BROADENING THE PERSPECTIVE OF ECONOMIC EVALUATION IN HEALTH CARE – A CASE STUDY IN DEMENTIA CARE IN THE UK

My thesis is an investigation of the methods to implement a broader societal perspective in economic evaluation. I proposed two potential approaches that could be used to implement a societal perspective in economic evaluation: An extended cost-per-QALY approach and a CCA-MCDA approach. The investigation was conducted in a case study of dementia care. The case study concerned the evaluation of 4 mutually exclusive options for primary care to early detect people with dementia. I reviewed previous economic evaluation studies in dementia and developed a new cost-effectiveness model for this evaluation. The model provided estimates for costs including health care, government-funded social care, privately funded social care and informal care. Benefits were measured in terms of patient QALYs and carer QALYs. Using the model’s estimates as the initial basis, I applied the principles of the extended cost-per-QALY approach and the CCA-MCDA to implement a broader societal perspective in the economic evaluation in the case study

Outcomes of aortic aneurysm surgery in England : a nationwide cohort study using hospital admissions data from 2002 to 2015

Background The United Kingdom aortic aneurysms (AA) services have undergone reconfiguration to improve outcomes. The National Health Service collects data on all hospital admissions in England. The complex administrative datasets generated have the potential to be used to monitor activity and outcomes, however, there are challenges in using these data as they are primarily collected for administrative purposes. The aim of this study was to develop standardised algorithms with the support of a clinical consensus group to identify all AA activity, classify the AA management into clinically meaningful case mix groups and define outcome measures that could be used to compare outcomes among AA service providers. \ud Methods In-patient data about aortic aneurysm (AA) admissions from the 2002/03 to 2014/15 were acquired. A stepwise approach, with input from a clinical consensus group, was used to identify relevant cases. The data is primarily coded into episodes, these were amalgamated to identify admissions; admissions were linked to understand patient pathways and index admissions. Cases were then divided into case-mix groups based upon examination of individually sampled and aggregate data. Consistent measures of outcome were developed, including length of stay, complications within the index admission, post-operative mortality and re-admission. Results Several issues were identified in the dataset including potential conflict in identifying emergency and elective cases and potential confusion if an inappropriate admission definition is used. Ninety six thousand seven hundred thirty-five patients were identified using the algorithms developed in this study to extract AA cases from Hospital episode statistics. From 2002 to 2015, 83,968 patients (87% of all cases identified) underwent repair for AA and 12,767 patients (13% of all cases identified) died in hospital without any AA repair. Six thousand three hundred twenty-nine patients (7.5%) had repair for complex AA and 77,639 (92.5%) had repair for infra-renal AA. Conclusion The proposed methods define homogeneous clinical groups and outcomes by combining administrative codes in the data. These methodologically robust methods can help examine outcomes associated with previous and current service provisions and aid future reconfiguration of aortic aneurysm surgery services

Cost effectiveness thresholds: the past, the present and the future

Cost-effectiveness (CE) thresholds are being discussed more frequently and there have been many new developments in this area; however, there is a lack of understanding about what thresholds mean and their implications. This paper provides an overview of the CE threshold literature. First, the meaning of a CE threshold and the key assumptions involved (perfect divisibility, marginal increments in budget, etc.) are highlighted using a hypothetical example, and the use of historic/heuristic estimates of the threshold is noted along with their limitations. Recent endeavours to estimate the empirical value of the thresholds, both from the supply side and the demand side, are then presented. The impact on CE thresholds of future directions for the field, such as thresholds across sectors and the incorporation of multiple criteria beyond quality-adjusted life-years as a measure of ‘value’, are highlighted. Finally, a number of common issues and misconceptions associated with CE thresholds are addressed