Economic returns to medical research funding.

Following the publication of the final paper in a planned series of four studies estimating the economic returns from biomedical and health research, we reflect on what we have learnt from these types of assessment.

Understanding factors associated with the translation of cardiovascular research: a multinational case study approach.

BACKGROUND: Funders of health research increasingly seek to understand how best to allocate resources in order to achieve maximum value from their funding. We built an international consortium and developed a multinational case study approach to assess benefits arising from health research. We used that to facilitate analysis of factors in the production of research that might be associated with translating research findings into wider impacts, and the complexities involved. METHODS: We built on the Payback Framework and expanded its application through conducting co-ordinated case studies on the payback from cardiovascular and stroke research in Australia, Canada and the United Kingdom. We selected a stratified random sample of projects from leading medical research funders. We devised a series of innovative steps to: minimize the effect of researcher bias; rate the level of impacts identified in the case studies; and interrogate case study narratives to identify factors that correlated with achieving high or low levels of impact. RESULTS: Twenty-nine detailed case studies produced many and diverse impacts. Over the 15 to 20 years examined, basic biomedical research has a greater impact than clinical research in terms of academic impacts such as knowledge production and research capacity building. Clinical research has greater levels of wider impact on health policies, practice, and generating health gains. There was no correlation between knowledge production and wider impacts. We identified various factors associated with high impact. Interaction between researchers and practitioners and the public is associated with achieving high academic impact and translation into wider impacts, as is basic research conducted with a clinical focus. Strategic thinking by clinical researchers, in terms of thinking through pathways by which research could potentially be translated into practice, is associated with high wider impact. Finally, we identified the complexity of factors behind research translation that can arise in a single case. CONCLUSIONS: We can systematically assess research impacts and use the findings to promote translation. Research funders can justify funding research of diverse types, but they should not assume academic impacts are proxies for wider impacts. They should encourage researchers to consider pathways towards impact and engage potential research users in research processes.

Illustrating potential efficiency gains from using cost-effectiveness evidence to reallocate Medicare expenditures.

OBJECTIVES: The Centers for Medicare & Medicaid Services does not explicitly use cost-effectiveness information in national coverage determinations. The objective of this study was to illustrate potential efficiency gains from reallocating Medicare expenditures by using cost-effectiveness information, and the consequences for health gains among Medicare beneficiaries. METHODS: We included national coverage determinations from 1999 through 2007. Estimates of cost-effectiveness were identified through a literature review. For coverage decisions with an associated cost-effectiveness estimate, we estimated utilization and size of the "unserved" eligible population by using a Medicare claims database (2007) and diagnostic and reimbursement codes. Technology costs originated from the cost-effectiveness literature or were estimated by using reimbursement codes. We illustrated potential aggregate health gains from increasing utilization of dominant interventions (i.e., cost saving and health increasing) and from reallocating expenditures by decreasing investment in cost-ineffective interventions and increasing investment in relatively cost-effective interventions. RESULTS: Complete information was available for 36 interventions. Increasing investment in dominant interventions alone led to an increase of 270,000 quality-adjusted life-years (QALYs) and savings of $12.9 billion. Reallocation of a broader array of interventions yielded an additional 1.8 million QALYs, approximately 0.17 QALYs per affected Medicare beneficiary. Compared with the distribution of resources prior to reallocation, following reallocation a greater proportion was directed to oncology, diagnostic imaging/tests, and the most prevalent diseases. A smaller proportion of resources went to cardiology, treatments (including drugs, surgeries, and medical devices, as opposed to nontreatments such as preventive services), and the least prevalent diseases. CONCLUSIONS: Using cost-effectiveness information has the potential to increase the aggregate health of Medicare beneficiaries while maintaining existing spending levels.

Factors predicting Medicare national coverage: an empirical analysis.

