Evaluation Of Health Care Programmes Research Articles

Development of the European Healthcare and Social Cost Database (EU HCSCD) for use in economic evaluation of healthcare programs

IntroductionCosts are one of the critical factors for the transferability of the results in health technology assessment and economic evaluation. The objective is to develop a cost database at the European level to facilitate cross-border cost comparisons in different settings and explains the factors that lead to differences in healthcare costs in different countries, taking into account the differences between health systems and other factors.MethodologyThe core of the database is compounded of three main categories (primary resources, composite goods and services, and complex processes and interventions) organized into 13 subcategories. A number of elements providing as detailed information of unit cost as possible were identified in order to mitigate the problem of comparability. Consortium partners validated both the database structure and selected costing items.ResultsTwenty-seven costing items included in the EU HCSCD resulted in 1450 unit costs when taking into account all item subtypes and countries. Cross-country differences in costs are driven by the type of resources included in the costing items (e.g., overhead costs in case of complex processes and interventions) or by the variety of existing brands and/or models and the type of unit value in most of the primary resources.ConclusionThe EU HCSCD is the only public unit healthcare and social cost database at European level that gather data on unit costs and explains differences in costs across countries. Its maintenance and regular data updating will enable establishing specific systems for generating and recording information that will meet many of its current limitations.

Probabilistic One-Way Sensitivity Analysis with Multiple Comparators: The Conditional Net Benefit Frontier.

Although there have been substantial developments in the analysis of uncertainty in economic evaluations of health care programmes, the development of methods for one-way sensitivity analysis has been notably slower. Conditional incremental net benefit was recently proposed as an approach for implementing probabilistic one-way sensitivity analysis for economic evaluations comparing two strategies. In this paper, we generalise this approach to economic evaluations that compare three or more strategies. We find that ‘conditional net benefit’ may be used to conduct probabilistic one-way sensitivity analysis for economic evaluations comparing any number of strategies. We also propose the ‘conditional net benefit frontier’, which may be used to identify the most cost-effective of any number of strategies conditional upon the specific value of a parameter of interest.

Incorporating environmental impacts into the economic evaluation of health care systems: Perspectives from ecological economics

Health care is responsible for a range of negative environmental impacts, including greenhouse gas emissions, air pollution, plastics waste, and pharmaceutical pollution of ecosystems through excretion and inappropriate disposal. Evidence on the scale of these impacts has been growing in high-income countries. To date, there has been only limited discussion of how environmental impacts might be incorporated into economic evaluations of health care programs, including health technology assessment. This paper considers why and how this aim might be achieved, using perspectives from both mainstream and ecological economics. There are strong arguments for using economic evaluation to internalise the negative environmental externalities currently being generated by health care, as well as precautionary arguments for health systems to better understand their exposure to their environmental impacts. The paper tests the feasibility of incorporating the costs of greenhouse gas emissions within costing for economic evaluation, and concludes that the use of shadow prices to achieve this aim is feasible. It suggests that this cost-based approach is preferable to more convoluted attempts to incorporate environmental impacts in the outcome component of health economic evaluations. The interaction between overuse, antimicrobial resistance and environmental harms of health care is identified as an area that would benefit from investigation using innovative economic methods.

Private and social time preference for health outcomes: A general population survey in Iran.

Despite the recent increase in economic evaluations of health care programs in low and middle income countries, there is still a surprising gap in evidence on the appropriate discount rate and the discounting of health outcomes such as quality adjusted life years (QALYs). Our study aimed to calculate the implied time preference rate for health outcomes in Iran and its key determinants. Data were gathered from one family member from each of the 650 households randomly selected in Tehran. The respondents’ private and social preferences for health outcomes were calculated using the time trade-off (TTO) technique based on the discounted utility model. We investigated the main assumptions of the discounted utility model through equality of mean comparison, and the association between private time preference and key socio-economic determinants using multilevel regression analysis. The mean and median implied rates were 5.8% and 4.9% for private time preference and 25.6% and 20% for social time preference respectively. Our study confirmed that magnitude, framing and time effects have a significant impact on implied discount rates, which means that the conventional discounted utility model’s main assumptions are violated in the Iranian general population. Other models of discounting which apply lower rates for far health outcomes might provide a more sensible solution to discounting health interventions with long-term impacts.

