Evaluation of quality of pharmacoeconomic studies involved in traditional Chinese medicine in China.

OBJECTIVES: The pharmacoeconomic studies of traditional Chinese medicine (TCM) are still in its infancy. Assessing the quality of pharmacoeconomic studies of TCM to improve the efficiency of health resource allocation and guide the rational use of medicine. METHODS: Four databases were searched from inception to January 2018. The Consolidated Health Economic Evaluation Reporting Standards statement (CHEERS) and the Quality of Health Economic Studies (QHES) were used to assess the reporting quality and methodological quality. STATA 12.0 and Meta analyst 3.13 were used to analyze the related data. RESULTS: A total of 178 studies were included. The methodological evaluation of the study found that the total score of QHES was 47.85 ± 8.09. The report quality evaluation results found that many studies did not report comprehensive information, such as lack of detailed reports on abstracts, study perspectives, time frames, discount rates, model selection, but the titles, study background and location, and health results, resource and cost estimates, analysis methods, and heterogeneity analysis are reported in more detail. Six of the ten stratification factors have statistically significant differences. CONCLUSION: The overall quality of pharmacoeconomic studies of TCM is low, and further standardization and improvement are needed to obtain reliable study results.

The status of health economic evaluation within decision making in Austria.

BACKGROUND: Given limited resources compared to the demand for them, spending resources efficiently is important. Key methods applied for supporting efficient resource allocation are health economic evaluations. METHODS: Based on secondary literature, we analyze international challenges for using two types of economic evaluations-cost-effectiveness analysis and cost-utility analysis-in reimbursement decisions and reflect on them for the Austrian case. RESULTS: The main challenges with the application of economic evaluations are related to the methods, the decision-making culture, and the respective system. The challenges also apply to the Austrian Bismarck system, where almost no formal requirements for using economic evaluations exist, except on a case-by-case basis. Resource allocation in Austria hence occurs, for the most part, implicitly. CONCLUSION: One way forward towards more explicit efficiency considerations may be to consider more descriptive study types and foster capacity building, standardization of methods and presentation of results, and a mandatory detailed guideline.

Appeal to the Rule of Rescue in health care: discriminating and not benevolent?

Thirty years of debate have passed since the term "Rule of Rescue" has been introduced into medical ethics. Its main focus was on whether or why medical treatment for acute conditions should have priority over preventive measures irrespective of opportunity costs. Recent contributions, taking account of the widespread reluctance to accept purely efficiency-oriented prioritization approaches, advance another objection: Prioritizing treatment, they hold, discriminates against statistical lives. The reference to opportunity costs has also been renewed in a distinctly ethical fashion: It has been stipulated that favoring help for identifiable lives amounts to a lack of benevolence for one's fellow creatures. The present article argues against both objections. It suggests that the debate's focus on consequences (deaths or severe ill health) should be reoriented by asking which aspects of such states of affairs are actually attributable to a decision maker who judges within a specific situation of choice.

Projecting expenditure on medicines in the UK NHS.

BACKGROUND: Expenditure on medicines is a readily identifiable element of health service costs. It is the focus of much attention by payers, not least in the UK even though the cost of medicines represents less than 10 % of total UK National Health Service (NHS) expenditure. Projecting future medicines spending enables the likely cost pressure to be allowed for in planning the scale and allocation of NHS resources. Simple extrapolations of past trends in expenditure fail to account for changes in the rate and mix of new medicines becoming available and in the scope for windfall savings when some medicines lose their patent protection. The objective of this study is to develop and test an improved method to project NHS pharmaceutical expenditure in the UK for the period 2012-2015. METHODS: We have adopted a product-by-product, bottom-up approach, which means that our projections are built up from individual products to the total market. Our projections of the impact of generic and biosimilars entry on prices and quantities of medicines sold, and of the rate of uptake of newly launched medicines, have been obtained from regression analysis of UK data. To address uncertainty, we have created a baseline and two other illustrative scenarios. We have compared our projections with actual expenditure for 2012. RESULTS: Our projections estimate that, between 2011 and 2015, with no change in policy or price regulation, the UK total medicines bill would increase at an average compound annual growth rate (CAGR) of between 3.1 and 4.1 %. Total NHS spending on branded medicines and total NHS spending on generics are projected to increase at average CAGRs of 0.5-1.8 and 10.0-11.0 %, respectively, over the same time period. For the total market, the actual growth rate for 2012 lay within our projected range. CONCLUSIONS: Our methodology provides a useful framework for projecting UK NHS medicines expenditure over the medium term and captures the impacts of existing medicines losing exclusivity and of new medicines being launched onto the market.

