Challenges For Economic Evaluation Research Articles

Landscape and challenges in economic evaluations of artificial intelligence in healthcare: a systematic review of methodology

BackgroundThe potential for artificial intelligence (AI) to transform healthcare cannot be ignored, and the development of AI technologies has increased significantly over the past decade. Furthermore, healthcare systems are under tremendous pressure, and efficient allocation of scarce healthcare resources is vital to ensure value for money. Health economic evaluations (HEEs) can be used to obtain information about cost-effectiveness. The literature acknowledges that the conduct of such evaluations differs between medical technologies (MedTechs) and pharmaceuticals, and poor quality evaluations can provide misleading results. This systematic review seeks to map the evidence on the general methodological quality of HEEs for AI technologies to identify potential areas which can be subject to quality improvements. We used the 35-item checklist by Drummond and Jefferson and four additional checklist domains proposed by Terricone et al. to assess the methodological quality of full HEEs of interventions that include AI.ResultsWe identified 29 studies for analysis. The included studies had higher completion scores for items related to study design than for items related to data collection and analysis and interpretation of results. However, none of the studies addressed MedTech-specific items.ConclusionsThere was a concerningly low number of full HEEs relative to the number of AI publications, however the trend is that the number of studies per year is increasing. Mapping the evidence of the methodological quality of HEEs of AI shows a need to improve the quality in particular the use of proxy measures as outcome, reporting, and interpretation of the ICER.

Challenges in economic evaluation of public health interventions: the example of surveillance of high risk pancreatic tumour patients

Abstract Evaluation of public health interventions raises a number of potential challenges in applying and performing economic analyses. The impact of interventions may extend beyond the health sector, and even within the health sector, the value may be difficult to estimate and extended beyond the health improvement of individuals. Screening and surveillance cancer programmes give the possibility to detect patients in a curable and treatable stage. Increasing number of expert recommendations and guidelines of cancer screening and surveillance have been recorded in the last decades. This scenario has increased the uncertainty on the most valuable and affordable approach to adopt. A case study can be provided by the premalignant pancreatic primarily cystic tumours surveillance. American, European and International guidelines for surveillance of asymptomatic cysts are available with significant differences in patients stratification, surveillance intensity (frequency of visits-exams), and duration. Further, real-world data suggest a significant variability in the surveillance approach even within Europe. However, no comparative data on different programmes efficacy are available, neither reliable medium-long term data on cancer risk. The lack of evidence must be considered with methodological issue associated to the inclusion of method to estimate inequalities created by the different programs and the indirect effect of healthcare resources consumption (e.g. CT and MRI) to access and allocation of these resources to other subjects (cancer and no cancer patients). Economic evaluations of surveillance or screening cancer program raise significant challenges, as data availability and methodological approach to apply. This scenario highlight the need of specific recommendation on data quality and type required to assess the programmes value and on methodological approach required (e.g. type of decision analytical models) to provide useful information for public health decision makers.

Methodological issues in economic evaluations of disease prevention and health promotion: an overview of systematic and scoping reviews

BackgroundWe aimed to provide a comprehensive overview of methodological challenges in economic evaluations of disease prevention and health promotion (DPHP)-measures.MethodsWe conducted an overview of reviews searching MEDLINE, EMBASE, NHS Economic Evaluation Database, Database of Promoting Health Effectiveness Reviews, Cochrane Database of Systematic Reviews (CDSR) and Database of Promoting Health Effectiveness Reviews (DOPHER) (from their inception to October 2021). We included both systematic and scoping reviews of economic evaluations in DPHP addressing following methodological aspects: (i) attribution of effects, (ii) outcomes, (iii) inter-sectoral (accruing to non-health sectors of society) costs and consequences and (iv) equity. Data were extracted according to the associated sub-criteria of the four methodological aspects including study design economic evaluation (e.g. model-based), type/scope of the outcomes (e.g. outcomes beyond health), perspective, cost categories related to non-health sectors of society, and consideration of equity (method of inclusion). Two reviewers independently screened all citations, full-text articles, and extracted data. A narrative synthesis without a meta-analysis or other statistical synthesis methods was conducted.ResultsThe reviewing process resulted in ten systematic and one scoping review summarizing 494 health economic evaluations. A lifelong time horizon was adopted in about 23% of DPHP evaluations, while 64% of trial-based evaluations had a time horizon up to 2 years. Preference-based outcomes (36%) and non-health outcomes (8%) were only applied in a minority of studies. Although the inclusion of inter-sectoral costs (i.e. costs accruing to non-health sectors of society) has increased in recent years, these were often neglected (between 6 and 23% depending on the cost category). Consideration to equity was barely given in economic evaluations, and only addressed in six of the eleven reviews.ConclusionsEconomic evaluations of DPHP measures give only little attention to the specific methodological challenges related to this area. For future economic DPHP evaluations a tool with structured guidance should be developed.This overview of reviews was not registered and a published protocol does not exist.