BACKGROUND: Interventions considered to be particularly controversial or expected to significantly impact the Medicare program in the United States are considered in National Coverage Determinations. Medicare coverage for such interventions is limited to those deemed "reasonable and necessary" for the diagnosis or treatment of an illness or injury. What constitutes reasonable and necessary has not, however, been clearly defined. OBJECTIVE: To determine factors associated with positive National Coverage Determinations. RESEARCH DESIGN: A dataset of coverage decisions from 1999 to 2007 (n=195) was created with the following variables: direction of coverage decision; quality of supporting evidence; availability of alternative interventions; cost-effectiveness of intervention; type of intervention; coverage requestor; and year of decision. Univariate and multivariate logistic regression analysis was used to determine factors associated with positive coverage. RESULTS: The following variables were independently associated with positive Medicare coverage: good or fair quality supporting evidence (adjusted odds ratio, OR=6.04, P<0.01); presence of an alternative intervention (OR=0.130, P<0.01); no associated estimate of cost-effectiveness (OR=0.190, P<0.05). In addition, in comparison with coverage decisions made in the years 1999 to 2001, those made in the years 2002 to 2003, 2004 to 2005, and 2006 to 2007, were associated with positive coverage [ORs of 0.311 (P<0.05), 0.310 (P<0.1), and 0.109 (P<0.01), respectively]. CONCLUSIONS: Findings suggest that good or fair quality supporting evidence is a strong predictor of positive coverage. Availability of alternative interventions, more recent decisions, and lack of an associated estimate of cost-effectiveness are associated with a decreased likelihood of positive coverage. The findings highlight Medicare's move to evidence-based coverage decisions, and suggest that coverage decisions are influenced by the availability of cost-effectiveness evidence.

Integrating health economics into the product development cycle: a case study of absorbable pins for treating hallux valgus.

BACKGROUND: The probability of reimbursement is a key factor in determining whether to proceed with or abandon a product during its development. The purpose of this article is to illustrate how the methods of iterative Bayesian economic evaluation proposed in the literature can be incorporated into the development process of new medical devices, adapting them to face the relative scarcity of data and time that characterizes the process. METHODS: A 3-stage economic evaluation was applied: an early phase in which simple methods allow for a quick prioritization of competing products; a mid-stage in which developers synthesize the data into a decision model, identify the parameters for which more information is most valuable, and explore uncertainty; and a late stage, in which all relevant information is synthesized. A retrospective analysis was conducted of the case study of absorbable pins, compared with metallic fixation, in osteotomy to treat hallux valgus. RESULTS: The results from the early analysis suggest absorbable pins to be cost-effective under the beliefs and assumptions applied. The outputs from the models at the mid-stage analyses show the device to be cost-effective with a high probability. Late-stage analysis synthesizes evidence from a randomized controlled trial and informative priors, which are based on previous evidence. It also suggests that absorbable pins are the most cost-effective strategy, although the uncertainty in the model output increased considerably. CONCLUSIONS: This example illustrates how the method proposed allows decisions in the product development cycle to be based on the best knowledge that is available at each stage.

Does Medicare have an implicit cost-effectiveness threshold?

BACKGROUND: Despite the huge cost of the program, the Centers for Medicare and Medicaid Services (CMS) has maintained a policy that cost-effectiveness is not considered in national coverage determinations (NCDs). OBJECTIVE: To assess whether an implicit cost-effectiveness threshold exists and to determine if economic evidence has been considered in previous NCDs. METHODS: A literature search was conducted to identify estimates of cost-effectiveness relevant to each NCD from 1999-2007 (n = 103). The economic evaluation that best represented each coverage decision was included in a review of the cost-effectiveness of medical interventions considered in NCDs. RESULTS: Of the 64 coverage decisions determined to have a corresponding cost-effectiveness estimate, 49 were associated with a positive coverage decision and 15 with a noncoverage decision. Of the positive decisions, 20 were associated with an economic evaluation that estimated the intervention to be dominant (costs less and was more effective than the alternative), 12 with an incremental cost-effectiveness ratio (ICER) of less than $50,000, 8 with an ICER greater than $50,000 but less than $100,000, and 9 with an ICER greater than $100,000. Fourteen of the sample of 64 decision memos cited or discussed cost-effectiveness information. CONCLUSIONS: CMS is covering a number of interventions that do not appear to be cost-effective, suggesting that resources could be allocated more efficiently. Although the authors identified several instances where cost-effectiveness evidence was cited in NCDs, they found no clear evidence of an implicit threshold.

Mapping of the EQ-5D index from clinical outcome measures and demographic variables in patients with coronary heart disease.

