NIHR CLAHRC Community e-newsletter – Health Economics Issue 57
Welcome to the community e-newsletter for the CLAHRCs, bringing you news from across the thirteen collaborations and the health service research community. This newsletter looks at the work NIHR CLAHRCs are doing around Health Economics.
CLAHRC East Midlands: COPD programme ‘cost-effective’
A self-management programme supported by CLAHRC East Midlands for people with chronic obstructive pulmonary disease (COPD) is cost effective compared to routine care, according to an economic analysis.
The Self-management Programme of Activity, Coping and Education or SPACE FOR COPD© is designed to help people with COPD manage their condition more effectively and reduce the impact it has on their day-to-day life.
This self-management programme has already demonstrated clinical benefits in the short-term, with evidence of sustained changes after six months, when delivered on an individual basis.
Results from an economic evaluation – titled ‘An Economic Evaluation of a self-management programme for patients with COPD’ – have now shown that the self-management programme, developed by University Hospitals of Leicester NHS Trust, is “likely to be cost-effective” over six months at a level recommended by the National Institute for Health and Care Excellence (NICE).
Now researchers are evaluating the effectiveness of delivering the programme manual to small groups of people based in community settings. If shown to work it has the potential to be rolled out across the East Midlands and further afield to support individuals with COPD, on a one-to-one basis with other modes of delivery being explored.
Read more here.
CLAHRC East of England: Estimating quality of life in people with asthma
Each week, 1400 acute asthma patients are admitted to hospital in England and Wales, costing the NHS over £1 billion. Asthma symptoms (e.g. shortness of breath, chest tightness and wheezing), can progressively worsen and reduce quality of life, with an average of three people dying a day.
With current studies tending to evaluate quality of life in asthmatics at specific time points, and the sporadic nature of asthma attacks, such attacks may not be captured in studies. The ESQUARE project will provide an alternative way to measure quality of life in asthmatics by recruiting patients during their asthma-related hospital admission or accident and emergency attendance with a follow-up of two months.
Several quality of life questionnaires will be completed by the patients and compared to test their validity. This will enable the loss in quality of life associated with a hospital admission or accident and emergency attendance to be estimated. Recruitment is ongoing in Norwich, Birmingham and Aberdeen, and more information about this project can be found here.
CLAHRC East of England: Are QALY gains an appropriate measure of the societal value of end-of-life care?
Competing healthcare interventions are increasingly prioritised in terms of cost per quality-adjusted life year (QALY) gained, which measures changes in quality-of-life and length of life. This framework allows for objective comparisons of value across different disease areas.
There is an argument, though, that this framework may not be appropriate for end-of-life care. Improvements in quality at the end-of-life are unavoidably of a limited duration, so individual QALY gains from end-of-life care will always be smaller than similar improvements to patients with longer life expectancies.
The QALY also neglects less quantifiable non-health benefits that play a central role in perceptions of a ‘quality death’. In this view, the relatively low priority often assigned to end-of-life care may reflect the limitations of the QALY rather than its true value.
This research will survey the public to understand the relationship between QALY gains and the value of end-of-life care, using stated preference methods. Evidence of an insignificant relationship between QALY gains and perceived value would suggest that conventional QALY gains are not an appropriate measure of the value of end-of-life care. This could inform improvements to the evaluation framework and ensure a fairer and more efficient allocation of healthcare resources to end-of-life care.
For more information, please visit http://www.clahrc-eoe.nihr.ac.uk/2016/02/are-qaly-gains-an-appropriate-measure-of-the-societal-value-of-end-of-life-care/
CLAHRC East of England: Examining the transparency and reproducibility of decision-analytic models
Within the resource limited NHS, a treatment strategy must be shown to be both effective and cost-effective before it can be adopted. Typically, cost-effectiveness is determined through an economic evaluation alongside a clinical trial.
However, the follow-up time of trials are often short, limiting the exploration of longer term costs and benefits. In such situations, economic modelling can be used to explore longer term costs and benefits, potentially utilising data from a range of sources. These models are often very complex, and can make many assumptions about the condition and treatment effects.
