The use of meta-analysis in economic evaluation

Meta-analysis provides a family of statistical techniques for combining the results of similar studies. This paper examines the meta-analysis of clinical data in economic studies, and points to the issues and considerations that must be addressed when designing and conducting a meta-analysis of clinical data for use in an economic evaluation. We investigate whether the standard approaches employed in the meta-analysis of clinical data are satisfactory to meet the demands of economic evaluation, and assess the meta-analyses contained in a sample of economic evaluations identified from the NHS conomic Evaluation Database. Finally, we provide guidance on the appropriate use of meta-analysis for economic evaluations.economic evaluation, meta-analysis

Modelling the long-term benefits of photodynamic therapy (PDT) with Verteporfin for age-related macular degeneration (AMD)

Age related macular degeneration (AMD) is the leading cause of blindness in the United Kingdom and the rest of the western world. It occurs in 15% to 30% of individuals over 75 years of age. About 15% of these patients develop a more aggressive wet form of the disease that causes severe loss of vision. This report contains estimates of the benefits of photodynamic therapy (PDT) with verteporfin therapy using a modeling approach based on clinical trial data. While this report covers only the effects of the treatment, the model built was customizable so that it could be populated with local cost data. This made it possible to use the model to help inform local formulary decisions.clinical trial, blindness, vision

Prioritising investments in health technology assessment: can we assess the potential value for money?

The objective was to develop an economic prioritisation model to assist those involved in (i) the selection and prioritisation of health technology assessment topics and (ii) commissioning of HTA projects. The model used decision analytic techniques to estimate the expected costs and benefits of the health care interventions which were the focus of the HTA question(s) considered by the NHS Health Technology Assessment Programme in England. Initial estimation of the value for money of HTA was conducted for a number of topics considered in 1997 and 1998. The main conclusion was that it is feasible to conduct ex ante assessments of the value for money of HTA for specific topics. However, a considerable amount of work is required to ensure that the methods used are valid, reliable, consistent and an efficient use of valuable research time.INAHTA, NCCHTA

NICEly does it: economic analysis within evidence-based clinical practice guidelines

There is increasing professional and policy interest in the role of clinical guidelines for promoting effective and efficient health care. The NHS Health Technology Assessment Programme identified an urgent need, when such guidelines are produced, to develop a framework and methods for incorporating the best evidence of effectiveness, taking into account information on cost-effectiveness. This paper describes the development of recent evidence-based guidelines, for use in primary care, which were the result of recent work by the North of England Guidelines Development Group. Their specific aim was to incorporate economic analysis into the guideline process and treatment recommendations. The introduction of economic data raised some methodological issues, specifically: in providing valid and generalisable cost estimates; in the grading of cost ‘evidence’; in finding a presentation helpful to clinicians. The approach used was to help clinicians aggregate the various attributes of treatment to make good treatment recommendations, rather than interpret cost-effectiveness ratios. In none of the guideline areas was there adequate information to estimate a cost per quality-adjusted-life-year. In the light of this research, future areas of work are identified and some recommendations are made for the forthcoming National Institute for Clinical Excellence.evidence-based medicine, economic evaluation, clinical guidelines, NICE

Use of economic evidence in the design of Health Improvement Programmes (HImPs)

