Use Of Economic Evaluation Research Articles

Working on new applications: Use of economic evaluation in burden of disease estimates

Abstract Burden of disease (BoD) analyses provide policy-makers with useful evidence to prioritise policy responses to major public health threats. Increasingly, however, epidemiological data alone is not considered as sufficient to inform decisions, particularly when funding is allocated within a single government approach and different sectors compete for a larger share of the overall budget. Similarly, other funders, such as charities and foundations, may want to prioritise budget allocation between health and non-health objectives. In all these cases, traditional BoD analyses need to be complemented by economic evaluations. In its simplest form, the economic component may mean adding an assessment of the healthcare costs caused by the diseases in the study. A more comprehensive, though still with limitations, approach is to use monetary values to measure the extent to which individuals are willing to exchange their income - which can be spent on other things - for the health outcomes they experience. Finally, in its most advanced and comprehensive form, analyses can include assessments of a number of relevant dimensions, such as those in the OECD’s Better Life Index. The latter approach is also consistent with, and its results support the implementation of, a health in all policies approach. This presentation will look at traditional and innovative approaches that can be used to add an economic dimension to BoD analyses. After introducing the rationale and key methodological issues of each approach, the presentation will discuss the advantages and disadvantages of each methodology and will identify areas where their use can be beneficial in guiding the decision-making process. Examples of the use of these methodologies in real-world analyses will also be presented to support the theoretical part of the discussion.

The Short Form 6 Dimensions (SF-6D): Development and Evolution.

This paper considers the development and evolution of the short-form 6 dimensions (SF-6D), a generic preference-weighted measure consisting of a health classification with accompanying value set that was developed from one of the widest used health related quality of life measures, the SF-36 health survey. This enabled health state utility values to be directly generated from SF-36 and SF-12 data for a range of purposes, including to produce quality adjusted life years for use in economic evaluation of healthcare interventions across a range of different conditions and treatments. This paper considers the rationale for the development of the measure, the development process, performance and how the SF-6D has evolved since its conception. This includes the development of an updated version, SF-6D version 2 (SF-6Dv2), which was generated to deal with some criticisms of the first version, and now includes a standalone version for inclusion in studies without relying on use of SF-36 or SF-12. Valuation methods have also evolved, from standard gamble in-person interviews to online discrete choice experiment surveys. International work related to the SF-6Dv1 and SF-6Dv2 is considered. We also consider recommendations for use, highlighting key psychometric evidence and reimbursement agency recommendations.

Psychometric validation of the Persian version of the CarerQol-7D instrument on caregivers of patients with multiple sclerosis.

Background: Providing informal care can deeply influence, both physically and emotionally, the quality of life (QoL) of caregivers, especially when the disease becomes chronic. CarerQol-7D is one of the most common instruments for measuring informal care. We aimed to develop a Persian version of the CarerQol-7D in the context of Iranian caregivers of patients with multiple sclerosis (MS). To this end, we investigated the validity and reliability of the mentioned instrument. Methods: In this cross-sectional study using consecutive sampling method, the backward-forward translation method was used to achieve the Persian version of CarerQol-7D. Structural equation modeling (SEM) was used to perform confirmatory factor analysis (CFA). Cronbach's alpha was also reported for this instrument for the evaluation of internal consistency. Results: This tool was evaluated based on a sample of 452 caregivers of patients with MS from Sina Hospital, Tehran, Iran. Most of the participants were men (62.6%) and spouses of patients (56.6%). Based on the correlation of caregivers' characteristics, the clinical validity of this tool was observed to be relatively moderate. The Cronbach's alpha for this tool was estimated to be 65%. The normed fit index (NFI) (0.906), relative fit index (RFI) (0.812), incremental fit index (IFI) (0.948), Tucker-Lewis index (TLI) (0.892), comparative fit index (CFI) (0.946), and root mean square error of approximation (RMSEA) (0.049) were the model fit indices for the CarerQol-7D instrument. Conclusion: The findings showed good internal consistency and strong validity of the CarerQol-7D. Thus, we suggest researchers use this instrument to measure the QoL of caregivers for use in economic evaluations.

A systematic review of health state utility values for older people with acute myeloid leukaemia.