BACKGROUND: The EuroQoL 5D (EQ-5D) is a questionnaire that provides a measure of utility for cost-effectiveness analysis. The EQ-5D has been widely used in many patient groups, including those with coronary heart disease. Studies often require patients to complete many questionnaires and the EQ-5D may not be gathered. This study aimed to assess whether demographic and clinical outcome variables, including scores from a disease specific measure, the Seattle Angina Questionnaire (SAQ), could be used to predict, or map, the EQ-5D index value where it is not available. METHODS: Patient-level data from 5 studies of cardiac interventions were used. The data were split into two groups - approximately 60% of the data were used as an estimation dataset for building models, and 40% were used as a validation dataset. Forward ordinary least squares linear regression methods and measures of prediction error were used to build a model to map to the EQ-5D index. Age, sex, a proxy measure of disease stage, Canadian Cardiovascular Society (CCS) angina severity class, treadmill exercise time (ETT) and scales of the SAQ were examined. RESULTS: The exertional capacity (ECS), disease perception (DPS) and anginal frequency scales (AFS) of the SAQ were the strongest predictors of the EQ-5D index and gave the smallest root mean square errors. A final model was chosen with age, gender, disease stage and the ECS, DPS and AFS scales of the SAQ. ETT and CCS did not improve prediction in the presence of the SAQ scales. Bland-Altman agreement between predicted and observed EQ-5D index values was reasonable for values greater than 0.4, but below this level predicted values were higher than observed. The 95% limits of agreement were wide (-0.34, 0.33). CONCLUSIONS: Mapping of the EQ-5D index in cardiac patients from demographics and commonly measured cardiac outcome variables is possible; however, prediction for values of the EQ-5D index below 0.4 was not accurate. The newly designed 5-level version of the EQ-5D with its increased ability to discriminate health states may improve prediction of EQ-5D index values.

A review of health utilities using the EQ-5D in studies of cardiovascular disease.

BACKGROUND: The EQ-5D has been extensively used to assess patient utility in trials of new treatments within the cardiovascular field. The aims of this study were to review evidence of the validity and reliability of the EQ-5D, and to summarise utility scores based on the use of the EQ-5D in clinical trials and in studies of patients with cardiovascular disease. METHODS: A structured literature search was conducted using keywords related to cardiovascular disease and EQ-5D. Original research studies of patients with cardiovascular disease that reported EQ-5D results and its measurement properties were included. RESULTS: Of 147 identified papers, 66 met the selection criteria, with 10 studies reporting evidence on validity or reliability and 60 reporting EQ-5D responses (VAS or self-classification). Mean EQ-5D index-based scores ranged from 0.24 (SD 0.39) to 0.90 (SD 0.16), while VAS scores ranged from 37 (SD 21) to 89 (no SD reported). Stratification of EQ-5D index scores by disease severity revealed that scores decreased from a mean of 0.78 (SD 0.18) to 0.51 (SD 0.21) for mild to severe disease in heart failure patients and from 0.80 (SD 0.05) to 0.45 (SD 0.22) for mild to severe disease in angina patients. CONCLUSIONS: The published evidence generally supports the validity and reliability of the EQ-5D as an outcome measure within the cardiovascular area. This review provides utility estimates across a range of cardiovascular subgroups and treatments that may be useful for future modelling of utilities and QALYs in economic evaluations within the cardiovascular area.

Relationship between the EQ-5D index and measures of clinical outcomes in selected studies of cardiovascular interventions.

BACKGROUND: The EuroQoL 5D (EQ-5D) has been widely used in studies of cardiac disease, but its measurement properties in this group are not well established. The study aimed to quantify the relationship between measures commonly used in studies of cardiac disease and the EQ-5D index across different levels of disease severity. METHODS: Patient-level data from 7 studies of cardiac interventions were used, which included randomised trials and observational studies. Relationships between the EQ-5D index and commonly used cardiac measures, Canadian Cardiovascular Society (CCS) angina severity class, treadmill exercise time (ETT) and scales of the Seattle Angina Questionnaire (SAQ) were examined. Mixed effects linear regression was used to assess these relationships, with the EQ-5D index as the response. RESULTS: Study sample sizes ranged from 68 to 2419. Mean baseline EQ-5D index ranged from 0.77 in patients at diagnosis (95% CI 0.75, 0.78) to 0.43 in patients with advanced disease (95% CI 0.39, 0.48) and differed significantly across studies (p < 0.001). There was evidence of a ceiling effect in patients at diagnosis. The minimum clinically important difference of a one minute increase in ETT was associated with a 0.019 (95% CI 0.014, 0.025) increase in EQ-5D index. One class increase in CCS was associated with a 0.11 (95% CI 0.09, 0.13) decrease in EQ-5D index. A 10 unit increase in SAQ scales was associated with increases between 0.04 and 0.07 in EQ-5D index (95% CIs 0.03, 0.05 and 0.05, 0.08). Tests of heterogeneity indicated the EQ-5D-covariate relationships were consistent across levels of disease severity for ETT and the treatment satisfaction scale of the SAQ, but heterogeneous for age, gender, CCS angina class and other scales of the SAQ. CONCLUSION: The EQ-5D index varies with coronary disease severity. The relationship between the EQ-5D index and an outcome measure used in cardiac intervention studies, ETT, was consistent across disease severity levels, but the relationship between demographic variables, CCS angina class and most of the SAQ scales and the EQ-5D index was heterogeneous for patients with different levels of coronary disease. Differences in the EQ-5D index associated with clinically important differences in cardiac measures can be quantified and vary between three important examples - angina class, ETT and SAQ.

