Social Decision-Making Analysis: A General Approach to Inform Decisions on Resources in the Public Sector.

OBJECTIVES: Public expenditure aims to achieve social objectives by improving a range of socially valuable attributes of benefit (arguments in a social welfare function). Public expenditure is typically allocated to public sector budgets, where budget holders are tasked with meeting a subset of social objectives. METHODS: Decision makers require an evidence-based assessment of whether a proposed investment is likely to be worthwhile given existing levels of public expenditure. However, others also require some assessment of whether the overall level and allocation of public expenditure are appropriate. This article proposes a more general theoretical framework for economic evaluation that addresses both these questions. RESULTS: Using a stylized example of the economic evaluation of a new intervention in a simplified UK context, we show that this more general framework can support decisions beyond the approval or rejection of single projects. It shows that broader considerations about the level and allocation of public expenditure are possible and necessary when evaluating specific investments, which requires evidence of the range of benefits offered by marginal changes in different types of public expenditure and normative choices of how the attributes of benefit gained and forgone are valued. CONCLUSIONS: The proposed framework shows how to assess the value of a proposed investment and whether and how the overall level of public expenditure and its allocation across public sector budgets might be changed. It highlights that cost-benefit analysis and cost-effectiveness analysis can be viewed as special cases of this framework, identifying the weakness with each.

Children's behavioral and mental health in primary care settings: A survey of self-reported comfort levels and practice patterns among pediatricians.

INTRODUCTION: Despite the well-documented youth mental health crisis, there has been a lag in the development of a specialized workforce to meet needs of young people experiencing these challenges. Little is known about the comfort of primary care pediatricians when faced with children and adolescents with mental health care concerns. METHOD: A brief online survey was conducted to assess patterns of behavioral and mental health concerns in pediatric practices affiliated with a pediatric health system in Alabama. The survey asked about frequency of conditions that providers encountered, comfort treating these conditions, and frequency of external referrals. RESULTS: Pediatric providers reported high volumes of children with mental health concerns and varying levels of comfort treating independently. Providers frequently refer externally. CONCLUSIONS: High rates of referrals could further stress an already overloaded system of specialty care. Interventions must be implemented to ensure a workforce prepared to meet the growing needs of youth requiring support for mental and behavioral health conditions. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Recommendations for Emerging Good Practice and Future Research in Relation to Family and Caregiver Health Spillovers in Health Economic Evaluations: A Report of the SHEER Task Force.

BACKGROUND: Omission of family and caregiver health spillovers from the economic evaluation of healthcare interventions remains common practice. When reported, a high degree of methodological inconsistency in incorporating spillovers has been observed. AIM: To promote emerging good practice, this paper from the Spillovers in Health Economic Evaluation and Research (SHEER) task force aims to provide guidance on the incorporation of family and caregiver health spillovers in cost-effectiveness and cost-utility analysis. SHEER also seeks to inform the basis for a spillover research agenda and future practice. METHODS: A modified nominal group technique was used to reach consensus on a set of recommendations, representative of the views of participating subject-matter experts. Through the structured discussions of the group, as well as on the basis of evidence identified during a review process, recommendations were proposed and voted upon, with voting being held over two rounds. RESULTS: This report describes 11 consensus recommendations for emerging good practice. SHEER advocates for the incorporation of health spillovers into analyses conducted from a healthcare/health payer perspective, and more generally inclusive perspectives such as a societal perspective. Where possible, spillovers related to displaced/foregone activities should be considered, as should the distributional consequences of inclusion. Time horizons ought to be sufficient to capture all relevant impacts. Currently, the collection of primary spillover data is preferred and clear justification should be provided when using secondary data. Transparency and consistency when reporting on the incorporation of health spillovers are crucial. In addition, given that the evidence base relating to health spillovers remains limited and requires much development, 12 avenues for future research are proposed. CONCLUSIONS: Consideration of health spillovers in economic evaluations has been called for by researchers and policymakers alike. Accordingly, it is hoped that the consensus recommendations of SHEER will motivate more widespread incorporation of health spillovers into analyses. The developing nature of spillover research necessitates that this guidance be viewed as an initial roadmap, rather than a strict checklist. Moreover, there is a need for balance between consistency in approach, where valuable in a decision making context, and variation in application, to reflect differing decision maker perspectives and to support innovation.