Older people with acute myeloid leukaemia (AML) have a poor prognosis, reduced health-related quality of life (HRQoL) and require substantial healthcare resources. The objectives of this systematic review were to determine what health state utility values (HSUVs) are reported in the literature that can be used in economic evaluations of interventions for older people with AML, identify research gaps, and discuss directions for future research. The following databases were searched for studies published from inception until Feb 2023: PubMed, EMBASE, CINAHL, PsycINFO, Cochrane, and EconLit. Studies were included if they reported on HSUVs of people with AML >60 years, or HRQoL data that could be mapped to HSUVs using currently published algorithms. Of 532 studies identified, 7 met inclusion (4 full studies and 3 conference abstracts). Twenty-eight potentially eligible studies were excluded as they did not report HRQoL measures in sufficient detail to be mapped to utility values. Included studies reported on health states of newly diagnosed disease (n=4 studies), intensive therapy (n=1 study), controlled remission (n=3 studies), and relapsed or refractory disease (n=2 studies). No studies reported on low intensity therapy or supportive care health states. Utility values were largely reported via the EuroQol and ranged from 0.535 (intensive therapy) to 0.834 (controlled remission). There are gaps in knowledge on HSUVs for older people with AML, particularly for certain treatment-related health states. Future articles should publish comprehensive HRQoL outcomes to enable use in economic evaluation.

A more equitable approach to economic evaluation: Directly developing conceptual capability wellbeing attributes for Tanzania and Malawi

Capability wellbeing can potentially provide a holistic outcome for health economic evaluation and the capability approach seems promising for African countries. As yet there is no work that has explored the evaluative space needed for health and care decision making at the whole population level and procedures that merely translate existing measures developed in the global north to contexts in the global south risk embedding structural inequalities. This work seeks to elicit the concepts within the capability wellbeing evaluative space for general adult populations in Tanzania and Malawi. Semi-structured interviews with 68 participants across Tanzania and Malawi were conducted between October 2021 and July 2022. Analysis used thematic coding frames and the writing of analytic accounts. Interview schedules were common across the two country settings, however data collection and analysis were conducted independently by two separate teams and only brought together once it was clear that the data from the two countries was sufficiently aligned for a single analysis. Eight common attributes of capability wellbeing were found across the two countries: financial security; basic needs; achievement and personal development; attachment, love and friendship; participation in community activities; faith and spirituality; health; making decisions without unwanted interference. These attributes can be used to generate outcome measures for use in economic evaluations comparing alternative health interventions. By centring the voices of Tanzanians and Malawians in the construction of attributes that describe a good life, the research can facilitate greater equity within economic evaluations across different global settings.

Estimating an EQ-5D-Y-3L Value Set for Brazil.

The EQ-5D-Y-3L is a generic measure of health-related quality of life in children and adolescents. Although the Brazilian-Portuguese EQ-5D-Y-3L version is available, there is no value set for it, hampering its use in economic evaluations. This study aimed to elicit a Brazilian EQ-5D-Y-3L value set based on preferences of the general adult population. Two independent samples of adults participated in an online discrete choice experiment (DCE) survey and a composite time trade-off (cTTO) face-to-face interview. The framing was "considering your views for a 10-year-old child". DCE data were analyzed using a mixed-logit model. The 243 DCE predicted values were mapped into the observed 28 cTTO values using linear and non-linear mapping approaches with and without intercept. Mapping approaches' performance was assessed to estimate the most valid method to rescale DCE predicted values using the model fit (R2), Akaike Information Criteria (AIC), root mean squared error (RMSE), and mean absolute error (MAE). A representative sample of 1376 Brazilian adults participated (DCE, 1152; cTTO, 211). The linear mapping without intercept (R2 = 96%; AIC, - 44; RMSE, 0.0803; MAE, - 0.0479) outperformed the non-linear without intercept (R2 = 98%; AIC, - 63; RMSE, 0.1385; MAE, - 0.1320). Utilities ranged from 1 (full health) to - 0.0059 (the worst health state). Highest weights were assigned to having pain or discomfort (pain/discomfort), followed by walking about (mobility), looking after myself (self-care), doing usual activities (usual activities), and feeling worried, sad, or unhappy (anxiety/depression). This study elicited the Brazilian EQ-5D-Y-3L value set using a mixed-logit DCE model with a power parameter based on a linear mapping without intercept, which can be used to estimate the quality-adjusted life-years for economic evaluations of health technologies targeting the Brazilian youth population.

