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Alongside analyses of clinical effectiveness, economic evaluation is increasingly being used as a tool to support the adoption of new healthcare technologies, including novel endovascular techniques. Where budget constraints exist, resource allocation decisions are inevitable and an economic evaluation provides an explicit framework from which to assess the relative benefit of alternative interventions. Methods of economic evaluation differ largely in the perspective taken (i.e. cost-effective for whom?), and the measurement and valuation of outcomes.
Though more often concerned with pharmaceutical interventions, European Health Technology Assessment bodies often recommend the use of cost–utility analyses for economic evaluation. For surgical interventions, these analyses often (though not exclusively) use data generated from randomised controlled trials (RCTs), but it will likely be appropriate to conduct modelling exercises to synthesise data to assess long-term differences in mean per patient cost and effects, reflecting sequelae. Health economists are increasingly involved in RCT design, as it is possible to gather much of the required data to perform an economic evaluation alongside trials through questionnaires and case report forms. Given the methodological considerations required, the incorporation of an economic evaluation should occur early in the design process.
Effectiveness can be characterised in various ways using clinical indicators, but health economists have sought to create generic outcome measures that allow comparison across disease areas. Cost–utility analyses commonly use quality-adjusted life years (QALYs), a composite outcome measure, which reflects both survival and health-related quality of life (HRQoL). HRQoL is often measured using self-reported, pre-scored questionnaires, for which quality of life weights are applied, dependent on patient responses. Generic, well-validated preference-based instruments (such as the EQ5D and SF6D) can be used to generate QALYs.
In economic evaluation, cost refers to the opportunity costs; the forgone benefit of not employing resources elsewhere, and (pragmatically) this often is reflected by prices. Costs included in the analysis may differ depending on the perspective adopted. These may be limited to health service costs only, or include wider societal costs, such as productivity losses and out-of-pocket costs to patients/carers. Any analyses should take a perspective appropriate to the intended audience and the approach should be stated clearly. For surgical interventions, costs usually relate to the inpatient episode, where there is greater potential for differences in resource use (e.g. devices used, clinical staff requirements, time in theatre, patient hospital stay). If appropriate, the long-term sequelae (e.g. hospital re-admissions, utilisation of primary care services) should be considered, as there may be additional resource implications following discharge. Choosing the time horizon over which to assess cost–utility is another important decision and given follow-up constraints of RCTs, economic modelling is often necessary to assess long-term differences in cost and effects.
To accurately reflect differences in the costs of two surgical alternatives, an element of micro costing is usually required, at least for the procedures being compared. This requires the collection of detailed resource use for surgical components at the patient level (e.g. consumables, time in theatre, specific clinical staff costs) to estimate mean costs, often in a subsample of patients. Appropriate unit costs should then be applied to each item of resource use. This may also require accounting considerations; employing appropriate methods to discount future costs, adjusting for capital costs over time, and apportioning overheads. National administrative databases of unit cost data are available and may be especially appropriate for long-term sequelae, such as hospital readmissions. Unit costs can be obtained from existing literature, but their appropriateness needs to be assessed.
Unless dominance is present (one treatment is more effective at lower costs), the results of analyses are presented as the incremental cost per QALY gained. Decision-makers must then assess whether this represents a good use of resources.
The ability to perform a comprehensive evaluation can be limited by availability of data or deemed unsuitable early in the development of a new surgical device/technique, though feasibility can be explored. Several texts are useful for reference and offer a greater level of detail on the use of economic evaluation in health care, comparisons of techniques, study designs, good guidance on gathering HRQoL data, and costing techniques and the necessary components of reporting analyses.
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