Economic issues associated with the operation and evaluation of telemedicine

This thesis was submitted for the degree of Doctor of Philosophy and awarded by Brunel University.Telemedicine offers an alternative referral strategy for fetal cardiology but is currently only used for ‘high-risk’ pregnancies. A case-study of a cost-consequences analysis comparing telemedicine to direct referral to a perinatal cardiologist is initially presented, which highlights that for high risk women for whom telemedicine was considered no cardiac anomalies were missed using either referral method. In the light of a review of the literature on the economics of telemedicine, three of the key methodological issues (of selection bias, of patient costs and using quality-adjusted life years (QALYs)) are explored to demonstrate how the case study analysis could be improved. Pregnant women were selected for referral based on their characteristics and risk factors; thus the cost and effects for the two groups may have been biased. Various methods identified in the literature are applied to the case study to reduce selection bias, but the analysis presented is unable to determine which method is best, given a number of limitations including the small sample size. The analysis is extended to include estimated total patient costs. However, when patient costs are added to the total costs of pregnancy, they did not substantially increase the overall cost. The results presented provide a guideline for future researchers and pregnant women of the likely costs during pregnancy. Given that the majority of missed cardiac anomalies were amongst low risk women, a decision analytical model is developed looking at the lifetime costs and QALYs of introducing telemedicine screening for pregnant women whose unborn babies are at a low risk of congenital heart disease. The analysis shows that offering telemedicine to all low risk women is the dominant strategy. The thesis demonstrates, within the constraints of existing data, that it would be cost-effective to provide telemedicine as part of an antenatal screening programme for all low risk women, and this would help prevent future ‘missed anomalies’.Research and Development Division of the Department of Healt

Health economics education in undergraduate medical training : introducing the health economics education (HEe) website

In the UK, the General Medical Council clearly stipulates that upon completion of training, medical students should be able to discuss the principles underlying the development of health and health service policy, including issues relating to health economics. In response, researchers from the UK and other countries have called for a need to incorporate health economics training into the undergraduate medical curricula. The Health Economics education website was developed to encourage and support teaching and learning in health economics for medical students. It was designed to function both as a forum for teachers of health economics to communicate and to share resources and also to provide instantaneous access to supporting literature and teaching materials on health economics. The website provides a range of free online material that can be used by both health economists and non-health economists to teach the basic principles of the discipline. The Health Economics education website is the only online education resource that exists for teaching health economics to medical undergraduate students and it provides teachers of health economics with a range of comprehensive basic and advanced teaching materials that are freely available. This article presents the website as a tool to encourage the incorporation of health economics training into the undergraduate medical curricula

Diagnostic assessment reviews : is cost-effectiveness analysis helpful or necessary?

Objective Diagnostic Assessment Reviews are part of the work programme of the National Institute of Health and Care Excellence (NICE) in England to evaluate emergent medical technologies and so ensure timely and consistent adoption within the National Health Service (NHS). New diagnostics have the potential to improve health outcomes and impact positively on health service resource use. This study sought to assess the quality of economic evidence informing Diagnostic Assessment Reviews. Methods We reviewed 27 Diagnostic Assessment Reviews that had been published by NICE as of 30 May 2017 by summarizing and interpreting the evidence that was used to carry out cost-effectiveness analyses. Common issues and challenges of the assessment process were illustrated. Findings DARs differed in the methods and assumptions used to construct economic models, and linkage of economic model and diagnostic findings. Even though some diagnostic technologies were estimated to be cost-effective, they were not always adopted for routine use in the NHS. The majority of Diagnostic Assessment Review economic models relied heavily on assumptions and expert opinion, with considerable uncertainty about the cost-effectiveness of diagnostic testing. Conclusions Diagnostic Assessment Reviews appraisals as commissioned by NICE typically feature varying evidence for diagnostic performance and limited evidence for resource implications and quality of life, often leading to recommendations for further research. Given the process opportunity cost, a two-stage topic selection process, with initial assessment specifying further research and proceeding to full assessment when adequate evidence is available may be more appropriate and help signal to diagnostics companies the type of research evidence required