The role of the national general medical journal: surveys of which journals UK clinicians read to inform their clinical practice / Papel de las revistas nacionales de medicina general: encuesta sobre qué revistas leen los médicos del Reino Unido para informarse sobre la práctica clínica

Background: For biomedical research findings to contribute toward health gains they must reach clinicians. Academic journals have historically been considered important information sources. Birken and Parkin found seven journals to most consistently contain the best pediatric evidence and, of these seven, four were general medical journals. Methods: We surveyed clinicians in three UK medical specialties (psychiatry, surgery and pediatrics), asking which journals they read and which they considered important to inform their clinical practice. Results: The readership of general medical journals, in comparison to specialty and sub-specialty journals, is widespread across the three UK medical specialties, although the importance of general medical journals varies widely. The BMJ is the most prominent general medical journal in terms of readership and importance but a dominant specialty or sub-specialty journal was usually more important for most groups. The Lancet is less widely read and less important, although more academics than non-academics consider it important. Conclusions: Overall, key general medical journals play an important role. Journal availability and cost, particularly in relation to membership for UK clinicians, and the position of academics and non-academics have to be considered in any analysis. Three of the four general medical journals containing the best pediatric evidence were found to be widely read by UK pediatricians and two UK-based general medical journals, the BMJ and The Lancet, were also considered important in our survey. Further investigation of the reasons for the importance of a journal and studies that would allow international comparisons would provide greater input to the discussion (AU)

Fundamento: Para que los hallazgos de la investigación biomédica contribuyan a mejorar la salud, es preciso que lleguen a los médicos. Históricamente, las revistas académicas se han considerado fuentes de información importante. Birken y Parkin encontraron que siete revistas contienen con más regularidad la mejor evidencia pediátrica y, de ellas, cuatro son de medicina general. Métodos: Encuestamos a médicos de tres especialidades del Reino Unido (psiquiatría, cirugía y pediatría), formulándoles preguntas sobre qué revistas leen y qué consideran importante para informarse sobre la práctica clínica. Resultados: En el Reino Unido, en comparación con las revistas de especialidades y subespecialidades, la lectura de revistas de medicina general es difundida a través de las tres especialidades citadas, aunque la importancia de estas revistas varía ampliamente. El British Medical Journal es la más destacada por lo que respecta a lectura e importancia, pero, en general, para los tres grupos de médicos es más importante una revista de especialidad o subespecialidad predominante. La lectura de Lancet es menos difundida y se considera menos importante, aunque un mayor número de académicos que de no acadé- micos la consideran importante. Conclusiones: En conjunto, las revistas de medicina general clave desempeñan un papel relevante. En cualquier análisis, es preciso considerar la disponibilidad y el coste de la revista, en particular en relación con el hecho de ser miembro de la sociedad o asociación para médicos del Reino Unido. Se encontró que los pediatras de este país leen ampliamente tres de las cuatro revistas de medicina general que contienen la mejor evidencia pediátrica, y, en la encuesta, también se consideraron importantes dos revistas de medicina general del RU, BMJ y Lancet. Una investigación adicional de las razones de la importancia de una revista y estudios que permitieran comparaciones internacionales proporcionarían mayor información para una discusión (AU)

Desarrollo y aplicación del Modelo Payback para la evaluación del impacto socioeconómico de la investigación en salud / Developing and applying the Payback Framework to assess the socioeconomic impact of health research

