News and events

Integrating health economics into the development and evaluation pipeline for medical tests

Dr. Bethany Shinkins, Lead of the Test Evaluation Group (TEG) at the University of Leeds

Modern medicine is increasingly reliant on medical tests; screening programs, diagnosis of disease, monitoring individuals with chronic disease, and prediction of treatment response and longer-term health all depend on tests. To recommend the use of a test, guideline developers
(such as NICE or CADTH) require high quality evidence that the test improves patient health and that it is cost-effective. There are a number of features unique to medical tests that make timely evidence generation in this area challenging.

This presentation will explore some of these complexities and provide an overview of our methodological development work in this space, including early economic modelling, target product profiles, outcome-based analytical performance specifications, adaptive trial designs and incorporating real world evidence into cost-effectiveness evaluations.

Please register your attendance at https://bit.ly/2FA329r

For further information please contact l.k.watson@exeter.ac.uk.

Financial problems and health inequalities in Europe: how does Italy compare?

Dr. Margherita Giannoni, Associate Professor Public and Health Economics at the University of Perugia, Italy

The presentation looks at the role that people’s financial difficulties have on the determinants of self-reported health in Italy as compared with selected other European countries.

The presentation will begin with an overview of the evolution of the Italian healthcare system and equity in health and access to healthcare in that country. Next, evidence from quantitative analysis conducted with colleagues will illustrate how being over indebted can influence people’s physical health. This includes a conceptual model that uses home ownership as a base to analyze the socioeconomic determinants of health, to test whether over-indebtedness and home ownership can be considered autonomous determinants of European individuals’ health.
The research shows that being in a household that is in arrears with payments and at risk of becoming deeply in debt is a consistent and robust predictor of poor health outcomes, whereas home ownership positively affects individual self-reported health.

Please register your attendance at https://bit.ly/2FA329r

For further information please contact l.k.watson@exeter.ac.uk. (It may be possible provide to video conference connection across Medical School campuses subject to room availability - please advise if this is interest to you.)

POSTPONED: Integrating health economics into the development and evaluation pipeline for medical tests

Dr. Bethany Shinkins, Lead of the Test Evaluation Group (TEG) at the University of Leeds 

Modern medicine is increasingly reliant on medical tests; screening programs, diagnosis of disease, monitoring individuals with chronic disease, and prediction of treatment response and longer-term health all depend on tests. To recommend the use of a test, guideline developers (such as NICE or CADTH) require high quality evidence that the test improves patient health and that it is cost-effective. There are a number of features unique to medical tests that make timely evidence generation in this area challenging.

This presentation will explore some of these complexities and provide an overview of our methodological development work in this space, including early economic modelling, target product profiles, outcome-based analytical performance specifications, adaptive trial designs and incorporating real world evidence into cost-effectiveness evaluations.

Please register your attendance at https://bit.ly/2PoYGYG

For further information please contact l.k.watson@exeter.ac.uk. (It may be possible provide to video conference connection across Medical School campuses subject to room availability - please advise if this is interest to you.)

The impact of removing financial incentives.

Dr Rachel Meacock, Health Organisation, Policy and Economics, University of Manchester

Pay-for-performance schemes link financial payments by purchasers to the quality of care supplied by healthcare providers. The use of financial incentives as a mechanism for quality improvement is now commonplace across health systems globally. Whilst the impact of introducing financial incentives has been studied extensively, little is known about the consequences of removing financial incentives once they are in place. The overall benefits of pay-for-performance programmes will depend upon whether any resulting quality improvements represent permanent or transitory improvements.

We study incentive removal from the long-running UK Quality and Outcomes Framework (QOF), which links financial incentives to the quality of care provided by GPs in England. Doctors have claimed the scheme distorts clinical decision-making and induces them to provide care to patients that did not need it. Therefore, we expect to see care no longer provided to patients for whom indicators were unnecessary or inappropriate.

We consider the implications of our findings for clinical decision-making, equity and the long-term success of pay-for-performance schemes.

Please register your attendance at https://bit.ly/2E9cYcg

For further information please contact l.k.watson@exeter.ac.uk. (It may be possible provide to video conference connection across Medical School campuses subject to room availability - please advise if this is interet to you.)

