Rationing in an era of multiple tight constraints: is cost-utility analysis still fit for purpose?

Cost-utility analysis may not be sufficient to support reimbursement decisions when the assessed health intervention requires a large proportion of the healthcare budget or when the monetary healthcare budget is not the only resource constraint. Such cases include joint replacement, COVID-19 interventions and settings where all resources are constrained (e.g. post-COVID-19 or in low/middle income countries). Using literature on health technology assessment, rationing and reimbursement in healthcare, we identified seven alternative frameworks for simultaneous decisions about (dis)investment and proposed modifications to deal with multiple resource constraints. These frameworks comprised: constrained optimisation; cost-effectiveness league table; ‘step-in-the-right-direction’ approach; heuristics based on effective gradients; weighted cost-effectiveness ratios; multi-criteria decision analysis (MCDA); and programme budgeting and marginal analysis (PBMA). We used numerical examples to demonstrate how five of these alternative frameworks would operate. The modified frameworks we propose could be used in local commissioning and/or health technology assessment to supplement standard cost-utility analysis for interventions that have large budget impact and/or are subject to additional constraints

A multidisciplinary approach to the study of slope instability in Derbyshire, with particular reference to Matlock

This study of slope instability in the Matlock region of Derbyshire uses, and tests the applicability of, a variety of techniques from reconnaissance through to site investigation. The aims have been to (i) provide a greater understanding of landsliding in this area and (ii) produce a critical assessment of the techniques employed. A procedure was developed for the application of Landsat-5 TM imagery to slope stability studies, however, such imagery was found to be of very limited use in the study area. Morphological and geomorphological mapping from aerial photographs and in the field proved to be of greatest use for supplying information on landslide location, morphology, type and recent activity, and also in identifying surface water conditions. These techniques are relatively rapid, require the minimum of equipment, and provide a large amount of relevant data in a short time. They are also applicable to both reconnaissance surveys and site investigations. The geomorphological survey of Oker Hill near Matlock revealed a large multiple rotational landslide. An ochre-precipitating spring is situated within this landslide. A similar spring occurs on Mam Tor landslide in north Derbyshire, and Vear (1981) has shown this to be evidence of pyrite oxidation of the shale, a process which is believed to lead to periodic slope failure. Analysis of core material from two boreholes through the Oker Hill landslide confirmed that pyrite has been lost from the failed material and that the present base of the weathered zone is in the pyritic shale. Pyrite oxidation is resulting in iron oxide staining, the loss of sulphur (presumably as sulphuric acid which will participate in further reactions) and in an overall deterioration of the rock quality of the shale

Objects As Polyagents: Tracing The Histories Of The Gweagal Spears

This paper explores the capacity for objects entangled in complex - and often painful - histories to become constituted of multiple agencies (Gell 1998) through their interaction with various actants in complex and ever-expanding networks of association (Latour 1993; 2005). It does so by analysing how such objects become symbols for multiple histories, presences, and political agendas throughout their social lives (Appadurai 1986; Kopytoff 1986). The paper also examines how these objects influence and construct the pathways of their social lives through their polyagency. ‘Polyagency’ reflects a theory of object agency that I have developed through engaging literature on materiality and agency (Gell 1998), consumption and object movement (Appadurai 1986; Kopytoff 1986), and networks of relationality (Latour 2005). It considers the multiple gathered identities that objects come to embody through the sum of their interactions with various human actors during the objects’ social lives - agencies which then become efficacious in later interactions with people. The productivity of this theory is demonstrated by applying it to the analysis of a complicated repatriation case involving the Gweagal Spears, currently owned by Trinity College and held at the Museum of Archaeology and Anthropology in Cambridge. This application illustrates the impact that innovations in theory and repatriation cases can have on the perceived role of museums regarding object return, decolonisation and reconciliation efforts through relationship-building with source communities.Isaac Newton Trust and Corpus Christi College (under the 'Newton College Masters Scheme'

A multidisciplinary approach to the study of slope instability in Derbyshire, with particular reference to Matlock

