This document discusses two projects conducted by NICE to estimate the health inequality impacts of public health interventions:
1. Plotting 134 NICE public health guideline interventions on a "health equity impact plane" based on their incremental population health benefits and reduction in health inequality. 71 interventions improved total health and reduced inequality.
2. A pilot study estimating the distributional cost-effectiveness of smoking cessation interventions. This involved adapting an existing model to incorporate evidence on how inputs like baseline risk, quit rates, and uptake vary by socioeconomic status.
The aggregate approach provides a simple feasible way to consider health inequality, but may miss differential effects. A bespoke approach can better capture differences but requires more data. Overall
Localization of Universal Health Coverage for Equitable Health Outcomes in NepalDeepak Karki
Presentation entitled "Localization of Universal Health Coverage for Equitable Health Outcomes in Nepal" by Dr Shiva Raj Adhikari on the 18th Anniversary of Nepalt Health Economics Association.
Building on the Evidence: Advancing Health Equity for Priority PopulationsWellesley Institute
This presentations offers critical insights on how to advance health equity for priority populations.
Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
With a population of nearly 30 million people, WHO estimates that approximately 13% of the population in Ghana suffer from a mental disorder, of which 3% suffer from a severe mental disorder and the other 10% suffer from a moderate to mild mental disorder (WHO, 2007).
Australia's health system needs to better connect the dots in a number of areas. Our work looks at connections between Australian chronic disease targets and indicators, WHO targets and indicators, and national progress.
Localization of Universal Health Coverage for Equitable Health Outcomes in NepalDeepak Karki
Presentation entitled "Localization of Universal Health Coverage for Equitable Health Outcomes in Nepal" by Dr Shiva Raj Adhikari on the 18th Anniversary of Nepalt Health Economics Association.
Building on the Evidence: Advancing Health Equity for Priority PopulationsWellesley Institute
This presentations offers critical insights on how to advance health equity for priority populations.
Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
With a population of nearly 30 million people, WHO estimates that approximately 13% of the population in Ghana suffer from a mental disorder, of which 3% suffer from a severe mental disorder and the other 10% suffer from a moderate to mild mental disorder (WHO, 2007).
Australia's health system needs to better connect the dots in a number of areas. Our work looks at connections between Australian chronic disease targets and indicators, WHO targets and indicators, and national progress.
Health Equity into Action: Building on Partnerships and CollaborationsWellesley Institute
This presentation offers insight on how to put health equity into action by building on partnerships and collaborations.
Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
Driving Health Equity in Canada: From Strategy to Action and ImpactWellesley Institute
This presentation provides insight on health equity and public action in Canada.
Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
As the burden of NCDs increases, various countries have introduced new and innovative modes of managing them in primary healthcare setting. APO, in conjunction with Duke Kunshan University, China, conducted a 4-country study (Bangladesh, China, Nepal and Viet Nam) to understand the different approaches used in involving CHWs in preventing and managing NCDs. Access full publication here http://bit.ly/2XnWwcd
This presentation offers insight on how to build health equity.
Dr. Cory Neudorf
CMHO, Saskatoon Health Region
Assistant Professor at the University of Saskatoon
Overview of tackling non-communicable diseases in EnglandDr Justin Varney
A presentation I gave in 2014 to a senior delegation of officials from Iraq on our approach in England to addressing the challenge of non-communicable disease
Driving Health Equity into Action: The Potential of Health Equity Impact Asse...Wellesley Institute
This presentation provides a critical analysis of the potential of a health equity impact assessment.
Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
This second edition of the health system review of Philippines shows the major changes that have occurred over the 7 years since the last review. Channelling of funds from sin tax to Health has shown unprecedented levels of finances are now available for UHC. PhilHealth has dramatically increased coverage of people as well as service providers that it works with from both government and non-government sectors. However major challenges remain; regional and socioeconomic disparities in the availability and accessibility of resources are prominent and there is a need to improve regulation of service providers. Philippines HiT reports on the current health system reforms undertaken including challenges of incorporating primary health care as in the overall health architecture of the country.
In recent years, Ghana, like many other developing countries has been going through an epidemiologic transition where the proportion of deaths from non-communicable diseases is rapidly increasing, particularly cardiovascular related diseases, cancers and diabetes (IHME, 2019).
This is primarily based on a chapter from our most recent publication.
I want to acknowledge the authors of the chapter:
Melisa Tan, Victoria Haldane, Sue-Anne Toh & Helena Legido-Quigley from NUS
Martin McKee from LSHTM
Summary of the current 4 main NCDs situation in Asia including risk factors
Examples of health system response
Challenges
The health system of Bangladesh has undergone a number of reforms and has established an extensive health service infrastructure in both the public and private sectors during the past four decades. Bangladesh has achieved impressive gains in population health, achieving the Millennium Development Goal 4 target of reducing under-five child mortality by two thirds between 1990 and 2015, and improving other key indicators such as maternal mortality, immunization coverage, and survival rates from malaria, tuberculosis, and diarrhoea diseases.