Examining health-related quality of life in ambulatory adult patients with chronic heart failure: insights from Malaysia using EQ-5D-5L.

Health-related quality-of-life (HRQoL) data for the chronic heart failure (HF) population in Malaysia are lacking. Using EQ-5D-5L, this study intended to describe their HRQoL, identify predictors of worse HRQoL, and derive EQ-5D-5L index scores for use in economic evaluations. A cross-sectional survey was conducted between April and September 2023 to collect EQ-5D-5L, sociodemographic, and clinical data from outpatients with HF across seven public specialist hospitals in Malaysia. Multivariable logistic and linear regression models were used to identify independent predictors of reported problems in the EQ-5D-5L dimensions, and predictors of index scores and EQ-VAS, respectively. EQ-5D-5L data from 424 outpatients of multi-ethnic background (mean age: 57.1years, 23.8% female, mean left ventricular ejection fraction: 35.7%, 89.7% NYHA class I-II) were collected using either Malay, English, or Chinese, achieving a 99.8% completion rate. Nearly half of the respondents reported issues in the Mobility, Usual Activities, and Pain/Discomfort dimensions. Mean EQ-5D-5L index was 0.820, lower than the general population, and significantly lower with NYHA class III-IV (0.747) versus NYHA class I (0.846) and NYHA class II (0.805). Besides NYHA class, independent predictors of worse HRQoL included Indian ethnicity, living alone, lower education, unemployment due to ill-health, and proxy-reported HRQoL, largely aligning with existing literature. Community-dwelling Malaysians with HF reported poorer HRQoL compared to the general population. The observed disparities in HRQoL among HF patients may be linked to specific patient characteristics, suggesting potential areas for targeted interventions. HRQoL assessment using EQ-5D-5L proves feasible and should be considered for routine implementation in local clinics.

Bayesian Hierarchical Models of Basket Trials in the Context of Economic Evaluation

What Was the Problem or Question? With the availability of advanced genomic profiling methods, basket trials are more commonly used for the clinical assessment of treatments targeting multiple cancer types with a common biomarker. Basket trials study a primary intervention across a range of different patient subgroups (e.g., with specific cancer types) that share similar features (e.g., mutations or biomarkers), in which the effect of the primary intervention may be expected to differ. Heterogeneity among cancer types, limited sample sizes, a lack of comparators, and the use of surrogate end points pose challenges when considering the application to economic evaluations. Bayesian hierarchical models (BHMs) are well suited to account for the heterogeneity among cancer types while borrowing information across cancer types in basket trials. There is a need for clearer guidance about how these methods can be used in health technology assessment (HTA). What Did We Do? To better understand the role of BHMs in economic evaluations, an overview of basket trials and the current understanding of their use in economic evaluations was conducted, an illustration of how BHMs can inform economic evaluations was provided with a detailed example, and considerations for interpretating and appraising this information were listed. What Did We Find? BHMs offer an approach to use information from basket trials to inform economic evaluations; however, there are limitations to be aware of when using this information in economic evaluations and also when interpreting the results of the economic information. This document describes these limitations, and contains an appraisal list that was developed to highlight the implications. These are aspects that CADTH considers when assessing analyses based on BHMs. The field of BHMs is evolving, and advice in this document will need to be revisited as methods develop. What Does This Mean? As CADTH anticipates the increased need for appraisal of tumour-agnostic therapies, this document provides clarity around an important and useful set of methods for their evaluation, while also highlighting necessary areas for further research.

The "Other E" in ELSI: The Use of Economic Evaluation to Inform the Expansion of Newborn Screening.

