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

What does economic evaluation mean in the context of children at the end of their life?

The ‘conventional framework’ of economic evaluation, the comparative public sector healthcare costs and quality adjusted life year (QALY) of two or more interventions, has become synonymous with commissioning decisions in many countries. However, while useful as a framework in guiding value-based decisions, it has limited relevance in areas such as end of life care in children and young people, where the costs fall across multiple stakeholders and QALY gains are not the primary outcome. This paper makes the case that the restricted relevance of the ‘conventional framework’ has contributed to the inconsistent and varied provision of care in this setting, and to the knock-on detrimental impact on children nearing the end of their lives as well as their families. We explore the challenges faced by those seeking to conduct economic evaluations in this setting alongside some potential solutions. We conclude that there is no magic bullet approach that will amalgamate the ‘conventional framework’ with the requirements of a meaningful economic evaluation in this setting. However, this does not imply a lack of need for the summation of the costs and outcomes of care able to inform decision makers, and that methods such as impact inventory analysis may facilitate increased flexibility in economic evaluations

Research-to-Policy Partnerships for Evidence-Informed Resource Allocation in Health Systems in Africa: An Example Using the Thanzi Programme

Objectives: Empirical data on the impact of research-to-policy interventions are scant, with the few attempts mainly focusing on ensuring policymakers’ timely access to evidence and evidence-informed dialogs. Methods: This article reflects on how the Thanzi Programme cultivates an approach of research-to-policy engagement in health economics. The program is structured around 3 interrelated pillars comprising research evidence generation, capacity and capability building, and research-and-policy engagement. Each pillar is described and examples from the Thanzi Programme are given, including illustrating how each pillar informs the other. Limitations and challenges of the approach are discussed, with examples of a way forward. Results: This program supports health system strengthening through addressing gaps identified by program partners. This includes providing health economics training and research and strengthened partnerships between in-country researchers and health policymakers, as well as between national and international researchers. Platforms bringing together researchers and policymakers to shape the research agenda, disseminate evidence, and foster an evidence-based dialog are institutionalized at country and regional levels. Health Economics and Policy Units have been established, which sit between the Ministries of Health and Universities, to augment policymakers and health economics researchers’ engagements on priority health policy matters and determine researchable policy questions. The establishment of the Health Economics Community of Practice as a substantive expert committee under the East Central and Southern Africa Health Community bolsters the contribution of health economics evidence in policy processes at the regional level. Conclusions: The Thanzi Programme is an example of how a research-and-policy partnership framework is being used to support evidence-informed health resource allocation decisions in Africa. It uses a combination of high-quality multidisciplinary research, sustained research and policymakers’ engagement and capacity strengthening to use research evidence to guide and support policy makers more effectively. Keywords: capacity building, health economics, knowledge translation, north-south partnership, research-to-policy engagement

Methods for network meta-analysis of continuous outcomes using individual patient data : a case study in acupuncture for chronic pain

Background: Network meta-analysis methods, which are an extension of the standard pair-wise synthesis framework, allow for the simultaneous comparison of multiple interventions and consideration of the entire body of evidence in a single statistical model. There are well-established advantages to using individual patient data to perform network meta-analysis and methods for network meta-analysis of individual patient data have already been developed for dichotomous and time-to-event data. This paper describes appropriate methods for the network meta-analysis of individual patient data on continuous outcomes. Methods: This paper introduces and describes network meta-analysis of individual patient data models for continuous outcomes using the analysis of covariance framework. Comparisons are made between this approach and change score and final score only approaches, which are frequently used and have been proposed in the methodological literature. A motivating example on the effectiveness of acupuncture for chronic pain is used to demonstrate the methods. Individual patient data on 28 randomised controlled trials were synthesised. Consistency of endpoints across the evidence base was obtained through standardisation and mapping exercises. Results: Individual patient data availability avoided the use of non-baseline-adjusted models, allowing instead for analysis of covariance models to be applied and thus improving the precision of treatment effect estimates while adjusting for baseline imbalance. Conclusions: The network meta-analysis of individual patient data using the analysis of covariance approach is advocated to be the most appropriate modelling approach for network meta-analysis of continuous outcomes, particularly in the presence of baseline imbalance. Further methods developments are required to address the challenge of analysing aggregate level data in the presence of baseline imbalance

Supporting Carers of People with Dementia : A mixed methods evaluation and feasibility study (January 2018)

Unpaid carers are the mainstay of the UK care system for people with dementia. Yet caring can have an impact on the well-being and health of the carer. Admiral Nursing is the only specialist nursing service in the UK that specifically focuses on supporting carers of people with dementia, but evidence of its effectiveness, costs, and relationships to other services is limited. This project aimed to address this gap and explore the feasibility of full-scale formal evaluation

Specialist nursing support for unpaid carers of people with dementia : a mixed-methods feasibility study

