Economic evaluation of health care technologies: A comparison of alternative decision modelling techniques

This thesis was submitted for the degree of Doctor of Philosophy and awarded by Brunel University, 14/6/2001.The focus of this thesis is on the application of decision models to the economic evaluation of health care technologies. The primary objective addresses the correct choice of modelling technique, as the attributes of the chosen technique could have a significant impact on the process, as well as the results, of an evaluation. Separate decision models, a Markov process and a discrete event simulation (DES) model are applied to a case study evaluation comparing alternative adjuvant therapies for early breast cancer. The case study models are built and analysed as stochastic models: whereby probability distributions are specified to represent the uncertainty about the true values of the model input parameters. Three secondary objectives are also specified. Firstly, the empirical application of the alternative decision models requires the specification of a 'modelling process' that is not well defined in the health economics literature. Secondly, a comparison of alternative methods for specifying probability distributions to describe the uncertainty in the model's input parameters is undertaken. The final secondary objective covers the application of methods for valuing the collection of additional information to inform the resource allocation decision. The empirical application of the two relevant modelling techniques clarifies the potential advantages derived from the increased flexibility provided by DES over Markov models. The thesis concludes that the use of DES should be strongly considered if either of the following issues appear relevant: model parameters are a function of the time spent in particular states, or the data describing the timing of events are not in the form of transition probabilities. The full description of the modelling process provides a resource for health economists wanting to use decision models. No definitive process is established, however, as there exist competing methods for various stages of the modelling process. The main conclusion from the comparison of methods for specifying probability distributions around the input parameters is that the theoretically specified distributions are most likely to provide a common baseline for comparisons between evaluations. The central question that remains to be addressed is which method is the most theoretically correct? The application of a Vol analysis provides useful insights into the methods employed and leads to the identification of particular methodological issues requiring future research in this area.North Thames training fellowship grant and MRC project gran

Is different better? Models of teaching and their influence on the net financial outcome for general practice teaching posts

Extent: 8p.Background: In Australia, training for general practice (GP) occurs within private practices and their involvement in teaching can have significant financial costs. At the same time there are growing demands for clinical places for all disciplines and for GP there is concern that there are insufficient teaching practices to meet the demand at the medical student, prevocational and vocational training levels. One option to address this may be to change how teaching occurs in the practice. A question that arises in posing such an option is whether different models of teaching change the costs for a teaching practice. The aim of this study is to determine the net financial outcome of teaching models in private GP. Methods: Modelling the financial implications for a range of teaching options using a costing framework developed from a survey of teaching practices in South Australia. Each option was compared with the traditional model of teaching where one GP supervisor is singularly responsible for one learner. The main outcome measure was net financial outcome per week. Decisions on the model cost parameters were made by the study’s Steering Group which comprised of experienced GP supervisors. Four teaching models are presented. Model 1 investigates the gains from teaching multiple same level learners, Models 2 and 3, the benefits of vertically integrated teaching using different permutations, and Model 4 the concept of a GP teacher who undertakes all the teaching. Results: There was a significant increase in net benefits of Aus$547 per week (95$459, $668) to the practice when a GP taught two same level learners (Model 1) and when a senior registrar participated in teaching a prevocational doctor (Model 3, Aus$263, 95% confidence intervals $80,$570). For Model 2, a practice could significantly reduce the loss if a registrar was involved in vertically integrated teaching which included the training of a medical student (Aus$551, 95$419, $718). The GP teacher model resulted in a net remuneration of Aus$207,335 per year, sourced predominantly from the GP teacher activities, with no loss to the practice. Conclusions: Our study costed teaching options that can maximise the financial outcomes from teaching. The inclusion of GP registrars in the teaching model or the supervisor teaching more than one same level learner results in a greater financial benefit. This gain was achieved through a reduction in supervisor teaching time and the sharing of administrative and teaching activities with GP registrars. We also show that a GP teacher who carries a minimal patient load can be a sustainable option for a practice. Further, the costing framework used for the teaching models presented in this study has the ability to be applied to any number of teaching model permutations.Caroline O Laurence, Linda E Black, Carolyn Cheah and Jonathan Karno

Prioritising models of healthcare service delivery for a more sustainable health system: a Delphi study of Australian health policy, clinical practice and management, academic and consumer stakeholders