Demands for Intersectoral Actions to Meet Health Challenges in East and Southern Africa and Methods for Their Evaluation.

OBJECTIVES: Focusing on the East, Central, and Southern African region, this study examines both regional and country-level initiatives aimed at promoting multisectoral collaboration to improve population health and the methods for their economic evaluation. METHODS: We explored the interventions that necessitate cooperation among policymakers from diverse sectors and the mechanisms that facilitate effective collaboration and coordination across these sectors. To gain insights into the demand for multisectoral collaboration in the East, Central, and Southern African region, we presented 3 country briefs, highlighting policy areas and initiatives that have successfully incorporated health-promoting actions from outside the health sector in Zimbabwe, Uganda, and Malawi. Additionally, we showcased initiatives undertaken by the Ministry of Health in each country to foster coordination with national and international stakeholders, along with existing coordination mechanisms established for intersectoral collaboration. Drawing on these examples, we identified the primary challenges in the economic evaluation of multisectoral programs aimed at improving health in the region. RESULTS: We illustrated how decision making in reality differs from the traditional single-sector and single-decision-maker perspective commonly used in cost-effectiveness analyses. To ensure economic evaluations can inform decision making in diverse settings and facilitate regional collaboration, we highlighted 3 fundamental principles: identifying policy objectives, defining the perspective of the analysis, and considering opportunity costs. We emphasized the importance of adopting a flexible and context-specific approach to economic evaluation. CONCLUSIONS: Through this work, we contribute to bridging the gap between theory and practice in the context of intersectoral activities aimed at improving health outcomes.

Prime editing in mice with an engineered pegRNA.

CRISPR editing involves double-strand breaks in DNA with attending insertions/deletions (indels) that may result in embryonic lethality in mice. The prime editing (PE) platform uses a prime editing guide RNA (pegRNA) and a Cas9 nickase fused to a modified reverse transcriptase to precisely introduce nucleotide substitutions or small indels without the unintended editing associated with DNA double-strand breaks. Recently, engineered pegRNAs (epegRNAs), with a 3'-extension that shields the primer-binding site of the pegRNA from nucleolytic attack, demonstrated superior activity over conventional pegRNAs in cultured cells. Here, we show the inability of three-component CRISPR or conventional PE to incorporate a nonsynonymous substitution in the Capn2 gene, expected to disrupt a phosphorylation site (S50A) in CAPN2. In contrast, an epegRNA with the same protospacer correctly installed the desired edit in two founder mice, as evidenced by robust genotyping assays for the detection of subtle nucleotide substitutions. Long-read sequencing demonstrated sequence fidelity around the edited site as well as top-ranked distal off-target sites. Western blotting and histological analysis of lipopolysaccharide-treated lung tissue revealed a decrease in phosphorylation of CAPN2 and notable alleviation of inflammation, respectively. These results demonstrate the first successful use of an epegRNA for germline transmission in an animal model and provide a solution to targeting essential developmental genes that otherwise may be challenging to edit.

One versus three weeks hypofractionated whole breast radiotherapy for early breast cancer treatment: the FAST-Forward phase III RCT.

