Incorporating external effects in economic evaluation: The case of smoking

This thesis was submitted for the degree of Doctor of Philosophy and awarded by Brunel University.The aim of this thesis is to explore methods to incorporate external effects on decision making of public health programmes in a UK setting, using smoking cessation as an example. The National Institute for Health and Clinical Excellence (NICE) methodological guidance for evaluating public health programmes is missing the incorporation of external effects. Therefore there is a need for considering their incorporation in such evaluations and to assess what are the appropiate methods to do so. Smoking cessation is an example where epidemiological evidence of external effects exists but has not generally been incorporated into economic evaluation. This thesis therefore focused in measuring the impact, in terms of costs and QALYs lost, of the incorporation of passive smoking, smoking during pregnancy and transmission of smoking behavior into economic evaluation of smoking cessation programmes previously developed to inform policy. A static Markov model is used to incorporate passive smoking and smoking during pregnancy, whereas transmisison of smoking behaviour is incorporated through a dynamic model. The findings show that some external effects can be incorporated without a system dynamic model, when this does occur, a static Markov model may be used to account for external effects in economic evaluation. Sometimes, to incorporate external effects, the model needs a change of population. Because smoking cessation interventions are generally highly cost-effective, the incorporation of external effects does not appear to change policy decisions, but there is a clear impact on the magnitude of the ICER. Passive smoking and smoking during pregnancy have higher impact in terms of costs and QALYs lost than transmission of smoking behaviour. Our discussion considers the validity of the methods used; how much the decision making process would be affected considering or not external effects on economic evaluation of smoking cessation interventions; and other valuation approaches for external effects, such as contingent valuation

Herramienta de retorno de la inversión en control del tabaquismo: ¿qué opinan aquellos que toman decisiones?

ResumenIntroducciónEl Proyecto Europeo EQUIPT pretende adaptar una herramienta de retorno de la inversión en tabaco para varios países, con el fin de proporcionar información sobre el retorno de invertir en estrategias y justificar la toma de decisiones. El objetivo de este estudio es identificar las necesidades de los usuarios en España para documentar la transferibilidad de la herramienta.MétodosEntrevistas telefónicas con actores relevantes sobre la implementación de la Herramienta EQUIPT, intención de uso y estrategias de control del tabaco.ResultadosLa herramienta puede añadir valor a la información utilizada al tomar decisiones y abogar por políticas coste-efectivas. Como inconvenientes, conocer cómo funcionará la herramienta, así como la formación y el tiempo que requerirá la consistencia y los cálculos internos.ConclusiónSe recogen conocimientos e ideas de los potenciales usuarios para ayudar a adaptar la Herramienta EQUIPT, de modo que proporcione ayuda en la toma de decisiones eficientes.AbstractIntroductionThe European EQUIPT study will co-create a return on investment tool in several countries, aiming to provide decision makers with information and justification on the returns that can be generated by investing in tobacco control. This study aimed to identify the needs of potential users in Spain in order to provide information on the transferability of the tool.MethodsTelephone interviews with stakeholders were conducted including questions about the implementation of the tool, intended use and tobacco control interventions.ResultsImplementing the tool could provide added value to the information used in decision-making to advocate for cost-effective policies. The main drawback would be the training and time needed to learn how the tool works and for internal calculations.ConclusionKnowledge and ideas from potential users collected in this study could inform the EQUIPT Tool adaptation. Thus, stakeholders could have an instrument that assists them on making healthcare decisions

Health and economic impact at a population level of both primary and secondary preventive lung cancer interventions: A model-based cost-effectiveness analysis

Objectives: Robust economic evaluations are needed to identify efficient strategies for lung cancer prevention that combine brief and intensive smoking cessation intervention programmes with screening using low-dose computed tomography (LDCT) at different ages, frequencies, and coverages. We aimed to assess the cost-effectiveness of smoking cessation approaches combined with lung cancer screening in the European context at a population level from a societal perspective. Materials and methods: A microsimulation model that describes the natural history of lung cancer and incorporates several prevention strategies was developed. Discounted lifetime QALYs and costs at a rate of 3% were used to calculate incremental cost-effectiveness ratios, defined as additional costs in 2017 Euros per QALY gained. Results: Smoking cessation interventions reduce the incidence of lung cancer by 8%-46% and are consistently more effective and cost-effective when starting at younger ages. Screening reduces lung cancer mortality by 1%-24% and is generally less effective and more costly than smoking cessation interventions. The most cost-effective strategy would be to implement intensive smoking cessation interventions at ages 35, 40 and 45, combined with screening every three years between the ages of 55 and 65. Conclusions: Combining smoking cessation interventions with LDCT screening is a very attractive prevention strategy that substantially diminishes the burden of lung cancer. These combined prevention strategies, especially when providing several intensive interventions for smoking cessation at early ages, are more cost-effective than both approaches separately and allow for a more intensified LDCT without losing efficiency