Given the importance of such models for NHS funding decisions, it is important that model structure and underlying assumptions are transparent and that any reported results are reproducible.
This project seeks to:
- Identify any existing model validation work
- Attempt several model replications based on published studies, gaining insight into the current state of literature
- Help inform future reporting guidelines
To find out more, please contact Emma McManus CLAHRC EoE.
CLAHRC Greater Manchester: 7-Day Access to Primary Care
7-day access to services is one of the government’s key policies for the NHS. NIHR CLAHRC Greater Manchester has been involved in several high profile and influential evaluations of 7-day primary care initiatives, and each project has had heavy involvement of health economists.
Currently, NIHR CLAHRC Greater Manchester is involved in the evaluation of two 7-day access projects. The first is an evaluation for NHS England of the rollout of 7-day GP access across Greater Manchester. This rollout of 7-day services was partly informed by their previous Demonstrators evaluation – a mixed-methods evaluation of several pilot schemes in Greater Manchester. The report for the rollout will be completed by summer 2017. The second project is an advisory role to the nationwide 7-day primary care pilot scheme evaluation, which was instigated due to CLAHRC GM’s Demonstrators project and related high impact publication in PLOS Medicine.
Both projects seek to understand the implications of 7-day primary care on the health care system, focussing on the effects on hospital services (A&E and admissions), patient satisfaction, costs of delivery, and implications for access and inequalities in access – these will help inform whether 7-day primary care services are likely to be an efficient use of NHS resources. CLAHRC GM has strong health economics input into the evaluations from the Manchester Centre for Health Economics, with a particular focus on policy evaluation techniques and inequalities in access to health care.
CLAHRC Greater Manchester: A whole system approach to improving Acute Kidney Injury outcomes in Greater Manchester
Acute Kidney Injury (AKI) complicates up to one in five hospital admissions and is associated with a large increase in mortality risk. Its treatment accounts for 1% of the NHS budget. Health economists within NIHR CLARHC Greater Manchester are involved in the evaluation of two interventions aiming to improve outcomes for patients with this prevalent, harmful and costly condition.
The first, implemented in Salford Royal and Central Manchester Foundation Trusts, targets AKI quality improvements in a secondary care setting. The initiatives are multifaceted, including the introduction of electronic alerts, nurse-led notification systems, and care checklists to encourage treatment of AKI patients in line with published guidelines. Health economists will evaluate their effects on health outcomes, including mortality rates and kidney disease progression, as well as drivers of treatment cost, including length of stay. The second is a primary care-focussed intervention, implemented in general practices covered by Bury Clinical Commissioning Group. This intervention aims to improve the identification and management of AKI patients post-discharge, and involves education, audit and feedback to aid the development of practice-level patient action plans. The rate of emergency readmission will be assessed as the primary outcome.
CLAHRC North Thames: Assessing the impact of diabetes prevention
Type 2 diabetes prevention is a top priority in England, with 2.6 million adults already diagnosed and 7 million at risk, costing the NHS about £10 billion annually.
A CLAHRC North Thames project has developed a simulation model to estimate the impact of a set of interventions to prevent or delay diabetes onset – either currently implemented, planned or clinically possible – in Newham.
Working with a wide range of stakeholders CLAHRC researchers have tailored the model to the local context, estimating the impact of four interventions. Additionally, value for money was assessed using the STAR (socio-technical allocation of resources) framework.
Results show a pharmacological intervention (i.e. metformin) currently not offered but clinically effective, would prevent the biggest number of cases and provide best value for money. Individual based lifestyle interventions would have a very limited impact and the worst relative value for money.
Email Chiara De Poli email@example.com
CLAHRC North Thames: The economics of multi-sectoral working
A £22bn financial challenge and year-on-year social care funding reductions funding require health services to reduce prevalence and severity of health need. This requires collaboration with other sectors. Interventions spanning sectors often require investment from one organisation or setting of care with financial benefit realised elsewhere.