Existe una presión creciente para que los impactos socioeconómicos de la investigación en salud sean evaluados. La demanda por parte de los gobiernos para justificar el gasto del dinero público es cada vez mayor. Además existe la creencia de que evaluando la forma en que se manifiestan los impactos o beneficios de la investigación sanitaria se ayuda a mantener informados a los responsables de dicha investigación de forma que aumenten los impactos futuros. Desde mediados de la década de los noventa, Buxton y Hanney, en el Health Economics Research Group, de la Universidad de Brunel, han estado desarrollando y aplicando el Modelo Payback para valorar los impactos de la investigación sanitaria. En colaboración con otros colegas, lo han aplicado en una serie de estudios para evaluar la rentabilidad de los programas de investigación en diversos campos (diabetes mellitus, artritis y enfermedad cardiovascular) y en varios países (como Reino Unido, Países Bajos, Irlanda, Australia y Canadá). Otros equipos de investigadores han aplicado el Modelo Payback en, por ejemplo, España y Hong Kong. El Modelo Payback está formado por dos elementos; el primero consiste en la categorización multidimensional de los beneficios de la investigación sanitaria. Ésta cubre cinco categorías principales, que van desde la tradicional producción de conocimiento y la formación y la focalización de la investigación hasta los impactos en la política y el desarrollo de productos, pasando por los beneficios sanitarios y económicos. El segundo elemento es un modelo lógico que permita identificar el mejor modo de evaluar estos impactos. Si bien el Modelo Payback puede requerir muchos recursos para ser aplicado, su uso ha proporcionado casos muy ilustrativos acerca de la rentabilidad que se genera por la investigación y ha ayudado a mantener informados a los responsables de la investigación (AU)

There is increasing pressure for assessments of the wider socioeconomic impacts of health research. Governments are making greater demands to justify the expenditure of public money. However, there is also a belief that assessing how the wider effects or benefits of health research arise should help to inform the management and organization of health research so as to increase future impacts. Since the mid- 1990s, Buxton and Hanney at the Health Economics Research Group, Brunel University, have been developing and applying the Payback Framework to assess the impacts of health research. Together with their colleagues, these researchers have applied this model in a series of studies to assess the payback from research programs in various fields (including diabetes, arthritis and cardiovascular disease) and in various countries (including the United Kingdom, The Netherlands, Ireland, Australia and Canada). Other teams of researchers have applied the Payback Framework in, for example, Spain and Hong Kong. The Payback Framework consists of two elements, the first being the multi-dimensional categorization of the benefits of health research, which covers five main categories ranging from traditional knowledge production and research training and targeting, to impacts on policy and product development through to health and economic gains. The second element is a logic model of how best to assess these impacts. Application of this framework can be resource intensive, but has provided illustrative ‘good news’ stories on the payback resulting from research and has helped to inform research management (AU)

Integrating health economics modeling in the product development cycle of medical devices: a Bayesian approach.

OBJECTIVES: Medical device companies are under growing pressure to provide health-economic evaluations of their products. Cost-effectiveness analyses are commonly undertaken as a one-off exercise at the late stage of development of new technologies; however, the benefits of an iterative use of economic evaluation during the development process of new products have been acknowledged in the literature. Furthermore, the use of Bayesian methods within health technology assessment has been shown to be of particular value in the dynamic framework of technology appraisal when new information becomes available in the life cycle of technologies. METHODS: In this study, we set out a methodology to adapt these methods for their application to directly support investment decisions in a commercial setting from early stages of the development of new medical devices. RESULTS AND CONCLUSIONS: Starting with relatively simple analysis from the very early development phase and proceeding to greater depth of analysis at later stages, a Bayesian approach facilitates the incorporation of all available evidence and would help companies to make better informed choices at each decision point.

Assessing the impact of health technology assessment in The Netherlands.

OBJECTIVES: Investments in health research should lead to improvements in health and health care. This is also the remit of the main HTA program in the Netherlands. The aims of this study were to assess whether the results of this program have led to such improvements and to analyze how best to assess the impact from health research. METHODS: We assessed the impact of individual HTA projects by adapting the "payback framework" developed in the United Kingdom. We conducted dossier reviews and sent a survey to principal investigators of forty-three projects awarded between 2000 and 2003. We then provided an overview of documented output and outcome that was assessed by ten HTA experts using a scoring method. Finally, we conducted five case studies using information from additional dossier review and semistructured key informant interviews. RESULTS: The findings confirm that the payback framework is a useful approach to assess the impact of HTA projects. We identified over 101 peer reviewed papers, more than twenty-five PhDs, citations of research in guidelines (six projects), and implementation of new treatment strategies (eleven projects). The case studies provided greater depth and understanding about the levels of impact that arise and why and how they have been achieved. CONCLUSIONS: It is generally too early to determine whether the HTA program led to actual changes in healthcare policy and practice. However, the results can be used as a baseline measurement for future evaluation and can help funding organizations or HTA agencies consider how to assess impact, possibly routinely. This, in turn, could help inform research strategies and justify expenditure for health research.