Guía y recomendaciones para la realización y presentación de evaluaciones económicas y análisis de impacto presupuestario de medicamentos en el ámbito del CatSalut

Avaluació econòmica de medicaments; Anàlisi d'impacte pressupostari; Catalunya; Economic evaluation of drugs; Budget impact analysis; Catalonia; Evaluación económica de medicamentos; Análisis de impacto presupuestario; CataluñaL'objectiu general d'aquesta Guia consisteix a presentar una proposta de recomanacions que haurien de seguir les avaluacions econòmiques (AE) i les anàlisis d'impacte pressupostari (AIP) de medicaments del Servei Català de la Salut (CatSalut).El objetivo general de esta Guía consiste en presentar una propuesta de recomendaciones que deberían seguir las evaluaciones económicas (EE) y los análisis de impacto presupuestario (AIP) de medicamentos del Servei Català de la Salut (CatSalut)

Increasing Cervical Cancer Screening Coverage: A Randomised, Community-based Clinical Trial

Background: Opportunistic cervical cancer screening can lead to suboptimal screening coverage. Coverage could be increased after a personalised invitation to the target population. We present a community randomized intervention study with three strategies aiming to increase screening coverage. Methods: The CRICERVA study is a community-based clinical trial to improve coverage of population-based screening in the Cerdanyola SAP area in Barcelona. A total of 32,858 women residing in the study area, aged 30 to 70 years were evaluated. A total of 15,965 women were identified as having no registration of a cervical cytology in the last 3.5 years within the Public Health data base system. Eligible women were assigned to one of four community randomized intervention groups (IGs): (1) (IG1 N = 4197) personalised invitation letter, (2) (IG2 N = 3601) personalised invitation letter + informative leaflet, (3) (IG3 N = 6088) personalised invitation letter + informative leaflet + personalised phone call and (4) (Control N = 2079) based on spontaneous demand of cervical cancer screening as officially recommended. To evaluate screening coverage, we used heterogeneity tests to compare impact of the interventions and mixed logistic regression models to assess the age effect. We refer a "rescue" visit as the screening visit resulting from the study invitation. Results: Among the 13,886 women in the IGs, 2,862 were evaluated as having an adequate screening history after the initial contact; 4,263 were lost to follow-up and 5,341 were identified as having insufficient screening and thus being eligible for a rescue visit. All intervention strategies significantly increased participation to screening compared to the control group. Coverage after the intervention reached 84.1% while the control group reached 64.8%. The final impact of our study was an increase of 20% in the three IGs and of 9% in the control group (p<0.001). Within the intervention arms, age was an important determinant of rescue visits showing a statistical interaction with the coverage attained in the IGs. Within the intervention groups, final screening coverage was significantly higher in IG3 (84.4%) (p< 0.001). However, the differences were more substantial in the age groups 50-59 and those 60+. The highest impact of the IG3 intervention was observed among women 60+ y.o with 32.0% of them being rescued for screening. The lowest impact of the interventions was in younger women. Conclusions: The study confirms that using individual contact methods and assigning a fixed screening date notably increases participation in screening. The response to the invitation is strongly dependent on age

A Social Return on Investment Analysis of Improving the Management of Chronic Obstructive Pulmonary Disease Within the Spanish National Healthcare System

Purpose: To define a set of proposals that would improve the current management of chronic obstructive pulmonary disease (COPD) within the Spanish National Healthcare System (SNHS) from a comprehensive multidisciplinary perspective and to assess the impact of its implementation from clinical, healthcare, economic, and social perspectives. Patients and Methods: A group of 20 stakeholders related to COPD (healthcare professionals, patients, and informal caregivers, among others) participated in an online Delphi process to agree on a set of 15 proposals that would improve the current management of COPD within the SNHS in four areas: diagnosis, risk stratification, management of exacerbations, and management of stable COPD. A one-year forecast-type social return on investment (SROI) analysis was used to estimate the impact that implementing the set of proposals would have in relation to the investment required. A sensitivity analysis was used to test the strength of the model when varying assumption-based data-points. Results: The hypothetical implementation of the complete set of 15 proposals would require a €668 million investment and would generate a €2079 million social impact concerning savings for the SNHS and quality of life improvements for patients and their informal caregivers, among others. Accordingly, for every euro invested in the set of proposals, a social return of €3.11 would be generated (€2.71 in the worst-case scenario and €3.62 in the best-case scenario) of both tangible (32.56%) and intangible nature (67.44%). Conclusion: Altogether, implementing this set of 15 proposals would generate a positive social impact, threefold the required investment. The results may inform decisions relative to healthcare policy and practice regarding COPD management within the SNHS, further contributing to reduce the large burden of COP