Background: FAST-Forward aimed to identify a 5-fraction schedule of adjuvant radiotherapy delivered in 1 week that was non-inferior in terms of local cancer control and as safe as the standard 15-fraction regimen after primary surgery for early breast cancer. Published acute toxicity and 5-year results are presented here with other aspects of the trial. Design: Multicentre phase III non-inferiority trial. Patients with invasive carcinoma of the breast (pT1-3pN0-1M0) after breast conservation surgery or mastectomy randomised (1 : 1 : 1) to 40 Gy in 15 fractions (3 weeks), 27 Gy or 26 Gy in 5 fractions (1 week) whole breast/chest wall (Main Trial). Primary endpoint was ipsilateral breast tumour relapse; assuming 2% 5-year incidence for 40 Gy, non-inferiority pre-defined as < 1.6% excess for 5-fraction schedules (critical hazard ratio = 1.81). Normal tissue effects were assessed independently by clinicians, patients and photographs. Sub-studies: Two acute skin toxicity sub-studies were undertaken to confirm safety of the test schedules. Primary endpoint was proportion of patients with grade ≥ 3 acute breast skin toxicity at any time from the start of radiotherapy to 4 weeks after completion. Nodal Sub-Study patients had breast/chest wall plus axillary radiotherapy testing the same three schedules, reduced to the 40 and 26 Gy groups on amendment, with the primary endpoint of 5-year patient-reported arm/hand swelling. Limitations: A sequential hypofractionated or simultaneous integrated boost has not been studied. Participants: Ninety-seven UK centres recruited 4096 patients (1361:40 Gy, 1367:27 Gy, 1368:26 Gy) into the Main Trial from November 2011 to June 2014. The Nodal Sub-Study recruited an additional 469 patients from 50 UK centres. One hundred and ninety and 162 Main Trial patients were included in the acute toxicity sub-studies. Results: Acute toxicity sub-studies evaluable patients: (1) acute grade 3 Radiation Therapy Oncology Group toxicity reported in 40 Gy/15 fractions 6/44 (13.6%); 27 Gy/5 fractions 5/51 (9.8%); 26 Gy/5 fractions 3/52 (5.8%). (2) Grade 3 common toxicity criteria for adverse effects toxicity reported for one patient. At 71-month median follow-up in the Main Trial, 79 ipsilateral breast tumour relapse events (40 Gy: 31, 27 Gy: 27, 26 Gy: 21); hazard ratios (95% confidence interval) versus 40 Gy were 27 Gy: 0.86 (0.51 to 1.44), 26 Gy: 0.67 (0.38 to 1.16). With 2.1% (1.4 to 3.1) 5-year incidence ipsilateral breast tumour relapse after 40 Gy, estimated absolute differences versus 40 Gy (non-inferiority test) were -0.3% (-1.0-0.9) for 27 Gy (p = 0.0022) and -0.7% (-1.3-0.3) for 26 Gy (p = 0.00019). Five-year prevalence of any clinician-assessed moderate/marked breast normal tissue effects was 40 Gy: 98/986 (9.9%), 27 Gy: 155/1005 (15.4%), 26 Gy: 121/1020 (11.9%). Across all clinician assessments from 1 to 5 years, odds ratios versus 40 Gy were 1.55 (1.32 to 1.83; p < 0.0001) for 27 Gy and 1.12 (0.94-1.34; p = 0.20) for 26 Gy. Patient and photographic assessments showed higher normal tissue effects risk for 27 Gy versus 40 Gy but not for 26 Gy. Nodal Sub-Study reported no arm/hand swelling in 80% and 77% in 40 Gy and 26 Gy at baseline, and 73% and 76% at 24 months. The prevalence of moderate/marked arm/hand swelling at 24 months was 10% versus 7% for 40 Gy compared with 26 Gy. Interpretation: Five-year local tumour incidence and normal tissue effects prevalence show 26 Gy in 5 fractions in 1 week is a safe and effective alternative to 40 Gy in 15 fractions for patients prescribed adjuvant local radiotherapy after primary surgery for early-stage breast cancer. Future work: Ten-year Main Trial follow-up is essential. Inclusion in hypofractionation meta-analysis ongoing. A future hypofractionated boost trial is strongly supported. Trial registration: FAST-Forward was sponsored by The Institute of Cancer Research and was registered as ISRCTN19906132. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 09/01/47) and is published in full in Health Technology Assessment; Vol. 27, No. 25. See the NIHR Funding and Awards website for further award information.