Abstract Background Unpaid carers are the mainstay of support for people with dementia. Admiral Nursing (AN) is the only specialist nursing service that specifically focuses on supporting such carers, but evidence of its effectiveness, costs and relationships with other health and social care services is limited. This project aimed to address this gap and explore the feasibility of a full-scale formal evaluation. Objectives To explore the relationships between characteristics of carers and people with dementia, service type and input and outcomes; to develop and test data collection methods for subsequent economic evaluation; to explore the effect of AN on outcomes and costs, compared with usual care; to explore the perceived system-wide impact of specialist support for carers of people with dementia, compared with usual care; and to implement new data collection methods in AN, which could also be used by other services, to facilitate evaluation. Design A mixed-methods study, using secondary analysis of an administrative data set, and primary (cross-sectional) quantitative and qualitative data collection. Setting Qualitative research with carers in four areas of England; a survey of carers in 32 local authority areas (16 with and 16 without AN); and qualitative interviews with professionals in four areas. Participants Thirty-five carers of people with dementia and 20 professionals were interviewed qualitatively; 346 carers completed in-scope questionnaires (46% through AN services and 54% from matched non-AN areas). Interventions Specialist nursing support for carers of people with dementia (with AN as an exemplar) compared with usual care. Main outcome measures The Adult Social Care Outcomes Toolkit for Carers; the EuroQol-5 Dimensions, five-level version; and the Caregiver Self-Efficacy for Managing Dementia Scale. Data sources Dementia UK’s AN administrative data set. Results Admiral Nurses are successfully targeting the most complex cases. They work predominantly with older carers who have the main responsibility for the person with dementia, who are heavily involved in caring activity and who may be at risk. Three outcome areas that are important to carers of people with dementia and are potentially affected by receiving support are (1) carer self-efficacy, (2) carer quality of life (3) and carer mental and physical health. The carers in the survey receiving support from AN were older, were more heavily involved in caring and had poorer outcomes than carers not in receipt of such support. When these differences were controlled for, carers supported by AN had better outcomes, although the differences did not reach statistical significance. Health and social care costs were similar in both groups. The perceived system-wide impact of services, such as AN, is not well understood by professional stakeholders. Limitations Challenges were experienced in identifying similar carers in areas with or without an AN service and in the cross-sectional nature of the work. Conclusions Specialist nursing support to carers of people with dementia may enable them to continue providing care to the end or very close to the end of the dementia journey. The outcomes for such carers may be no different from, or even slightly better than, those of similar carers without this support, although the costs to health and social care services are the same in each case. Future work Future research could investigate the impact of specialist support for carers on admission to long-term care. There is also a need for more work to encourage routine use of the selected outcome measures in dementia service delivery. Funding The National Institute for Health Research Health Services and Delivery Research programme

Partnerships between deaf people and hearing dogs (PEDRO) : Effectiveness and Cost-Effectiveness of Receiving a Hearing Dog on Mental Well-Being and Health in People With Hearing Loss: Protocol for a Randomized Controlled Trial

Background People with hearing loss, particularly those who lose their hearing in adulthood, are at increased risk of social isolation, mental health difficulties, unemployment, loss of independence, risk of accidents, and impaired quality of life. In the United Kingdom (UK), a single third sector organisation provides hearing dogs, a specific type of assistance dog trained to provide sound support to people with hearing loss. These dogs may also deliver numerous psychosocial benefits to recipients. This has not previously been fully investigated. Objective To evaluate the impact of a hearing dog partnership on the lives of individuals with severe or profound hearing loss. Methods and Analysis A two-arm, randomised controlled trial conducted within the UK, with 162 hearing dog applicants, aged 18 years and over. Participants will be randomised 1:1 using a matched-pairs design to receive a hearing dog sooner than usual (intervention arm – Arm B) or to receive a hearing dog within the usual timeframe (comparator arm – Arm A). In the effectiveness analysis, the primary outcome is a comparison of mental wellbeing six-months after Arm B have received a hearing dog (Arm A: not yet received hearing dog), measured using the Short Warwick Edinburgh Mental Wellbeing Scale. Secondary outcome measures include the PHQ-9, GAD-7 and WSAS. An economic evaluation will assess cost-effectiveness including health-related quality-adjusted life years using the EQ-5D-5L and social-care-related-quality-adjusted life-years. Participants will be followed up for up to two years. A nested qualitative study will investigate the impacts of having a hearing dog and how these impacts come about. Results The study was funded by the National Institute for Health Research’s School for Social Care Research. Recruitment commenced in March 2017 and is now complete. 165 participants were randomised. Data collection will continue until January 2020. Results will be published in peer-reviewed journals and at conferences. A summary of the findings will be made available to participants. Ethical approval was received from the University of York’s Department of Social Policy and Social Work Research Ethics Committee (reference SPSW/S/17/1). Conclusions The findings from this study will provide, for the first time, strong and reliable evidence on the impact of having a hearing dog on people’s lives in terms of their quality of life, well-being and mental health. Trial registration The trial has been retrospectively registered International Standard Randomised Controlled Trial Number (ISRCTN) 36452009; https://doi.org/10.1186/ISRCTN36452009. Trial status: Ongoing