COVID-19 health policy evaluation: integrating health and economic perspectives with a data envelopment analysis approach

The COVID-19 pandemic is a global challenge to humankind. To improve the knowledge regarding relevant, efficient and effective COVID-19 measures in health policy, this paper applies a multi-criteria evaluation approach with population, health care, and economic datasets from 19 countries within the OECD. The comparative investigation was based on a Data Envelopment Analysis approach as an efficiency measurement method. Results indicate that on the one hand, factors like population size, population density, and country development stage, did not play a major role in successful pandemic management. On the other hand, pre-pandemic healthcare system policies were decisive. Healthcare systems with a primary care orientation and a high proportion of primary care doctors compared to specialists were found to be more efficient than systems with a medium level of resources that were partly financed through public funding and characterized by a high level of access regulation. Roughly two weeks after the introduction of ad hoc measures, e.g., lockdowns and quarantine policies, we did not observe a direct impact on country-level healthcare efficiency, while delayed lockdowns led to significantly lower efficiency levels during the first COVID-19 wave in 2020. From an economic perspective, strategies without general lockdowns were identified as a more efficient strategy than the full lockdown strategy. Additionally, governmental support of short-term work is promising. Improving the efficiency of COVID-19 countermeasures is crucial in saving as many lives as possible with limited resources.

Can competition improve hospital quality of care? A difference-in-differences approach to evaluate the effect of increasing quality transparency on hospital quality

Public reporting on the quality of care is intended to guide patients to the provider with the highest quality and to stimulate a fair competition on quality. We apply a difference-in-differences design to test whether hospital quality has improved more in markets that are more competitive after the first public release of performance data in Germany in 2008. Panel data from 947 hospitals from 2006 to 2010 are used. Due to the high complexity of the treatment of stroke patients, we approximate general hospital quality by the 30-day risk-adjusted mortality rate for stroke treatment. Market structure is measured (comparatively) by the Herfindahl–Hirschman index (HHI) and by the number of hospitals in the relevant market. Predicted market shares based on exogenous variables only are used to compute the HHI to allow a causal interpretation of the reform effect. A homogenous positive effect of competition on quality of care is found. This effect is mainly driven by the response of non-profit hospitals that have a narrow range of services and private for-profit hospitals with a medium range of services. The results highlight the relevance of outcome transparency to enhance hospital quality competition.

Measuring the acceptability of EQ-5D-3L health states for different ages: a new adaptive survey methodology

Background Acceptable health and sufficientarianism are emerging concepts in health resource allocation. We defined acceptability as the proportion of the general population who consider a health state acceptable for a given age. Previous studies surveyed the acceptability of health problems separately per EQ-5D-3L domain, while the acceptability of health states with co-occurring problems was barely explored. Objective To quantify the acceptability of 243 EQ-5D-3L health states for six ages from 30 to 80 years: 1458 health state–age combinations (HAcs), denoted as the acceptability set of EQ-5D-3L. Methods In 2019, an online representative survey was conducted in the Hungarian general population. We developed a novel adaptive survey algorithm and a matching statistical measurement model. The acceptability of problems was evaluated separately per EQ-5D-3L domain, followed by joint evaluation of up to 15 HAcs. The selection of HAcs depended on respondents’ previous responses. We used an empirical Bayes measurement model to estimate the full acceptability set. Results 1375 respondents (female: 50.7%) were included with mean (SD) age of 46.7 (14.6) years. We demonstrated that single problems that were acceptable separately for a given age were less acceptable when co-occurring jointly (p < 0.001). For 30 years of age, EQ-5D-3L health states of ‘11112’ (11.9%) and ‘33333’ (1%), while for 80 years of age ‘21111’ (93.3%) and ‘33333’ (7.4%) had highest and lowest acceptability (% of population), respectively. Conclusion The acceptability set of EQ-5D-3L quantifies societal preferences concerning age and disease severity. Its measurement profiles and potential role in health resource allocation needs further exploration.

Cost-effectiveness of screening smokers and ex-smokers for lung cancer in the Netherlands in different age groups

Objective We aimed to assess the cost-effectiveness of screening smokers and ex-smokers for lung cancer in the Netherlands. Methods A Markov model was used to evaluate the health effects and costs of lung cancer screening from the healthcare perspective. The effects and costs of ten screening scenarios with different start and stop ages of screening were examined across a lifetime horizon in a cohort of 100,000 smokers and ex- smokers 50 years and older. Results The incremental cost-effectiveness ratios (ICERs) of screening smokers and ex-smokers aged 50–60 years, 50–70 years, and 50 years and older are below the cost-effectiveness threshold of € 20,000 per quality adjusted life year (QALY) gained. Screening 50–60-year-old smokers and ex-smokers was the most cost-effective scenario with an ICER of € 14,094 per QALY gained. However, screening smokers and ex-smokers 50 years and older yielded the highest QALYs and resulted in an ICER of € 16,594 per QALY, which is below the threshold of € 20,000 per QALY. All screening scenarios compared to no screening resulted in CERs between the € 14,000 and € 16,000 per QALY gained. The efficiency frontier showed that screening smokers and ex-smokers in the age groups 70 years and older, 60–70 years, 60 years and older are excluded by extended dominance by no screening, screening smokers and ex-smokers aged 50–60 years and 50–70 years. Conclusion This study showed that lung cancer screening is cost-effective in the Netherlands.