The utilization and application of genomic information generated from precision medicine continues to increase with the goal of improving health outcomes. Increasingly researchers, health care professionals, and public health teams include an examination of the ethical, legal, and social issues (ELSI) in their consideration of the use of precision medicine for newborn and pediatric health. In addition to ELSI considerations, stakeholders could benefit from an understanding of economics, the other "E" in ELSI. The use of an economic evaluation could aid decision-making on whether to screen newborns who may be at risk for disease, to diagnose newborns and children who present with symptoms, to inform the treatment and management of diagnosed individuals. In this manuscript we review the core concepts of economic evaluation, the framework of decision-analysis, and key parameters for consideration in assessing the economics of NBS program(s). We describe the common language used in the economic evaluation and provide a practical overview of health economic evaluations including 1) their purpose, 2) different types and components, 3) evaluation of the different types and components of economic evaluations (i.e., cost-effectiveness vs. cost-benefit analysis), 4) impact of societal or healthcare perspectives on the analysis, 5) health outcomes, 6) time horizon for the analysis, 7) identification of appropriate comparators, and 8) resources for economic data. We conclude with a use case to demonstrate the application and understanding of economic considerations for in the advancement and expansion of NBS.

Development of a value-based scoring system for the MobQoL-7D: a novel tool for measuring quality-adjusted life years in the context of mobility impairment

Purpose To create a preference-based value set scoring system for the MobQoL-7D outcome measure, and to examine differences in the health state preferences of the general population and individuals with impaired mobility. Methods and materials A preference elicitation study was undertaken to ascribe utility weights to all health states (i.e., all unique combination of answers) described by the MobQoL-7D. The elicitation exercise was developed using the Online Elicitation of Personal Utility Functions (OPUF) tool. Two UK sample groups were recruited; firstly a representative general population sample (N = 504), secondly a balanced sample of individuals with impaired mobility (N = 368). Distinct preference-based value sets were developed for each sample. Differences in dimension ranking, weighting, and overall utility values were assessed. Results The general population sample considered most health states, especially the more severe states, to be worse than the mobility impaired sample comparatively. Statistically significant differences between the samples were observed in four of the seven MobQoL-7D dimensions. Conclusions This study is the first to provide preference-based value sets for the MobQoL-7D, ready for use in economic evaluations, QALY calculation, and other clinical or research applications. The study demonstrates how the general public and individuals with impaired mobility value health states differently.

Using Expert Elicitation to Adjust Published Intervention Effects to Reflect the Local Context.

Local health services make limited use of economic evaluation to inform their decisions on the funding of new health service interventions. One barrier to use is the relevance of published intervention evaluations to the local setting.Expert elicitation methods provide a structured way to consider differences between the evaluation and local settings and to explicitly and transparently adjust published effect estimates for use in local economic evaluations.The pragmatic elicitation methods reported in this article offer a feasible and acceptable approach to adjusting published intervention effects to better reflect the effects expected in the local context. This increases the relevance of economic evaluations for local decision makers.

OP162 Making Local Economic Evaluation More Relevant: Using Expert Elicitation To Adjust Published Intervention Effects To Reflect Local Context

IntroductionExpert elicitation is often used in economic analyses to estimate uncertain or unobserved parameters for decision models. However, it has rarely been used in the context of local decision-making. A pragmatic elicitation process was used during a local economic evaluation to prompt local experts to assess the relevance of the published evidence to their setting, and to adjust the published effect estimates to better reflect the intervention effect expected in their setting.MethodsElicitation was undertaken for two interventions that targeted the prevention of hospital-acquired hypoglycemia. Six clinical experts from within the Southern Adelaide Local Health Network (SALHN) were systematically presented with information on the setting of the published evaluation and their local setting. This included information on the hospital and quality of care, patient characteristics, and the research context. After comparing the settings, the experts were asked to estimate the most realistic, most pessimistic, and most optimistic intervention effects for their local context.ResultsThe local intervention effect was estimated to be smaller than the published estimate for both interventions. For one intervention, this was driven by the lower complexity of the local patient cohort. For the other intervention, it was driven by differences in the scope of implementation, with hospital-wide local implementation expected to reduce staff buy-in relative to the targeted implementation used in the published evaluation. The elicited local intervention effects were used in a cost-consequence analysis to estimate the likely costs and effects of the interventions if they were implemented locally.ConclusionsThe pragmatic elicitation process provides a feasible and acceptable way to assess and transparently adjust the published effect estimates to better reflect the expected intervention effect in the local setting.Including this step in local economic evaluations can increase the relevance of these evaluations to local decision makers. Further development and application of these methods may facilitate greater use of economic evaluation in local settings.

