Use of health economic evaluation in the implementation and improvement science fields—a systematic literature review

Abstract

Background Economic evaluation can inform whether strategies designed to improve the quality of health care delivery and the uptake of evidence-based practices represent a cost-effective use of limited resources. We report a systematic review and critical appraisal of the application of health economic methods in improvement/implementation research. Method A systematic literature search identified 1668 papers across the Agris, Embase, Global Health, HMIC, PsycINFO, Social Policy and Practice, MEDLINE and EconLit databases between 2004 and 2016. Abstracts were screened in Rayyan database, and key data extracted into Microsoft Excel. Evidence was critically appraised using the Quality of Health Economic Studies (QHES) framework. Results Thirty studies were included—all health economic studies that included implementation or improvement as a part of the evaluation. Studies were conducted mostly in Europe (62%) or North America (23%) and were largely hospital-based (70%). The field was split between improvement ( N = 16) and implementation ( N = 14) studies. The most common intervention evaluated (43%) was staffing reconfiguration, specifically changing from physician-led to nurse-led care delivery. Most studies ( N = 19) were ex-post economic evaluations carried out empirically—of those, 17 were cost effectiveness analyses. We found four cost utility analyses that used economic modelling rather than empirical methods. Two cost-consequence analyses were also found. Specific implementation costs considered included costs associated with staff training in new care delivery pathways, the impacts of new processes on patient and carer costs and the costs of developing new care processes/pathways. Over half (55%) of the included studies were rated ‘good’ on QHES. Study quality was boosted through inclusion of appropriate comparators and reporting of incremental analysis (where relevant); and diminished through use of post-hoc subgroup analysis, limited reporting of the handling of uncertainty and justification for choice of discount rates. Conclusions The quantity of published economic evaluations applied to the field of improvement and implementation research remains modest; however, quality is overall good. Implementation and improvement scientists should work closely with health economists to consider costs associated with improvement interventions and their associated implementation strategies. We offer a set of concrete recommendations to facilitate this endeavour.

Costing the implementation of public health interventions in resource-limited settings: a conceptual framework

“…Economic evaluations are frequently used to inform prioritization of health interventions and resource allocation for public health [1]. Unfortunately, most existing economic evaluations of public health interventions have done so retrospectively [2], thereby limiting their ability to fully assess the costs of implementation, especially during the early stages of design and initiation. A growing number of studies are exploring these implementation costs, but many continue to do so in retrospective fashion, and interventions in resource-limited settings-where implementation costs may represent a disproportionate fraction of total intervention costs-are sorely under-represented [2].…”

“…Unfortunately, most existing economic evaluations of public health interventions have done so retrospectively [2], thereby limiting their ability to fully assess the costs of implementation, especially during the early stages of design and initiation. A growing number of studies are exploring these implementation costs, but many continue to do so in retrospective fashion, and interventions in resource-limited settings-where implementation costs may represent a disproportionate fraction of total intervention costs-are sorely under-represented [2]. As such, most published economic evaluations may have greatly underestimated the costs of public health interventions, particularly those studied in resource-limited settings.…”

Excellent multi-stakeholder acceptability and reimbursable costs in a pilot pragmatic trial of an evidence-based physical activity counseling intervention for patients with type 2 diabetes

“…For quantitative implementation outcome assessments, Feasibility included time spent on each counseling call, and the implementation costs per patient counseling call. We considered costs from the perspective of the clinic leader who would decide to adopt Be ACTIVE for a clinic (i.e., intraorganizational health system perspective) (47), and used a time-based activity micro-costing approach (48). Specifically, we aggregated the counseling time required across all participant coaching visits, and translated the time required to deliver a single coaching session into costs as a pro-rated portion of each counselor's salary and benefits.…”

Priority domains, aims, and testable hypotheses for implementation research: Protocol for a scoping review and evidence map

“…Testing the cost-effectiveness of an IS that has been shown to have superior effectiveness, relative to an active-control IS, is termed IR testing an upper right quadrant (URQ) hypothesis. It is considered a priority testable hypothesis for IR as knowing the effectiveness of an intervention/strategy is not su cient for many potential users, especially decision makers who need to know whether the bene ts from the intervention/strategy are commensurate with its costs (i.e., whether it delivers value), [35][36][37][38] Further, noting that economic evaluation of implementation strategies "has been neglected," Foy et al encouraged IR with an economic evaluation component. 22 Building upon Garner et al (2012), 31 which found pay-for-performance to be an effective IS for improving the implementation and effectiveness of A-CRA in a superiority trial, Garner et al (2018) 39 provide an example of IR testing an URQ hypothesis.…”