Cost-effectiveness of a European preventive cardiology programme in primary care: A Markov modelling approach

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license.OBJECTIVE: To investigate the longer-term cost-effectiveness of a nurse-coordinated preventive cardiology programme for primary prevention of cardiovascular disease (CVD) compared to routine practice from a health service perspective. DESIGN: A matched, paired cluster-randomised controlled trial. SETTING: Six pairs of general practices in six countries. PARTICIPANTS: 1019 patients were randomised to the EUROACTION intervention programme and 1005 patients to usual care (UC) and who completed the 1-year follow-up. OUTCOME MEASURES: Evidence on health outcomes and costs was based on patient-level data from the study, which had a 1-year follow-up period. Future risk of CVD events was modelled, using published risk models based on patient characteristics. An individual-level Markov model for each patient was used to extrapolate beyond the end of the trial, which was populated with data from published sources. We used an 11-year time horizon and investigated the impact on the cost-effectiveness of varying the duration of the effect of the intervention beyond the end of the trial. Results are expressed as incremental cost per quality-adjusted life-year gained. RESULTS: Unadjusted results found the intervention to be more costly and also more effective than UC. However, after adjusting for differences in age, gender, country and baseline risk factors, the intervention was dominated by UC, but this analysis was not able to take into account the lifestyle changes in terms of diet and physical activity. CONCLUSIONS: Although the EUROACTION study achieved healthier lifestyle changes and improvements in management of blood pressure and lipids for patients at high risk of CVD, compared to UC, it was not possible to show, using available risk equations which do not incorporate diet and physical activity, that the intervention reduced longer-term cardiovascular risk cost-effectively. Whether or not an intervention such as that offered by EUROACTION is cost-effective requires a longer-term trial with major cardiovascular events as the outcome.This study is sponsored solely by AstraZeneca through the provision of an unconditional educational grant

Economic issues associated with the operation and evaluation of telemedicine

Telemedicine offers an alternative referral strategy for fetal cardiology but is currently only used for ‘high-risk’ pregnancies. A case-study of a cost-consequences analysis comparing telemedicine to direct referral to a perinatal cardiologist is initially presented, which highlights that for high risk women for whom telemedicine was considered no cardiac anomalies were missed using either referral method. In the light of a review of the literature on the economics of telemedicine, three of the key methodological issues (of selection bias, of patient costs and using quality-adjusted life years (QALYs)) are explored to demonstrate how the case study analysis could be improved. Pregnant women were selected for referral based on their characteristics and risk factors; thus the cost and effects for the two groups may have been biased. Various methods identified in the literature are applied to the case study to reduce selection bias, but the analysis presented is unable to determine which method is best, given a number of limitations including the small sample size. The analysis is extended to include estimated total patient costs. However, when patient costs are added to the total costs of pregnancy, they did not substantially increase the overall cost. The results presented provide a guideline for future researchers and pregnant women of the likely costs during pregnancy. Given that the majority of missed cardiac anomalies were amongst low risk women, a decision analytical model is developed looking at the lifetime costs and QALYs of introducing telemedicine screening for pregnant women whose unborn babies are at a low risk of congenital heart disease. The analysis shows that offering telemedicine to all low risk women is the dominant strategy. The thesis demonstrates, within the constraints of existing data, that it would be cost-effective to provide telemedicine as part of an antenatal screening programme for all low risk women, and this would help prevent future ‘missed anomalies’.EThOS - Electronic Theses Online ServiceResearch and Development Division of the Department of HealthGBUnited Kingdo

A systematic review of economic evaluations for donor human milk versus standard feeding in infants