Quasi-market and cost-containment in Beveridge systems: the Lombardy model of Italy.

In the very recent past, the Lombardy health care system - established in 1997 on the quasi market model - has caught the interest of researchers and politicians in different OECD countries(1). Its merits, compared to other Italian regional systems, are the control of health care spending and the balanced budget, in a frame of good quality of services and patient choice. From the theoretical point of view, an appealing aspect of the Lombardy model is its gradual shift from a quasi market (QM) to a "quasi administered" system, which maintains all the typical features of the QM orientation - separation between purchasers and providers, the co-presence of public, not for profit and public providers, and patient free choice - but has deliberately sacrificed competition in order to control health expenditure. Another aspect of the Lombardy model is the sharp presence of private providers: the evidence that private sector is mainly concentrated in the long term care, where risks of complications are lower and financial remuneration is higher, suggests that a closer control should be exerted on hospital activity. Furthermore, possible distortions such as cream skimming and cherry picking by the private providers need more consideration. Another concern is linked to health spending control: equity issues could arise when observing a still relatively high share of private (out of pocket) health care expenditure. The paper stems from a literature review and tries to analyse the evolution of this regional system, the institutional path that brought to the implementation of the model, its theoretical basis, its merits and criticism. The period considered ranges from 1997, when the reform was enacted, to 2010.

Achieving conservation when opportunity costs are high: optimizing reserve design in Alberta's oil sands region.

Recent studies have shown that conservation gains can be achieved when the spatial distributions of biological benefits and economic costs are incorporated in the conservation planning process. Using Alberta, Canada, as a case study we apply these techniques in the context of coarse-filter reserve design. Because targets for ecosystem representation and other coarse-filter design elements are difficult to define objectively we use a trade-off analysis to systematically explore the relationship between conservation targets and economic opportunity costs. We use the Marxan conservation planning software to generate reserve designs at each level of conservation target to ensure that our quantification of conservation and economic outcomes represents the optimal allocation of resources in each case. Opportunity cost is most affected by the ecological representation target and this relationship is nonlinear. Although petroleum resources are present throughout most of Alberta, and include highly valuable oil sands deposits, our analysis indicates that over 30% of public lands could be protected while maintaining access to more than 97% of the value of the region's resources. Our case study demonstrates that optimal resource allocation can be usefully employed to support strategic decision making in the context of land-use planning, even when conservation targets are not well defined.

Is it time to implement a value-for-money approach in healthcare of the elderly?

This commentary addresses several issues raised by Chappell and Hollander in their review of policy issues that should be addressed to improve care for the elderly in Canada. First, the author takes some issue with the suggestion that the continuing care system needs to be re-validated. The data seem to indicate that the issue is not re-validation of the system but, rather, operational reform of the current system. Thus, the recommendation to focus on improving integrated care for seniors, which is a process measure, is a very timely one. Then the author raises the question of recommending a value-for-money approach to care of the elderly. Although fraught with problems and a lack of data, increasing numbers of researchers and others are suggesting that there is a need to question how we are spending scarce resources. A value-for-money policy would contribute evidence about the most effective use of services for older people.

Spanish recommendations on economic evaluation of health technologies.

The economic evaluation of health technologies has become a major tool in health policy in Europe for prioritizing the allocation of health resources and the approval of new technologies. The objective of this proposal was to develop guidelines for the economic evaluation of health technologies in Spain. A group of researchers specialized in economic evaluation of health technologies developed the document reported here, following the initiative of other countries in this framework, to provide recommendations for the standardization of methodology applicable to economic evaluation of health technologies in Spain. Recommendations appear under 17 headings or sections. In each case, the recommended requirements to be satisfied by economic evaluation of health technologies are provided. Each recommendation is followed by a commentary providing justification and compares and contrasts the proposals with other available alternatives. The economic evaluation of health technologies should have a role in assessing health technologies, providing useful information for decision making regarding their adoption, and they should be transparent and based on scientific evidence.

Retrospective analysis of Healthcare Resource Group coding allocation for local anaesthetic video-assisted 'medical' thoracoscopy in a UK tertiary respiratory centre.

