A lack of cost information has been cited as a barrier to implementation and a limitation of implementation research. This paper explains how implementation researchers might optimize their ...measurement and inclusion of costs, building on traditional economic evaluations comparing costs and effectiveness of health interventions. The objective of all economic evaluation is to inform decision-making for resource allocation and to measure costs that reflect opportunity costs-the value of resource inputs in their next best alternative use, which generally vary by decision-maker perspective(s) and time horizon(s). Analyses that examine different perspectives or time horizons must consider cost estimation accuracy, because over longer time horizons, all costs are variable; however, with shorter time horizons and narrower perspectives, one must differentiate the fixed and variable costs, with fixed costs generally excluded from the evaluation. This paper defines relevant costs, identifies sources of cost data, and discusses cost relevance to potential decision-makers contemplating or implementing evidence-based interventions. Costs may come from the healthcare sector, informal healthcare sector, patient, participant or caregiver, and other sectors such as housing, criminal justice, social services, and education. Finally, we define and consider the relevance of costs by phase of implementation and time horizon, including pre-implementation and planning, implementation, intervention, downstream, and adaptation, and through replication, sustainment, de-implementation, or spread.
ObjectiveTo examine whether any differential change in emergency admissions could be attributed to integrated care by comparing pioneer and non-pioneer populations from a pre-pioneer baseline period ...(April 2010 to March 2013) over two follow-up periods: to 2014/2015 and to 2015/2016.DesignDifference-in-differences analysis of emergency hospital admissions from English Hospital Episode Statistics.SettingLocal authorities in England classified as either pioneer or non-pioneer.ParticipantsEmergency admissions to all NHS hospitals in England with local authority determined by area of residence of the patient.InterventionWave 1 of the integrated care and support pioneer programme announced in November 2013.Primary outcome measureChange in hospital emergency admissions.ResultsThe increase in the pioneer emergency admission rate from baseline to 2014/2015 was smaller at 1.93% and significantly different from that of the non-pioneers at 4.84% (p=0.0379). The increase in the pioneer emergency admission rate from baseline to 2015/2016 was again smaller than for the non-pioneers but the difference was not statistically significant (p=0.1879).ConclusionsIt is ambitious to expect unequivocal changes in a high level and indirect indicator of health and social care integration such as emergency hospital admissions to arise as a result of the changes in local health and social care provision across organisations brought about by the pioneers in their early years. We should treat any sign that the pioneers have had such an impact with caution. Nevertheless, there does seem to be an indication from the current analysis that there were some changes in hospital use associated with the first year of pioneer status that are worthy of further exploration.
Abstract Objective In a budget-constrained health-care system, decisions about investing in strategies to promote implementation have to be made alongside decisions about health-care provision and ...research funding. Using a Bayesian decision-theoretic approach, an analytic framework has been developed to inform these separate but related decisions, establishing the expected value of both perfect information (EVPI) and perfect implementation (EVPIM). We applied this framework to inform decision-making about resource allocation to metastatic hormone-refractory prostate cancer (mHRPC) in the UK. Methods Based on available evidence on the cost-effectiveness of all plausible treatments for mHRPC, we determined which treatment option(s) were cost-effective and explored the uncertainty surrounding this decision. Given the decision uncertainty and the variation in care provided by health-care professionals, we then determined the EVPI and EVPIM. Finally, we performed sensitivity analyses to explore the influence of alternative assumptions regarding various decision parameters on the efficiency of resource allocation. Results Depending on the cost-effectiveness threshold (λ), we identified mitoxantrone plus prednisone/prednisolone and docetaxel plus prednisone/prednisolone (3 weekly) as the optimal treatments for mHRPC. Given current clinical practice, there appears to be considerable scope for improving the efficiency of health-care provision: the EVPI (estimated to be over £13 million) indicates that acquiring further information could be cost-effective; and the EVPIM (estimated to be over £4 million) suggests that investing in strategies to implement the treatments regimens being identified as optimal is potentially worthwhile. Through sensitivity analyses, we found that the EVPI and EVPIM are mainly driven by λ, the number of treatment options being considered, the current level of implementation, and the size of the eligible patient population. Conclusion The application demonstrates that the framework provides a simple and useful analytic tool for decision-makers to address resource allocation problems between health-care provision, further research, and implementation efforts.