Evaluation practices in the field of Food and Nutrition

ABSTRACT The objective of this study was to characterize and analyze the different existing methods for the evaluation of food and nutrition programs and services in Brazil, through a systematic review of the literature focused on complete articles published in national indexed journals. We searched the PubMed, MedLine and LILACS databases using the following search terms and Boolean operators: “evaluation and program”; “project”; “intervention”; “servisse”; “actions and nutrition”; “nutritional”. The research was restricted to articles written in Portuguese, English and Spanish and published between 2001 and 2015. Twenty-two studies were selected and the analysis indicates; most were carried out through quantitative approaches and external evaluations based on epidemiological theory; participatory evaluation strategies are still uncommon; Impact assessments and implementation were predominant; there is little diversity in terms of references to the theoretical framework in the field of evaluation of health care programs in the planning and execution of the evaluation processes analyzed. The results of this study indicate the need for a more comprehensive evaluation considering the complexity of the interventions evaluated using the theoretical-methodological apparatus available in the literature to understand the importance of the different perspectives of the agents involved in the evaluation processes.

Perception and practice of application of economic evaluation among teaching dental faculty of Bengaluru City, India

Introduction: Economic evaluation of healthcare programs is now commonplace in medicine and is becoming increasingly important in dentistry. As faculty members are involved in academic research activities and publication of various studies which help in decision-making, it is imperative to have the basic knowledge of economic evaluations to contribute significant results for the implementation of new programs and to modify the existing ones. Aim: To assess the knowledge about economic evaluation on research and practice by the teaching dental faculty of Bengaluru city, to assess the attitude toward application of economic evaluation, and to assess its practical applications. Materials and Methods: A cross-sectional study was conducted in Bengaluru city. Among 17 dental colleges located in the city, eight colleges were randomly selected, and 300 participants were included. A self-administered questionnaire was prepared and validated. Participants who were present and willing to participate on the date of visit were included. Results: Among 300 participants, 16.7% participants responded as this was purely public health topic but refused to participate in the study after giving consent. Nearly 53% participants had knowledge regarding health economics and around 8% participants had learned the method of application in various aspects and used in research purposes. Around 18.4% participants viewed lack of training and credibility of studies as important barriers. Moreover, participants wished for a better explanation of the practical relevance of studies. Conclusion: Knowledge and practice was poor among the participants. Better explanation of the practical relevance, continuing dental education programs, and workshops pertaining to health economics should be conducted to create awareness and to improve knowledge and application of these techniques.

Cost Effectiveness of Achieving Targets of Low-Density Lipoprotein Particle Number Versus Low-Density Lipoprotein Cholesterol Level

A recent analysis of a commercially insured US population found fewer cardiovascular disease (CVD) events in high-risk patients attaining low levels of low-density lipoprotein (LDL), as measured by LDL particle number (LDL-P) versus low LDL cholesterol (LDL-C). Here, we investigated the cost effectiveness of LDL-lowering therapy guided by LDL-P. Patients were selected from the HealthCore Integrated Research Database and followed for 12 to 36months. Patients who achieved LDL-P <1,000nmol/l were placed into the LDL-P cohort, whereas those without LDL-P tests, but who achieved LDL-C <100mg/dl, were placed into the LDL-C cohort. CVD-related costs included all health plan paid amounts related to CVD events or lipid management. Cost effectiveness was assessed through incremental cost-effectiveness ratios, defined as difference in total costs across the cohorts divided by difference in CVD events, measured over follow-up. Each cohort included 2,094, 1,242, and 705 patients over 12-, 24-, and 36-month follow-up. Patients in the LDL-P cohort received more aggressive lipid-lowering therapy and had fewer CVD events during follow-up compared to patients in the LDL-C cohort. This led to greater pharmacy costs and lower medical costs over time. Incremental cost-effectiveness ratio estimates ranged from $23,131 per CVD event avoided at 12months to $3,439 and-$4,555 at 24- and 36-month follow-up, suggesting a high likelihood that achieving LDL-P <1,000nmol/l is cost effective. In conclusion, LDL-lowering therapy guided by LDL-P was demonstrated to be cost effective, with greater clinical and economic benefit seen over longer time horizons and with the increased use of generic statins.

Perspectives of People Living with HIV on Access to Health Care: Protocol for a Scoping Review.