Costs of an early intervention versus a conservative strategy in acute coronary syndrome.

BACKGROUND: The Randomised Intervention Treatment of unstable Angina (RITA-3) found that non-ST-elevation myocardial infarction and unstable angina patients randomised to routine early arteriography experienced a lower rate of death or myocardial infarction than patients randomised to conservative therapy over a five year period of follow up. This paper uses data from the RITA-3 trial to compare the health service costs of the two strategies. METHODS: The resource use data included initial arteriography and revascularisation procedures in the early intervention group and subsequently in both groups; in-patient days in hospital for any reason in the first year of follow-up; incidence of myocardial infarction; and cardiac medication. RESULTS: After five years, the early intervention arm accrued a total mean cost of pound sterling 11,340 (euro 15,592) and the conservative arm a mean of pound sterling 9749(euro 13,405), an additional mean cost in the intervention arm of pound sterling 1591 (95% CI pound sterling 851 to pound sterling 2276) (euro 2188; 95%CI euro 1160 to euro 3228). On average, costs increased with age and were higher in male patients and in patients with severe angina. However, the incremental cost of the intervention strategy was consistent across different patient sub-groups. CONCLUSION: Over a period of 5 years, the initial additional cost of a strategy of early intervention is only partially offset by subsequent interventions in patients managed conservatively.

The role of the national general medical journal: surveys of which journals UK clinicians read to inform their clinical practice.

BACKGROUND: For biomedical research findings to contribute toward health gains they must reach clinicians. Academic journals have historically been considered important information sources. Birken and Parkin found seven journals to most consistently contain the best pediatric evidence and, of these seven, four were general medical journals. METHODS: We surveyed clinicians in three UK medical specialties (psychiatry, surgery and pediatrics), asking which journals they read and which they considered important to inform their clinical practice. RESULTS: The readership of general medical journals, in comparison to specialty and sub-specialty journals, is widespread across the three UK medical specialties, although the importance of general medical journals varies widely. The BMJ is the most prominent general medical journal in terms of readership and importance but a dominant specialty or sub-specialty journal was usually more important for most groups. The Lancet is less widely read and less important, although more academics than non-academics consider it important. CONCLUSIONS: Overall, key general medical journals play an important role. Journal availability and cost, particularly in relation to membership for UK clinicians, and the position of academics and non-academics have to be considered in any analysis. Three of the four general medical journals containing the best pediatric evidence were found to be widely read by UK pediatricians and two UK-based general medical journals, the BMJ and The Lancet, were also considered important in our survey. Further investigation of the reasons for the importance of a journal and studies that would allow international comparisons would provide greater input to the discussion.

[Developing and applying the Payback Framework to assess the socioeconomic impact of health research]. / Desarrollo y aplicación del Modelo Payback para la evaluación del impacto socioeconómico de la investigación en salud.

There is increasing pressure for assessments of the wider socioeconomic impacts of health research. Governments are making greater demands to justify the expenditure of public money. However, there is also a belief that assessing how the wider effects or benefits of health research arise should help to inform the management and organization of health research so as to increase future impacts. Since the mid- 1990s, Buxton and Hanney at the Health Economics Research Group, Brunel University, have been developing and applying the Payback Framework to assess the impacts of health research. Together with their colleagues, these researchers have applied this model in a series of studies to assess the payback from research programs in various fields (including diabetes, arthritis and cardiovascular disease) and in various countries (including the United Kingdom, The Netherlands, Ireland, Australia and Canada). Other teams of researchers have applied the Payback Framework in, for example, Spain and Hong Kong. The Payback Framework consists of two elements, the first being the multi-dimensional categorization of the benefits of health research, which covers five main categories ranging from traditional knowledge production and research training and targeting, to impacts on policy and product development through to health and economic gains. The second element is a logic model of how best to assess these impacts. Application of this framework can be resource intensive, but has provided illustrative 'good news' stories on the payback resulting from research and has helped to inform research management.