Framework For Economic Evaluation Research Articles

Botulinum toxin type A in the management of equinus in children with cerebral palsy: an evidence-based economic evaluation.

The aim of this study was to compare two methods of conservative management of calf spasticity and equinus gait--intramuscular injection of botulinum toxin type A (BTX-A) and serial casting. An economic evaluation framework was adopted to assess whether BTX-A offers value for money in the management of equinus gait due to calf spasticity in children with cerebral palsy. Short- to medium-term health care costs and outcomes were estimated for the comparison. This study was embarked upon to provide clinical and economic data as part of an application to the Pharmaceutical Benefits Advisory Committee (PBAC) for the reimbursement of BOTOX by the Australian Commonwealth Government. This is the primary mechanism for reimbursement of pharmaceuticals in Australia, as they are not routinely reimbursed through health insurance companies. The perspective of the analysis was that of the Australian health system. Randomized controlled trials (RCTs) exist comparing one treatment cycle of BTX-A with serial casting (Corry et al., 1998; Flett et al., 1999). A long-term prospective study provided data on multiple cycles of BTX-A treatment in a more naturalistic setting (Boyd et al., 1999). A simple economic modelling approach was used to establish resource utilization by treatment arm. Only direct medical costs were considered (BTX-A, medical personnel time and medical consumables). Clinical efficacy was obtained from the randomized controlled trials (Corry et al., 1998; Flett et al., 1999). Patient/parent preference was obtained from long-term follow-up (Corry et al., 1998) and a preference questionnaire (Flett et al., 1999). Australian treatment patterns and patient demographics were obtained from the naturalistic study (Boyd et al., 1999). The RCTs demonstrated equivalent efficacy of BTX-A and serial casting; however, with BTX-A the effect lasted longer and was clearly the preferred treatment. For patients with hemiplegia the costs of an episode of treatment with BTX-A or serial casting are ($AUD) $595 and $435, respectively, and thus the additional costs associated with BTX-A are $160. The corresponding costs for patients with diplegia are $1045 for BTX-A treatment and $870 for serial casting and thus the additional cost associated with BTX-A is $175. With an overall treatment duration of 3.7 years and an average treatment interval of 10 months, patients would receive an average of 5.4 treatments. Thus, for patients with hemiplegia the total additional cost, discounted at 5% annually, for BTX-A is $793. For patients with diplegia the total additional cost for BTX-A is $867. CONCLUSIONS AND CLINICAL INTERPRETATIONS: BTX-A is an effective, safe and acceptable treatment modality and is associated with only a modest increase in direct medical costs per child per year. BTX-A can be considered a valuable and cost-effective treatment in the conservative management of equinus due to calf spasticity in children with cerebral palsy. This conclusion is supported by the acceptance of the Pharmaceutical Benefits Advisory Committee (PBAC) recommendation that BOTOX should attract a full Government subsidy in Australia.

Evidence-based medicine and health economics: a case study of end stage renal disease.

This paper explores the potential for use of an economic evaluation framework alongside systematic reviews. Clinical issues in dialysis therapy for end stage renal disease are used as case studies. The effectiveness data required were obtained from a systematic review of randomized controlled trials. Resource use and cost data were obtained from three sources; the identified randomized controlled trials, a separate review of observational studies and primary data collection. The results of the case studies show that, although simple economic evaluations were possible, issues arose, such as how transferable results are between settings and how appropriate it is to focus on the average patient. The interface between economic evaluation and systematic reviews needs to be further developed in order to ensure that the best available evidence can be used to inform future policy and research.

The economic evaluation of control and eradication of epidemic livestock diseases.

Many countries have implemented strategies to control and eradicate epidemic diseases. These strategies are usually based on either stamping-out or routine vaccination, sometimes complemented by emergency vaccination. The authors describe these strategies, using examples to illustrate each one. The economic evaluation of control and eradication of epidemic diseases is a complex matter. The authors provide further insight into this area by describing the various elements involved in both the 'non-outbreak periods' and the 'outbreak periods'. In addition, a system of categorisation of the direct costs and consequential losses is suggested for the calculation of costs and losses incurred by outbreaks. The economic impact of epidemic diseases on farmers and the livestock sector as a whole differs; these differences may be influenced by the control and eradication strategies applied. An attempt is made to provide a basic framework for economic evaluation on various economic levels.