PP49 Cost Of Cardiac Implantable Electronic Device (CIED) Infections In Australia: A Private And Public Sector Payer Perspective

IntroductionIn Australia, approximately 200,000 patients have a cardiac implantable electronic device (CIED), and in an aging population that number is rising. CIED-related infections are also increasing, causing considerable morbidity and mortality, and substantial healthcare costs. Internationally, the rate of CIED infection ranges from 1.0 percent to 1.6 percent, while in Australia, the reported range is from less than 1 percent to 7.0 percent. The average hospital cost to treat an infection in the US ranges between USD48,000–USD83,000. To date, few publications have estimated the cost of CIED infections in Australia. Critical appraisal of these studies has highlighted issues in their methodology, making them unreliable sources for use in economic evaluations. The purpose of this study was to utilize Australian routinely collected health data to robustly model costs of CIED infections to reduce uncertainty for future health technology assessment (HTA).MethodsThe cost of treating a CIED infection was modeled for the public and private sector including cost of system removal and re-implantation procedures, hospital and intensive care unit (ICU) stay, and outpatient follow-up. Cost inputs were obtained from the Australian Prostheses List, Medicare Benefits Schedule, Australian Institute of Health and Welfare, and Private Hospital Data Bureau. Other inputs were obtained by surveying Australian clinicians, which were validated with published data. Phone interviews and online surveys were conducted with clinicians to elicit specific Australian practice pathways for patients with a CIED infection.ResultsThe majority of patients with a CIED have their device system removed (95-100%) and re-implanted (83%) once the infection has cleared. In the private sector, cost of infection ranged from AUD80,869 (USD54,384) for a single chamber pacemaker (PM), to AUD140,103 (USD94,248) for a dual chamber Implantable Cardioverter-defibrillator (ICD). Modeled costs of CIED infection were slightly lower in the public sector (AUD73,643-AUD88,446 (USD49,555 – USD59,516) for the same devices).ConclusionsThe cost of a CIED infections to the healthcare system is high and differs by device type. Utilizing local real-world data to estimate costs will improve accuracy of economic evaluations and reduce uncertainty for decision makers.

Eliciting a value set for the Swedish Capability-Adjusted Life Years instrument (CALY-SWE)

PurposeOur aim was to elicit a value set for Capability-Adjusted Life Years Sweden (CALY-SWE); a capability-grounded quality of life instrument intended for use in economic evaluations of social interventions with broad consequences beyond health.MethodsBuilding on methods commonly used in the quality-adjusted life years EQ-5D context, we collected time-trade off (TTO) and discrete choice experiment (DCE) data through an online survey from a general population sample of 1697 Swedish participants. We assessed data quality using a score based on the severity of inconsistencies. For generating the value set, we compared different model features, including hybrid modeling of DCE and TTO versus TTO data only, censoring of TTO answers, varying intercept, and accommodating for heteroskedasticity. We also assessed the models’ DCE logit fidelity to measure agreement with potentially less-biased DCE data. To anchor the best capability state to 1 on the 0 to 1 scale, we included a multiplicative scaling factor.ResultsWe excluded 20% of the TTO answers of participants with the largest inconsistencies to improve data quality. A hybrid model with an anchor scale and censoring was chosen to generate the value set; models with heteroskedasticity considerations or individually varying intercepts did not offer substantial improvement. The lowest capability weight was 0.114. Health, social relations, and finance and housing attributes contributed the largest capability gains, followed by occupation, security, and political and civil rights.ConclusionWe elicited a value set for CALY-SWE for use in economic evaluations of interventions with broad social consequences.

Why it is so challenging to perform economic evaluations of interventions in autism and what to do about it.

