Burden of disease and economic evaluation of healthcare interventions: are we investigating what really matters?

BACKGROUND: The allocation of limited available healthcare resources demands an agreed rational allocation principle and the consequent priority setting. We assessed the association between economic evaluations of healthcare interventions published in Spain (1983-2008) and the disease burden in the population. METHODS: Electronic databases (e.g., PubMed/MEDLINE, SCOPUS, ISI Web of Knowledge, CRD, IME, IBECS) and reports from health technology assessment agencies were systematically reviewed. For each article, multiple variables were recorded such as: year and journal of publication, type of study, health intervention targetted, perspective of analysis, type of costs and sources of information, first author's affiliation, explicit recommendations aimed at decision-making, and the main disease cause to which the intervention was addressed. The following disease burden measures were calculated: years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life years (DALYs), and mortality by cause. Correlation and linear regression models were fitted. RESULTS: Four hundred and seventy-seven economic evaluations were identified. Cardiovascular diseases (15.7%), infectious diseases (15.3%), malignant neoplasms (13.2%), and neuropsychiatric diseases (9.6%) were the conditions most commonly addressed. Accidents and injuries, congenital anomalies, oral conditions, nutritional deficiencies and other neoplasms were the categories with a lowest number of studies (0.6% for each of them). For the main disease categories (n = 20), a correlation was seen with: mortality 0.67 (p = 0.001), DALYs 0.63 (p = 0.003), YLLs 0.54 (p = 0.014), and YLDs 0.51 (p = 0.018). By disease sub-categories (n = 51), the correlations were generally low and non statistically significant. CONCLUSIONS: Examining discrepancies between economic evaluations in particular diseases and the overall burden of disease helps shed light on whether there are potentially over- and under-investigated areas. The approach taken could help policy-makers understand whether resources for economic evaluation are being allocated by using summary measures of population health.

Systems to support health technology assessment (HTA) in member states of the European union with limited institutionalization of HTA.

OBJECTIVES: The aim of this study was to support health technology assessment (HTA) capacity building in Member States of the European Union with limited experience or without institutionalized HTA. The main output is a Handbook on HTA Capacity Building. METHODS: The methods used were worldwide surveys of (i) HTA organizations, (ii) information management units, and (iii) HTA educational programs. The results of two surveys (i & ii) were combined with expert opinion to produce the Handbook on HTA Capacity Building. RESULTS: Survey of HTA organizations (n = 41, response rate 35 percent). Most of the organizations were established by the government (61 percent), and all were not-for-profit. Working on HTA (80.5 percent) and doing research (63.4 percent) were the main lines of activity. Survey on information management units (n = 23, response rate 23 percent). Most (74.2 percent) of the responding HTA agencies reported having personnel dedicated to HTA information services. Survey on HTA educational programs (n = 48, response rate 60 percent). In total, nine Master of Science (MSc) programs were identified (three MSc in HTA and six MSc in HTA-related areas). Handbook on HTA Capacity Building. A group of twenty experts from thirteen countries developed the handbook. It consists of nine chapters focusing on HTA institutional development (structural setup, work processes, and visibility). CONCLUSIONS: Setting up organizational structures and establishing effective HTA programs that guide key policy decisions is a challenging task. There are no standard models or pathways. "One size fits all" is not a useful principle because of the wide systemic and cultural differences between countries. The Handbook on HTA Capacity Building includes approaches for overall institutional development, especially in formulating objectives, setting up structures, and defining work processes.

Patient registries of acute coronary syndrome: assessing or biasing the clinical real world data?

BACKGROUND: The risk of selection bias in registries and its consequences are relatively unexplored. We sought to assess selection bias in a recent registry about acute coronary syndrome and to explore the way of conducting and reporting patient registries of acute coronary syndrome. METHODS AND RESULTS: We analyzed data from patients of a national acute coronary syndrome registry undergoing an audit about the comprehensiveness of the recruitment/inclusion. Patients initially included by hospital investigators (n=3265) were compared to eligible nonincluded (missed) patients (n=1439). We assessed, for 25 exposure variables, the deviation of the in-hospital mortality relative risks calculated in the initial sample from the actual relative risks. Missed patients were of higher risk and received less recommended therapies than the included patients. In-hospital mortality was almost 3 times higher in the missed population (9.34% [95% CI, 7.84 to 10.85] versus 3.9% [95% CI, 2.89 to 4.92]). Initial relative risks diverged from the actual relative risks more than expected by chance (P<0.05) in 21 variables, being higher than 10% in 17 variables. This deviation persisted on a smaller degree on multivariable analysis. Additionally, we reviewed a sample of 129 patient registries focused on acute coronary syndrome published in thirteen journals, collecting information on good registry performance items. Only in 38 (29.4%) and 48 (37.2%) registries was any audit of recruitment/inclusion and data abstraction, respectively, mentioned. Only 4 (3.1%) authors acknowledged potential selection bias because of incomplete recruitment. CONCLUSIONS: Irregular inclusion can introduce substantial systematic bias in registries. This problem has not been explicitly addressed in a substantial number of them.

[Development of a geographic filter for PubMed to identify studies performed in Spain]. / Construcción de un filtro geográfico para la identificación en PubMed de estudios realizados en España.

INTRODUCTION AND OBJECTIVES: The increasing size of the PubMed (Medline) database has made it necessary to develop specific tools for information retrieval (i.e., filters). The current configuration of the Limits option in PubMed does not enable searches to be limited according to geographic criteria. Our objectives, therefore, were a) to develop a geographic filter for the retrieval from PubMed of studies performed in the Spanish population, and b) to assess its performance. METHODS: A second-generation filter was constructed by reviewing previous strategies. It involved the selection of three types of record that included: a) the term Spain in different languages; b) Spanish place names (i.e., mainly those of autonomous regions and provinces), and c) acronyms for health services in autonomous regions. The performance of the filter (i.e., its sensitivity and specificity) was assessed in a representative sample (i.e., clinical trials indexed in PubMed under the MeSH term Myocardial Infarction) by comparison with the results of a manual search (the gold standard). In addition, the filter's performance was also evaluated by comparing it with a simple search for the term Spain[ad]. RESULTS: Use of the filter retrieved 74 (98.7%) of the relevant references. The sensitivity (88.1%) was higher than that of the simple search strategy (45.8%), and excellent specificity (100%) was achieved in both cases. CONCLUSIONS: A geographic filter has been developed for identifying studies in PubMed that involve the Spanish population.