Introduction 1. In recent years considerable efforts have been made to increase the evidence base for decision making within the NHS. Under the NHS R&D Programme a sizeable percentage of NHS resources have been spent on research, one of the largest programmes of research being in the field of health technology assessment. 2. However, whilst the generation of more research evidence is important, mechanisms still need to be developed to increase its use in NHS decision making. The NHS White Paper of 1997 (paragraph 7.5) pointed out that “there are unjustifiable variations in the application of evidence on clinical and cost-effectiveness”. 3. The concept of the Health Improvement Programme (HImP) was first introduced in “The New NHS. Modern: Dependable” (NHS Executive, 1997). This white paper gave the lead responsibility to health authorities to provide a framework for health and social care provision through multi-agency partnership and in collaboration with the public. One of the main aims of the HImP is to produce action plans based on evidence to address local and national priorities. HImPs cover a three year long cycle and are revised annually. The second phase HImPs ran from April 2000 to April 2003 and these are the focus of this project. 4. To date, a small number of reviews of HImPs have been conducted (Abbott et al, 2000, Arora et at 1999 & 2000, Carruthers et al, 1999) but there has been limited exploration of the role of evidence in relation to the HImP, and no specific effort has been made to examine whether the HImP has proved to be a useful vehicle in arranging provision of care to improve the health of the population, given resource constraints. This report explores the evidence base of these second phase HImPs with particular reference to the contribution of economic evidence. Methods 5. In order to examine the use of evidence in the design of HImPs, a threestage project was undertaken. First, a survey of all English health authorities was conducted to elicit HImP leaders’ views on the use of evidence in the design of their own HImP. Second, 10 individuals involved in the HImP and who worked for different health authorities were interviewed to explore their views on the HImP, the role of evidence and the impact of the HImP. Third, a random sample of 25% of all 2000-2003 HImP documents from the health authorities in England were reviewed in order to investigate whether the health care priorities chosen reflect government objectives and whether there was any evidence of the use of economic evidence in the production of the HImP documents. Findings 6. The main findings were that, first, HImPs are seen as having multiple objectives. Whereas the improvement of health is viewed as the prime objective, other important objectives are to reduce health inequalities and to develop partnerships. 7. Second, the notion of evidence is interpreted broadly. Namely, data drawn from classical research studies and published in the literature, do not encompass the range of inputs to the design of a HImP. Many of the inputs relate to national guidance and local professional opinion, which in turn might be based on data from research studies. 8. Third, basic concepts of economics are well understood, if not always applied. This is partly because the level of access to economic analyses and economics expertise was low. Even where economic studies did exist, it was not clear how they could be interpreted and used. 9. Fourth, local constraints greatly influence the development of HImPs. These constraints include time limitations, lack of certain expertise and the need for political acceptability. These often restricted the extent of the search for, interpretation and use of economic evidence. 10. Finally, most importantly, national guidance from National Service Frameworks (NSFs) and the National Institute for Clinical Excellence (NICE) s very influential in the design of HImPs. Given the constraints at the local level, national guidance was assumed to have a sound evidence base and was usually followed, although sometimes adapted in the light of local circumstances. Therefore, the use of national guidance may be the best route to improving the evidence base of HImPs. Research and policy implications 11. The results of this research lend considerable support to a number of research and policy implications, many of which are already underway. The ain implications are: (i) the evidence base of national guidance should be maintained, if not strengthened; (ii) efforts should continue to generate, synthesise and disseminate evidence on a national level; (iii) quantifiable targets (for health improvement) and the role for evidence in priority setting need to be stressed; (iv) the local role in assembling evidence needs to be clearly defined and adequately resourced; (v) efforts to educate health care professionals in evidence-based medicine and economics should be maintained, or strengthened; (vi) more research should be undertaken into the cost-effectiveness of broader socio-economic interventions to improve health. 12. Finally, the research and policy implications of this study also need to be reviewed in the light of the recently announced organisational changes in the NHS, especially the creation of strategic health authorities and the developing role of PCGs/Ts. In particular, it will be important to ensure that PCGs/Ts have the resources and expertise to gather, synthesise and interpret evidence, including economic evidence. Introduction In recent years considerable efforts have been made to increase the evidence base for decision making within the NHS. Under the NHS R&D Programme a sizeable percentage of NHS resources have been spent on research, one of the largest programmes of research being in the field of health technology assessment. In addition, institutions such as the NHS Centre for Reviews and Dissemination, the Cochrane Collaboration and the National Coordinating Centre for Health Technology Assessment have greatly contributed to the communication of research findings to the NHS. The NHS white paper of 1997 (para 7.5) pointed out that “there are unjustifiable variations in the application of evidence on clinical and cost-effectiveness” (NHS Executive, 1997). This view is echoed by several surveys of NHS decision-makers (Crump et al, 2000, Drummond et al, 1997; Duthie et al, 1999) which showed a generally low uptake of available economic evidence and dentified a number of barriers to its use. At the national level, the advent of the National Institute of Clinical Excellence (NICE) (DH, 1999) provides a vehicle by which clinical and cost-effectiveness evidence can be used in decisions about the use of health care interventions, either through technology appraisal or clinical guidelines development. However, at the local level, within the NHS, it is less clear how appropriate evidence (in particular economic evidence) can be brought to bear on NHS decisions. Under the existing structure, many of the decisions about the use of health care interventions will increasingly be taken by Primary Care Groups (PCGs) and rimary Care Trusts (PCTs). However, most of these will be too small to have a capacity to collect, assimilate and apply evidence. The health authorities’ main mechanism for coordinating health care provision, in partnership with PCGs/PCTs, NHS Trusts and other agencies is the Health Improvement Programme (HImP). Therefore, the objective of the research was to study HImPs in order to investigate the extent to which evidence, in particular economic evidence, had been used in their development.HImP

Childhood and adolescent influenza vaccination in Europe : A review of current policies and recommendations for the future

Children and adolescents experience some of the highest rates of influenza infection and the subsequent burden on both infected children and their parents/carers is substantial. Vaccinating children and adolescents against seasonal influenza has the potential to reduce the burden of disease in both vaccinated and unvaccinated individuals due to the pivotal role that younger age groups play in the transmission of infection. While countries such as the USA, Canada and the UK have consequently recommended the universal vaccination of children, the vast majority of European countries have not yet extended their vaccination policies to this age group. This review examines the rationale for childhood and adolescent vaccination against seasonal influenza and reviews current vaccination policies in Europe. We discuss key policy considerations for European countries that must be considered when extending vaccination programmes to younger age groups alongside recommendations for European policy makers based on our findings

QCD on 2+2 anisotropic lattices

We discuss the implementation of QCD on 2+2 anisotropic lattices. Technical details regarding the choice of the action as well as perturbative and non-perturbative improvement are analyzed. The physical applications of the program are presented.Comment: 3 pages, 1 figure. Talk given by G. Burgio at Lattice02, MIT. To appear on Nucl. Phys. B (proc. Suppl.

