(衛(wèi)生經(jīng)濟(jì)學(xué)課件)CEA

1、( (衛(wèi)生經(jīng)濟(jì)學(xué)課件衛(wèi)生經(jīng)濟(jì)學(xué)課件)CEA)CEA7Components of economic evaluation in health careHealth care programResources consumedCost Consequences Health care sector Patient & familyOther sectors Valuation Measurement Identification Resources saved Other value created Health state changed Effects Utility WTP Global W

2、TP Health care sector Patient & familyOther sectors 8Cost-effectiveness analysis Conditions of cost effectiveness analysis What is effectiveness Measure of effectiveness Cost-effectiveness analysis9Conditions of cost effectiveness analysis There is one unambiguous objective of the intervention(s) an

3、d therefore a clear dimension along which effectiveness can be assessed. For example, years of life gained, cases found. There are many objectives, but that the alternative interventions are thought to achieve these to the same extent (cost-minimization analysis). 10What is effectiveness? Effectiven

4、ess is the natural results of a program. it is expressed by natural unit of results, such as life -years saved, cases found, etc.11How to obtain the effectiveness data (1)? Existing medical literature Quality Relevance Case-load, higher selective? Expertise of medical and other staff, double blind?

5、Use placebo? Existence of backup facilities, does the trial require additional tests? Are patients closely monitored?12Levels of evidence and grades of recommendationLevel ofevidenceGrade ofrecommendationLevel ILarge randomised trials withleaver-cut results and low riskof errorGrade ALevel IISmall r

6、andomised trials withuncertain results and moderateto high risk or errorGrade BLevel IIINon-randomised,contemporaneous controlsGrade CLevel IVNon-randomised, historicalcontrolsGrade DLevel VNo controls, case series onlyGrade EAppraisal of the quality of medical evidence13How to deal with more public

7、ations? Meta-analysis or systematic review Principals literature search techniques inclusion/exclusion criteria choice of endpoints records of individual study characteristics details about the therapy tests of statistical homogeneity statistical pooling procedures sensitivity analysis14How to obtai

8、n the effectiveness data (2)? Undertaking economic analysis alongside clinical trials choice of comparison therapy intermediate versus final health outcomes inadequate patient follow-up or sample size protocol-driven costs and outcomes, costs of doing research rather than costs of providing the ther

9、apy clinical trial is usually designed to address safety and efficacy questions, has more strict conditions; however, CEA is to evaluate the costs and effectiveness under the conditions of routine use 15Measure of effectiveness (1) Intermediate health output can project final output Final health out

10、put Linkage of intermediate and final outcomes relative risk observational or case control studies random intervention studies modeling 16Measure of effectiveness (2) Should productivity changes be included? Depend on the viewpoint for the analysis. From a government budget perspective? From a socie

11、tal viewpoint? How to measure the productivity changes by average wage or by gross earnings? Double-counting problem. Less likely in CEA. Equity consideration expressing productivity changes as the number of days of work or normal activity lost or gained, not dollar amount using a general wage rate,

12、 not the actual wages of individuals affected by the programme.17Measure of effectiveness (3) Effectiveness discounting Against: not make sense in the context of health For: leaving effects undiscounted leads to quite impossible conclusions, not reasonable if only discounting costs, not effects. The

13、 current state suggests the effects should be treated in the same way as costs, and discounted at the same rate. So It is advisable to set out all the consequences and costs in the years in which they occur and to present them undiscounted, so that different discount rates can be used.18Cost-effecti

14、veness analysis Cost per unit output Incremental cost-effectiveness analysisProgramme Costs ($)No. of correctdiagnosis$ per correctdiagnosisMethod A3214881422264Method Aplus anothertest if A isnegative6035522013003Increment28206459478119Sensitivity analysis (1) Identify the uncertain parameters a nu

15、mber of sources of uncertainty no data may be available and informed guesses are required imprecise estimation value judgements may be incorporated, e.g. choice of discount rate, etc. generalisability of study results to other settings all variables are potential candidates for sensitivity analysis

16、giving the reasons why particular variables are not included.20Sensitivity analysis (2) Specify the plausible range over which uncertain factors reviewing the literature consulting expert opinion confidence interval around the mean21Sensitivity analysis (3) Calculate study results based on combinati

17、ons of the best guess, most conservative, and least conservative estimates. one-way analysis: to estimate for each parameter multi-way analysis: more than one parameter is uncertain scenario analysis: the best guess scenario, the most optimistic (best case) scenario, the most pessimistic (worst case

18、) scenario. threshold analysis, increasing costs of one or several parameters above which the programme would not be acceptable22Exercise one Suppose one were evaluating two programmes in the field of mental health. One programme requires institutionalisation of the patient for a given period; the other, being a community-based programme using community psychiatric nurses in association with outpatient hospital visits, mean that patients can remain in their own homes. Please identify, measure, value and compare the costs and effectiveness.23Exercise two Assume you ha