Published online: 18 March 2021Objectives. Healthcare expenditure is growing at an unsustainable rate in developed countries. A recent scoping review identified several alternative healthcare delivery models with the potential to improve health system sustainability. Our objective was to obtain input and consensus from an expert Delphi panel about which alternative models they considered most promising for increasing value in healthcare delivery in Australia and to contribute to shaping a research agenda in the field. Methods. The panel first reviewed a list of 84 models obtained through the preceding scoping review and contributed additional ideas in an open round. In a subsequent scoring round, the panel rated the priority of each model in terms of its potential to improve health care sustainability in Australia. Consensus was assumed when 50% of the panel rated a model as (very) high priority (consensus on high priority) or as not a priority or low priority (consensus on low priority). Results. Eighty-two of 149 invited participants (55%) representing all Australian states/territories and wide expertise completed round one; 71 completed round two. Consensus on high priority was achieved for 59 alternative models; 14 were rated as (very) high priority by 70% of the panel. Top priorities included improving medical service provision in aged care facilities, providing single-point-access multidisciplinary care for people with chronic conditions and providing tailored early discharge and hospital at home instead of in-patient care. No consensus was reached on 47 models, but no model was deemed low priority. Conclusions. Input froman expert stakeholder panel identified healthcare deliverymodels not previously synthesised in systematic reviews that are a priority to investigate. Strong consensus exists among stakeholders regarding which models require the most urgent attention in terms of (cost-)effectiveness research. These findings contribute to shaping a research agenda on healthcare delivery models and where stakeholder engagement in Australia is likely to be high. What is known about the topic? Healthcare expenditure is growing at an unsustainable rate in high-income countries worldwide. A recent scoping review of systematic reviews identified a substantial body of evidence about the effects of a wide range of models of healthcare service delivery that can inform health system improvements. Given the large number of systematic reviews available on numerous models of care, a method for gaining consensus on the models of highest priority for implementation (where evidence demonstrates this will lead to beneficial effects and resource savings) or for further research (where evidence about effects is uncertain) in the Australian context is warranted. What does this paper add? This paper describes a method for reaching consensus on high-priority alternative models of service delivery in Australia. Stakeholders with leadership roles in health policy and government organisations, hospital and primary care networks, academic institutions and consumer advocacy organisations were asked to identify and rate alternative models based on their knowledge of the healthcare system. We reached consensus among 70% of stakeholders that improving medical care in residential aged care facilities, providing single-point-access multidisciplinary care for patients with a range of chronic conditions and providing early discharge and hospital at home instead of in-patient stay for people with a range of conditions are of highest priority for further investigation. What are the implications for practitioners? Decision makers seeking to optimise the efficiency and sustainability of healthcare service delivery in Australia could consider the alternative models rated as high priority by the expert stakeholder panel in this Delphi study. These models reflect the most promising alternatives for increasing value in the delivery of health care in Australia based on stakeholders’ knowledge of the health system. Although they indicate areas where stakeholder engagement is likely to be high, further research is needed to demonstrate the effectiveness and costeffectiveness of some of these models.Polina Putrik, Rebecca Jessup, Rachelle Buchbinder, Paul Glasziou, Jonathan Karnon and Denise A. O’Conno

Sugar consumption from high sugar beverages, and the potential effects of a text-based information label in an Australian population: postal survey

OBJECTIVE: To provide evidence on the effects of two front-of-pack text-based information labels on purchasing of high sugar beverages. Labels advise of increased risk of obesity or diabetes associated with high sugar beverage consumption. METHODS: A postal survey was developed to obtain information on current household beverage purchases, understanding of the proposed information labels, and stated changes in purchasing resulting from the application of the labels. RESULTS: 130 completed surveys were returned (response rate 66%). In a typical week, 79.2% of households purchased at least one of five high sugar beverages. In purchasing households, estimated sugar intake from high sugar beverages alone ranged from 12.3g to 2307.2g per person per week (equivalent to 30 to 5603kJ per day), with a median intake of 185.1g (450kJ per day). 41.7% (95%CI 25.5 to 59.2) of diabetes label respondents and 35.3% (95%CI 22.4 to 49.9) of obesity label respondents stated they would reduce purchasing of at least one labelled high sugar beverage. CONCLUSION AND IMPLICATIONS: Provides preliminary evidence that front-of-pack text-based information labels advising consumers of health risk may be a potentially effective way to reduce purchasing and consumption of high sugar beverages.Jodi P. Gray, Jonathan Karnon and Leslee Blackwellhttp://www.adelaide.edu.au/pcsip/drinks