Men's information-seeking behavior regarding cancer risk and screening: A meta-narrative systematic review

Objective: Preventive strategies are known to reduce cancer risk and incidence and improve prognosis. Men seldom seek medical information about cancer prevention and risk reduction. The aim of this meta-narrative systematic review was to critically appraise evidence from qualitative, quantitative, and mixed-methods studies that explored men's information-seeking behaviors in relation to cancer prevention and risk reduction. Methods: MEDLINE, CINAHL Plus with Full Text, PsycINFO, PsycARTICLES, Psychology and Behavioral Sciences Collection, Education Full Text, and ERIC were systematically searched for studies published in English between January 1, 2006 and May 30, 2016. A total of 4117 titles were identified; of which, 31 studies were included (21 qualitative studies, 9 quantitative studies, and 1 mixed-methods study). The methodological quality of the studies was appraised by using different tools. Results: Most studies focused on screening for prostate (n = 18) and colorectal cancer (n = 7). Most men were passive information-gatherers rather than active information-seekers. Key sources of information included the Internet for active information-seekers and health care professionals for passive information-gatherers. Barriers to information-seeking included information overload, embarrassment, and fear. Low literacy and health literacy levels were addressed in 3 studies and were identified as impediments to active information-seeking. Facilitators to information-seeking included family support, media, celebrity endorsements, and targeted information. Conclusions: Men's information-seeking behavior regarding cancer risk reduction, prevention, and screening is influenced by several factors. This necessitates targeted interventions aimed at raising awareness of cancer prevention and screening, while accounting for men's informational needs, preferred learning strategies, and literacy levels

Gauge Theories on a 2+2 Anisotropic Lattice

The implementation of gauge theories on a four-dimensional anisotropic lattice with two distinct lattice spacings is discussed, with special attention to the case where two axes are finely and two axes are coarsely discretized. Feynman rules for the Wilson gauge action are derived and the renormalizability of the theory and the recovery of the continuum limit are analyzed. The calculation of the gluon propagator and the restoration of Lorentz invariance in on-shell states is presented to one-loop order in lattice perturbation theory for $SU(N_c)$ on both 2+2 and 3+1 lattices.Comment: 27 pages, uses feynmf. Font compatibility adjuste

The Effectiveness of Alcohol Screening and Brief Intervention in Emergency Departments: A Multicentre Pragmatic Cluster Randomized Controlled Trial

BACKGROUND: Alcohol misuse is common in people attending emergency departments (EDs) and there is some evidence of efficacy of alcohol screening and brief interventions (SBI). This study investigated the effectiveness of SBI approaches of different intensities delivered by ED staff in nine typical EDs in England: the SIPS ED trial. METHODS AND FINDINGS: Pragmatic multicentre cluster randomized controlled trial of SBI for hazardous and harmful drinkers presenting to ED. Nine EDs were randomized to three conditions: a patient information leaflet (PIL), 5 minutes of brief advice (BA), and referral to an alcohol health worker who provided 20 minutes of brief lifestyle counseling (BLC). The primary outcome measure was the Alcohol Use Disorders Identification Test (AUDIT) status at 6 months. Of 5899 patients aged 18 or more presenting to EDs, 3737 (63·3%) were eligible to participate and 1497 (40·1%) screened positive for hazardous or harmful drinking, of whom 1204 (80·4%) gave consent to participate in the trial. Follow up rates were 72% (n?=?863) at six, and 67% (n?=?810) at 12 months. There was no evidence of any differences between intervention conditions for AUDIT status or any other outcome measures at months 6 or 12 in an intention to treat analysis. At month 6, compared to the PIL group, the odds ratio of being AUDIT negative for brief advice was 1·103 (95% CI 0·328 to 3·715). The odds ratio comparing BLC to PIL was 1·247 (95% CI 0·315 to 4·939). A per protocol analysis confirmed these findings. CONCLUSIONS: SBI is difficult to implement in typical EDs. The results do not support widespread implementation of alcohol SBI in ED beyond screening followed by simple clinical feedback and alcohol information, which is likely to be easier and less expensive to implement than more complex interventions