Patients diagnosed with early breast cancer are often recommended to have radiotherapy after surgery because research has shown that it lowers the risk of the cancer returning. However, it may cause some short- and long-term side effects. Previous clinical trials showed that the same, or even better, outcomes with a lower total dose of radiotherapy given in fewer, larger daily doses compared with older historical treatment schedules. The National Institute for Health and Care Research Health Technology Assessment Programme-funded FAST-Forward Trial aimed to see whether the number of doses could be reduced further without reducing the beneficial effects of radiotherapy. Between November 2011 and June 2014, 4096 patients agreed to take part in the FAST-Forward Main Trial testing three schedules of radiotherapy to the breast. Standard treatment given on 15 days over 3 weeks (Control Group) was compared with two different lower dose schedules where treatment was given on 5 days over 1 week (lower dose Test Groups). An additional 469 patients entered a sub-study where the gland area under the arm also received radiotherapy (Nodal Sub-Study). Main Trial 5-year results reported in April 2020 showed that the number of patients whose cancer had returned in the treated breast was low in all groups: around 2 in 100 (2.1%) for the Control Group, and 1.7% in the higher dose and 1.4% in the lower dose Test Groups. The majority of reported side effects assessed by patients and doctors up to 5 years after radiotherapy were mild for all treatment groups. Patients in the Control Group and in the lower dose Test Group experienced similar levels of side effects. More side effects were reported in the higher dose Test Group, although differences were small. Overall, the FAST-Forward findings suggest that the lower dose 1-week schedule gave similar results in terms of the cancer returning and side effects to the standard 3-week treatment and this schedule can now be used to help treat future patients.

Effect of CDC adjustment of state-reported data on community water fluoridation statistics.

OBJECTIVES: Advancing community water fluoridation (CWF) coverage is a national health objective. The Centers for Disease Control and Prevention began adjusting state-reported data to calculate CWF coverage in 2012, and then modified methods in 2016. We evaluate improvements attributable to data adjustment and implications for interpreting trends. METHODS: To assess adjustment, we compared the percentage deviation of state-reported data and data adjusted by both methods to the standard estimated by the U.S. Geological Survey. To assess effects on estimated CWF trends, we compared statistics calculated with data adjusted by each method. RESULTS: The 2016 method outperformed on all points of evaluation. The CWF national objective measure (percentage of community water system population receiving fluoridated water) was negligibly affected by method. Percentage of US population receiving fluoridated water was lower with the 2016 method versus the 2012. CONCLUSIONS: Adjustment of state-reported data improved overall quality of CWF coverage measures and had minimal impact on key measures.

CRISPR-Cas9 Long-Read Sequencing for Mapping Transgenes in the Mouse Genome.

Microinjected transgenes, both large and small, are known to insert randomly into the mouse genome. Traditional methods of mapping a transgene are challenging, thus complicating breeding strategies and accurate interpretation of phenotypes, particularly when a transgene disrupts critical coding or noncoding sequences. As the vast majority of transgenic mouse lines remain unmapped, we developed CRISPR-Cas9 Long-Read Sequencing (CRISPR-LRS) to ascertain transgene integration loci. This novel approach mapped a wide size range of transgenes and uncovered more complex transgene-induced host genome re-arrangements than previously appreciated. CRISPR-LRS offers a facile, informative approach to establish robust breeding practices and will enable researchers to study a gene without confounding genetic issues. Finally, CRISPR-LRS will find utility in rapidly and accurately interrogating gene/genome editing fidelity in experimental and clinical settings.

Distributional Cost-Effectiveness Analysis of Health Technologies: Data Requirements and Challenges.

Governments and health technology assessment agencies are putting greater focus on and efforts in understanding and addressing health inequities. Cost-effectiveness analyses are used to evaluate the costs and health gains of different interventions to inform the decision-making process on funding of new treatments. Distributional cost-effectiveness analysis (DCEA) is an extension of cost-effectiveness analysis that quantifies the equity impact of funding new treatments. Key challenges for the routine and consistent implementation of DCEA are the lack of clearly defined equity concerns from decision makers and endorsed measures to define equity subgroups and the availability of evidence that allows analysis of differences in data inputs associated with the equity characteristics of interest. In this article, we detail the data gaps and challenges to build robust DCEA analysis routinely in health technology assessment and suggest actions to overcome these hurdles.

Cost-effectiveness of 5 fraction and partial breast radiotherapy for early breast cancer in the UK: model-based multi-trial analysis.

