QALYs and the capability approach
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This explores the applicability of Sen's capability approach to the economic evaluation of health care programmes. An individual's capability set describes his freedom to choose valuable activities and states of being (functionings). Direct estimation and valuation of capability sets is not feasible at present. Standard preference-based methods such as willingness to pay are feasible, but problematic due to the adaptive and constructed nature of individual preferences over time and under uncertainty. An alternative is to re-interpret the QALY as a cardinal and interpersonally comparable index of the value of the individual's capability set. This approach has limitations, since the link between QALYs and capabilities is not straightforward. Nevertheless, the QALY approach is recognisable as an application of the capability approach since it pays close attention to functionings, through the use of survey-based multi-attribute health state valuation instruments, and permits conceptions of value other than the traditional utilitarian ones of choice, desire-fulfilment and happiness. Furthermore, suitably re-interpreted, it can account for (i) non-separability between health and non-health components of value; and suitably modified it can also account for (ii) process attributes of care, which may have a direct effect on non-health functionings such as comfort and dignity, and (iii) sub-group diversity in the value of the same health functionings.
Using Evidence in the development of local health policies
M. Drummond, D.H. Smith et H. Weatherly
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Objectives: This paper explores the use of evidence, focusing on economic evidence in particular, in
the development of local health policies through an in-depth study of Health Improvement Programmes
(HImPs) in England.
Methods: A questionnaire was sent to the person responsible for coordinating the development of the
HImP in each of the 102 English health authorities. In addition, semi-structured interviews were conducted
with 10 HImP leaders, and a random sample of 26 HImP documents was reviewed using a
standard pro forma.
Results: Of the 102 mail questionnaires sent out, 68 (67%) were returned. It was found that those
developing HImPs had multiple objectives, only some of which (e.g., efficiency in healthcare provision)
would necessarily require evidence.Where evidence was used, this was a mixture of internal (experiential)
and external (empirical) evidence, with the balance (66%) being in favor of the latter. Government
reports and guidance from the National Institute for Clinical Excellence (NICE), were the main sources
of external evidence, rather than published papers. Key barriers to the use of economic evidence were
lack of time and availability and the difficulties in synthesizing information at the local level.
Conclusions: Based on responses to our survey, the main ways of increasing the use of evidence in the
development of local health policies in England are to produce more evidence-based national guidance
and to produce accessible summaries of the available literature for local decision makers.
Resource use data by patient report or hospital records: Do they agree?
James Campbell, Adrian Grant, Andrew D.M. Kennedy, Anne P. Leigh-Brown et David J. Torgerson
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Economic evaluations alongside clinical trials are becoming increasingly common. Cost data are often collected through the use of postal questionnaires; however, the accuracy of this method is uncertain. We compared postal questionnaires with hospital records for collecting data on physiotherapy service use.
As part of a randomised trial of orthopaedic medicine compared with orthopaedic surgery we collected physiotherapy use data on a group of patients from retrospective postal questionnaires and from hospital records.
315 patients were referred for physiotherapy. Hospital data on attendances was available for 30% (n = 96), compared with 48% (n = 150) of patients completing questionnaire data (95% Cl for difference = 10% to 24%); 19% (n = 59) had data available from both sources. The two methods produced an intraclass correlation coefficient of 0.54 (95% Cl 0.31 to 0.70). However, the two methods produced significantly different estimates of resource use with patient self report recalling a mean of 1.3 extra visits (95% Cl 0.4 to 2.2) compared with hospital records.
Using questionnaires in this study produced data on a greater number of patients compared with examination of hospital records. However, the two data sources did differ in the quantity of physiotherapy used and this should be taken into account in any analysis.
Logical inconsistencies in survey respondents' health state valuations - a methodological challenge for estimating social tariffs
N.J. Devlin, P. Hansen, Paul Kind et A. Williams
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Logical inconsistencies in survey respondents' valuations of hypothetical health states - represented by the EQ-5D, for example - present a conundrum as to whether or not their responses ought to be included for estimating social tariffs. A logical inconsistency occurs when a state that in logical terms is unambiguously less severe than another is assigned a lower value. Excluding such responses is defensible on data quality grounds but puts at risk the representativeness of the estimated tariff, given it is meant to represent the preferences of society. This paper explores the rationale for and effect of excluding, to varying degrees, responses distinguished by the number of pairwise inconsistencies they contain, and reports equations for two tariffs that arise from contrasting approaches. The data are from a random sample of adult New Zealanders whose visual analogue scale valuations for a selection of EQ-5D states were collected in 1999 via a postal survey to which 1360 people responded (a 50% response rate). We conclude that there is no simple, generalisable rule to guide exclusions and therefore researchers ought to explore the sensitivity of their estimated tariffs (and ultimately QALY estimates) to alternative treatments of logically inconsistent responses.
