital of the Liguria Region were involved in the design of a pre-admission process model. The model was embedded in a Web based software, adopting Italian URGs with minor modifications. The SWALIS pre-admission process was based on the following steps: 1) urgency assessment into URGs; 2) correspondent assignment of a pre-set MTBT; 3) real time prioritization of every referral on the list, according to urgency and waiting time. In the second project phase a prospective descriptive study was performed, when a single general surgery unit was selected as the deployment and test bed, managing all registrations from March 2004 to March 2007 (1809 ordinary and 597 day cases). From August 2005, once the SWALIS model had been modified, waiting lists were monitored and analyzed, measuring the impact of the model by a set of performance indexes (average waiting time, length of the waiting list) and Appropriate Performance Index (API).</p> <p>Results</p> <p>The SWALIS pre-admission model was used for all registrations in the test period, fully covering the case mix of the patients referred to surgery. The software produced real time data and advanced parameters, providing patients and users useful tools to manage waiting lists and to schedule hospital admissions with ease and efficiency. The model protected patients from horizontal and vertical inequities, while positive changes in API were observed in the latest period, meaning that more patients were treated within their MTBT.</p> <p>Conclusion</p> <p>The SWALIS model achieves the purpose of providing useful data to monitor waiting lists appropriately. It allows homogeneous and standardized prioritization, enhancing transparency, efficiency and equity. Due to its applicability, it might represent a pragmatic approach towards surgical waiting lists, useful in both clinical practice and strategic resource management.</p
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