PURPOSE: We estimated the cost-effectiveness of 4 radiotherapy modalities to treat early breast cancer in the UK. In a subgroup of patients eligible for all modalities, we compared whole-breast (WB) and partial breast (PB) radiotherapy delivered in either 15 (WB15F, PB15F) or 5 fractions (WB5F, PB5F). In a subgroup ineligible for PB radiotherapy, we compared WB15F to WB5F. METHODS: We developed a Markov cohort model to simulate lifetime healthcare costs and quality-adjusted life years (QALYs) for each modality. This was informed by the clinical analysis of two non-inferiority trials (FAST Forward and IMPORT LOW) and supplemented with external literature. The primary analysis assumed that radiotherapy modality influences health only through its impact on locoregional recurrence and radiotherapy-related adverse events. RESULTS: In the primary analysis, PB5F had the least cost and greatest expected QALYs. WB5F had the least cost and the greatest expected QALYs in those only eligible for WB radiotherapy. Applying a cost-effectiveness threshold of £15,000/QALY, there was a 62% chance that PB5F was the cost-effective alternative in the PB eligible group, and there was a 100% chance that WB5F was cost-effective in the subgroup ineligible for PB radiotherapy. CONCLUSIONS: Hypofractionation to 5 fractions and partial breast radiotherapy modalities offer potentially important benefits to the UK health system.

Generation and Comparative Analysis of an Itga8-CreER T2 Mouse with Preferential Activity in Vascular Smooth Muscle Cells.

All current smooth muscle cell (SMC) Cre mice similarly recombine floxed alleles in vascular and visceral SMCs. Here, we present an Itga8-CreER T2 knock-in mouse and compare its activity with a Myh11-CreER T2 mouse. Both Cre drivers demonstrate equivalent recombination in vascular SMCs. However, Myh11-CreER T2 mice, but not Itga8-CreER T2 mice, display high activity in visceral SMC-containing tissues such as intestine, show early tamoxifen-independent activity, and produce high levels of CreERT2 protein. Whereas Myh11-CreER T2 -mediated knockout of serum response factor (Srf) causes a lethal intestinal phenotype precluding analysis of the vasculature, loss of Srf with Itga8-CreER T2 (Srf Itga8 ) yields viable mice with no evidence of intestinal pathology. Male and female Srf Itga8 mice exhibit vascular contractile incompetence, and angiotensin II causes elevated blood pressure in wild type, but not Srf Itga8 , male mice. These findings establish the Itga8-CreER T2 mouse as an alternative to existing SMC Cre mice for unfettered phenotyping of vascular SMCs following selective gene loss.

Mixed-methods feasibility cluster randomised controlled trial of a paramedic-administered breathlessness management intervention for acute-on-chronic breathlessness (BREATHE): study findings.

Introduction: One-fifth of emergency department presentations by ambulance are due to acute-on-chronic breathlessness. We explored the feasibility of an evaluation-phase, cluster randomised controlled trial (cRCT) of the effectiveness and cost-effectiveness of a paramedic-administered, non-pharmacological breathlessness intervention for people with acute-on-chronic breathlessness at ambulance call-out (BREATHE) regarding breathlessness intensity and conveyance to hospital. Methods: This mixed-methods, feasibility cRCT (ISRCTN80330546) randomised paramedics to usual care or intervention plus usual care. Retrospective patient consent to use call-out data (primary end-point) and prospective patient/carer consent for follow-up was sought. Potential primary outcomes included breathlessness intensity (numerical rating scale) and conveyance. Follow-up included: interviews with patients/carers and questionnaires at 14 days, 1 and 6 months; paramedic focus groups and surveys. Results: Recruitment was during COVID-19, with high demands on paramedics and fewer call-outs by eligible patients. We enrolled 29 paramedics; nine withdrew. Randomisation/trial procedures were acceptable. Paramedics recruited 13 patients, not meeting recruitment target (n=36); eight patients and three carers were followed-up. Data quality was good but insufficient for future sample size estimation. The intervention did not extend call-out time, was delivered with fidelity and was acceptable to patients, carers and paramedics. There were no repeat call-outs within 48 h. All trained paramedics strongly recommended BREATHE as a highly relevant, simple intervention. Conclusion: Patient recruitment to target was not feasible during the pandemic. Training and intervention were acceptable and delivered with fidelity. Results include valuable information on recruitment, consent, attrition and data collection that will inform the design and delivery of a definitive trial.