Challenges in economic evaluations in obstetric care: a scoping review and expert opinion.

ObjectiveThe aim of this study is to identify items of economic evaluation guidelines that are frequently not complied within obstetric economic evaluations and to search for reasons for non‐adherence.DesignScoping review and qualitative study.SettingLiterature on economic evaluations in obstetric care and interviews with experts.Population or sampleThe sample included 229 scientific articles and five experts.MethodsA systematic literature search was performed. All types of literature about economic evaluations in obstetric care were included. The adherence to guidelines was assessed and articles were qualitatively analysed on additional information about reasons for non‐adherence. Issues that arose from the scoping review were discussed with experts.Main outcome measuresAdherence to guideline items of the included economic evaluations studies. Analytical themes describing reasons for non‐adherence, resulting from qualitative analysis of articles and interviews with experts.ResultsA total of 184 economic evaluations and 45 other type of articles were included. Guideline items frequently not complied with were time horizon, type of economic evaluation and effect measure. Reasons for non‐adherence had to do with paucity of long‐term health data and assessing and combining outcomes for mother and child resulting from obstetric interventions.ConclusionsThis study identified items of guidelines that are frequently not complied with and the reasons behind this. The results are a starting point for a broad consensus building on how to deal with these challenges that can result in special guidance for the conduct of economic evaluations in obstetric care.Tweetable abstractNon‐adherence to guidelines in obstetric economic evaluation studies: the difficulties in detail.

Economic evaluation of nurse practitioner and clinical nurse specialist roles: A methodological review

BackgroundAdvanced practice nurses (e.g., nurse practitioners and clinical nurse specialists) have been introduced internationally to increase access to high quality care and to tackle increasing health care expenditures. While randomised controlled trials and systematic reviews have demonstrated the effectiveness of nurse practitioner and clinical nurse specialist roles, their cost-effectiveness has been challenged. The poor quality of economic evaluations of these roles to date raises the question of whether current economic evaluation guidelines are adequate when examining their cost-effectiveness. ObjectiveTo examine whether current guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles. MethodsOur methodological review was informed by a qualitative synthesis of four sources of information: 1) narrative review of literature reviews and discussion papers on economic evaluation of advanced practice nursing roles; 2) quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials; 3) review of guidelines for economic evaluation; and, 4) input from an expert panel. ResultsThe narrative literature review revealed several challenges in economic evaluations of advanced practice nursing roles (e.g., complexity of the roles, variability in models and practice settings where the roles are implemented, and impact on outcomes that are difficult to measure). The quality assessment of economic evaluations of nurse practitioner and clinical nurse specialist roles alongside randomised controlled trials identified methodological limitations of these studies. When we applied the Guidelines for the Economic Evaluation of Health Technologies: Canada to the identified challenges and limitations, discussed those with experts and qualitatively synthesized all findings, we concluded that standard guidelines for economic evaluation are appropriate for economic evaluations of nurse practitioner and clinical nurse specialist roles and should be routinely followed. However, seven out of 15 current guideline sections (describing a decision problem, choosing type of economic evaluation, selecting comparators, determining the study perspective, estimating effectiveness, measuring and valuing health, and assessing resource use and costs) may require additional role-specific considerations to capture costs and effects of these roles. ConclusionCurrent guidelines for economic evaluation should form the foundation for economic evaluations of nurse practitioner and clinical nurse specialist roles. The proposed role-specific considerations, which clarify application of standard guidelines sections to economic evaluation of nurse practitioner and clinical nurse specialist roles, may strengthen the quality and comprehensiveness of future economic evaluations of these roles.