Optometrist prescribing of therapeutic agents: findings of the AESOP survey
J. Mason et A.R. Mason
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Throughout the USA and in some parts of Australia and Canada, licensed optometrists may prescribe therapeutic agents for certain eye conditions. However, this role is not currently available to European optometrists. The extension of prescribing rights to new professional groups was the subject of a UK government-commissioned review, which cited optometrists as potential candidates. A recent literature review found limited evidence to assess the appropriateness of eye care delivered by different health care providers. To inform the UK decision, we therefore conducted a national postal survey to explore how optometric practice might change with the introduction of therapeutic prescribing. The Anonymous Enquiry of the Scope for Optometrist Prescribing (AESOP), was sent to a random 10% sample of registered optometrists. Over 80% of respondents indicated that optometrists should be able to train as therapeutic prescribers. Most respondents were willing to undergo training, periodic re-accreditation and continuing education, as well to participate in simple professional audit of their prescribing. Respondents anticipated that referrals to general practitioners (GPs) would be reduced by nearly 40% and to ophthalmologists via a GP by nearly 20%. Optometrist participation could increase patient access to therapeutic ocular care by between 29% and 50%. Authorising UK optometrists to prescribe therapeutically for eye diseases would appear to make good use of their existing skills and improve patient access to eye care, while relieving pressures upon other healthcare providers. Tentative economic analysis suggests that the introduction of independent optometrist prescribing may be cost neutral. However, adequate comparative research on the performance of optometrists as prescribers is needed and the issue of reimbursement will require careful consideration.
Equity of access to health care services: theory and evidence from the UK
M. Goddard et P. Smith
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The pursuit of equity of access to health care is a central objective of many health care systems. This paper first sets out a general theoretical framework within which equity of access can be examined. It then applies the framework by examining the extent to which research evidence has been able to detect systematic inequities of access in UK, where equity of access has been a central focus in the National Health Service since its inception in 1948. Inequity between socio-economic groups is used as an illustrative example, and the extent of inequity of access experienced is explored in each of five service areas: general practitioner consultations; acute hospital care; mental health services; preventative medicine and health promotion; and long-term health care. The paper concludes that there appear to be important inequities in access to some types of health care in the UK, but that the evidence is often methodologically inadequate, making it difficult to draw firm conclusions. In particular, it is difficult to establish the causes of inequities which in turn limits the scope for recommending appropriate policy to reduce inequities of access. The theoretical framework and the lessons learned from the UK are of direct relevance to researchers from other countries seeking to examine equity of access in a wide variety of institutional settings.
The UK NHS Economic Evaluation Database: Economic: Issues in evaluations of health technology
J. Christie, M. Drummond, J.M. Glanville, J. Kleijnen, J. Nixon et B. Stoykova
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OBJECTIVE: The U.K. NHS Economic Evaluation Database (EED) project is commissioned to identify
papers on economic evaluations of health technologies and to disseminate their findings to NHS decision
makers by means of structured abstracts that are available through a public database and the Cochrane
Library. This paper discusses current issues relating to the economic aspects of producing NHS EED
METHODS: A review of NHS EED was undertaken between 1994 and 1999 to determine the methodologies
adopted and issues that influence the usefulness of economic evaluations. Methods adopted to
improve the quality of NHS EED abstracts are also reported.
RESULTS: Eighty-five percent of NHS EED abstracts are cost-effectiveness analyses (CEAs), 9.3% are
cost-utility analyses (CUAs), and only 1.4% are cost-benefit analyses (CBAs). Of the total abstracts,
65.9% are based on single studies, 19.5% on reviews, 3.9% on estimates of effectiveness, and 10.7%
on combinations of these sources. Models are utilized in 16.7% of CEAs, 60.2% of CUAs, and 20% of
CBAs. Analyses of CBA studies reveal a degree of misuse of well-established definitions. NHS EED
internal control mechanisms are reported that provide a means of ensuring that abstracts are based on
sound academic principles.
CONCLUSIONS: Most economic evaluations are conducted by means of CEA, followed by CUA, while
CBA accounts for an extreme minority of cases. Single studies form the principal source of effectiveness
data, although models are widely used, principally in CUA. The structure of NHS EED abstracts provides
decision makers with the principal results and an interpretation of the relative strengths and weaknesses
of economic evaluations.