BackgroundStrategies to improve access to health care for people living with human immunodeficiency virus (PLHIV) have demonstrated limited success. Whereas previous approaches have been informed by the views of health providers and decision-makers, it is believed that incorporating patient perspectives into the design and evaluations of health care programs will lead to improved access to health care services.ObjectiveWe aim to map the literature on the perspectives of PLHIV concerning access to health care services, to identify gaps in evidence, and to produce an evidence-informed research action plan to guide the Living with HIV program of research.MethodsThis scoping review includes peer-reviewed and grey literature from 1946 to May 2014 using double data extraction. Variations of the search terms “HIV”, “patient satisfaction”, and “health services accessibility” are used to identify relevant literature. The search strategy is being developed in consultation with content experts, review methodologists, and a librarian, and validated using gold standard studies identified by those stakeholders. The inclusion criteria are (1) the study includes the perspectives of PLHIV, (2) study design includes qualitative, quantitative, or mixed methods, and (3) outcome measures are limited to patient satisfaction, their implied needs, beliefs, and desires in relation to access to health care. The papers are extracted by two independent reviewers, including quality assessment. Data is then collated, summarized, and thematically analyzed.ResultsA total of 12,857 references were retrieved, of which 326 documents were identified as eligible in pre-screening, and 64 articles met the inclusion criteria (56% qualitative studies, 38% quantitative studies and 6% mixed-method studies). Only four studies were conducted in Canada. Data synthesis is in progress and full results are expected in June, 2016.ConclusionsThis scoping review will record and characterize the extensive body of literature on perspectives of PLHIV regarding access to health care. A literature repository will be developed to assist stakeholders, decision-makers, and PLHIV in developing and implementing patient-oriented health care programs.

Economic Studies Part 2: Evaluating the Quality

There are many opportunities for bias in economic evaluations. Thus, critical appraisal of economic studies is very important but complex. No standard methodology for appraisal has been universally adopted. However, consideration of the common elements that constitute a high-quality economic study provides the clinician with the tools to understand when one might be dealing with a high-quality study, a deeply flawed one, or one that made the best use of the data available. Studies of economic impact have become increasingly important in health policy decisions given the finite resources available for health care. While they should not be the sole basis of decision making, such studies provide potentially valuable information if well done. It is therefore important that high-quality economic studies be conducted and the results of economic studies be placed in the context of their quality. Learn more about economic evaluation Drummond MF, Sculpher MJ, Torrance GW, O'Brien BJ, Stoddart GL. Methods for the Economic Evaluation of Health Care Programs. New York, NY: Oxford University Press; 2005 What is an economic evaluation? Introduction to Economic Evaluation. Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/owcd/EET/SeriesIntroduction/1.html Health Economics Information Resources. A self-study course. National Information Center on Health Services Research and Health Care Technology (NICHSR). Available at: http://www.nlm.nih.gov/nichsr/edu/healthecon/beginningend.pdf Boos N. The impact of economic evaluation on quality management in spine surgery. Eur Spine J 2009;18(Suppl 3):338–347 Holtz A, Nelson HD, Reid E. Our questions, our decisions: standards for patient-centered outcomes research. Preliminary Draft Methodology Report; PCORI Methodology Committee; Patient-Centered Outcomes Research Institute 2012; Available at: http://www.pcori.org/assets/Preliminary-Draft-Methodology-Report.pdf Funding This article was funded by AOSpine.

A new test of the construct validity of the CarerQol instrument: measuring the impact of informal care giving

PurposeMost economic evaluations of health care programmes do not consider the effects of informal care, while this could lead to suboptimal policy decisions. This study investigates the construct validity of the CarerQol instrument, which measures and values carer effects, in a new population of informal caregivers.MethodsA questionnaire was distributed by mail (n = 1,100, net response rate = 21%) to regional informal care support centers throughout the Netherlands. Two types of construct validity, i.e., convergent and clinical validity, have been analyzed. Convergent validity was assessed with Spearman’s correlation coefficients and multivariate correlation between the burden dimensions (CarerQol-7D) and the valuation component (CarerQol-VAS) of the CarerQol. Additionally, convergent validity was analyzed with Spearman’s correlation coefficients between the CarerQol and other measures of subjective caregiver burden (SRB, PU). Clinical validity was evaluated with multivariate correlation between CarerQol-VAS and CarerQol-7D, characteristics of caregivers, care recipients and care situation among the whole sample of caregivers and subgroups.ResultsThe positive (negative) dimensions of CarerQol-7D were positively (negatively) related to CarerQol-VAS, and almost all had moderate strength of convergent validity. CarerQol-VAS was positively associated with PU and negatively with SRB. The CarerQol-VAS reflects differences in important background characteristics of informal care: type of relationship, age of the care recipient and duration of care giving were associated with higher CarerQol-VAS scores. These results confirmed earlier tests of the construct validity of the CarerQol. Furthermore, the dimensions of CarerQol-7D significantly explained differences in CarerQol-VAS scores among subgroups of carers.ConclusionNotwithstanding the limitations of our study, such as the low response rate, this study shows that the CarerQol provides a valid means to measure carer effects for use in economic evaluations. Future research should derive a valuation set for the CarerQol and further address the instrument’s content validity, sensitivity and reliability.

