Methods for the economic evaluation of changes to the organisation and delivery of health services: principal challenges and recommendations

Abstract

There is a requirement for economic evaluation of health technologies seeking public funding across Europe. Changes to the organisation and delivery of health services, including changes to health policy, are not covered by such appraisals. These changes also have consequences for National Health Service (NHS) funds, yet undergo no mandatory cost-effectiveness assessment. The focus on health technologies may have occurred because larger-scale service changes pose more complex challenges to evaluators. This paper discusses the principal challenges faced when performing economic evaluations of changes to the organisation and delivery of health services and provides recommendations for overcoming them. The five principal challenges identified are as follows: undertaking ex-ante evaluation; evaluating impacts in terms of quality-adjusted life years; assessing costs and opportunity costs; accounting for spillover effects; and generalisability. Of these challenges, methods for estimating the impact on costs and quality-adjusted life years are those most in need of development. Methods are available for ex-ante evaluation, assessing opportunity costs and examining generalisability. However, these are rarely applied in practice. The general principles of assessing the cost-effectiveness of interventions should be applied to all NHS spending, not just that involving health technologies. Advancements in this area have the potential to improve the allocation of scarce NHS resources.

Cost and effects of integrated care: a systematic literature review and meta-analysis

“…The results indicate that integrated care was associated with lower costs and improved outcomes compared with usual care, especially in studies with a follow-up period over a year. This may reflect the need for a sufficiently long follow-up period for effects to emerge, especially if there is a learning period following implementation [ 85 ]. In addition, studies with an extended follow-up period are more likely to capture long-term reductions in cost that may negate and surpass the initial investment in developing and implementing integrated care [ 86 ].…”

Conducting Value for Money Analyses for Non-randomised Interventional Studies Including Service Evaluations: An Educational Review with Recommendations

“…NICE's processes and guidelines have influenced reimbursement agencies internationally specific to their HTA processes [4,5]. However, such guidelines have been described to not always be practical nor relevant in every decision-making context [33,[35][36][37][38][39][40][41][42][43][44]. Such guidelines may also align more with research practices than service evaluations, whereby the former could include conducting expensive RCTs whereas the latter may be a more 'budget and time' conscious approach.…”

“…This is partly because it is NICE's 'gold standard' reference case, with NICE's guidelines [3] informing HTA processes internationally [4]. There are several papers debating the extent that economic evaluations of different forms of interventions fit a typical HTA [33,34], such that current guidelines may not be fully applicable, including: public health [35][36][37], antimicrobials [38], diagnostics [39], medical devices [40], genetics [41], digital [42], environmental [43], and service and delivery interventions [33,44]. Whatever the intervention of interest, Drummond et al [26] suggest that an economic evaluation would "explicitly consider the relative consequences of the alternatives and compare them with the relative costs" (p. 5).…”

The use of evaluation methods for the overall assessment of health policy: potential and limitations

“…These processes can hardly be considered as an equivalent of evaluation, mainly due to a different reference point (as in the case of impact assessment) or unstructured nature (as in the case of expert consultations, often not requiring them to apply a methodical approach). In international literature, the prospective evaluation procedure usually occurs in the context of investment decisions or research projects [24,25]. The subject literature also lacks studies that would indicate the limitations of this type of evaluation while being used in health policy.…”