Economics of gastroenteropancreatic neuroendocrine tumors : a systematic review

Despite current interest, enthusiasm and progress in the development of therapies for gastroenteropancreatic (GEP) neuroendocrine tumors (NETs), there are substantial gaps in the published literature regarding cost-of-illness analyses, economic evaluation and budget impact analyses. Compounding the issue is that data on resource utilization and cost-effectiveness of different diagnostic and therapeutic modalities for GEP-NETs are scarce. A systematic review on the economic impact of GEP-NETs was carried out using four databases: EMBASE, PubMed, the National Health Service Economic Evaluation Database and Cochrane review. Fully published articles from January 2000 to May 2017, in English and Spanish, were included. All articles that satisfied the inclusion criteria were included in the systematic review; summary descriptive statistics were used to describe the methodological characteristics. The 14 studies selected included cost-of-illness analyses (n = 4), economic evaluations (n = 7) and budget impact analyses (n = 3). Almost all studies were performed in the United States. Healthcare costs for patients with NETs included medication, outpatient visits, hospitalizations, and check-ups/tests. Reducing adverse events is an area where cost savings could be achieved; however, there was not enough evidence on the cost impact of adverse events. There is a lack of data related to resource utilization in the field of GEP-NETs. Therefore, cost-effectiveness and budget impact studies of existing and emerging treatments are urgently needed to help the decision-making process for patients with NETs

Seguridad, eficacia y evaluación económica de la implantación de un programa de cribado de aneurisma de aorta abdominal

Aneurisma d'aorta abdominal; Dolor crònic; CribratgeAneurisma de aorta abdominal; Dolor crónico; CribadoAbdominal aortic aneurysm; Chronic pain; ScreeningL’objectiu general d’aquest informe és avaluar l’evidència disponible sobre seguretat, eficàcia clínica i cost-efectivitat de la implantació d’un programa de cribratge de l’AAA mitjançant ecografia abdominal per ultrasons en la població de risc, a més de realitzar una avaluació econòmica, i respondre als criteris del Document marc sobre cribratges poblacionals, amb la condició de valorar la seva inclusió dins de la cartera comuna de serveis del Sistema Nacional de Salut espanyol.El objetivo general de este informe es evaluar la evidencia disponible sobre seguridad, eficacia clínica y coste-efectividad de la implantación de un programa de cribado del AAA mediante ecografía abdominal por ultrasonidos en la población de riesgo, además de realizar una evaluación económica, y responder a los criterios del Documento marco sobre cribados poblacionales, con tal de valorar su inclusión dentro de la cartera común de servicios del Sistema Nacional de Salud español.The general objective of this report is to evaluate the available evidence on safety, clinical efficacy and cost-effectiveness of the implementation of an AAA screening programme, using ultrasound abdominal ultrasound in the population at risk. Other objectives are to carry out an economic evaluation, and to respond to the criteria of the Framework document on population screening, in order to assess its inclusion in the common portfolio of services of the Spanish National Health System

OPTIMIZING USABILITY OF AN ECONOMIC DECISION SUPPORT TOOL: PROTOTYPE OF THE EQUIPT TOOL

Objectives: Economic decision-support tools can provide valuable information for tobacco control stakeholders, but their usability may impact the adoption of such tools. This study aims to illustrate a mixed-method usability evaluation of an economic decision-support tool for tobacco control, using the EQUIPT ROI tool prototype as a case study. Methods: A cross-sectional mixed methods design was used, including a heuristic evaluation, a thinking aloud approach, and a questionnaire testing and exploring the usability of the Return of Investment tool. Results: A total of sixty-six users evaluated the tool (thinking aloud) and completed the questionnaire. For the heuristic evaluation, four experts evaluated the interface. In total twenty-one percent of the respondents perceived good usability. A total of 118 usability problems were identified, from which twenty-six problems were categorized as most severe, indicating high priority to fix them before implementation. Conclusions: Combining user-based and expert-based evaluation methods is recommended as these were shown to identify unique usability problems. The evaluation provides input to optimize usability of a decision-support tool, and may serve as a vantage point for other developers to conduct usability evaluations to refine similar tools before wide-scale implementation. Such studies could reduce implementation gaps by optimizing usability, enhancing in turn the research impact of such interventions