The Economics of Home Dialysis: Acting for the Individual While Planning Responsibly for the Population

Traditional medical education paradigms tend not to focus on health economics and economic evaluation. This has led to a culture in which bedside clinicians simply allocate health care resources made available to them, with often minimal input as to what these resources are at the population or health care system level. Life sustaining chronic dialysis therapies for end-stage renal disease are heterogeneous in terms of health care costs and the quality of life provided to patients receiving them. From the traditional clinician's perspective, they may be considered equivalent because there are no well-designed randomized control trials establishing the superiority of one particular dialysis modality in terms of all-cause mortality or cardiovascular events. The intent of this review is to provide clinicians practicing in the area of chronic kidney disease some insights into the concepts of economic evaluation and how it may be integrated into clinical decision making at a programmatic level while not compromising individual patient care at the bedside. An epidemiologic perspective will be used to help frame how the implementation of home dialysis modalities vary depending on local health policies in place. Lessons learned by regional nephrology care systems may be readily transferable to other jurisdictions in augmenting the uptake of home dialysis modalities where they are dwindling or struggling to grow. A high-level understanding of economic data in this area may help influence health policy in the direction of the most efficient provision of dialysis to patients while not adversely affecting their quality of life or health outcomes.

Gesundheitsökonomische Evaluation

Economic evaluation of healthcare programmes helps us to assure the efficient use of healthcare resources. Cost-minimisation analysis, cost-effectiveness analysis, cost-utility analysis and cost-benefit analysis are the most commonly applied evaluation types. They differ in how they measure outcomes of healthcare interventions. Several guidelines for conducting economic evaluations exist. Furthermore, checklists have been developed for systematic critical appraisal of economic evaluations. Even though economic evaluations increase the transparency of resource allocation decisions and make decision criteria more explicit, they do not replace public discussions on the availability of overall resources for the public health care system.

Cost-effectiveness of interventions to prevent disability in leprosy: a systematic review.

BackgroundPrevention of disability (POD) is one of the key objectives of leprosy programmes. Recently, coverage and access have been identified as the priority issues in POD. Assessing the cost-effectiveness of POD interventions is highly relevant to understanding the barriers and opportunities to achieving universal coverage and access with limited resources. The purpose of this study was to systematically review the quality of existing cost-effectiveness evidence and discuss implications for future research and strategies to prevent disability in leprosy and other disabling conditions.Methodology/Principal FindingsWe searched electronic databases (NHS EED, MEDLINE, EMBASE, and LILACS) and databases of ongoing trials (www.controlled-trials.com/mrct/, www.who.int/trialsearch). We checked reference lists and contacted experts for further relevant studies. We included studies that reported both cost and effectiveness outcomes of two or more alternative interventions to prevent disability in leprosy. We assessed the quality of the identified studies using a standard checklist for critical appraisal of economic evaluations of health care programmes. We found 66 citations to potentially relevant studies and three met our criteria. Two were randomised controlled trials (footwear, management of neuritis) and one was a generic model-based study (cost per DALY). Generally, the studies were small in size, reported inadequately all relevant costs, uncertainties in estimates, and issues of concern and were based on limited data sources. No cost-effectiveness data on self-care, which is a key strategy in POD, was found.Conclusion/SignificanceEvidence for cost-effectiveness of POD interventions for leprosy is scarce. High quality research is needed to identify POD interventions that offer value for money where resources are very scarce, and to develop strategies aimed at available, affordable and sustainable quality POD services for leprosy. The findings are relevant for other chronically disabling conditions, such as lymphatic filariasis, Buruli ulcer and diabetes in developing countries.

Where Does High‐Quality Research in Economic Evaluation Come From?