Probabilistic microsimulation to examine the cost-effectiveness of hospital admission screening strategies for carbapenemase-producing enterobacteriaceae (CPE) in the United Kingdom

Background Antimicrobial resistance has been recognised as a global threat with carbapenemase- producing-Enterobacteriaceae (CPE) as a prime example. CPE has similarities to COVID-19 where asymptomatic patients may be colonised representing a source for onward transmission. There are limited treatment options for CPE infection leading to poor outcomes and increased costs. Admission screening can prevent cross-transmission by pre-emptively isolating colonised patients. Objective We assess the relative cost-effectiveness of screening programmes compared with no- screening. Methods A microsimulation parameterised with NHS Scotland date was used to model scenarios of the prevalence of CPE colonised patients on admission. Screening strategies were (a) two-step screening involving a clinical risk assessment (CRA) checklist followed by microbiological testing of high-risk patients; and (b) universal screening. Strategies were considered with either culture or polymerase chain reaction (PCR) tests. All costs were reported in 2019 UK pounds with a healthcare system perspective. Results In the low prevalence scenario, no screening had the highest probability of cost-effectiveness. Among screening strategies, the two CRA screening options were the most likely to be cost-effective. Screening was more likely to be cost-effective than no screening in the prevalence of 1 CPE colonised in 500 admitted patients or more. There was substantial uncertainty with the probabilities rarely exceeding 40% and similar results between strategies. Screening reduced non-isolated bed-days and CPE colonisation. The cost of screening was low in relation to total costs. Conclusion The specificity of the CRA checklist was the parameter with the highest impact on the cost-effectiveness. Further primary data collection is needed to build models with less uncertainty in the parameters.

Modelling decay in effectiveness for evaluation of behaviour change interventions: a tutorial for public health economists

Background and purpose Recent methodological reviews of evaluations of behaviour change interventions in public health have highlighted that the decay in effectiveness over time has been mostly overlooked, potentially leading to suboptimal decision-making. While, in principle, discrete-time Markov chains—the most commonly used modelling approach—can be adapted to account for decay in effectiveness, this framework inherently lends itself to strong model simplifications. The application of formal and more appropriate modelling approaches has been supported, but limited progress has been made to date. The purpose of this paper is to encourage this shift by offering a practical guide on how to model decay in effectiveness using a continuous-time Markov chain (CTMC)-based approach. Methods A CTMC approach is demonstrated, with a contextualized tutorial being presented to facilitate learning and uptake. A worked example based on the stylized case study in physical activity promotion is illustrated with accompanying R code. Discussion The proposed framework presents a relatively small incremental change from the current modelling practice. CTMC represents a technical solution which, in absence of relevant data, allows for formally testing the sensitivity of results to assumptions regarding the long-term sustainability of intervention effects and improving model transparency. Conclusions The use of CTMC should be considered in evaluations where decay in effectiveness is likely to be a key factor to consider. This would enable more robust model-based evaluations of population-level programmes to promote behaviour change and reduce the uncertainty surrounding the decision to invest in these public health interventions.

Value appropriation in hepatitis C

Background In 2015, the Swedish government in an unprecedented move decided to allocate 150 million € to provide funding for new drugs for hepatitis C. This was triggered by the introduction of the first second generation of direct-acting antivirals (DAAs) promising higher cure rates and reduced side effects. The drugs were cost-effective but had a prohibitive budget impact. Subsequently, additional products have entered the market leading to reduction in prices and expansions of the eligible patient base. Methods We estimated the social surplus generated by the new DAAs in Stockholm, Sweden, for the years 2014–2019. The actual use and cost of the drugs was based on registry data. Effects on future health care costs, indirect costs and QALY gains were estimated using a Markov model based primarily on Swedish data and using previous generations of interferon-based therapies as the counterfactual. Results A considerable social surplus was generated, 15% of which was appropriated by the producers whose share fell rapidly over time as prices fell. Most of the consumer surplus was generated by QALY gains, although 10% was from reduced indirect costs. QALY gains increased less rapidly than the number of treated patients as the eligibility criteria was loosened. Conclusions The transfer of funds from the government to the regions helped generate substantial surplus for both consumers and producers with indirect costs playing an important role. The funding model may serve as a model for the financing of innovative treatments in the future.