Impact of school sealant programs on oral health among youth and identification of potential barriers to implementation.

BACKGROUND: School sealant programs (SSPs) increase sealant prevalence among children lacking access to oral health care. SSPs, however, are substantially underused. From 2013 through 2018, the Centers for Disease Control and Prevention funded 18 states for SSP activities in high-need schools (≥ 50% free and reduced-price meal program participation). From 2019 through 2020, the authors assessed SSPs' impact in reducing caries and how states expanded SSPs. The authors also discuss potential barriers to expansion. METHODS: For Aim 1, the authors used a published methodology and SSP baseline screening and 1-year retention data to estimate averted caries over 9 years attributable to SSPs. For Aim 2, the authors used state responses to an online survey, phone interviews, and annual administrative reports. RESULTS: Using data for 62,750 children attending 18.6% of high-need schools in 16 states, the authors estimated that 7.5% of sound, unsealed molars would develop caries annually without sealants and placing 4 sealants would prevent caries in 1 molar. Fourteen states reported SSP expansion in high-need schools. The 2 most frequently reported barriers to SSP expansion were levels of funding and policies requiring dentists to be present at assessment or sealant placement. CONCLUSIONS: The authors found that SSPs typically served children at elevated caries risk and reduced caries. In addition, the authors identified funding levels and policies governing supervision of dental hygienists as possible barriers to SSP expansion. PRACTICAL IMPLICATIONS: Increasing SSP prevalence could reduce caries. Further research on potential barriers to SSP implementation identified in this study could provide critical information for long-term SSP sustainability.

Incorporating Concern for Health Equity Into Resource Allocation Decisions: Development of a Tool and Population-Based Valuation for Uganda.

OBJECTIVES: Health economic analyses that simultaneously address the concerns of increasing population health and reducing health inequalities require information on public preferences for using healthcare resources to reduce health inequalities and how this is valued relative to improving total population health. Previous research has quantified this preference in the form of an inequality aversion parameter in a specified social welfare function. This study aimed to elicit general population's views on health inequality and to estimate an inequality aversion parameter in Uganda. METHODS: Adult respondents from the general population were recruited and interviewed using survey adapted from an existing questionnaire, including trade-off questions between 2 hypothetical healthcare programs. Data on participants' demographic and socioeconomic characteristics and health-related quality of life measured by 5-level version of EQ-5D were collected. RESULTS: A nationally representative sample of 165 participants were included, with mean age of 37.1 years and mean 5-level version of EQ-5D at 0.836. Most respondents indicated willingness to trade-off some total population health to reduce health inequality. Translating the preferences into an Atkinson inequality aversion parameter (14.70) implies that health gain to the poorest 20% of people should be given approximately 6 times the weight of health gains to the richest 20%. CONCLUSIONS: Our study suggests it is feasible to adapt questionnaires of this type for a Ugandan population and this approach could be used to measure public aversion to health inequality in other settings. The elicited inequality aversion parameter can be used to support the assessment of health inequality impact in economic evaluation in Uganda.

Dental health status, use, and insurance coverage among adults with chronic conditions: Implications for medical-dental integration in the United States.

BACKGROUND: The authors examined potential benefits and difficulties in integrating oral health care and medical care for adults with chronic conditions (CCs). METHODS: The authors used National Health and Nutrition Examination Survey 2009-2016 data to estimate crude (age- and sex-standardized) and model-adjusted estimates to examine the association between dental disease (severe tooth loss, untreated caries) and chronic disease (≥ 3 CCs, fair or poor health) and Medical Expenditure Panel Survey 2014-2016 data to estimate crude estimates of past-year medical and dental use and financial access according to CC status. Reported differences are significant at P < .05. RESULTS: National prevalences of reporting fair or poor health and 3 or more CCs were both approximately 15%. Standardized prevalence of dental disease was notably higher among adults reporting CCs than those not reporting. After controlling for covariates, the magnitude of the association was substantially lower, although the association remained significant. Adults with CCs were approximately 50% more likely to report having a past-year medical visit and no dental visit than those not reporting CCs. Among adults reporting CCs, prevalence of having no private dental insurance and low income was approximately 20% and 60% higher, respectively, than that among adults not reporting CCs. CONCLUSIONS: Adults with CCs had higher prevalence of dental disease, past-year medical visit and no dental visit, and limited financial access. PRACTICAL IMPLICATIONS: Medical visits may be the only opportunity to provide dental education and referrals to adults with CCs. Improved medical-dental integration could improve oral health care access and oral health among these adults who are at higher risk of dental disease.