Reservoir management of the Wytch Farm Oil Field, Dorset, UK: providing options for growth into later field life

The Wytch Farm Oil Field, currently on plateau, produces up to 110 × 10 3 BOPD, 17.6 × 10 6 SCF gas and 725 tonnes LPG per day. Original reserves are 450 × 10 6 BBL with a proven 230 × 10 6 BBL oil equivalent remaining. The Triassic fluvio-lacustrine Sherwood Sandstone, at 1535mTVDSS (true vertical depth, subsea), is the largest and most prolific reservoir. Approximately half the reserves are in an offshore extension being developed by extended reach drilling (ERD) at step-outs of up to 10.1 km from onshore Poole Harbour. Projects to increase reserves, extend plateau and slow decline include: additional ERD wells; infill drilling; miscible gas injection; and pattern water flooding of the low nett: gross Upper Sherwood all whilst maintaining reservoir pressure. Reservoir description is central to realizing these opportunities for growth. Structural uncertainty has been reduced through acquisition of the first transition-zone 3D seismic survey in the UK. An extensive RFT (repeat formation test) and production log database has been acquired in the onshore and ERD wells. These dynamic data, together with static data from core and outcrop studies, and >21km of ERD formation evaluation logs, are used to develop a high-resolution, fluvio–lacustrine sequence architecture of the Sherwood. The deterministic model enhances predictability of flow barriers, baffles and high permeability intervals. This understanding of fluid flow and recovery provides the framework for economic evaluation, which, with clear communication of uncertainty across disciplines, is the key to successful management of the reservoir into later field life.

The use of QALY and non-QALY measures of health-related quality of life. Assessing the state of the art.

There are now a large number of instruments available for assessing health-related quality of life, many of which are used within economic evaluations. When considering the use of quality-of-life instruments, meaningful questions need to be asked to determine whether an instrument has been used judiciously. Such questions should consider whether the instrument is valid and suitable for the particular study question, whether the instrument is compatible with the economic evaluation framework used, and subsequently whether the conclusions presented in the study are legitimate. In order to illustrate the value of these questions we have applied them to a number of economic evaluations. The studies used were identified via a systematic review of the health economics literature. In our assessment of a sample of published material, we found that reporting is frequently unhelpful and that the inappropriate use of instruments and techniques casts doubt on the conclusions of economic evaluations. Furthermore, our systematic review of the health economics literature has shown that the general format of reported economic evaluations falls short of the commonly accepted ideal. We examined the health economics literature for 1995 and only identified a handful of studies which satisfied the economic evaluation criteria as accepted by most economists. It is hoped that raising awareness of these issues will urge evaluators, referees and publishers not to lose sight of the needs of the decision-maker when considering the detail which should be present in a reported evaluation.

A proposed framework for economic evaluation of telemedicine.

Economic evaluation of telemedicine compares the costs and other consequences of delivering specific services through telemedicine vs. alternative means. Cost-effectiveness analysis, the most common method used for health issues, helps to assess whether the expected health benefits are worth the investment. Telemedicine raises particular challenges for evaluators: a telemedicine system may have multiple uses and joint costs that are difficult to apportion to one service, the existence of a system may lead to expanded indications for use, and technological change may rapidly make an evaluation outdated. Public and private regulation and payment may affect the diffusion of telemedicine. Uncertainty surrounds the policy of the U.S. Food and Drug Administration, which is still formulating its position. Changes are underway in policies on licensure and credentialing of clinicians, which have traditionally been done by state and by site, to reflect the fact that telemedicine services may cross these regional boundaries. Lack of insurance coverage for telemedicine services has been considered an impediment to adoption with fee-for-service payment. Under capitation payment and fixed budgets, however, providers have financial incentives to use the most efficient method to deliver services, and these arrangements would favor telemedicine if it is the less costly alternative. If telemedicine were most costly and the health benefits worth the cost, monitoring might be needed to ensure the quality of care.

Economic evaluation in healthcare. A brief history and future directions.

Over the last decade there has been tremendous interest in economic evaluations of healthcare programmes, especially in the pharmaceutical field. Economic evaluations started about 30 years ago as rather crude analyses, in which the value of improved health was measured in terms of increased labour production. Now, more refined methods are available to measure health changes in terms of quality-adjusted life-years gained or willingness to pay. It is important to continue this development, and major fields for future work include the incorporation of quality-of-life measurements into economic evaluations and the linking of cost-effectiveness and cost-benefit analyses into a unified framework of economic evaluation. How to incorporate distributional issues is another important area. Finally, it seems crucial to further explore the link between economic evaluation and decision making, since the purpose of economic evaluations is to affect decision making.

COMPUTER APPLICATIONS: GRADING SOFTWARE PROGRAMS ACCOMPANYING SELECTED PRINCIPLES TEXTS

An increasing number of non‐statistical software packages are being written as supplementary instructional material for economics Principles texts. This paper reviews the software programs currently available as ancillary material to eight major Principles texts. To avoid simply listing what the programs do, a detailed framework for economic software evaluation was created and applied to each program. This evaluation instrument gives the reviewer a total of 31 questions, in jive different categories, to guide the software review. A summary table is presented which allows direct comparison of each package across each of the five evaluation categories.