A prototype software framework for transparent, reusable and updatable computational health economic models

Most health economic analyses are undertaken with the aid of computers. However, the ethical dimensions of implementing health economic models as software (or computational health economic models (CHEMs)) are poorly understood. We propose that developers and funders of CHEMs share ethical responsibilities to (i) establish socially acceptable user requirements and design specifications; (ii) ensure fitness for purpose; and (iii) support socially beneficial use. We further propose that a transparent (T), reusable (R) and updatable (U) CHEM is suggestive of a project team that has largely fulfilled these responsibilities. We propose six criteria for assessing CHEMs: (T1) software files are open access; (T2) project team contributions and judgments are easily identified; (R1) programming practices promote generalisability and transferability; (R2) licenses restrict only unethical reuse; (U1) maintenance infrastructure is in place; and (U2) new releases are systematically retested and appropriately deprecated. To facilitate CHEMs that meet TRU criteria, we have developed a prototype software framework in the open-source programming language R. The framework comprises six code libraries for authoring CHEMs, supplying CHEMs with data and undertaking analyses with CHEMs. The prototype software framework integrates with services for software development and research data archiving. We determine that an initial set of youth mental health CHEMs we developed with the prototype software framework wholly meet criteria T1-2, R1-2 and U1 and partially meet criterion U2. Our assessment criteria and prototype software framework can help inform and improve ethical implementation of CHEMs. Resource barriers to ethical CHEM practice should be addressed by research funders.Comment: 17 pages, 4 tables, 1 figur

Effectiveness of earlier antenatal screening for sickle cell disease and thalassaemia in primary care: cluster randomised trial

Objective To evaluate the effectiveness of offering antenatal screening for sickle cell disease and thalassaemia in primary care as a way of facilitating earlier uptake of screening

Estimating the effectiveness and cost-effectiveness of establishing additional endovascular Thrombectomy stroke Centres in England::a discrete event simulation

Background We have previously modelled that the optimal number of comprehensive stroke centres (CSC) providing endovascular thrombectomy (EVT) in England would be 30 (net 6 new centres). We now estimate the relative effectiveness and cost-effectiveness of increasing the number of centres from 24 to 30. Methods We constructed a discrete event simulation (DES) to estimate the effectiveness and lifetime cost-effectiveness (from a payer perspective) using 1 year’s incidence of stroke in England. 2000 iterations of the simulation were performed comparing baseline 24 centres to 30. Results Of 80,800 patients admitted to hospital with acute stroke/year, 21,740 would be affected by the service reconfiguration. The median time to treatment for eligible early presenters (< 270 min since onset) would reduce from 195 (IQR 155–249) to 165 (IQR 105–224) minutes. Our model predicts reconfiguration would mean an additional 33 independent patients (modified Rankin scale [mRS] 0–1) and 30 fewer dependent/dead patients (mRS 3–6) per year. The net addition of 6 centres generates 190 QALYs (95%CI − 6 to 399) and results in net savings to the healthcare system of £1,864,000/year (95% CI -1,204,000 to £5,017,000). The estimated budget impact was a saving of £980,000 in year 1 and £7.07 million in years 2 to 5. Conclusion Changes in acute stroke service configuration will produce clinical and cost benefits when the time taken for patients to receive treatment is reduced. Benefits are highly likely to be cost saving over 5 years before any capital investment above £8 million is required

A randomized controlled trial to assess the clinical and cost effectiveness of a nurse-led Antenatal Asthma Management Service in South Australia (AAMS study)