PERSEPHONE; 6 vs. 12 months of adjuvant trastuzumab in patients with HER2+ early breast cancer: A cost effectiveness analysis.

Professor Claire Hulme, Health Economics Group, Institute of Health Research, UEMS 

Please register your attendance at https://bit.ly/2E9cYcg

Adjuvant trastuzumab has significantly improved outcomes for HER2+ EBC, using the 12m duration empirically adopted from pivotal registration trials. Given an annual per patient cost of trastuzumab treatment of over £30,000, a shorter duration has the potential to improve cost-effectiveness if efficacy is maintained.

This cost-effectiveness analysis was based on data from the PERSEPHONE trial, a phase III non-inferiority RCT comparing 6 to 12m Trastuzumab, the largest reduced-duration non-inferiority trial internationally. A landmark analysis 6 months into treatment was conducted, comparing costs and quality of life throughout follow-up (6m – 24m post treatment start). Multiple imputation was required to impute incomplete quality of life data. Quality Adjusted Life Years (QALYs) were adjusted for differences at baseline. Uncertainty is estimated using the non-parametric bootstrap method. 4009 patients were disease free at 6m (6m: n=2000, 12m: n=2009) and therefore eligible for the analysis. The average costs for an individual in the 6m arm and 12 month arm were £2,538.64 (95% CI: £2,383.38 - £2700.72) and £12,333.83 (95% CI: £12,098.58 - £12,562.27), respectively, giving an average cost saving of £9,793.25 (95% CI: £9,515.86 - £10,071.64) per individual. Trastuzumab treatment and administration accounted for £9,699.58 (95% CI: £9,436.20 - £9.954.67) of this cost saving, the remaining arising from cardiac assessment and treatment costs and inpatient days. The average QALYs for an individual in the 6m arm and 12 month arm were 1.146 (95% CI: 1.131 – 1.161) and 1.128 (95% CI: 1.113 – 1.144), respectively, giving an average QALY difference of 0.018 (95% CI: -0.003 – 0.039). Thus, the 6m arm dominated with a probability of being cost effective of 100%. 6m of Trastuzumab was shown to be cost effective compared to 12m with cost-savings and no evidence of a detriment to quality of life.

Authors: Hulme C, Hall P, Shinkins B, Chehadah F, McCabe C, Dunn J, Hiller L, Earl HM. This research was funded by the NIHR HTA Programme (06/303/98). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health

For further information please contact l.k.watson@exeter.ac.uk. (It may be possible provide to video conference connection across Medical School campuses subject to room availability - please advise if this is interet to you.)

POSTPONED - Severity Adjusted Probability Of Being Cost-Effective: A Novel Approach To Integrate Severity And Cost-Effectiveness With Applications To Norway And The Netherlands

Dr Matthijs Versteegh, Institute for Medical Technology Assessment, Erasmus University of Rotterdam

Please register your attendance at https://bit.ly/2E9cYcg

In the context of priority setting, a differential cost-effectiveness threshold can be used to reflect a higher societal willingness-to-pay for Quality Adjusted Life Year gains in the worse off. This can reflect distributional concerns for particular groups, such as those who are more severely ill. Now that more countries use such a framework –Norway and The Netherlands have formally adopted it - applying the framework correctly becomes even more important. In order to operationalize a decision model with severity-based thresholds, one needs to define severity and estimate it in the context of treatments. An often ignored issue in this context is the uncertainty surrounding estimates of severity. However, since all estimates of severity, which subsequently translate into higher or lower thresholds, are surrounded with uncertainty, this should be adequately dealt with. In his talk for Exeter staff, Matthijs will present a new method to integrate ‘severity based thresholds’ with cost-effectiveness models. He will also show a simple tool to calculate QALY losses for the UK, including uncertainty.

For further information please contact l.k.watson@exeter.ac.uk. (It may be possible provide to video conference connection across Medical School campuses subject to room availability - please advise if this is interet to you.)