Pharmacotherapy: The Journal of Human Pharmacology and Drug TherapyVolume 29, Issue 1 p. 1-2 Free Access Where Does High-Quality Research in Economic Evaluation Come From? James X. Zhang Ph.D., M.S., Corresponding Author James X. Zhang Ph.D., M.S. Department of Pharmacy, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia. Department of Pharmacy, School of Pharmacy, Medical College of Virginia Campus, Virginia Commonwealth University, 209E McGuire Hall, P.O. Box 980533, Richmond, VA 23298; e-mail: [email protected].Search for more papers by this author James X. Zhang Ph.D., M.S., Corresponding Author James X. Zhang Ph.D., M.S. Department of Pharmacy, School of Pharmacy, Virginia Commonwealth University, Richmond, Virginia. Department of Pharmacy, School of Pharmacy, Medical College of Virginia Campus, Virginia Commonwealth University, 209E McGuire Hall, P.O. Box 980533, Richmond, VA 23298; e-mail: [email protected].Search for more papers by this author First published: 06 January 2012 https://doi.org/10.1592/phco.29.1.1AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1 Newhouse, J.P.. An iconoclastic view of health cost containment. Health Aff 1993; 12(suppl 1): 152– 71. 2 World Health Organization. The world health report 2000: health systems—improving performance. Geneva: World Health Organization, 2000. 3 Perez, A., Doloresco, F., Hoffman, J.M.et al. Economic evaluations of clinical pharmacy services: 2001–2005. Pharmacotherapy 2009; 29(1): 129. 4 Gold, M.R., Siegel, J.E., Russell, L.B.et al. Cost-effectiveness in health and medicine New York: Oxford University Press, 1996. 5 Drummond, M.F., O'Brien, B., Stoddart, G.L., Torrance, G.W.. Methods for the economic evaluation of health care programmes, 2nd ed. Oxford: Oxford University Press, 1997. Volume29, Issue1January 2009Pages 1-2 ReferencesRelatedInformation

Gesundheitsökonomie: Der Effizienz auf der Spur

Economic terms such as efficiency, optimality and social welfare carry strong positive connotations. Sometimes non-economists may overlook the substantive difference between the scientific definition of these terms and their use in common parlance. This difference will be highly relevant if and when economic statements about efficiency are presented or interpreted in a normative way, i.e., implying that efficiency equals social desirability. Any statement about efficiency rests on implicit or explicit assumptions concerning the appropriate effectiveness criterion because efficiency invariably is an instrumental or secondary objective only, subject to clarification of the primary objectives to be pursued. In the absence of an agreement on the primary objectives of a collectively funded health scheme, the pursuit of efficiency may lead to health care allocation decisions that are not in line with prevailing social value judgements. Therefore, exposition and acceptance of the specific value judgements underlying economic evaluations of health care programmes should be a prerequisite to any attempt towards their normative interpretation. As regards the implementation of cost benefit evaluation in health care, the cautious stance taken by the German Institute for Quality and Efficiency in Health Care (IQWiG) appears to be well justified in the absence of such a fundamental consensus, especially when these evaluations are meant to address issues of allocative efficiency.

The Limits of Cost-Effectiveness Analysis

The competitive worldwide economic environment and ever-increasing costs of health care have created a setting in which understanding costs and making sure that we achieve good value in health care are paramount. One approach to seeking value is through the use of cost-effectiveness analysis. Although this science is now several decades old, it has been refined over the last several years, with increasingly sophisticated statistical and standardized methods.1,2 Is cost-effectiveness analysis useful? Does it help in medical decision making and in allocation of scarce resources? In the accompanying article, “Cost, Effectiveness, and Cost-Effectiveness” Diamond and Kaul3 argue that cost-effectiveness analysis is not a useful approach. Although we agree with many of the points that Diamond and Kaul raise, we do not agree with their conclusion. Cost-effectiveness analysis involves an assessment of both cost and effectiveness. The distribution of each needs to be understood. A cost-effectiveness analysis is only as valid as its underlying measures of effectiveness and cost, a discussion that is beyond the scope of this article. However, the methods to make these assessments vary considerably. There are standards for cost-effectiveness, but at times, perfectly adhering to these standards is not realistic, and compromises are often made that may be entirely scientifically legitimate.4 Cost-effectiveness is, by nature, incremental. Thus, it is necessary to look at the added costs compared with a control group. Selection of the appropriate control group is a challenge itself. At times, the appropriate control is placebo, and at other times, it is active therapy; the appropriate control is dependent on the clinical question being asked. However, when cost-effectiveness analysis is conducted using data from a clinical trial, the selection of the control group will not be a decision that the analyst can affect (at least after the trial has been completed). When …

Una panoramica delle metodologie per la valutazione delle cure informali negli studi di economia sanitaria

This paper compares several applied valuation methods for including informal care in economic evaluations of healthcare programmes: the proxy good method; the opportunity cost method; the contingent valuation method (CVM); conjoint measurement (CM); and valuation of health effects in terms of health-related quality of life (HR-QOL) and well-being. The comparison focuses on three questions: what outcome measures are available for including informal care in economic evaluations of healthcare programmes; whether these measures are compatible with the common types of economic evaluation; and, when applying these measures, whether all relevant aspects of informal care are incorporated.