Background: Pregnancy presents a unique situation for the management of asthma as it can alter the course of asthma severity and its treatment, which in turn can affect pregnancy outcomes. Despite awareness of the substantial adverse effects associated with asthma during pregnancy, little has been done to improve its management and reduce associated perinatal morbidity and mortality. The aim of this randomized controlled trial is to evaluate the clinical and cost effectiveness of an Antenatal Asthma Management Service. Methods/design: Design: Multicentre, randomized controlled trial. Inclusion criteria: Women with physician diagnosed asthma, which is not currently in remission, who are less than 20 weeks gestation with a singleton pregnancy and do not have a chronic medical condition. Trial entry and randomization: Eligible women with asthma, stratified by treatment site, disease severity and parity, will be randomized into either the ‘Standard Care Group’ or the ‘Intervention Group’. Study groups: Both groups will be followed prospectively throughout pregnancy. Women in the ‘Standard Care Group’ will receive routine obstetric care reflecting current clinical practice in Australian hospitals. Women in the ‘Intervention Group’ will receive additional care through the nurse-led Antenatal Asthma Management Service, based in the antenatal outpatient clinic. Women will receive asthma education with a full assessment of their asthma at 18, 24, 30 and 36 weeks gestation. Each antenatal visit will include a 60 min session where asthma management skills are assessed including: medication adherence and knowledge, inhaler device technique, recognition of asthma deterioration and possession of a written asthma action plan. Furthermore, subjects will receive education about asthma control and management skills including trigger avoidance and smoking cessation counseling when appropriate. Primary study outcome: Asthma exacerbations during pregnancy. Sample size: A sample size of 378 women will be sufficient to show an absolute reduction in asthma exacerbations during pregnancy of 20% (alpha 0.05 two-tailed, 90% power, 5% loss to follow-up). Discussion: The integration of an asthma education program within the antenatal clinic setting has the significant potential to improve the participation of pregnant women in the self-management of their asthma, reduce asthma exacerbations and improve perinatal health outcomes.Luke E Grzeskowiak, Gustaaf Dekker, Karen Rivers, Kate Roberts-Thomson, Anil Roy, Brian Smith, Jeffery Bowden, Robert Bryce, Michael Davies, Justin Beilby, Anne Wilson, Philippa Middleton, Richard Ruffin, Jonathan Karnon, Vicki L Clifton and for the AAMS study grou

Estimating the returns to UK publicly funded cancer-related research in terms of the net value of improved health outcomes

© 2014 Glover et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Background - Building on an approach developed to assess the economic returns to cardiovascular research, we estimated the economic returns from UK public and charitable funded cancer-related research that arise from the net value of the improved health outcomes. Methods - To assess these economic returns from cancer-related research in the UK we estimated: 1) public and charitable expenditure on cancer-related research in the UK from 1970 to 2009; 2) net monetary benefit (NMB), that is, the health benefit measured in quality adjusted life years (QALYs) valued in monetary terms (using a base-case value of a QALY of GB£25,000) minus the cost of delivering that benefit, for a prioritised list of interventions from 1991 to 2010; 3) the proportion of NMB attributable to UK research; 4) the elapsed time between research funding and health gain; and 5) the internal rate of return (IRR) from cancer-related research investments on health benefits. We analysed the uncertainties in the IRR estimate using sensitivity analyses to illustrate the effect of some key parameters. Results - In 2011/12 prices, total expenditure on cancer-related research from 1970 to 2009 was £15 billion. The NMB of the 5.9 million QALYs gained from the prioritised interventions from 1991 to 2010 was £124 billion. Calculation of the IRR incorporated an estimated elapsed time of 15 years. We related 17% of the annual NMB estimated to be attributable to UK research (for each of the 20 years 1991 to 2010) to 20 years of research investment 15 years earlier (that is, for 1976 to 1995). This produced a best-estimate IRR of 10%, compared with 9% previously estimated for cardiovascular disease research. The sensitivity analysis demonstrated the importance of smoking reduction as a major source of improved cancer-related health outcomes. Conclusions - We have demonstrated a substantive IRR from net health gain to public and charitable funding of cancer-related research in the UK, and further validated the approach that we originally used in assessing the returns from cardiovascular research. In doing so, we have highlighted a number of weaknesses and key assumptions that need strengthening in further investigations. Nevertheless, these cautious estimates demonstrate that the returns from past cancer research have been substantial, and justify the investments made during the period 1976 to 1995.Wellcome Trust, Cancer Research UK, the National Institute of Health Research, and the Academy of Medical Sciences