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

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

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

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

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

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

Medical decision making at the individual and population level: The increasing role of evidence

The major change in medical decision making over the last 50 years has been the realisation that treatment decisions would be improved if doctors’ existing knowledge was supplemented by evidence generated systematically through health services research. This paper discusses this changing paradigm and explains the related activities of evidence-based medicine, comparative effectiveness research, and health technology assessment. The latter is particularly important for making decisions on the provision of healthcare at the population level. The key steps in undertaking health technology assessments are explained, focusing on the types of literature they generate

Pushing the boundaries of evaluation, diffusion, and use of medical devices in Europe: Insights from the COMED project

The field of medical devices has attracted considerable interest from scholarly research in health economics in recent years. Medical devices are indispensable tools for quality health care delivery, but their assessment and appropriate use pose significant challenges to healthcare systems. More research is needed to overcome existing gaps associated with evaluation of digital technologies, address challenges in the use of real-world data in generating evidence for decision-making and to uncover drivers of variation in access to medical devices across countries. Furthermore, the translation of the results and recommendations stemming from research projects into health technology assessment practices needs to be strengthened. The European Union (EU) project COMED aimed to address these gaps by improving existing research and developing new research streams on the methods for evaluation and diffusion of medical devices. The project also intended to provide directly applicable policy advice and tools to inform decision-making, with the aim of impacting public health in the EU. This Health Economics Supplement, together with references of other published outputs of the project, is intended to be the main source for researchers and policy makers seeking information on the COMED project

Assessing efficiency in the new National Health Service

Increased efficiency is one of the major objectives of the reforms of the NHS. However, this begs the question of how efficiency will be assessed, since one cannot necessarily assume that the adoption of market principles will automatically lead to efficiency. This paper discusses the methods for assessing the efficiency of health care programmes and treatments, the ways in which the reforms are likely to encourage assessment of efficiency and the monitoring systems that should be put in place to assess that more efficient health care provision has been secured as a result of the reforms. It is concluded that while there has been relatively little formal assessment of the efficiency of alternative programmes and treatments to date, the reforms present new opportunities. Efficiency assessments could be used by purchasing authorities in deciding whether or not to place a contract and in deciding upon the contract specification. They could also help providers decide upon the most appropriate treatment technologies. In the primary care sector, efficiency assessments of drug therapy could assist in the monitoring of the indicative prescribing scheme.NHS, efficiency

Australian guidelines for cost-effectiveness studies of pharmaceuticals: the thin end of the boomerang?

In the summer of 1990, the Australian government took a major step by requiring evidence of cost-effectiveness of new medicines prior to reimbursement by the public health care system. This paper assesses whether the methodological principles behind the guidelines are sound and whether they raise important new logistical and policy implications. It is concluded that, whilst the guidelines may represent ‘the thin end of the wedge’ for the pharmaceutical industry, in that other countries may follow the Australian lead, they also may represent the ‘thin end of the boomerang’ for government. Namely, the development of explicit guidelines for public funding decisions concerning new health technologies, places as many demands on funders (the government) as it does on the suppliers (the industry).pharmaceutical industry, Australia, medicines