Reviewing the Evidence to Inform the Population of Cost-Effectiveness Models within Health Technology Assessments

ObjectivesHealth technology assessments (HTAs) typically require the development of a cost-effectiveness model, which necessitates the identification, selection, and use of other types of information beyond clinical effectiveness evidence to populate the model parameters. The reviewing activity associated with model development should be transparent and reproducible but can result in a tension between being both timely and systematic. Little procedural guidance exists in this area. The purpose of this article was to provide guidance, informed by focus groups, on what might constitute a systematic and transparent approach to reviewing information to populate model parameters.MethodsA focus group series was held with HTA experts in the United Kingdom including systematic reviewers, information specialists, and health economic modelers to explore these issues. Framework analysis was used to analyze the qualitative data elicited during focus groups.ResultsSuggestions included the use of rapid reviewing methods and the need to consider the trade-off between relevance and quality. The need for transparency in the reporting of review methods was emphasized. It was suggested that additional attention should be given to the reporting of parameters deemed to be more important to the model or where the preferred decision regarding the choice of evidence is equivocal.DiscussionThese recommendations form part of a Technical Support Document produced for the National Institute for Health and Clinical Excellence Decision Support Unit in the United Kingdom. It is intended that these recommendations will help to ensure a more systematic, transparent, and reproducible process for the review of model parameters within HTA.     

行为经济学视角下突发性公共卫生危机中公众健康决策分析

结合2019年突发公共卫生事件,分析突发性公共卫生危机中信息传播特点,从行为经济学视角分析社会规范和情绪对公众健康决策的影响,并对危机发生时公众情绪引导和公开信息传播策略并进行探讨。     

Assessing the Health Perspectives of Unique Populations of Adolescents: A Focus Group Study

Few articles report on youth's perceptions about health-related issues and needs and even fewer have given voice to youth with disabilities, chronic health conditions, or youth in therapeutic foster care. The purpose of this study was to explore perceptions of health issues from the perspectives of youth placed in therapeutic foster care, youth with chronic medical conditions, and youth with disabilities. Twelve focus groups with 67 youth aged 13–20 were conducted in rural, suburban, and urban communities in the Commonwealth of Virginia. Data analysis revealed both within unique group themes and themes that cut across unique groups. Youth in therapeutic foster care with chronic health conditions or with disabilities perceive themselves as being different from their peers. Participants in each group expressed concerns about the unique issues that they confront daily and how these challenges differentiate them from youth who do not share their life experiences. They expressed the desire for other youth to understand them better and to not treat them differently. Discussion and implications focus on the need to create programs to support the unique needs of these youth.     

Use of Cost-Effectiveness Analysis in Health-Care Resource Allocation Decision-Making: How Are Cost-Effectiveness Thresholds Expected to Emerge?

BACKGROUND: An increasing number of health-care systems, both public and private, such as managed-care organizations, are adopting results from cost-effectiveness (CE) analysis as one of the measures to inform decisions on allocation of health-care resources. It is expected that thresholds for CE ratios may be established for the acceptance of reimbursement or formulary listing. OBJECTIVE: This paper provides an overview of the development of and debate on CE thresholds, reviews threshold figures (i.e., cost per unit of health gain) currently proposed for or applied to resource-allocation decisions, and explores how thresholds may emerge. DISCUSSION: At the time of this review, there is no evidence from the literature that any health-care system has yet implemented explicit CE ratio thresholds. The fact that some government agencies have utilized results from CE analysis in pricing/reimbursement decisions allows for retrospective analysis of the consistency of these decisions. As CE analysis becomes more widely utilized in assisting health-care decision-making, this may cause decision-makers to become increasingly consistent. CONCLUSIONS: When CE analysis is conducted, well-established methodology should be used and transparency should be ensured. CE thresholds are expected to emerge in many countries, driven by the need for transparent and consistent decision-making. Future thresholds will likely be higher in most high-income countries than currently cited rules of thumb.     

军队卫生辅助决策信息系统研发与应用

本文介绍了系统的研发背景、设计目标、设计原则、关键技术和系统功能,并对医院、疗养院卫生统计信息管理提出了新的要求。     

Health Services Research as a Source of Legislative Analysis and Input: The Role of the California Health Benefits Review Program

This article examines the role of the California Health Benefits Review Program (CHBRP) as a source of information in state health policy making. It explains why the California benefits review process relies heavily on university-based researchers and employs a broad set of criteria for review, which set it apart from similar programs in other states. It then analyzes the politics of health insurance mandates and how independent research and analysis might alter the perceived benefits and costs of health insurance mandates and thus political outcomes. It considers how research and analysis is typically used by policy makers, and illustrates how participants inside and outside of state government have used the reports prepared by CHBRP as both guidance in policy design and as political ammunition. Although there is consensus that the review process has reduced the number of mandate bills that are passed out of the legislature, both supporters and opponents favor the new process and generally believe the reports strengthen their case in legislative debates over health insurance mandates. The role of the CHBRP is narrowly defined by statute at the present time, but the program may well face pressure to evolve from its current academic orientation into a more interactive, advisory role for legislators in the future.     