OP22 Societal Perspective On Cost Drivers For Health Technology Assessment

INTRODUCTION:Understanding cost drivers and estimating societal costs are important challenges for economic evaluation of health technologies in low-and-middle-income countries (LMICs) (1). This study assessed community experiences of health resource utilization and perceived cost drivers from a societal perspective to inform the design of an economic model for the Community Level Interventions for Pre-eclampsia (CLIP) trials (2).METHODS:Qualitative research was undertaken alongside the CLIP trial in two districts of Sindh province, Pakistan. Nine focus groups were conducted with a wide range of stakeholders, including pregnant women, mothers-in-law, husbands, fathers-in-law, healthcare providers at community and health facility-levels, and health decision-/policy-makers at the district-level. The societal perspective included out-of-pocket (OOP), health system, and program implementation costs related to CLIP. Thematic analysis was performed using NVivo software.RESULTS:Most pregnant women and male decision makers reported a large burden of OOP costs for in- and out-patient care, informal care from traditional healers, self-medication, childbirth, newborn care, transport to health facility, and missed wages by caretakers. Many healthcare providers identified health system costs associated with human resources for hypertension risk assessment, transport, and communication about patient referrals. Health decision-/policy-makers recognized program implementation costs (such as the mobile health infrastructure, staff training, and monitoring/supervision) as major investments for the health system.CONCLUSIONS:Our investigation of care-seeking practices revealed financial implications for families of pregnant women, and program implementation costs for the health system. The societal perspective provided comprehensive knowledge of cost drivers to guide an economic appraisal of the CLIP trial in Sindh, Pakistan.

PRM40 - Challenges in Economic Evaluations Conducted Alongside Clinical Trials of Schizophrenia: The Case of the Actions Study

Improvement in outcomes of schizophrenia is challenging to assess in a clinical trial setting. The objective of this study is to draw on the results of the ACTIONS study to highlight the challenges faced while conducting the economic evaluation. The ACTIONS study (n=62), a multicenter, double-blind, randomized, placebo-controlled trial, sought to establish the clinical and cost-effectiveness of augmenting antipsychotic medication with the antidepressant citalopram for the management of negative symptoms in schizophrenia. Patients with schizophrenia on continuing, stable antipsychotic medication with persistent negative symptoms were followed for 12 months. A within-trial economic evaluation was conducted. The importance of measuring outcomes that are sensitive to changes, and assess productivity loss and carer burden are imminent. While the clinical analysis found trend towards improved outcomes in terms of avolition/amotivation, there was no evidence of improvement either in the EQ-5D-3L or ICECAP-A measures. This questions if these measures are able to capture additional changes in the negative symptoms alongside the improvement in positive symptoms. After adjusting for baseline differences, there was no statistically significant difference between arms in any cost category, except non-mental health inpatient costs but was this due to the infrequent occurrence of non-mental health hospital use. Costing brought up issues of potential selection imbalance at randomization and representativeness in terms of employment, substance abuse, and residency in psychiatric institutions. Small sample size, randomization imbalance respective of health economic factors, lack of adherence to medications and doctor visits, and loss-to-follow-up due to changing residency status of the patients pose additional challenges of assessing the outcomes and costs of schizophrenia patients for economic evaluation. Future clinical studies in schizophrenia should consider including employment, substance abuse, and current residential status in the study inclusion/exclusion criteria in order to reduce variability in the costs.

Pounds, shillings and pence: Ways to Cost NHS complementary therapy services – The SEAT and BISCUIT studies