This study of slope instability in the Matlock region of Derbyshire uses, and tests the applicability of, a variety of techniques from reconnaissance through to site investigation. The aims have been to (i) provide a greater understanding of landsliding in this area and (ii) produce a critical assessment of the techniques employed. A procedure was developed for the application of Landsat-5 TM imagery to slope stability studies, however, such imagery was found to be of very limited use in the study area. Morphological and geomorphological mapping from aerial photographs and in the field proved to be of greatest use for supplying information on landslide location, morphology, type and recent activity, and also in identifying surface water conditions. These techniques are relatively rapid, require the minimum of equipment, and provide a large amount of relevant data in a short time. They are also applicable to both reconnaissance surveys and site investigations. The geomorphological survey of Oker Hill near Matlock revealed a large multiple rotational landslide. An ochre-precipitating spring is situated within this landslide. A similar spring occurs on Mam Tor landslide in north Derbyshire, and Vear (1981) has shown this to be evidence of pyrite oxidation of the shale, a process which is believed to lead to periodic slope failure. Analysis of core material from two boreholes through the Oker Hill landslide confirmed that pyrite has been lost from the failed material and that the present base of the weathered zone is in the pyritic shale. Pyrite oxidation is resulting in iron oxide staining, the loss of sulphur (presumably as sulphuric acid which will participate in further reactions) and in an overall deterioration of the rock quality of the shale

Using orthopaedic health care resources efficiently: a cost analysis of day surgery for unicompartmental knee replacement

Background: Day surgery for unicompartmental knee replacement (UKR) could potentially reduce hospital costs. We aimed to measure the impact of introducing a day surgery UKR pathway on mean length of stay (LOS) and costs for the UK NHS, compared to an accelerated inpatient pathway. Secondly, the study aimed to compare the magnitude of costs using three costing approaches: top-down costing; simple micro-costing; and real-world costing. Methods: We conducted an observational, before-and-after study of 2,111 UKR patients at one NHS hospital: 1,094 patients followed the day surgery pathway between September 2017 and February 2020; and 1,017 patients followed the accelerated inpatient pathway between September 2013 and February 2016. Top-down costs were estimated using Average NHS Costs. Simple micro-costing used the cost per bed-day. Real-world costs for this centre were estimated by costing actual changes in staffing levels. Results: 532 (48.5%) patients in the day surgery pathway were discharged on the day of surgery compared with 36 (3.5%) patients in the accelerated inpatient pathway. The day surgery pathway reduced the mean LOS by 2.2 (95% CI: 1.81, 2.53) nights and was associated with an 18% decrease in Average NHS Costs (p < 0.001). Mean savings were £1,429 per patient with the Average NHS Costs approach, £905 per patient with the micro-costing approach, and £577 per patient with the “real-world” costing approach. Overall, moving NHS UKR surgeries to a day surgery pathway could save the NHS £8,659,740 per year. Conclusion: Day surgery for UKR could produce substantial cost savings for hospitals and the NHS

Rationing of total knee replacement: a cost-effectiveness analysis on a large trial data set

PMID: 22290396 [PubMed] PMCID: PMC3269047 Free PMC ArticlePeer reviewedPublisher PD

Using QALYs as an outcome for assessing global prediction accuracy in diabetes simulation models

Objectives: (1) To demonstrate the use of quality-adjusted life-years (QALYs) as an outcome measure for comparing performance between simulation models and identifying the most accurate model for economic evaluation and health technology assessment. QALYs relate directly to decision-making and combine mortality and diverse clinical events into a single measure using evidence-based weights that reflect population preferences. (2) To explore the usefulness of Q2 (Q-squared), the proportional reduction in error, as a model performance metric and compare it with other metrics: MSE; mean absolute error; bias (mean residual); and R2. Methods: We simulated all EXSCEL trial participants (n=14,729) using the UK Prospective Diabetes Study Outcomes Model software versions 1 (UKPDS-OM1) and 2 (UKPDS-OM2). The EXSCEL trial compared once-weekly exenatide with placebo (median 3.2 years’ follow-up). Default UKPDS-OM2 utilities were used to estimate undiscounted QALYs over the trial period based on the observed events and survival. These were compared with the QALYs predicted by UKPDS-OM1/2 for the same period. Results: UKPDS-OM2 predicted patients’ QALYs more accurately than UKPDS-OM1 (MSE: 0.210 vs. 0.253; Q2: 0.822 vs. 0.786). UKPDS-OM2 underestimated QALYs by an average of 0.127, vs. 0.150 for UKPDS-OM1. UKPDS-OM2 predictions were more accurate for mortality, myocardial infarction and stroke, while UKPDS-OM1 better predicted blindness and heart disease. Q2 facilitated comparisons between subgroups and (unlike R2) was lower for biased predictors. Conclusions: Q2 for QALYs was useful for comparing global prediction accuracy (across all clinical events) of diabetes models. It could be used for model registries, choosing between simulation models for economic evaluation and evaluating the impact of recalibration. Similar methods could be used in other disease areas