Reviews on the cost/outcome of donor human milk (DHM) for infants requiring care in the neonatal intensive care unit (NICU) setting have been undertaken. However, the cost‐effectiveness evidence is unclear. Therefore, we conducted a systematic review of published full economic evaluations of DHM versus standard feeding in infants in neonatal care with the aim of undertaking a narrative synthesis of the cost‐effectiveness evidence and critical appraisal of the methods used. MEDLINE, EMBASE, Web of Science, Cochrane Library, Centre for Reviews and Dissemination (CRD) and PROSPERO databases were searched. Studies were included if they were full economic evaluations (model‐based or trial‐based), the participants were infants in neonatal units requiring nutritional support, the intervention was DHM and the comparator was any standard feeding option. There were no restrictions on outcome measures. Two authors independently assessed eligibility, extracted data, assessed quality and cross‐checked results, with disagreements resolved by consensus. Information extracted focused on study context, and economic evaluation methods and results. Of 2861 studies, seven were included. Six (86%) studies originated from high‐income countries. Four (57%) of the studies were model‐based. Although we could not directly compare the different studies, due to the heterogenous nature of health and economic parameters used in the studies, all DHM interventions indicated cost‐effective or cost saving results. This review suggests that economic evaluation of DHM interventions is an expanding area of research. Although these interventions show promise, future economic evaluations of DHM interventions need to explicitly provide more details on long‐term costs and consequences

A systematic review of economic evaluations assessing the cost-effectiveness of licensed drugs used for previously treated epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) negative advanced/metastatic non-small cell lung cancer

Background Non-small cell lung cancer (NSCLC) is one of the most commonly diagnosed cancers. There are many published studies of cost-effectiveness analyses of licensed treatments, but no study has compared these studies or their approaches simultaneously. Objective To investigate the methodology used in published economic analyses of licensed interventions for previously treated advanced/metastatic NSCLC in patients without anaplastic lymphoma kinase or epidermal growth factor receptor expression. Methods A systematic review was performed, including a systematic search of key databases (e.g. MEDLINE, EMBASE, Web of Knowledge, Cost-effectiveness Registry) limited to the period from 01 January 2001 to 26 July 2019. Two reviewers independently screened, extracted data and quality appraised identified studies. The reporting quality of the studies was assessed by using the Consolidated Health Economic Evaluation Reporting Standards and the Philips’ checklists. Results Thirty-one published records met the inclusion criteria, which corresponded to 30 individual cost-effectiveness analyses. Analytical approaches included partitioned survival models (n = 14), state-transition models (n = 7) and retrospective analyses of new or published data (n = 8). Model structure was generally consistent, with pre-progression, post-progression and death health states used most commonly. Other characteristics varied more widely, including the perspective of analysis, discounting, time horizon, usually to align with the country that the analysis was set in. Conclusions There are a wide range of approaches in the modelling of treatments for advanced NSCLC; however, the model structures are consistent. There is variation in the exploration of sensitivity analyses, with considerable uncertainty remaining in most evaluations. Improved reporting is necessary to ensure transparency in future analyses

Cost-Effectiveness of Manual Therapy for the Management of Musculoskeletal Conditions: A Systematic Review and Narrative Synthesis of Evidence From Randomized Controlled Trials

AbstractObjectivesThe purpose of this study was to systematically review trial-based economic evaluations of manual therapy relative to other alternative interventions used for the management of musculoskeletal conditions.MethodsA comprehensive literature search was undertaken in major medical, health-related, science and health economic electronic databases.ResultsTwenty-five publications were included (11 trial-based economic evaluations). The studies compared cost-effectiveness and/or cost-utility of manual therapy interventions to other treatment alternatives in reducing pain (spinal, shoulder, ankle). Manual therapy techniques (eg, osteopathic spinal manipulation, physiotherapy manipulation and mobilization techniques, and chiropractic manipulation with or without other treatments) were more cost-effective than usual general practitioner (GP) care alone or with exercise, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. Chiropractic manipulation was found to be less costly and more effective than alternative treatment compared with either physiotherapy or GP care in improving neck pain.ConclusionsPreliminary evidence from this review shows some economic advantage of manual therapy relative to other interventions used for the management of musculoskeletal conditions, indicating that some manual therapy techniques may be more cost-effective than usual GP care, spinal stabilization, GP advice, advice to remain active, or brief pain management for improving low back and shoulder pain/disability. However, at present, there is a paucity of evidence on the cost-effectiveness and/or cost-utility evaluations for manual therapy interventions. Further improvements in the methodological conduct and reporting quality of economic evaluations of manual therapy are warranted in order to facilitate adequate evidence-based decisions among policy makers, health care practitioners, and patients