Health technology adoption in Canada: moving from appraisal to optimization

Dr Jeff Round, Institute of Health Economics, Alberta, Canada 

Please register your attendance at https://bit.ly/2E9cYcg

This seminar will discuss how reimbursement and technology approval organisations are expanding the remit of health technology appraisal from narrow questions of health technology appraisals (HTA) to wider questions of health technology optimization (HTO). Typically decisions about whether or not some technology, intervention or programme should be funded are expressed as either a simple ‘Yes’ or ‘No’. This approach works well in cases where an intervention and its effects are both clearly defined and limited in scope. Health technology appraisal bodies such as NICE or CADTH frequently evaluate technologies in this fashion. In the Canadian province or Alberta, the HTA body responsible for such decisions is increasingly exploring decision making processes that go beyond individual appraisals to focus on wider questions of technology optimization. Jeff Round will draw on recent experience in Alberta of an appraisal and optimization programme around services for the treatment and rehabilitation of people who have suffered an ischemic stroke. He will illustrate the impact that focusing on optimization can have for a health system, and the challenges for analysts in moving to more complex decision making processes.

For further information please contact l.k.watson@exeter.ac.uk. (It may be possible provide to video conference connection across Medical School campuses subject to room availability - please advise if this is interet to you.)

Economic Evaluation (cost-effectiveness analysis) in Alzheimer’s Disease/Dementia.

Tracy Comans, Associate Professor in Health Economics, NHMRC Boosting Dementia Research Leadership Fellow, University of Queensland, Brisbane, Australia

Kim-Huong Nguyen, Research Fellow in Health Economics, University of Queensland, Brisbane, Australia

Ron Handels, Health Economist, Alzheimer’s Centrum, Lindburg, University of Maastricht, Karolinska Institute, Stockholm, Sweden

Colin Green, Professor of Health Economics, Institute of Health Research, University of Exeter Medical School, Exeter, UK

Please register your attendance at https://bit.ly/2AUBdZM

For further information please contact l.k.watson@exeter.ac.uk.

EQ5D: 3L, 5L what the L?

Professor Allan Wailoo
University of Sheffield 

EQ-5D is the most widely used measure of health-related quality of life for economic evaluation. It is NICE’s preferred measure. To date this has been the 3-level version (3L), but a newer 5-level version (5L) has been produced by the EuroQoL group. 5L was intended to retain many of the features of 3L but be more sensitive. However, there are differences between the two versions in terms of both the descriptive system and the valuations for health states. These differences raise difficult issues for decision makers seeking consistency.

This talk will discuss work that has been done by a team in Sheffield looking at differences between 3L and 5L. It will show how one can estimate 3L from 5L, and vice versa, using either patient level data or summary statistics. It will then show the expected outcome of moving from 3L to 5L in a series of trial based cost-effectiveness studies, and a sample of NICE Technology Appraisals. The differences are substantial. Finally, the talk will outline ongoing work being undertaken for NICE and DH that will help determine whether and how to use 5L in future economic evaluations.

For further information please contact l.k.watson@exeter.ac.uk. (It may be possible provide to video conference connection across Medical School campuses subject to room availability - please advise if this is interet to you.)

Seminar: Subjective wellbeing in economics and health policy

Professor Bernard van den Berg
Professor of Health Economics, University of Groningen

Conceptualizing and measuring subjective wellbeing has become part of mainstream economics over the last decade or so. Policy makers worldwide seem to encourage the refinement of measures of subjective wellbeing to measure national progress.

The UK Cabinet Office asked the Office for National Statistics in 2010 to measure wellbeing or quality of life. This posed challenges for health policy which heavily relies on the measurement of health-related quality of life. The National Institute for Health and Care Excellence (NICE) guidance on public health for instance, mentions the possibility that wellbeing could complement existing measures of health-related quality of life. The NICE guidance on social care seems to suggest the possibility of going beyond health and to use wellbeing as the main outcome measure for cost-effectiveness analyses in a social care setting.

This presentation provides an introduction to the economic and health economic literature on subjective wellbeing. It uses case studies to illustrate the main empirical findings of the health economic literature. I also aim to explore and discuss how subjective wellbeing could potentially improve health policy.

For further information please contact l.k.watson@exeter.ac.uk. (It may be possible provide to video conference connection across Medical School campuses subject to room availability - please advise if this is interet to you.)