A CLAHRC project is investigating the role of financial incentives – identified as a barrier to implementing such investment and achieving cross-sector collaboration.
Semi-structured interviews with leaders from three local health economies (Barking and Dagenham, Havering and Redbridge) and national policy makers have elicited experiences of multi-sectoral working and perspectives on financial incentives. Anonymised health and population data, connected on an individual level, is being collected from a three-year retrospective cohort across Barking (200,000 population).
Regression analysis will seek to identify characteristics associated with increased health and social care spend, and explore whether there are specific population segments for whom multi-sectoral working would have maximal benefit.
Email Jenny Shand firstname.lastname@example.org
CLAHRC North West Coast: Health Inequalities Assessment Toolkit (HIAT)
The HIAT (http://www.hiat.org.uk/) is a free online resource that has been developed by CLAHRC NWC for researchers to clarify what aspects of health inequalities and socio-economic drivers are relevant to the topic to be addressed in their proposed work.
Tailored for individual CLAHRC NWC applications it remains a valuable resource including worked examples of applying the HIAT and questions to help researchers clarify the pathways linking activity to a reduction in socio-economic inequalities in health.
CLAHRC North West London: QI4U
While it has always been important to spend allotments for health services wisely, maintaining an awareness and record of efficiency is now both effective and beneficial for the improvement of the quality of services and care.
In the last year NIHR CLAHRC NWL have developed an independent eLearning resource called QI4U as part of an effort to build capacity in a systematic approach to quality improvement for front-line NHS staff and service users. QI4U is available for anybody who has an interest in effective quality improvement of healthcare services for the benefit of patients. QI4U is targeted towards but not limited to front-line clinicians, academics, patients and service users.
Read more here.
PenCLAHRC: Avoidable acute admissions
A research team supported by NIHR PenCLAHRC produced a national report which addressed the question: how can frontline expertise and models of care best contribute to safely reducing acute hospital admissions with related cost savings? The question is especially pertinent now as health trusts struggle with demand. With analysis of working practice and patient experience in four NHS acute hospital trusts in the South West of England, the report was published in Health Services and Delivery Research.
Find out more about the project here.
PenCLAHRC: Patterns for neonatal care in England
A team from the Peninsula Collaboration for Health Operational Research and Development(PenCHORD, part of NIHR PenCLAHRC), is working on a project to model current and future patterns of neonatal care in England. The anticipated outcomes of the work will cover workload issues in each hospital; resource utilisation, nursing costs, as well as the proportion of babies cared for away from the most appropriate hospital; the distance between a mother’s home and the place of care, the number and distance of transfers, and; the number of infants that cannot be cared for within the mother’s home neonatal network.
PenCLAHRC: Report on new estimates of the size of the lesbian, gay and bisexual population of England
Public Health England (PHE) has published a report, compiled by researchers supported by NIHR PenCLAHRC, estimating the size of the Lesbian, Gay and Bisexual (LGB) population in England.
The report estimates that 2.5% of the population of England have self-identified as lesbian, gay or bisexual, but this is likely to be an underestimate.
There is evidence to suggest that minority sexual orientation groups can experience high prevalence of poor mental health and low wellbeing. In order to assess health outcomes by sexual orientation, there is a need for a widely accepted national estimate of the size of the LGB population in England.
The analysis will help: address the current major gaps in existing data and analysis relating to health outcomes and patient experience for LGB populations, and; understand inequalities in health and care outcomes for different populations in England.
This will help support targeted preventative and early intervention work to address health inequalities and demonstrate the provision of equitable access for LGB individuals.
This analysis provides a robust estimate of the size of the LGB population and will support health and social care organisations to:
- Address the current gaps in existing data and analysis relating to health outcomes and patient experience for LGB populations.
- Understand inequalities in health and care outcomes for different populations in England. This would support targeted preventative and early intervention work to address health inequalities.
- Demonstrate the provision of equitable access for LGB individuals.
