International Lessons in New Methods for Grading and Integrating Cost Effectiveness Evidence into Clinical Practice Guidelines

Economic evidence is influential in health technology assessment world-wide. Clinical Practice Guidelines (CPG) can enable economists to include economic information on health care provision. Application of economic evidence in CPGs, and its integration into clinical practice and national decision making is hampered by objections from professions, paucity of economic evidence or lack of policy commitment. The use of state-of-art economic methodologies will improve this. Economic evidence can be graded by 'checklists' to establish the best evidence for decision making given methodological rigor. New economic evaluation checklists, Multi-Criteria Decision Analyses (MCDA) and other decision criteria enable health economists to impact on decision making world-wide. We analyse the methodologies for integrating economic evidence into CPG agencies globally, including the Agency of Health Research and Quality (AHRQ) in the USA, National Health and Medical Research Council (NHMRC) and Australian political reforms. The Guidelines and Economists Network International (GENI) Board members from Australia, UK, Canada and Denmark presented the findings at the conference of the International Health Economists Association (IHEA) and we report conclusions and developments since. The Consolidated Guidelines for the Reporting of Economic Evaluations (CHEERS) 24 item check list can be used by AHRQ, NHMRC, other CPG and health organisations, in conjunction with the Drummond ten-point check list and a questionnaire that scores that checklist for grading studies, when assessing economic evidence. Cost-effectiveness Analysis (CEA) thresholds, opportunity cost and willingness-to-pay (WTP) are crucial issues for decision rules in CEA generally, including end-of-life therapies. Limitations of inter-rater reliability in checklists can be addressed by including more than one assessor to reach a consensus, especially when impacting on treatment decisions. We identify priority areas to generate economic evidence for CPGs by NHMRC, AHRQ, and other agencies. The evidence may cover demand for care issues such as involved time, logistics, innovation price, price sensitivity, substitutes and complements, WTP, absenteeism and presentism. Supply issues may include economies of scale, efficiency changes, and return on investment. Involved equity and efficiency measures may include cost-of-illness, disease burden, quality-of-life, budget impact, cost-effective ratios, net benefits and disparities in access and outcomes.. Priority setting remains essential and trade-off decisions between policy criteria can be based on MCDA, both in evidence based clinical medicine and in health planning

Improving cost effectiveness, distributional justice and allocative efficiency in hospital funding and service delivery in Australia and internationally

Abstract not availabl

Improving cost effectiveness, distributional justice and allocative efficiency in hospital funding and service delivery in Australia and internationally

Abstract not availabl

The risk-adjusted vision beyond casemix (DRG) funding in Australia

Hospital funding, Risk adjustment, Diagnosis-Related Groups, Diagnostic Cost Groups, Casemix funding,

Risk adjustment policy options for casemix funding: international lessons in financing reform

Risk adjustment, Casemix funding, Diagnosis-related groups, Hospital costs,

Pathways to Improved Detection and Prevention of Colorectal Cancer: Achieving Goals for Australia's Health to 2000

A diet high in fat and alcohol and low in vegetables and fruits increases risk for colorectal cancer. Males smoking hand rolled cigarettes and cigars and pipes are also at greater risk. Interventions to decrease the consumption of red meats, encourage physical activity and increase intake of vegetables and fruit, calcium, whey protein concentrate, insoluble dietary fibre from barley grain and Vitamin E are promising. The results of cost-effectiveness analyses of screening protocols vary. This reflects variations in methodology, costs, protocols, and assumptions. A recent Japanese study incorporates many alternative protocols and compares biochemical and immunological FOBT. There would be great value in replicating this in Australia. It found that the immunological test (IF) offers a cost-effective method. The strategy of IF every two years, followed by colonoscopy if IF tests are positive was the most cost-effective strategy. Screening should commence between the ages of 40 and 45. An Australian study showed that the two most efficient strategies for testing FOBT positive persons were (a) a combination of repeat FOBT, rigid sigmoidoscopy and barium enema and (b) a combination of flexible sigmoidoscopy and colonoscopy. The 1994 guidelines of the Australian Gastroenterology Institute and the Australian Cancer Society do not recommend routine screening for those over 50 who have no symptoms and no special risk factors. However, they do suggest the use of FOBT and/or sigmoidoscopy for those persons aged 50-75 years making an informed request for screening. They also indicate that a positive FOBT must be investigated by colonoscopy or by flexible sigmoidoscopy and double contrast barium enema if colonoscopy is not available. The guidelines could be improved by careful consideration of the Australian findings, and following a replication of the Japanese study in Australia

Pathways to cost-effective prevention, detection and treatment of prostate cancer in Australia: achieving goals for Australia's health to 2000 and beyond

The current review supports the recommendations of the Australian Health Technology Advisory Committee (AHTAC) against the screening of asymptomatic men for prostate cancer. Australian researchers should link in with two large randomised controlled trials of prostate cancer interventions being undertaken in the USA and Europe; and consider more disaggregated and carefully targetted screening and treatment strategies. Treatment staging. The use of pelvic CT and bone scans for clinical staging in patients with Prostate Specific Antigen (PSA) level of less than 20 ng/ml should not be advocated because they have a very low yield and are not cost effective. The use of modified pelvic lymphadenectomy for staging either by open or laparoscopy is also questioned because the yield of positive diagnosis is very low. Open staging pelvic lymph node dissection (PLND) may no longer be justified for patients undergoing radical retropubic prostatectomy.. Androgen blockade combined with flutamide can reduce the relative risk of progressive disease by 25%. For minimal disease the average survival is increased by 5.2 months at an incremental cost of $25,300 per LYG. For severe disease, average survival increased by 4 months at an incremental cost of$20,000 per LYG. Flutamide shows promise with incremental costeffectiveness being more favourable than most therapies. Screening. A recent comprehensive US study found that optimal Prostate Specific Antigen (PSA) for the initial screening decision was 3.0ng/ml, but rose to 5.0ng/ml in combination with Digital Rectal Examination (DRE). Age related PSA performed no better than PSA. Rather than perform systematic biopsy on all patients with PSA levels higher than 4ng/ml, it may be possible to achieve a 16-5 5% reduction in biopsies (with a respective cancer loss of 4-25%) by limiting biopsy to those with an increased PSAD (Prostate Specific Antigen Density) level and/or abnormal results of DRE. The greatest biopsy reduction relative to cancer yield and lowest cost per cancer detected occurred with PSAD-driven biopsy strategics. A Swedish study found that the most cost-effective approach involved Transrectal Ultrasound (TRUS) of males with PSA of 4ng/ml or greater at a cost of $4,590 per cancer treated for cure. It detected 80$14,200, increasing to $51,290 per life year saved at age 75. However, this analysis used favourable assumptions about disease progression rates and treatment effectiveness and did not incorporate quality of life measures