Health economics in local government settings: a focus on childhood obesity

Dr Emma Frew

Reader in Health Economics, University of Birmingham

In April 2013, responsibility for public health in England moved away from the National Health Service
to local authorities (LAs). Financial support was provided through ring-fenced public health budgets
for LAs to work with providers of health and non-health services, as well as community organisations
to improve population health and wellbeing (HM Government, 2012c). More recently however,
budgets have been cut, in 2015/6 the LA public health budget was cut by 7% (£200 million), and it
has to be further cut by 3.9% annually over the next five years – amounting to a long term reduction
in real-terms of £600 million by 2020/21. Alongside these cuts, in October 2015, the Government
announced that by the end of Parliament, LA’s will be able to keep 100% of business rates they raise
locally and the public health budget will be no longer ring-fenced. Moving public health into LAs has
provided opportunity to integrate public health with other LA functions such as education, planning,
housing, crime to improve population health and wellbeing. Together with the rapidly changing
financial context, there has also been a move towards ‘place-based’ activities, aligning providers of
care to achieve common objectives that are about meeting the needs of local populations.

One key public health priority it to tackle the alarming levels of childhood obesity. Children who are
overweight have an increased risk of disease, have lower quality of life and an increased risk of adult
obesity causing a huge societal burden over the life course. This seminar will focus on how health
economics can contribute to childhood obesity interventions within a LA setting. Consideration will be
given to the organizational, political, and financial context, and the need for LA’s to align priorities to
improve population health and wellbeing, whilst reducing inequalities. It will discuss how the
‘traditional’ methods of economic evaluation fit within that context and provide insight into how the
economist can contribute to decision making within this setting. It will use case-studies from
Birmingham LA to present novel, innovative ways of changing the obesogenic environment and
discuss how economics can be used to evaluate these approaches.

For further information please contact l.k.watson@exeter.ac.uk. (It may be possible provide to video conference connection across Medical School campuses subject to room availability - please advise if this is interet to you.)

On cost effectiveness analysis and person-centred healthcare

Andrea Manca

Professor of Health Economics, University of York

14th November 2016

Person-centred healthcare (more often referred to as personalised or precision medicine) is becoming one of the hottest topics on the public and private agenda worldwide. It has supporters among the industry, patients organisations, healthcare professionals, academics, funders and politicians. Devoting energies and resources to pursue (and hopefully realise) the promises of person-centred healthcare would seem to be a win-win strategy for a number of stakeholders. Indeed, recent years have seen an acceleration in R&D reports towards the development of novel person-centred diagnostics, drugs and medical devices (both therapeutic and support). But here lies the critical issue: how can Society shape the future of healthcare, identify and prioritise R&D investments towards acceptable, cost-effective and sustainable person-centred interventions with the highest return in terms of population health and other relevant outcomes? Cost-Effectiveness Analysis (CEA) for Health Technology Assessment (HTA) plays a pivotal role in informing such decisions in many jurisdictions around the world. However, the design and analysis of CEAs has traditionally followed the standards of mainstream clinical epidemiology and evaluation studies, reporting results based on sample means, which are expected to represent the average patient. This view of the world has been recently challenged by the need to (a) recognize individuals' heterogeneity in factors that may systematically affect costs and health outcomes, (b) reflect these characteristics in the design and analysis of CEA studies, and (c) inform more nuanced (clinical and health policy) decisions regarding funding treatments provision and further research effort priorities. This talk discusses these and a number of other issues that the current evaluative framework for healthcare decision making needs to overcome, if it is to survive the demands posed by the person-centred healthcare (r)evolution, presenting recent methodological advances that may help our pursuit of it.

Andrea is Professor of Health Economics at the University of York and Visiting Scientist at the Luxembourg Institute of Health. His current research interests focus on the development and application of health economics methods to facilitate the evaluation of person-centred healthcare technologies. He is a member of NICE Technology Appraisal Committee and co-editor of the journal PLOS One. https://www.york.ac.uk/che/staff/research/andrea-manca/.

For further information please contact l.k.watson@exeter.ac.uk. (It may be possible provide to video conference connection across Medical School campuses subject to room availability - please advise if this is interet to you.)

Orphan Drugs: Still in need of incentives?