CLAHRC South London: Evaluating the cost-effectiveness of a new clinic to improve the lung health of people who use addiction servicesA large number of addiction service users are dying from physical health problems, including chronic obstructive pulmonary disease [COPD]. COPD is common, preventable and treatable and the majority of cases are caused, and exacerbated by, smoking. Yet addiction service users often don’t get referred for specialist treatment or help to stop smoking.
A project led by Caroline Jolley, a respiratory physician and senior lecturer in human physiology at King’s College London aimed to improve the recognition and documentation of signs and symptoms of respiratory problems among users of addiction services, particularly in relation to COPD. Dr Jolley set up a pilot drop-in lung health screening clinic within the Drug and Alcohol Service run by South London and Maudsley NHS Trust.
Health economists from King’s Improvement Science (KIS), a quality improvement programme and part of NIHR CLAHRC South London, then analysed this service to find out whether the costs of introducing the health clinic are justifiable and offer value for money.
The initial analysis shows that they could be a cost-effective use of resource depending on how many people engage with treatment and what combination of treatment is needed. However, more data and evidence is needed through well-designed monitoring and evaluation of newly implemented models of lung health assessment. Read more
CLAHRC Wessex: Clever maths from CLAHRC Wessex
A team from NIHR CLAHRC Wessex has been using health data and modelling to create a new design for sexual health services in our region. A paper is expected shortly and one of the authors Dr Rudabeh Meskarian is taking her finding to the STEM event at the House of Commons in March. In the meantime, see for yourself here.
CLAHRC Wessex: Living well where you are
Dr Hilda Hounkpatin has been examining the influence of affluence and location on people’s kidney health. Take a look at what she found out in this link.
CLAHRC Wessex: GENIE out the bottle
The GENIE networking tool is being launched this March 29 in Winchester. If you’d like to attend get in touch at email@example.com.
For a taste of what GENIE is about see https://vimeo.com/204348912.
CLAHRC West: Extending the liaison psychiatry service: evaluating the economic impact in emergency department attendances for self-harm
CLAHRC West has been working with University Hospitals Bristol NHS Foundation Trust to evaluate the impact of their expansion of the Liaison Psychiatry Service (LPS) on patient management, outcomes and treatment costs for emergency department (ED) attendances for self-harm.
Work by the Bristol Health Partners Improving Care in Self-Harm Health Integration Team (STITCH HIT) contributed to the decision to expand liaison services. More people were presenting at the Bristol Royal Infirmary emergency department in the evenings, especially on weekends, but the liaison psychiatry service only covered normal office hours. Bristol Clinical Commissioning Group (CCG) made a £250k annual investment to extend the service to 8am to 10pm seven days a week.
Our evaluation looks at improvements in and the timeliness of service delivery, as well as the economic impact of this service extension. We are hoping to publish our findings in the next few months.
CLAHRC West: Piloting quality of life questionnaires to measure capability wellbeing to inform commissioning
CLAHRC West is finalising a research collaboration agreement with Gloucestershire CCG to pilot quality of life questionnaires that measure a person’s capability wellbeing, and using them to inform outcome-based commissioning.
To maximise patient health and wellbeing benefits from limited resources, outcomes across the health and social care system must be compared. Generic quality of life questionnaires are useful in this scenario, but the standard approach of measuring health-related quality of life to generate quality-adjusted life years by health economists is not holistic enough to inform commissioning across health and social care.
‘Capability wellbeing’ measures, such as ICECAP, that ask questions about a person’s quality of life in terms of their ability to have independence, love and friendship and enjoyment in their life, have been recently developed for this purpose.
This project looks at the feasibility of collecting and analysing capability wellbeing measures across a number of pilots in different patient groups and settings in Gloucestershire. It will involve quantitative analysis of the patient completed capability wellbeing measures for these pilot groups. It will also involve qualitative analysis by conducting interviews with patients, clinical professionals and commissioners, to develop a greater understanding of the feasibility and acceptability of collecting the measures with patients, as well as the usefulness of the data collected for outcome-based commissioning by Gloucestershire CCG.