Economic evaluation is used to determine the optimal provision of services and programs under budget constraints and to inform public and private payer funding decisions. To maximize value-for-money in the design and delivery of programs and services for persons with autism spectrum disorder (ASD), it's essential to generate high-quality economic evidence to inform budget allocation. There is a paucity however, of economic evaluations of interventions for ASD. This is due in part to challenges in conducting economic evaluations in this population and the lack of guidance on suitable approaches. These challenges are related to the inherent heterogeneity of the autistic population; establishing short- and long-term effectiveness; measurement of costs and the availability of valid instruments for collecting economic data; the appropriateness of outcomes for use in economic evaluation; and achieving statistical power. This commentary addresses a lack of awareness and needed guidance on these issues by discussing the challenges and providing recommendations for how economic evaluations in ASD could be improved to generate high-quality evidence for program funding decision-making.

HTA70 Use of Economic Evaluation of Vaccines: The Experience in Colombia, 2000 to 2021

To describe the use of economic evaluation to update the antigens dispensed by the Colombian Expanded Program on Immunization (EPI) from 2000 and 2021.

Health economic evaluations for Indonesia: a systematic review assessing evidence quality and adherence to the Indonesian Health Technology Assessment (HTA) Guideline.

The Government of Indonesia implemented health technology assessment (HTA) to ensure quality and cost control in the National Health Insurance Program (Jaminan Kesehatan Nasional/JKN). The current aim of the study was to improve the usefulness of future economic evaluation for resource allocation by appraising current methodology, reporting, and source of evidence quality of studies. The inclusion and exclusion criteria were applied to search for relevant studies using a systematic review. The methodology and reporting adherence were appraised according to Indonesia's HTA Guideline issued in 2017. The differences in adherence before and after the guideline dissemination were compared using Chi-square and Fisher's exact tests for methodology adherence wherever appropriate, and the Mann-Whitney test for reporting adherence. The source of evidence quality was assessed using evidence hierarchy. Two scenarios of the study start date and the guideline dissemination period were tested using sensitivity analyses. Eighty-four studies were obtained from PubMed, Embase, Ovid, and two local journals. Only two articles cited the guideline. No statistically significant difference (P>0.05) was found between the pre-dissemination and post-dissemination period with respect to methodology adherence, except for outcome choice. Studies during the post-dissemination period showed a higher score for reporting which was statistically significant (P=0.01). However, the sensitivity analyses revealed no statistically significant difference (P>0.05) in methodology (except for modelling type, P=0.03) and reporting adherence between the two periods. The guideline did not impact the methodology and reporting standard used in the included studies. Recommendations were provided to improve the usefulness of economic evaluations for Indonesia. The Access and Delivery Partnership (ADP) hosted by the United Nations Development Programme (UNDP) and the Health Systems Research Institute (HSRI).

Economic evaluation of pharmacy services: a systematic review of the literature (2016-2020).

Economic evaluation is crucial for healthcare decision-makers to select effective interventions. An updated systematic review of the economic evaluation of pharmacy services is required in the current healthcare environment. To conduct a systematic review of literature on economic evaluation of pharmacy services. Literature (2016-2020) was searched on PubMed, Web of Sciences, Scopus, ScienceDirect, and SpringerLink. An additional search was conducted in five health economic-related journals. The studies performed an economic analysis describing pharmacy services and settings. The reviewing checklist for economic evaluation was used for quality assessment. The incremental cost-effectiveness ratio and willingness-to-pay threshold were the main measures for cost-effective analysis (CEA) and cost-utility analysis (CUA), while cost-saving, cost-benefit-ratio (CBR), and net benefit were used for cost-minimization analysis (CMA) and cost-benefit analysis (CBA). Forty-three articles were reviewed. The major practice settings were in the USA (n = 6), the UK (n = 6), Canada (n = 6), and the Netherlands (n = 6). Twelve studies had good quality according to the reviewing checklist. CUA was used most frequently (n = 15), followed by CBA (n = 12). Some inconsistent findings (n = 14) existed among the included studies. Most agreed (n = 29) that pharmacy services economically impact the healthcare system: hospital-based (n = 13), community pharmacy (n = 13), and primary care (n = 3). Pharmacy services were found to be cost-effectiveness or cost-saving among both developed (n = 32) and in developing countries (n = 11). The increased use of economic evaluation of pharmacy services confirms the worth of pharmacy services in improving patients' health outcomes in all settings. Therefore, economic evaluation should be incorporated into developing innovative pharmacy services.