Dyfrig Hughes

Professor of Health Economics, Bangor University

14th June 2016

Orphan Drug Legislations incentivise the development of treatments for rare diseases that would otherwise not be profitable investment opportunities. Incentives include 10 years of market exclusivity. More than 503 orphan drugs and biologic products for rare diseases have been approved by the FDA since 1983, compared with 10 such products in the decade prior to the Orphan Drug Act. 

Many orphan drugs are not cost-effective, yet most are generally available on the NHS, suggesting a societal preference for treatments of rare diseases. Eculizumab was approved by NICE at a cost of £340,000 per patient per year. The cystic fibrosis drug ivacaftor, which costs over £180,000 per patient per year, bypassed NICE, was rejected by the SMC only for a New Medicines Fund to be announced on the very same day, and was also rejected by the AWMSG before the decision was reversed by Wales’ Health Minister. 

This presentation will focus on research into: i) public views on preferential funding of treatments for rare diseases; and ii) the profitability and market value of companies selling orphan drugs.

For further information please contact l.k.watson@exeter.ac.uk. (It may be possible provide to video conference connection across Medical School campuses subject to room availability - please advise if this is interest to you.)

Dr Joel Smith

Mapping or crosswalking involves the development of mathematical algorithms to predict health-related utility values using responses to some other measure of health. In the absence of prospectively collected generic preference-based measures of health-related quality of life (HRQoL), mapping methods may be used to predict preference based utility values from disease-specific scales to inform resource allocation decisions. Simple linear or generalised linear regressions used to devise mapping algorithms are often used with little or no consideration of model uncertainty. Reporting a single “best” or “appropriate” model is typical of this literature as is the ad hoc inclusion of potential confounding variables in a single model.

We examine how Bayesian variable selection and model averaging can be used to incorporate model uncertainty into inferences about parameters and prediction when assessing the association (if any) between the EQ-5D and the Modified Rankin Scale (mRS), a simple and widely used means of grading patient handicap following stroke. We address “adjustment uncertainty” or uncertainty about which variables should be included in the mapping model using a novel approach called Bayesian adjustment for confounding (BAC).

External validation of an existing mapping algorithm from the mRS to EQ-5D will be presented. We will compare the performance of traditional mapping studies that condition inference on a single model with alternative specifications using the BAC approach. The potential for generating and applying misleading mapping algorithms to predict EQ-5D scores for individuals following a stroke given their degree of handicap is illustrated. 

Professor Colin Green

Health Economics Group, University of Exeter Medical School

Part of the Inaugural Lecture Series. More details can be found here.

The effects of self-management of long-term conditions on health and healthcare utilisation: evidence from a short panel

Professor Matt Sutton

Professor of Health Economics, Manchester Centre for Health Economics, Institute of Population Health

EMS G18, St Lukes, Exeter

Better self-management of long-term conditions is frequently cited as a way to improve population health and reduce costs to the health and social care system. Such selfmanagement activities include exercise and diet, rest and relaxation, information-seeking, use of alternative therapies, and adherence to medication. However, relatively little is known about the distribution and consequences of such behaviours. Moreover, identification of the effects of such self-investments on health and healthcare utilisation is beset with estimation problems. We use three waves of data from a survey of over 4,000 individuals with long-term conditions to examine the effects of 12 forms of self-management behaviours on a range of health and healthcare utilisation outcomes. This unique dataset allows us to control for variations between individuals in their attitudes towards self-management and their reporting behaviour, and for reverse causality.

For further information please contact l.k.watson@exeter.ac.uk

Time preference, preset bias and physical activity.

Professor Marjon van der Pol

Chair in Health Economics, Health Economics Research Unit, University of Aberdeen, UK

Increasing the level of physical activity in the population remains a major policy concern. In order to devise effective interventions it is crucial to know what determines whether people engage in physical activity. Several potential determinants have been explored including socio-economic characteristics, time constraints and motivation. In the Grossman model, physical activity is considered to be a health investment which has short term costs (time and financial costs of engaging in physical activity) and long term benefits (improved health). Given the differential timing of costs and benefits, it can be hypothesised that individuals with high time preference rates are less likely to invest. The main interest in this paper is in the role of time inconsistent preferences. Individuals often plan to engage in physical activity next week but fail to follow through when next week arrives. This can be explained by the enhanced significance that individuals attach to outcomes that occur now (present bias). This paper examines the relationship between time preference, present bias and physical activity participation. The paper uses the 2006 National Longitudinal Survey of Youth (NLSY) data which has a rich set of variables including time preferences elicited using stated preference methods and a relatively large sample of over 6000 individuals for analysis. Preliminary results show that i) time preferences significantly impact women’s physical activity participation but not men’s, and ii) that present bias influences physical activity participation decisions in women but not in men. The results suggest that pre-commitment strategies may be effective in encouraging physical activity participation in women.