Informing decisions with disparate stakeholders: cross-sector evaluation of cash transfers in Malawi.

The Social Cash Transfer Programme (SCTP) in Malawi is a cross-sectoral policy with impacts on health, education, nutrition, agriculture and welfare. Implementation of the SCTP requires collaboration across sectors and across national and international stakeholders. Economic evaluation can inform investment by indicating whether benefits exceed costs, but economic evaluations that provide an overall benefit-cost ratio typically assume a common agreed objective and agreed set of value judgements. In reality, the various stakeholders involved in the delivery of the SCTP may have different remits and objectives and may differ in how they value the impacts of the programme. We use the SCTP as a case study to illustrate a cross-sectoral analytical framework that accounts for these differences. The stakeholders that contribute to the SCTP include the Ministry of Gender, Ministry of Finance, Ministry of Economic Planning and Development and Global Fund. We estimate how the SCTP changes outcomes in education, health, net production and poverty, and distinguish outcomes in three groups: SCTP recipients; population in Malawi not eligible for the SCTP and population in other countries. After estimating the direct effects and opportunity costs from investing in the SCTP, we summarize the results according to different perspectives. The SCTP is estimated to provide benefits in excess of costs from the perspective of national stakeholders. From the perspective of an international donor interested in health outcomes, its health benefits do not outweigh the opportunity costs unless health improvement in SCTP recipients is valued at 18 times that of other potential spending beneficiaries or the donor values broader outcomes than health alone. This work illustrates the potential of a cross-sectoral economic evaluation to guide debate about stakeholder contributions to the SCTP, and the value judgements required to favour the SCTP above other policy options.

Developing the EQ-5D-5L Value Set for Uganda Using the 'Lite' Protocol.

OBJECTIVE: A 'lite' version of the EQ-5D-5L valuation protocol, which requires a smaller sample by collecting more data from each participant, was proposed and used to develop an EQ-5D-5L value set for Uganda. METHODS: Adult respondents from the general Ugandan population were quota sampled based on age and sex. Eligible participants were asked to complete 20 composite time trade-off tasks in the tablet-assisted personal interviews using the offline EuroQol Portable Valuation Technology software under routine quality control. No discrete choice experiment task was administered. The composite time trade-off data were modelled using four additive and two multiplicative regression models. Model performance was evaluated based on face validity, prediction accuracy in cross-validation and in predicting mild health states. The final value set was generated using the best-performing model. RESULTS: A representative sample (N = 545) participated in this study. Responses to composite time trade-off tasks from 492 participants were included in the primary analysis. All models showed face validity and generated comparable prediction accuracy. The Tobit model with constrained intercepts and corrected for heteroscedasticity was considered the preferred model for the value set on the basis of better performance. The value set ranges from - 1.116 (state 55555) to 1 (state 11111) with 'pain/discomfort' as the most important dimension. CONCLUSIONS: This is the first EQ-5D-5L valuation study using a 'lite' protocol involving composite time trade-off data only. Our results suggest its feasibility in resource-constrained settings. The established EQ-5D-5L value set for Uganda is expected to be used for economic evaluations and decision making in Uganda and the East Africa region.

Program Evaluation of Population- and System-Level Policies: Evidence for Decision Making.