BACKGROUND: Correct service costing is essential but may not always be done accurately. AIM: To assess the accuracy of Healthcare Resource Group (HRG) coding allocation for patients undergoing local anaesthetic video-assisted thoracoscopy (LAVAT) against predicted codes under Payment by Results (PbR). DESIGN: Single centre retrospective study. Tertiary respiratory centre in Leicestershire. METHODS: One hundred twenty-five patients undergoing LAVAT from July 2005 to July 2008. MAIN OUTCOME MEASURES: Predicted and actual revenue per LAVAT episode based on predicted and actual HRG codes allocated. RESULTS: Among 125 patients undergoing LAVAT, the actual HRG code matched the predicted code in only 39 cases (31.2%), odds ratio (OR) 0.002, 95% confidence intervals (CIs) 0.0001-0.03, P < 0.0001. In 51 cases (40.8%), this resulted in a median (interquartile range) excess of PbR revenue of 574 pounds (574-1366) per episode; a total estimated overspend of 29,274 pounds. In 35 cases (28.0%), this resulted in a median underspend of --1093 pounds (-1285 to -851) per episode; a total estimated underspend of 38,529 pounds, with a total estimated financial error of 67,529 pounds. The net median (interquartile range) difference for PbR-related revenue was 0 pounds (-89 to + 574). Factors associated with coding discrepancy were longer length of stay (OR = 2.52, 95% CIs = 1.09-5.81, P = 0.03) and talc pleurodesis (OR = 2.25, 95% CI = 1.01-4.99, P = 0.06). CONCLUSION: HRG coding allocation errors occur frequently. The potential financial implications of this are significant for providers and commissioners. Future strategies are required at multiple levels (NHS Trust, Primary Care Trust and Department of Health) to minimize future discrepancies and financial error.

To survive is not enough. Quality of life in CKD--the need for a new generation of health-oriented economists.

CKD is utilized as a paradigm, a chronic disease which allows decades of life conquered with great effort through a machine, a life with many losses and many dependencies. We must understand the patient's needs, which are not related to availability of drugs and machines and hospitals. We cannot provide good medical care with the limited amount of national product devoted to health care. Society is much older than ever before. We need a new cadre of economists working on health care with vision and ability, keeping in mind that there are no resources and there are no expenses which can be cut in medical care nowadays. We have to switch from curative medicine towards prevention, by implementing clinical research, bearing in mind that in the Western world, democracy was granted through the correct allocation of resources. The search for happiness and good quality of life are old concepts born in the Mediterranean area over the centuries, starting with Hesiod and Homer, and sleep and dreams were being investigated centuries before Freud was born.

Can a publicly funded home care system successfully allocate service based on perceived need rather than socioeconomic status? A Canadian experience.

The present quantitative study evaluates the degree to which socioeconomic status (SES), as opposed to perceived need, determines utilisation of publicly funded home care in Ontario, Canada. The Registered Persons Data Base of the Ontario Health Insurance Plan was used to identify the age, sex and place of residence for all Ontarians who had coverage for the complete calendar year 1998. Utilisation was characterised in two dimensions: (1) propensity - the probability that an individual received service, which was estimated using a multinomial logit equation; and (2) intensity - the amount of service received, conditional on receipt. Short- and long-term service intensity were modelled separately using ordinary least squares regression. Age, sex and co-morbidity were the best predictors (P < 0.0001) of whether or not an individual received publicly funded home care as well as how much care was received, with sicker individuals having increased utilisation. The propensity and intensity of service receipt increased with lower SES (P < 0.0001), and decreased with the proportion of recent immigrants in the region (P < 0.0001), after controlling for age, sex and co-morbidity. Although the allocation of publicly funded home care service was primarily based on perceived need rather than ability to pay, barriers to utilisation for those from areas with a high proportion of recent immigrants were identified. Future research is needed to assess whether the current mix and level of publicly funded resources are indeed sufficient to offset the added costs associated with the provision of high-quality home care.

Optimal allocation of testing dollars: the example of HIV counseling, testing, and referral.

BACKGROUND: Health screening programs can be represented as a pathway of sequential processes: offering a test, obtaining consent, conducting the test, providing results, and linking to appropriate care. Using the example of HIV testing, the authors explore the optimal targeting of funds within this pathway. METHODS: The authors develop a microsimulation of HIV testing services and decompose the likelihood that an unidentified HIV-infected person will receive care into the probability of testing [P(test)] and the probability of follow-up [P(follow)] defined as returning for results and linking to care. The authors examine the clinical impact and cost-effectiveness of alternative investments in these component probabilities. RESULTS: At 1% undiagnosed HIV prevalence, cost-effectiveness ratios for HIV testing cluster around $33,000/QALY (quality-adjusted life year) gained. A program with a yield of 0.16 via P(test)=0.20 and P(follow)=0.80 has a cost-effectiveness ratio of $32,900/QALY compared with $36,300/QALY for a program where P(test)=0.80 and P(follow)=0.20. Interventions that improve the probability of success in later stages in the testing pathway [P(follow)] are more cost-effective than investments devoted to earlier stages [P(test)]. CONCLUSIONS: Equivalent pathway outcomes in a screening program do not confer equal value. Limited screening resources are best targeted toward returning for results and linkage among those already identified with disease rather than offering testing to additional people.