Professor Stirling Bryan

Director, Centre for Clinical Epidemiology & Evaluation

A major driver of cost growth in health care is the rapid increase in the utilization of existing technology and not simply the adoption of new technology.  Health economists and their HTA colleagues have become obsessed by technology adoption questions and have largely ignored ‘technology management’ questions.  Technology management would include the life-cycle assessment of technologies in use, to assess their real-world performance; and monitoring of technology indication creep.  A rebalancing of focus might encourage a more self-critical and learning culture amongst those involved in technology evaluation.  Further, it would facilitate health economists and health technology assessment analysts to make a more significant contribution to health care system efficiency.

Dr Ed Wilson

Senior Research Associate in Health Economics, University of Cambridge

22 May 2014

In designing economic evaluations alongside clinical trials, analysts are frequently faced with alternative methods to collect the same data. For example, drug costs can be estimated by quantifying exact consumption of every drug by every patient. Alternatively they can be approximated based on total prescriptions of a particular drug or drug class. Hospitalisations can be costed by quantifying exact time input from different staff, tests conducted, treatments administered and ‘appropriate’ allocation of overheads, or based simply on a cost per admission.

A priori one method may be considered superior to the other but is also more expensive to collect. In this paper we extend the principles of value of information analysis to compare the expected return on investment (expected net benefit of sampling) from each process thus assisting decisions as to how best to design a clinical trial.

We apply this method to a previously collected dataset to estimate the value of conducting a further trial by identifying the optimal mix of observations on drug costs at two 'levels' of detail: by individual item and by drug class. We find that using a mix between the two data collection processes leads to a small increase in the expected net benefit of sampling compared with using one or the other method alone.

Professor Jack Dowie

Professor Emeritus of Health Impact Analysis, Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine

4 March 2014

The growing interest in addressing heterogeneity formally and analytically is a reflection of the move - or at least talk about moving - to more ‘personalised’ heath care.

At the clinical level the existence of biological-clinical and/or sociodemographic heterogeneity and use of such variables reflecting this, is not at all controversial in either research or practice. Use of subgrouping based on such variables is also fairly well accepted at the health policy level, such as in NICE-type coverage/reimbursement decisions, where any debate is about the use of particular variables, rather than the principle of subgrouping.

Acknowledgement of preference heterogeneity and use of preference variables is a totally different story. It is becoming less controversial at the clinical level, where the role of preferences in influencing patient behaviour, especially treatment adherence, is well-accepted; however as yet only a few decision aids attempt to process patient’s preferences explicitly and analytically at the point of care. But major controversy surrounds the use of individual person’s preferences – necessarily subgrouped - in the forming of public health policy. The debate reveals that an essentially reductionist view is still pretty pervasive: preferences are epi-phenomena that are either actually ‘caused by’ biological-clinical and/or sociodemographic variables, or in practice need to be treated as such.

This presentation falls into two section. The first shows how MCDA-based decision support can provide the basis for better individual level decision making, using an Australian trial on prostate cancer screening. The second shows, at a proof of method level, how the same data could contribute to a more preference-sensitive analysis of public health policy on prostate cancer screening, via the use of CA to produced preference-based public subgroups (not patient subgroups). But do we want that? The debate is reviewed.

Valuing the economic benefits of complex interventions: when maximising health is not sufficient.