BACKGROUND: Policy evaluations often focus on ex post estimation of causal effects on short-term surrogate outcomes. The value of such information is limited for decision making, as the failure to reflect policy-relevant outcomes and disregard for opportunity costs prohibits the assessment of value for money. Further, these evaluations do not always consider all relevant evidence, other courses of action, or decision uncertainty. METHODS: In this article, we explore how policy evaluation could better meet the needs of decision making. We begin by defining the evidence required to inform decision making. We then conduct a literature review of challenges in evaluating policies. Finally, we highlight potential methods available to help address these challenges. RESULTS: The evidence required to inform decision making includes the impacts on the policy-relevant outcomes, the costs and associated opportunity costs, and the consequences of uncertainty. Challenges in evaluating health policies are described using 8 categories: 1) valuation space; 2) comparators; 3) time of evaluation; 4) mechanisms of action; 5) effects; 6) resources, constraints, and opportunity costs; 7) fidelity, adaptation, and level of implementation; and 8) generalizability and external validity. Methods from a broad set of disciplines are available to improve policy evaluation, relating to causal inference, decision-analytic modeling, theory of change, realist evaluation, and structured expert elicitation. LIMITATIONS: The targeted review may not identify all possible challenges, and the methods covered are not exhaustive. CONCLUSIONS: Evaluations should provide appropriate evidence to inform decision making. There are challenges in evaluating policies, but methods from multiple disciplines are available to address these challenges. IMPLICATIONS: Evaluators need to carefully consider the decision being informed, the necessary evidence to inform it, and the appropriate methods.[Box: see text].

Incorporating health inequality impact into economic evaluation in low- and middle-income countries: a systematic review.

INTRODUCTION: As well as improving population health, promoting equity in health is one of the key goals of health policy in low- and middle-income countries (LMICs). However, it is less clear how equity is defined, or how it may impact on resource allocation decisions. We investigated the degree to which health inequalities have been considered in economic evaluation of health interventions in LMICs, and what demographic or socioeconomic characteristics were used to define equity relevant subgroups. AREAS COVERED: We reviewed publications since 2010 from three main databases following the search strategy developed by including the key terms 'health inequalities/health disparities/health equity,' 'economics' and 'low- and middle-income countries' in the title or abstract. Twelve studies were identified, mainly focusing on interventions for the more vulnerable groups such as children and women. EXPERT OPINION: Some attempts have been made to assess interventions' impact on health inequality and there is increasing interest in evaluating it, although research in this area is lacking. Population subgroups highlighted in the included studies were those differing in socioeconomic status. Most studies reported the results across subgroups to illustrate inequality impact, and the newly developed methods, extended cost-effectiveness analysis and distributional cost-effectiveness analysis, have also been applied.

Uncertainty Analysis in Intervention Impact on Health Inequality for Resource Allocation Decisions.

Cost-effectiveness analysis, routinely used in health care to inform funding decisions, can be extended to consider impact on health inequality. Distributional cost-effectiveness analysis (DCEA) incorporates socioeconomic differences in model parameters to capture how an intervention would affect both overall population health and differences in health between population groups. In DCEA, uncertainty analysis can consider the decision uncertainty around on both impacts (i.e., the probability that an intervention will increase overall health and the probability that it will reduce inequality). Using an illustrative example assessing smoking cessation interventions (2 active interventions and a "no-intervention" arm), we demonstrate how the uncertainty analysis could be conducted in DCEA to inform policy recommendations. We perform value of information (VOI) analysis and analysis of covariance (ANCOVA) to identify what additional evidence would add most value to the level of confidence in the DCEA results. The analyses were conducted for both national and local authority-level decisions to explore whether the conclusions about decision uncertainty based on the national-level estimates could inform local policy. For the comparisons between active interventions and "no intervention," there was no uncertainty that providing the smoking cessation intervention would increase overall health but increase inequality. However, there was uncertainty in the direction of both impacts when comparing between the 2 active interventions. VOI and ANCOVA show that uncertainty in socioeconomic differences in intervention effectiveness and uptake contributes most to the uncertainty in the DCEA results. This suggests potential value of collecting additional evidence on intervention-related inequalities for this evaluation. We also found different levels of decision uncertainty between settings, implying that different types and levels of additional evidence are required for decisions in different localities.