CLAHRC West: Evaluating the NHS ‘business case’ investment process in the West
CLAHRC West has just received ethical and Health Research Authority approval to evaluate the local NHS ‘business case’ investment process. Approximately £4 million was allocated for service development in 2016/17, although the current financial crisis in the NHS means that the majority of investments considered will be ‘invest to save’ proposals.
Using ethnographic methods researchers will conduct systematic observations of decision-making fora and interview key decision-makers to gain a thorough understanding of the decision-making process. CLAHRC West is particularly interested in understanding how information about the effectiveness and cost-effectiveness of proposed service developments are presented and understood by decision-makers, and the overall importance of this information in the prioritisation process.
An important element of the study will be to identify areas where decision-makers could be better supported to make decisions, resulting in a more effective and cost-effective allocation of NHS resources. CLAHRC West may also lead in developing a training intervention for commissioners.
CLAHRC West Midlands: Iodine supplementation is cost-saving for the health service and to society
A model-based economic evaluation, using data from published literature and expert clinical input, was used to compare the costs and benefits of iodine supplementation for singleton pregnant women with a mild-to-moderate iodine deficiency versus ‘standard care’.
A decision-tree model was used to carry-out two analyses of the costs and benefits from a health service perspective and a wider societal perspective. Conservative assumptions were used regarding benefits, and potentially overestimating adverse outcomes.
Iodine supplementation was shown to be ‘dominant’ in both scenarios. The analysis showed the following:
|Perspective||Cost-saving per month||Average gain of IQ for child|
These findings suggest that iodine supplementation could save money and improve a child’s IQ. Current evidence suggests that a policy to introduce iodine supplementation during pregnancy would be beneficial to both the health service and society.
This work was conducted by the prevention and detection of diseases Theme by collaborators at the University of Birmingham and published in the Lancet Diabetes and Endocrinology journal and also as a CLAHRC WM BITE.
Monahan M, Boelaert K, Jolly K, et al. Costs and benefits of iodine supplementation for pregnant women in a mildly to moderately iodine-deficient population: a modelling analysis. Lancet Diabetes Endocrinol. 2015; 3(9): 715-22.
CLAHRC West Midlands: Stockpiling neuraminidase inhibitors for pandemic influenza
Pandemic influenza is one of the highest-risk, highest impact events that the government has to prepare for. One policy option is to stock pile anti-influenza drugs, neuraminidase inhibitors (NAI). However, there is a lot of uncertainty surrounding the effectiveness of NAIs, and a stockpile can be expensive.
While RCT evidence shows some evidence of reduction in symptoms, improved time to alleviation of symptoms, and reduced risk of pneumonia, little is known about its effects on mortality given than deaths from seasonal influenza are rare. A meta-analysis of observational data from the 2009 influenza pandemic did show some evidence of a reduction in risk of mortality associated with NAIs, but some critics argued that this evidence was subject to bias.
A simple decision analysis was conducted to estimate the expected net benefits of stockpiling NAIs. The effectiveness evidence was ‘bias adjusted’ through a process of expert elicitation and extrapolated to total numbers of deaths averted. The distributions of epidemiological parameters, such as the clinical attack rate, were estimated from previous influenza pandemics.
The expected net benefit of the stockpile was positive, suggesting a decision maker should stockpile, given an objective of maximising total population health. There was a 77% probability the stockpile had negative net benefits; in many cases the stockpile expired without a pandemic arising. However, the potentially large gains from a rare but severe pandemic justified the cost.
Controversies still exist around the use of NAIs for pandemic influenza. This study was not designed to be proscriptive but it is hoped to provide a transparent, methodological framework within which to make a decision.
This study was supported by the Research Methods theme and led by research fellow Dr Sam Watsonat University of Warwick.
Watson SI, Chen Y-F, Nguyen-Van-Tam JS, et al. Evidence synthesis and decision modelling to support complex decisions: stockpiling neuraminidase inhibitors for pandemic influenza usage. F1000 Research. 2016; 5: 2293.