Evidence, economics and ethics: resource allocation in health services organizations.

Priority setting is a challenge for health services organizations across health systems. Because demand for health services exceeds available resources, health services priorities must be set to ensure resources are used appropriately to meet the community's health needs. Various approaches have been developed to assist decision-makers to set priorities in their organizations. The dominant approaches come from evidence-based medicine, economics and ethics.

[Relevance of surgical outpatient clinics in academic university centers to health care in Germany]. / Stellenwert einer allgemeinen chirurgischen Hochschulambulanz für die medizinische Patientenversorgung Eine ergänzende Erhebung zur "Deutschen Hochschulambulanzenstudie".

During the observation period between 2001 and 2003, all outpatient surgical therapy, including degrees of urgency, surgical care volume, regional provenance of patients, diagnoses, and referral channels were prospectively analysed at the Surgical Department of the University of Heidelberg, Germany. The data gathered do not merely describe the volume and characteristics of care encountered at this academic surgical institution but also provide further insight into the variability of resource utilisation and associated patient flow. Additionally, a retrospective evaluation using structured interviews and questionnaires was performed to differentiate and quantify patient care, teaching, and research activities. This study illustrates the high relevance of academic outpatient institutions to regional provision of general surgical care in Germany. There is a clear dominance of medical support functions, while research and teaching activities are of only minor relevance and realised particularly in subspecialty clinics. These data should give important stimuli for the future planning of health care in Germany. Outpatient clinics for general surgery appear to be an excellent basis for regional models of integrated health care delivery in the future.

Tackling regional health inequalities in france by resource allocation : a case for complementary instrumental and process-based approaches?

This article aims to evaluate the results of two different approaches underlying the attempts to reduce health inequalities in France. In the 'instrumental' approach, resource allocation is based on an indicator to assess the well-being or the quality of life associated with healthcare provision, the argument being that additional resources would respond to needs that could then be treated quickly and efficiently. This governs the distribution of regional hospital budgets. In the second approach, health professionals and users in a given region are involved in a consensus process to define those priorities to be included in programme formulation. This 'procedural' approach is employed in the case of the regional health programmes. In this second approach, the evaluation of the results runs parallel with an analysis of the process using Rawlsian principles, whereas the first approach is based on the classical economic model.At this stage, a pragmatic analysis based on both the comparison of regional hospital budgets during the period 1992-2003 (calculated using a 'RAWP [resource allocation working party]-like' formula) and the evolution of regional health policies through the evaluation of programmes for the prevention of suicide, alcohol-related diseases and cancers provides a partial assessment of the impact of the two types of approaches, the second having a greater effect on the reduction of regional inequalities.

The evolution of PBMA: towards a macro-level priority setting framework for health regions.

To date, relatively little work on priority setting has been carried out at a macro-level across major portfolios within integrated health care organizations. This paper describes a macro marginal analysis (MMA) process for setting priorities and allocating resources in health authorities, based on work carried out in a major urban health region in Alberta, Canada. MMA centers around an expert working group of managers and clinicians who are charged with identifying areas for resource re-allocation on an ongoing basis. Trade-offs between services are based on locally defined criteria and are informed by multiple inputs such as evidence from the literature and local expert opinion. The approach is put forth as a significant improvement on historical resource allocation patterns.

Stated preference methods in health care evaluation: an emerging methodological paradigm in health economics.

One focus of health economics is the trade-off between limited resources and the (health) needs of a community. Cost-effectiveness analysis (CEA), while being one of the most accepted evaluation methodologies in health economics, does not account for many important costs and benefits of health care interventions. Some health economists have attempted to modify CEA to account for these deficiencies, while others have been working on alternative methodologies. One group of alternative methodologies can be described as stated preference techniques. These aim to measure both health and non-health outcomes (ie costs and benefits), and include qualitative analysis, conjoint analysis (often referred to as discrete choice analysis/modelling) and willingness to pay (or contingent valuation). This paper provides an overview of stated preference techniques in health economics, with particular focus on their strengths as compared with traditional evaluation methods in health care. The limitations and policy implications of these methods are also discussed.