Nonmedical Costs of Colorectal Cancer Screening With the Fecal Occult Blood Test and Colonoscopy

The nonmedical costs of colorectal cancer screening are unknown. However, they might influence screening uptake and impact the cost-effectiveness of colorectal cancer screening modalities. Consecutive individuals presenting for colorectal cancer screening in the Calgary Health Region were recruited from 4 community laboratory collection sites (fecal occult blood test) and 2 endoscopy units (colonoscopy). Subjects completed a questionnaire including items on time off work for the subject and any accompanying caregiver, travel details, and direct out-of-pocket expenses (bowel prep). Time costs were valued at Government of Canada wage rates. Travel costs included estimated costs for travel by car and actual parking costs and taxi and public transportation fares. Car users' costs were calculated by using a Canadian Automobile Association estimate of motoring costs per kilometer. Costs are in 2006 Canadian dollars. The final sample included 604 subjects who underwent fecal occult blood test (mean age, 62 years; 51% male; 43% employed) and 723 who underwent colonoscopy (mean age, 56; 49% male; 66% employed). Eighty percent of colonoscopy subjects required an accompanying caregiver, compared with only 5% for fecal occult blood test. The nonmedical costs (subject +/- caregiver) averaged $308 for colonoscopy and $36 for fecal occult blood test. The nonmedical costs of colorectal cancer screening are substantial, especially for colonoscopy. However, the costs are similar with repeated fecal occult blood tests. These costs might be one factor accounting for low colorectal cancer screening uptake rates. Nonmedical costs should be incorporated into economic analyses of colorectal cancer screening.

Emotions and decision rules in discrete choice experiments for valuing health care programmes for the elderly

The evaluation of health care programmes is commonly approached with stated preference methods such as contingent valuation or discrete choice experiments. These methods provide useful information for policy decisions involving health regulations and infrastructures for health care. However, econometric modelling of these data usually relies on a number of maintained assumptions, such as the use of the compensatory or random utility maximization rule. On the other hand, health policy issues can raise emotional concerns among individuals, which might induce other types of choice behaviour. In this paper we consider potential deviations from the general compensatory rule, and how these deviations might be explained by the emotional state of the subject. We utilized a mixture econometric model which allows for various potential decisions rules within the sample, such as the complete ignorance, conjunctive rule and satisfactory rules. The results show that deviations from the full linear compensatory decision rule are predominant, but they are significantly less observed for those subjects with a medium emotional state about the issue of caring for the health state of the elderly. The implication is that the emotional impact of health policy issues should be taken into account when making assumptions of individual choice behaviour in health valuation methods.

Estimation, Power and Sample Size Calculations for Stochastic Cost and Effectiveness Analysis

Various methods have been proposed to address uncertainty in economic evaluations of healthcare programmes. One approach suggested in the literature is to estimate separate confidence intervals for the incremental costs and effects of a new health programme in comparison with an existing programme. These intervals are then combined to generate a rectangular confidence region in the cost-effectiveness plane that implicitly defines a corresponding confidence interval for the incremental cost-effectiveness ratio (ICER). The same approach has been used to calculate sample sizes and study power. This application of the rectangle method is consistent with the adoption of ICERs and a threshold as a decision rule, this being the most commonly used approach in empirical applications of cost-effectiveness analysis, as well as the one recommended by agencies that assess medical technology around the world. In this paper, we first outline the rectangle method, and then propose a modification that recognises that separate inferences are being drawn on the cost and effectiveness domains, and that corrects for multiple statistical comparisons. The confidence rectangle is otherwise too small, the corresponding confidence interval for the ICER is too narrow and sample sizes are under-estimated. Our modification corrects these problems. A further difficulty is that the placement of the confidence rectangle around the null value is somewhat arbitrary, and does not correspond to a unique value of ICERs. As a result, different values of sample size and power for the estimation of ICERs can be obtained, depending on the null values of the cost and effectiveness. We conclude that it is important to clearly identify the analytic goal in terms of estimating differential costs, differential effects or a combination of the two using the ICER index. These ideas are illustrated using numerical examples.