Economic evaluations can inform decisions about the efficiency and allocation of resources to implementation strategies-strategies explicitly designed to inform care providers and patients about the ...best available research evidence and to enhance its use in their practices. These strategies are increasingly popular in health care, especially in light of growing concerns about quality of care and limits on resources. But such concerns have hardly motivated health authorities and other decision-makers to spend on some form of economic evaluation in their assessments of implementation strategies. This editorial addresses the importance of economic evaluation in the context of implementation science-particularly, how these analyses can be most efficiently incorporated into decision-making processes about implementation strategies.
Abstract Objective Despite the emphasis on efficiency of health-care services delivery, there is an imperfect evidence base to inform decisions about whether and how to develop and implement ...guidelines into clinical practice. In general, studies evaluating the economics of guideline implementation lack methodological rigor. We conducted a systematic review of empiric studies to assess advances in the economic evaluations of guideline implementation. Methods The Cochrane Effective Professional and Organisational Change Group specialized register and the MEDLINE database were searched for English publications between January 1998 and July 2004 that reported objective effect measures and implementation costs. We extracted data on study characteristics, quality of study design, and economic methodology. It was assessed whether the economic evaluations followed methodological guidance. Results We included 24 economic evaluations, involving 21 controlled trials and three interrupted time series designs. The studies involved varying settings, targeted professionals, targeted behaviors, clinical guidelines, and implementation strategies. Overall, it was difficult to determine the quality of study designs owing to poor reporting. In addition, most economic evaluations were methodologically flawed: studies did not follow guidelines for evaluation design, data collection, and data analysis. Conclusion The increasing importance of the value for money of providing health care seems to be reflected by an increase in empiric economic evaluations of guideline implementation. Because of the heterogeneity and poor methodological quality of these studies, however, the resulting evidence is still of limited use in decision-making. There seems to be a need for more methodological guidance, especially in terms of data collection and data synthesis, to appropriately evaluate the economics of developing and implementing guidelines into clinical practice.
Abstract Objective In a budget-constrained health care system, decisions regarding resource allocation towards research and implementation are critical and can be informed by cost-effectiveness ...analysis. The objective of this study was to assess the societal value of conducting further research to inform reimbursement decisions and implementation of cost-effective psychotherapy for clusters B and C personality disorders (PDs). Methods Value of information and value of implementation analyses were conducted using previously developed cost-effectiveness models for clusters B and C PDs to evaluate the parameters that contribute to most of the decision uncertainty, and to calculate the population expected values of perfect information (pEVPI) and perfect implementation (pEVPIM). Results The pEVPI was estimated to be €425 million for cluster B PDs and €315 million for cluster C PDs, indicating that gathering additional evidence is expected to be cost-effective. The categories of parameters for which reduction of uncertainty would be most valuable were transition probabilities and health state costs. The pEVPIM was estimated to be €595 million for cluster B PDs and €1,372 million for cluster C PDs, suggesting that investing in implementation of cost-effective psychotherapy is likely to be worthwhile. Conclusions The societal value of additional research on psychotherapy for clusters B and C PDs is substantial, especially when prioritizing information on transition probabilities and health state costs. Active implementation of cost-effective treatment strategies into clinical practice is likely to improve the efficiency of health care provision in The Netherlands.
Purpose
This study examines the association between mental health problems in adolescence and general practice (GP) costs during adulthood up to age 50 in the UK.
Methods
We conducted secondary ...analyses of three British birth cohorts (individuals born in single weeks in 1946, 1958 and 1970). Data for the three cohorts were analysed separately. All respondents who participated in the cohort studies were included. Adolescent mental health status was assessed in each cohort using the Rutter scale (or, for one cohort, a forerunner of that scale) completed in interviews with parents and teachers when cohort members were aged around 16. Presence and severity of conduct and emotional problems were modelled as independent variables in two-part regression models in which the dependent variable was costs of GP services from data collection sweeps up to mid-adulthood. All analyses were adjusted for covariates (cognitive ability, mother's education, housing tenure, father's social class and childhood physical disability).
Results
Adolescent conduct and emotional problems, particularly when coexisting, were associated with relatively high GP costs in adulthood up to age 50. Associations were generally stronger in females than males.
Conclusion
Associations between adolescent mental health problems and annual GP cost were evident decades later, to age 50, suggesting that there could be significant future savings to healthcare budgets if rates of adolescent conduct and emotional problems could be reduced.
Trial registration
Not applicable.