Background To inform their decisions, commissioners need to know if particular services reduce NHS costs and procur cost savings elsewhere within the system. A review of service evaluations of NHS complementary therapy services found that most did not investigate the impact of these services on NHS costs such as GP consultations, hospital visits and medications. Two recent studies have attempted to tackle the challenges in economic evaluation of NHS complementary therapy services, using different approaches. The SEAT study evaluated an Alexander Technique (AT) service in a hospital pain clinic. The BISCUIT study focused on the economic evaluation of the Bristol Homeopathic Hospital. The aim of this presentation is to reflect on these two studies’ approaches to economic evaluation, compare their usefulness and present results. Methods The SEAT study recruited 43 service users via the hospital pain clinic who attended weekly Alexander Technique lessons over six consecutive weeks. They self-reported personal and NHS costs at the first session, six weeks and 3 months after baseline. As part of the BISCUIT study, 15 case participants who attended the Bristol Homeopathic Hospital and 19 community control participants were matched for GP practice, condition, age and sex and reported personal and NHS costs at five time points over 15 months. In addition, GP medical record data was extracted on NHS resource use and sick notes for all 34 BISCUIT participants. SEAT and BISCUIT data were priced using a variety of different sources (i.e. NHS reference costs, British National Formulary, Unit Costs of Health and Social Care). SEAT data were analysed for NHS and personal costs whereby standard weekly costs were calculated at three time points and compared. BISCUIT data were analysed from a NHS cost and societal cost perspective whereby annual costs for cases and controls were compared. Results For the SEAT study, we found that total costs for AT service users did not decrease between baseline (mean £55.53 [95% CI £39.97 to £71.10]) and three months (mean £61.19 [95% CI £14.89 to £107.49]). However NHS and personal costs associated specifically with pain reduced substantially from £27.43 (95% CI 19.26 to £35.60) to £11.68 (95% CI £4.55 to £18.81). Results for the BISCUIT study are still undergoing analysis. For both the SEAT and BISCUIT studies, we found that there was substantial variability. Conclusions The SEAT and BISCUIT studies are breaking new ground in finding commissioner friendly approaches to costing NHS complementary therapy services. At this conference, we would like to disseminate our learning so that future evaluators of NHS complementary therapy services can incorporate cost analyses into their research design. This would be of key interest to healthcare commissioners considering the funding of NHS complementary therapy services.

Challenges in Economic Evaluation of Psoriatic Arthritis

Psoriatic arthritis (PsA) is a heterogeneous chronic inflammatory disorder of the peripheral joints, peripheral entheses, synovial sheaths of tendons, and spine associated with psoriasis. PsA is characterized by different clinical phenotypes and its course is variable1. Patients can also have gut2 and eye involvement3. In addition, patients with PsA or psoriasis have increased frequency of insulin resistance, obesity, type 2 diabetes, metabolic syndrome, hypertension, hyperlipidemia, and cardiovascular disease compared with the general population4. Recently, a new designation has been proposed with the aim to cover all these clinical situations: psoriatic disease5. In the past, PsA was considered a rare and mild disease. The prevalence of psoriasis in the general population is currently estimated to be around 2%–3%, with one-third of patients developing associated musculoskeletal manifestations. In the last 20 years, evidence has been gathered demonstrating that PsA is destructive and deforming in 40%–60% of patients, with joint damage emerging in the first years of the disease course6. It is believed that around 20% of patients with PsA develop a serious destructive disease. Patients with PsA suffer from functional impairment, decreased quality of life (QOL), and psychosocial disability, and have a significant increase in mortality versus the general population7,8. Therapies for PsA have been inadequate until recently. Nonsteroidal antiinflammatory drugs are useful in improving symptoms but have no effect on the progression of radiographic joint damage. Local corticosteroid injections may be of great aid in patients with persistent mono- or oligoarthritis but use of systemic glucocorticoid treatment is not supported by evidence. Traditional disease-modifying antirheumatic drugs (DMARD), which are the second-line treatment, are employed in PsA to control symptoms, but there is no evidence that they slow the progression of structural joint damage. The introduction of …

Future Challenges for the Economic Evaluation of Healthcare

The continued growth in the economic evaluation of healthcare over the past 25 years has led to a shortage of trained health economists globally, leading to a number of universities and/or national governments developing specialised health economics programmes to train more health economists. One of the common problems with many of these training programmes is that they only educate new health economists to the Masters level, and as such they are unable to cover the many skills needed by a successful health economist. Furthermore, government and industry interests have ensured that economic evaluation is a heavily regulated environment that gives little incentive to seek further education. These two related factors (under-education and over-regulation) have lead to a situation where economic evaluation methods may adversely limit innovation of therapeutics and devices in clinical areas that perform badly when evaluated on the cost per QALY scale. The good news, however, is that the tide is turning and theoretically sound adjustments (such as risk adjustments and stated preferences) to the current paradigm are now being considered. This, of cause, is just the tip of the iceberg with other important issues such as time preference and the endogeneity of preference remaining very much under-researched areas in health. This paper concludes that many of these real-world issues, such as patient preferences, can be avoided by using artificial objective functions such as cost per QALY, but this comes at the cost of irrelevance and the misallocation of resources. If we are to meet all of the future challenges in economic evaluation in healthcare then we must focus more on advanced education and far less on the regulation of health economists.