Determining the efficiency path to universal health coverage: cost-effectiveness thresholds for 174 countries based on growth in life expectancy and health expenditures

Assessment of the efficiency of interventions is paramount to achieving equitable health-care systems. One key barrier to the widespread use of economic evaluations in resource allocation decisions is the absence of a widely accepted method to define cost-effectiveness thresholds to judge whether an intervention is cost-effective in a particular jurisdiction. We aimed to develop a method to estimate cost-effectiveness thresholds on the basis of health expenditures per capita and life expectancy at birth and empirically derive these thresholds for 174 countries. We developed a conceptual framework to assess how the adoption and coverage of new interventions with a given incremental cost-effectiveness ratio will affect the rate of increase of health expenditures per capita and life expectancy at the population level. The cost-effectiveness threshold can be derived so that the effect of new interventions on the evolution of life expectancy and health expenditure per capita is set within predefined goals. To provide guidance on cost-effectiveness thresholds and secular trends for 174 countries, we projected country-level health expenditure per capita and life expectancy increases by income level based on World Bank data for the period 2010-19. Cost-effectiveness thresholds per quality-adjusted life-year (QALY) ranged between US$87 (Democratic Republic of the Congo) and $95 958 (USA) and were less than 0·5 gross domestic product (GDP) per capita in 96% of low-income countries, 76% of lower-middle-income countries, 31% of upper-middle-income countries, and 26% of high-income countries. Cost-effectiveness thresholds per QALY were less than 1 GDP per capita in 168 (97%) of the 174 countries. Cost-effectiveness thresholds per life-year ranged between $78 and $80 529 and between 0·12 and 1·24 GDP per capita, and were less than 1 GDP per capita in 171 (98%) countries. This approach, based on widely available data, can provide a useful reference for countries using economic evaluations to inform resource-allocation decisions and can enrich international efforts to estimate cost-effectiveness thresholds. Our results show lower thresholds than those currently in use in many countries. Institute for Clinical Effectiveness and Health Policy (IECS).

Reliability, acceptability, validity and responsiveness of the CHU9D and PedsQL in the measurement of quality of life in children and adolescents with overweight and obesity

BackgroundThe Paediatric Quality of life Inventory (PedsQLTM) Generic Core Scales and the Child Health Utilities 9 Dimensions (CHU9D) are two paediatric health-related quality of life (HRQoL) measures commonly used in overweight and obesity research. However, no studies have comprehensively established the psychometric properties of these instruments in the context of paediatric overweight and obesity. The aim of this study was to assess the reliability, acceptability, validity and responsiveness of the PedsQL and the CHU9D in the measurement of HRQoL among children and adolescents living with overweight and obesity.Subjects/MethodsSubjects were 6544 child participants of the Longitudinal Study of Australian Children, with up to 3 repeated measures of PedsQL and CHU9D and aged between 10 and 17 years. Weight and height were measured objectively by trained operators, and weight status determined using World Health Organisation growth standards. We examined reliability, acceptability, known group and convergent validity and responsiveness, using recognised methods.ResultsBoth PedsQL and CHU9D demonstrated good internal consistency reliability, and high acceptability. Neither instrument showed strong convergent validity, but PedsQL appears to be superior to the CHU9D in known groups validity and responsiveness. Compared with healthy weight, mean (95%CI) differences in PedsQL scores for children with obesity were: boys −5.6 (−6.2, −4.4); girls −6.7 (−8.1, −5.4) and differences in CHU9D utility were: boys −0.02 (−0.034, −0.006); girls −0.035 (−0.054, −0.015). Differences in scores for overweight compared with healthy weight were: PedsQL boys −2.2 (−3.0, −1.4) and girls −1.3 (−2.0, −0.6) and CHU9D boys: no significant difference; girls −0.014 (−0.026, −0.003).ConclusionPedsQL and CHU9D overall demonstrated good psychometric properties, supporting their use in measuring HRQoL in paediatric overweight and obesity. CHU9D had poorer responsiveness and did not discriminate between overweight and healthy weight in boys, which may limit its use in economic evaluation.