Professor Katherine Payne

Professor of Health Economics, Manchester Centre for Health Economics, Institute of Population Health, University of Manchester

24^th September 2013

Complex interventions, involving a number of discrete, but interlinked, components, pose specific challenges for the design and conduct of studies to value their economic impact, in general, and how to value benefits, specifically. This presentation will draw on an example of a complex intervention, clinical genetics services, and describe an empirical programme of work designed to identify: (i) the attributes that comprise both health and non-health aspects of benefits (ii) if it is possible to evaluate such an intervention using current NICE appraisal processes. The results of this empirical study suggest that genetic services and tests, are a good example of a complex intervention and have broader objectives than just health gain, which may usefully be measured using the concept related to capability which we have called ‘empowerment’. The National Institute for Health and Clinical Excellence (NICE) has discrete appraisal processes for health technologies and public health interventions and assumes that the key objective is to improve health status. This may be problematic on two levels. An intervention may not fit into one of the current appraisal systems and/or maximising health is not the only objective. Further methodological work is required to identify the trade-off between non-health (empowerment) and health benefits for other complex interventions. We do not advocate a move away from QALY maximisation but do suggest there is a need for a more considered approach that can take account of the perceived value for non-health attributes for some complex interventions.

Recent developments in measuring ‘capability wellbeing’

Dr Hareth Al-Janabi

Birmingham Fellow, School of Health and Population Sciences, University of Birmingham

6^th June 2013

Broader measures of wellbeing, that are sensitive to both non-health as well as health impacts may be useful in quantifying the benefits of healthcare for economic evaluation. Previous work in this area resulted in 'capability-based' measure of wellbeing for older people (ICECAP-O). This talk will focus on the development and application of a measure of capability wellbeing for the whole adult population (the ICECAP-A). Five dimensions of capability wellbeing are included in the measure: "stability", "attachment", "achievement", "autonomy" and "enjoyment". On the whole, evidence on the feasibility, reliability and validity of the ICECAP-A is encouraging, however the picture is nuanced. Current work at Birmingham is addressing validity in clinical contexts and techniques to use the ICECAP measures in resource allocation decisions.

Evaluating the impact of ‘bolt-on’ items to EQ-5D: results from the NICEQoL project

Louise Longworth

Reader at Brunel University

28^th February 2013

The EQ-5D is a commonly used measure of health-related quality of life and is widely used in economic evaluations of health interventions; however there are concerns about its validity and responsiveness in some specific conditions. One potential solution to this problem is to develop ‘bolt-on’ items to the EQ-5D.

Three potential bolt-on items to EQ-5D were developed to describe the following health problems: vision impairment, hearing impairment and tiredness. The bolt-ons were valued in an exploratory study: members of the general population valued EQ-5D health states described with the bolt-ons using the time trade-off method in face-to-face interviews.  All three bolt-ons had a significant impact on EQ-5D health state values; however the impact was strongest for the vision bolt-on and this was selected for full valuation (EQ+Vision).  EQ-5D states with and without the ‘Vision’ item were valued, again using the time trade-off method. Random effects models were used to analyse the data for EQ-5D and EQ+Vision separately.

A total of 300 members of the general public completed time trade-off valuations for the exploratory study and a further 312 people completed interviews for the full valuation study. The full valuation model for EQ+Vision demonstrates that the inclusion of ‘Vision’ has a significant impact on EQ-5D health state values.  No statistically significant differences were found in the values provided by people reporting problems with their own vision compared to those who reported no problems.

The results of the study demonstrate that the inclusion of ‘Vision’ has a significant impact on EQ-5D health state values; however the effect is not straight forward.  The results from both studies demonstrate that the impact of the bolt-on items depend upon the severity of the EQ-5D state to which they are added.

Improving analytical approaches in cost-effectiveness studies- the case of cluster trials

Richard Grieve

Reader, London School of Hygiene and Tropical Medicine

28^th November 2012

Policy-makers use cost-effectiveness analyses (CEA) to inform decisions. However, published studies continue to use inappropriate analytical methods. In particular, a recent review highlighted that most published CEA that use cluster trials ignore the inherent clustering. I will present multilevel models and bootstrap approaches that accommodate the hierarchical nature of data from cluster trials. The relative performance of the alternative methods will be contrasted in simulation studies and case studies. I will also discuss recent developments for handling missing data that are clustered within providers. The talk will conclude by identifying new areas for methodological development in CEA. 

Richard Grieve is a reader in health economics at LSHTM. He leads research developing new analytical approaches for handling selection bias, clustering and missing data in economic evaluation.