Value of information (VOI) techniques can provide estimates of the expected benefits from clinical research studies that can inform decisions about the design and priority of those studies. Most VOI ...studies use decision-analytic models to characterize the uncertainty of the effects of interventions on health outcomes, but the complexity of constructing such models can pose barriers to some practical applications of VOI. However, because some clinical studies can directly characterize uncertainty in health outcomes, it may sometimes be possible to perform VOI analysis with only minimal modeling. This article 1) develops a framework to define and classify minimal modeling approaches to VOI, 2) reviews existing VOI studies that apply minimal modeling approaches, and 3) illustrates and discusses the application of the minimal modeling to 2 new clinical applications to which the approach appears well suited because clinical trials with comprehensive outcomes provide preliminary estimates of the uncertainty in outcomes. The authors conclude that minimal modeling approaches to VOI can be readily applied in some instances to estimate the expected benefits of clinical research.
Integrated Care Pioneers Miller, Robin; Smith, Judith; Durrand, Mary Alison ...
International journal of integrated care,
10/2017, Letnik:
17, Številka:
5
Journal Article
Recenzirano
Odprti dostop
Horizontal integration between health and social care services is seen as keen to both enable timely discharge from hospital and to provide preventative support than enables individuals to maintain ...their independence. The integrated care pioneer programme in England is seeking to explore innovative approaches to improving integration between health and social care. Twenty-five areas (known as Pioneers) have been selected to experiment with new ways of coordinating these services in order to improve the integrated care experienced by individuals and their families.The Pioneers are being supported by a number of national partners and other experts and have developed local approaches to better integrating across health and social care services. Whilst all different and tailored to their local aspects, there are aspects that are common to many. These include an emphasis on general practice as the co-ordinating hub, mulit-disciplinary teams to bring together different professionals, new approaches to self-management, and engagement of the voluntary and community sector. The programme is therefore potentially a rich source of learning for other countries seeking to improve horizontal integration across health and care services.A five year longer term evaluation of the pioneer programme is underway. This will assess the extent to which the Pioneers are successful in providing ‘person-centred coordinated care’, including improved outcomes and quality of care, in a cost-effective way. The evaluation also has a strong action research component which seeks to share emerging findings with the Pioneers and the wider policy and practice communities and support them in responding to these in their work.By the time of the conference the evaluation will be two years in. It is proposed that the evaluation team run a whole parallel session which will provide - an overview of the integrated care pioneer programme; the evaluation methodology including economic evaluation of multi-disciplinary teams; and emerging findings from panel surveys and interviews. It is also hoped to engage 1 or 2 pioneers sites in the session (details to be confirmed).Limitations of the session are that the evaluation is only half-way through, but as there will be approximately two years of work from a large scale project there will be insights of merit.
In the Netherlands, decisions about the reimbursement of new pharmaceuticals are based on cost effectiveness, as well as therapeutic value and budget impact. Since 1 January 2005, drug manufacturers ...are formally required to substantiate the cost effectiveness of drugs that have therapeutic added value in comparison with existing ones through pharmacoeconomic evaluations. Dutch guidelines for pharmacoeconomic research provide methods guidance, ensuring consistency in both the evidence and the decision-making process about drug reimbursement.
This study reviewed the methodological quality of all 21 formally required pharmacoeconomic evaluations of new pharmaceuticals between 1 January 2005 and 1 October 2008, and verified whether these evaluations complied with pharmacoeconomic guidelines.
Data on the quality of the pharmacoeconomic evaluations were extracted from the pharmacoeconomic reports published by the Dutch Health Care Insurance Board (CVZ). The Board's newsletters provided information on the advice to, and reimbursement decisions made by, the Dutch Minister of Health. All data extraction was carried out by two independent reviewers, and descriptive analyses were conducted.
The methodological quality was sound in only 8 of the 21 pharmacoeconomic evaluations. In most cases, the perspective of analysis, the comparator drugs, and the reporting of both total and incremental costs and effects were correct. However, drug indication, form (i.e. cost utility/cost effectiveness) and time horizon of the evaluations were frequently flawed. Moreover, the costs and effects of the pharmaceuticals were not always analysed correctly, and modelling studies were often non-transparent. Twelve drugs were reimbursed, and nine were not.
The compliance with pharmacoeconomic guidelines in economic evaluations of new pharmaceuticals can be improved. This would improve the methodological quality of the pharmacoeconomic evaluations and ensure consistency in the evidence and the decision-making process for drug reimbursement in the Netherlands.
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