确定医院计量器具检定周期的方法

运用统计学的原理,对某台诊疗计量器具的计量性能和使用情况进行分析,并逐项进行综合评定和量比,从而确定某台诊疗计量器具的检定周期。     

基于面板数据模型的政府卫生支出及影响因素研究

目的:分析我国政府卫生支出规模的影响因素.方法:利用1997-2009年各省市的数据,采用面板数据回归模型对我国政府卫生支出进行分析.结果:各省市政府卫生支出对国内生产总值的弹性估计,除海南省外,均保持了0.01以上的显著性水平;对财政支出的弹性估计,在0.1的水平下,8个省市具有显著性.结论:国内生产总值为我国政府卫生支出的主要影响因素.     

Use of Syndromic Data to Determine Oral Health Visit Burden on Emergency Departments

Objective

The objective was to use syndromic surveillance data from the North Carolina Disease Event Tracking and Epidemiologic Collection Tool NCDETECT and from BioSense to quantify the burden on North Carolina (NC) emergency departments of oral health-related visits more appropriate for care in a dental office (ED). Calculations were sought in terms of the Medicaid-covered visit rate relative to the Medicaid-eligible population by age group and by county.

Introduction

Concern over oral health-related ED visits stems from the increasing number of unemployed and uninsured, the cost burden of these visits, and the unavailability of indicated dental care in EDs [1]. Of particular interest to NC state public health planners are Medicaid-covered visits. Syndromic data in biosurveillance systems offer a means to quantify these visits overall and by county and age group.

Methods

Using BioSense data received from NCDETECT, 60.8 million records from 12.9 million ED visits were collected, covering all NC visits for state fiscal years (SFY) 2008–2010. Roughly 4% of visits were dropped because of patient residence zip codes missing or outside NC. A careful multi-step procedure involving both dentist consultants and data analysis was used to derive classification criteria for visits whose main reason was a nontraumatic oral health problem [2]. This procedure yielded 243,970 visits by ∼174,600 patients based on hospital-specific patient identifiers. Nontraumatic oral health-related visits were collected in a study set with added fields for method of payment, patient residence county, and age group. Based on previous studies, consultant preferences, and NC Medicaid eligibility guidelines, selected age groups were 0–14, 15–19, 20–29, 30–49, 50+ years. Stratified counts of Medicaid-eligibles were obtained from the NC Dental Director by study year. Using these tables and the ED visit study set, rates of nontraumatic oral health-related Medicaid visits per 10,000 eligibles were tabulated by county and age group for each study year. Demographics of multiple-visit patients were also studied.

Results

Rates of ED oral health-related visits were substantially higher for young adults than for other age groups. From statewide rates in

Empirical Testing of the External Validity of a Discrete Choice Experiment to Determine Preferred Treatment Option: The Case of Sleep Apnea

There is an increasing use of the discrete choice experiment (DCE) method in health care to estimate preferences of individuals and the public for different services. Despite this increasing use, there are few studies that investigate the validity of the DCE in health. This study investigates the external validity of DCE by comparing the predicted treatment choices from the DCE to the actual treatment choices made by the same respondents using a decision board (DB) approach. The sample includes 140 patients who came for a sleep apnea routine visit in a hospital setting. Each respondent answered 10 DCE tasks and 1 DB task. The preferences were estimated with a generalized multinomial logit model and the predicted and actual treatment choices were compared both at the sample and individual levels. The results raise questions about the external validity of DCE in health. At the sample level, the comparison showed large but not significant differences between the two methods. This can be explained in part by the aggregation process that obscures variability in the individuals’ preferences. At the individual level, the comparison showed that the two methods led to significantly different patterns of choices. Copyright © 2014 John Wiley & Sons, Ltd.     

新时期军队卫生管理统计工作转变分析

本文分析了军队后方医院和军区、总部两级卫生管理机构统计工作的现状,提出在新时期新形势下卫生管理统计工作转变的思路和设想。从依托平台、技术支持、工作内容、环节动态、统计单元、数据发布等方面进行了阐述,意欲使卫生管理统计工作在管理实践中真正发挥作用。     

Challenges in Valuing Temporary Health States for Economic Evaluation: A Review of Empirical Applications of the Chained Time Trade-Off Method

Background

The time trade-off (TTO) technique is commonly used to elicit health state utilities. Nevertheless, when the health states being valued are temporary, the TTO approach may be unsuitable. A variant of TTO— chained TTO—has been suggested to be used when the health states are temporary, but little research has been done on how chained TTO should be conducted.