'Online' geriatric assessment procedure for older adults referred for geriatric assessment during an acute care episode for consideration of reliability of triage decisions

Background Comprehensive geriatric assessment has been shown to improve patient outcomes, but the geriatricians who deliver it are in short-supply. A web-based method of comprehensive geriatric assessment has been developed with the potential to improve access to specialist geriatric expertise. The current study aims to test the reliability and safety of comprehensive geriatric assessment performed “online” in making geriatric triage decisions. It will also explore the accuracy of the procedure in identifying common geriatric syndromes, and its cost relative to conventional “live” consultations. Methods/Design The study population will consist of 270 acutely hospitalized patients referred for geriatric consultation at three sites. Paired assessments (live and online) will be conducted by independent, blinded geriatricians and the level of agreement examined. This will be compared with the level of agreement between two independent, blinded geriatricians each consulting with the patient in person (i.e. “live”). Agreement between the triage decision from live-live assessments and between the triage decision from live-online assessments will be calculated using kappa statistics. Agreement between the online and live detection of common geriatric syndromes will also be assessed using kappa statistics. Resource use data will be collected for online and live-live assessments to allow comparison between the two procedures. Discussion If the online approach is found to be less precise than live assessment, further analysis will seek to identify patient subgroups where disagreement is more likely. This may enable a protocol to be developed that avoids unsafe clinical decisions at a distance. Trial registration Trial registration number: ACTRN1261100093692

How are maternal and fetal outcomes incorporated when measuring benefits of interventions in pregnancy? Findings from a systematic review of cost-utility analyses

Objective: Medical interventions used in pregnancy can affect the length and quality of life of both the pregnant person and fetus. The aim of this systematic review was to identify and describe the theoretical frameworks that underpin outcome measurement in cost-utility analyses of pregnancy interventions. Methods: Searches were conducted in the Paediatric Economic Database Evaluation (PEDE) database (up to 2017), as well as Medline, Embase and EconLit (2017–2019). We included all cost-utility analyses of any intervention given during pregnancy, published in English. We conducted a narrative synthesis of: study design; outcome construction (life expectancy, quality adjustment, discount rate); and whether the Incremental Cost-Effectiveness Ratio (ICER) was constructed using maternal or fetal outcomes. Where both outcomes were included, methods for combining them were extracted. Results: We identified 127 cost-utility analyses in pregnancy, of which 89 reported QALYs and 38 DALYs. Outcomes were considered solely for the fetus in 59 studies (47%), solely for the pregnant person in 13 studies (10%), and for both in 49 studies (39%). The choice to include or exclude one or both sets of outcomes was not consistent within particular clinical areas. Where outcomes for both mother and baby were included, methods for combining these outcomes varied. Twenty-nine studies summed QALYs/DALYs for maternal and fetal outcomes, with no adjustment. The remaining 20 took a variety of approaches designed to weigh maternal and fetal outcomes differently. These include (1) treating fetal outcomes as a component of maternal quality of life, rather than (or in addition to) an independent individual health outcome; (2) treating the maternal-fetal dyad as a single entity and applying a single utility value to each combination of outcomes; and (3) assigning a shorter time horizon to fetal outcomes to reduce the weight of lifetime fetal outcomes. Each approach made different assumptions about the relative value of maternal and fetal health outcomes, demonstrating a lack of consistency and the need for guidance. Conclusion: Methods for capturing QALY/DALY outcomes in cost-utility analysis in pregnancy vary widely. This lack of consistency indicates a need for new methods to support the valuation of maternal and fetal health outcomes