Sam is also the editor an interesting blog; you may like to subscribe to this here: https://aheblog.com/
CLAHRC West Midlands: Leading the development of the methods to measure the health economic impact of service delivery research
CLAHRC West Midlands has identified that while health economics methods are well developed for areas such as Health Technology Assessment (HTA) for devices and drugs, these methods need to be adapted and extended when applied to examples of service delivery such as the redesign of a service or treatment pathway. Many service delivery interventions are designed to reduce adverse events, but it is difficult to account for the separate utilities of myriad different adverse events.
CLAHRC West Midlands has produced an approach to group adverse events by severity and duration, and calculate utility by group (Yao GL, Novielli N, Manaseki-Holland S, et al. Evaluation of a predevelopment service delivery intervention: an application to improve clinical handovers. BMJ Qual Saf; 21(s1):i29-38; Lilford RJ, Girling AJ, Sheikh A, et al. Protocol for evaluation of the cost-effectiveness of ePrescribing systems and candidate prototype for other related health information technologies. BMC Health Serv Res. 2014; 14: 314).
Complex service change can also result in a large number of end points at multiple levels within a healthcare system and these causal chains need to be defined and modelled accurately. Bayesian methods could potentially provide solutions to some of these issues (Watson SI & Lilford RJ. Integrating multiple sources of evidence: a Bayesian perspective. In: Raine R, Fitzpatrick R, Barratt H, et al. Challenges, solutions and future directions in the evaluation of service innovations in health care and public health. Southampton (UK): NIHR Journals Library; 2016). We are using these methods to conduct evaluations of ePrescribing on an NIHR Programme grant, and of consultant working at weekends on a Health Service and Delivery grant.
In addition to these mainly epistemological issues, there are numerous costing issues concerning, for example, what to do when resources (e.g. bed days) are saved but the costs are not released.
There is a pressing need to develop the subject of microeconomics of service interventions – a subject that has attracted nugatory attention compared to Health Technology Assessment. A workshop involving CLAHRCs, HS&DR and MRC was recently convened under the chairmanship of Jo Rycroft-Malone, and a report will be produced by Dr Sam Watson.
For further information, please contact CLAHRC West Midlands central team.
Richard is also the editor of the CLAHRC West Midlands News Blog; you may like to subscribe to this here: https://clahrcwmblog.wordpress.com/
CLAHRC Yorkshire and Humber: The Cost-Effectiveness of Population Health Checks
Since their initiation in 2009 the policy of providing NHS Health Checks to 40-74 year olds has proved controversial with a poor level of coverage and overall program performance substantially below initial targets of reduction in cardiovascular disease risk factors.
This work aimed to assess the cost-effectiveness evaluation of the NHS Health Checks in their current form using the impact of the policy on reducing the long term risk factors associated with obesity, one of the primary factors associated with many of the targeted diseases.
This focussed analysis seeks to answer the question: has the reduced level of obesity caused by NHS Health Checks, been sufficient to justify the cost of the entire policy to the NHS? The analysis employs a publicly available economic evaluation toolkit to estimate how an observed reduction in the mean BMI in the target population impacts long term population health and costs to the NHS. Initial results for the study can be found here.
CLAHRC Yorkshire and Humber
An on-going study at the University of Sheffield is comparing EQ-5D-5L and EQ-5D-3L data in the United Kingdom using the GP Patient Survey (GPPS). The study will also generate population norm data for the EQ-5D-5L. EQ-5D-5L was developed to address concerns with the discriminative properties of EQ-5D-3L. Clara Mukuria from the CLAHRC YH HEOM theme is working alongside colleagues at the University, Roberta Ara and Ben van Hout.
Results will add to the growing body of knowledge on the performance of EQ-5D-5L as well as population norm data that can be used by researchers in the UK. Find out more about HEOM Theme http://clahrc-yh.nihr.ac.uk/our-themes/health-economics-and-outcome-measurement