Ethical Issues in the Economic Assessment of Health Care Technologies

This paper challenges traditional views which oppose health economics and medical ethics by arguing that economic assessment is a necessary complement to medical ethics and can help to improve public participation and democratic processes in choices about resource allocation for health care technologies. In support of this argument, four points are emphasized: (1) Most current biomedical ethical debates implicitly deal with economic issues of resource allocation. (2) Clinical decisions, which usually respect the Hippocratic code of ethics, are nevertheless influenced by economic incentives and constraints. (3) Economic assessment is concerned with both efficiency and equity and potential trade-offs between the two, which means that ethical judgements are always embedded in welfare economics. (4) The real debate is not between economics on the one side and medical ethics on the other. Rather it is between different ethical conceptions of social justice and the contrasting approaches they entail to reconciling individual interests and preferences with collective goods and welfare. This revised version was published online in August 2006 with corrections to the Cover Date.     

Research and Advice Giving: A Functional View of Evidence‐Informed Policy Advice in a Canadian Ministry of Health

Context: As evidence-based medicine grows in influence and scope, its applicability to health policy prompts two questions: Can the principles and, more specifically, the tools used to bring research into the clinical world apply to civil servants offering advice to politicians? If not, what approach should the evidence-oriented health policy organization take to improve the use of research?Methods: This article reviews evidence-based medicine and models of research use in policy. Then it reports the results of interviews with civil servants in the Ontario Ministry of Health, which recently adopted a stewardship rather than an operational role, incorporating many evidence-oriented strategies. The interviews focused on functional roles for research-based evidence in policy advice.Findings: The clinical context and tools for evidence-based medicine can rarely be generalized to policy. Most current models of research use offer lessons to researchers wishing to apply their work to policy but little help for civil servants wishing to become more evidence oriented. The interviews revealed functional roles for research in setting agendas (noting upcoming issues and screening interest groups’ claims), developing new policies (reducing uncertainty, helping speak truth to power, and preventing repetition and duplication), and monitoring or modifying existing policies (continuously improving programs and creating a culture of inquiry). Each area requires different tools to help filter the push of evidence from researchers and set agendas, to facilitate the urgent pull on relevant research by civil servants developing new policy, and to support ongoing linkage and exchange between civil servants and researchers for monitoring and modifying existing policy.Conclusions: A functional framework for evidence-informed policy advice is useful for distinguishing the activity from evidence-based medicine and “auditing” the balance of efforts across the different functional roles of research in policy.     

A Nonparametric Statistical Method That Improves Physician Cost of Care Analysis

Objective

To develop a compositing method that demonstrates improved performance compared with commonly used tests for statistical analysis of physician cost of care data.

Data Source

Commercial preferred provider organization (PPO) claims data for internists from a large metropolitan area.

Study Design

We created a nonparametric composite performance metric that maintains risk adjustment using the Wilcoxon rank-sum (WRS) test. We compared the resulting algorithm to the parametric observed-to-expected ratio, with and without a statistical test, for stability of physician cost ratings among different outlier trimming methods and across two partially overlapping time periods.

Principal Findings

The WRS algorithm showed significantly greater within-physician stability among several typical outlier trimming and capping methods. The algorithm also showed significantly greater within-physician stability when the same physicians were analyzed across time periods.

Conclusions

The nonparametric algorithm described is a more robust and more stable methodology for evaluating physician cost of care than commonly used observed-to-expected ratio techniques. Use of such an algorithm can improve physician cost assessment for important current applications such as public reporting, pay for performance, and tiered benefit design.     

Implementation Barriers to Value of Information Analysis in Health Technology Decision Making: Results From a Process Evaluation

ObjectivesValue of information (VOI) analysis can support health technology assessment decision making, but it is a long way from being standard use. The objective of this study was to understand barriers to the implementation of VOI analysis and propose actions to overcome these.MethodsWe performed a process evaluation of VOI analysis use within decision making on tomosynthesis versus digital mammography for use in the Dutch breast cancer population screening. Based on steering committee meeting attendance and regular meetings with analysts, we developed a list of barriers to VOI use, which were analyzed using an established diffusion model. We proposed actions to address these barriers. Barriers and actions were discussed and validated in a workshop with stakeholders representing patients, clinicians, regulators, policy advisors, researchers, and the industry.ResultsConsensus was reached on groups of barriers, which included characteristics of VOI analysis itself, stakeholder’s attitudes, analysts’ and policy makers’ skills and knowledge, system readiness, and implementation in the organization. Observed barriers did not only pertain to VOI analysis itself but also to formulating the objective of the assessment, economic modeling, and broader aspects of uncertainty assessment. Actions to overcome these barriers related to organizational changes, knowledge transfer, cultural change, and tools.ConclusionsThis in-depth analysis of barriers to implementation of VOI analysis and resulting actions and tools may be useful to health technology assessment organizations that wish to implement VOI analysis in technology assessment and research prioritization. Further research should focus on application and evaluation of the proposed actions in real-world assessment processes.