Synopsis: Impact of Health Systems Strengthening on HealthHFG Project
Leaders in low- and middle-income countries (LMICs) require timely and compelling evidence about how to strengthen their health systems to improve the health and well-being of their citizens. Yet, evidence on how to strengthen health system performance to achieve sustainable health improvements at scale, particularly toward Ending Preventable Child and Maternal Deaths (EPCMD), fostering an AIDS-Free Generation (AFG), and Protecting Communities against Infectious Diseases (PCID) is limited. The evidence that does exist is scattered, insufficiently analyzed, and not widely disseminated. Without evidence, decision-makers lack a sound basis for investing scarce health funds in health systems strengthening (HSS) in an environment of competing investment options.
USAID is committed to advancing the evidence base on HSS and this commissioned report clearly demonstrates that HSS can improve health in LMICs.
This report, based on a review of systematic reviews of the effects on health of HSS, presents a significant body of evidence linking HSS interventions to measureable impact on health for vulnerable people in LMICs. Making decisions on who delivers health services and where and how these services are organized is important to achieve priority health goals such as EPCMD, AFG, and PCID. The findings of this report document the value of investing in HSS.
Health Equity into Action: Building on Partnerships and CollaborationsWellesley Institute
This presentation offers insight on how to put health equity into action by building on partnerships and collaborations.
Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
Driving Health Equity in Canada: From Strategy to Action and ImpactWellesley Institute
This presentation provides insight on health equity and public action in Canada.
Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
As the burden of NCDs increases, various countries have introduced new and innovative modes of managing them in primary healthcare setting. APO, in conjunction with Duke Kunshan University, China, conducted a 4-country study (Bangladesh, China, Nepal and Viet Nam) to understand the different approaches used in involving CHWs in preventing and managing NCDs. Access full publication here http://bit.ly/2XnWwcd
This presentation offers insight on how to build health equity.
Dr. Cory Neudorf
CMHO, Saskatoon Health Region
Assistant Professor at the University of Saskatoon
Overview of tackling non-communicable diseases in EnglandDr Justin Varney
A presentation I gave in 2014 to a senior delegation of officials from Iraq on our approach in England to addressing the challenge of non-communicable disease
Driving Health Equity into Action: The Potential of Health Equity Impact Asse...Wellesley Institute
This presentation provides a critical analysis of the potential of a health equity impact assessment.
Bob Gardner, Director of Policy
www.wellesleyinstitute.com
Follow us on twitter @wellesleyWI
This second edition of the health system review of Philippines shows the major changes that have occurred over the 7 years since the last review. Channelling of funds from sin tax to Health has shown unprecedented levels of finances are now available for UHC. PhilHealth has dramatically increased coverage of people as well as service providers that it works with from both government and non-government sectors. However major challenges remain; regional and socioeconomic disparities in the availability and accessibility of resources are prominent and there is a need to improve regulation of service providers. Philippines HiT reports on the current health system reforms undertaken including challenges of incorporating primary health care as in the overall health architecture of the country.
In recent years, Ghana, like many other developing countries has been going through an epidemiologic transition where the proportion of deaths from non-communicable diseases is rapidly increasing, particularly cardiovascular related diseases, cancers and diabetes (IHME, 2019).
This is primarily based on a chapter from our most recent publication.
I want to acknowledge the authors of the chapter:
Melisa Tan, Victoria Haldane, Sue-Anne Toh & Helena Legido-Quigley from NUS
Martin McKee from LSHTM
Summary of the current 4 main NCDs situation in Asia including risk factors
Examples of health system response
Challenges
The health system of Bangladesh has undergone a number of reforms and has established an extensive health service infrastructure in both the public and private sectors during the past four decades. Bangladesh has achieved impressive gains in population health, achieving the Millennium Development Goal 4 target of reducing under-five child mortality by two thirds between 1990 and 2015, and improving other key indicators such as maternal mortality, immunization coverage, and survival rates from malaria, tuberculosis, and diarrhoea diseases.
Synopsis: Impact of Health Systems Strengthening on HealthHFG Project
Leaders in low- and middle-income countries (LMICs) require timely and compelling evidence about how to strengthen their health systems to improve the health and well-being of their citizens. Yet, evidence on how to strengthen health system performance to achieve sustainable health improvements at scale, particularly toward Ending Preventable Child and Maternal Deaths (EPCMD), fostering an AIDS-Free Generation (AFG), and Protecting Communities against Infectious Diseases (PCID) is limited. The evidence that does exist is scattered, insufficiently analyzed, and not widely disseminated. Without evidence, decision-makers lack a sound basis for investing scarce health funds in health systems strengthening (HSS) in an environment of competing investment options.
USAID is committed to advancing the evidence base on HSS and this commissioned report clearly demonstrates that HSS can improve health in LMICs.
This report, based on a review of systematic reviews of the effects on health of HSS, presents a significant body of evidence linking HSS interventions to measureable impact on health for vulnerable people in LMICs. Making decisions on who delivers health services and where and how these services are organized is important to achieve priority health goals such as EPCMD, AFG, and PCID. The findings of this report document the value of investing in HSS.
Introduction and definition of healthcare
Concepts and values in healthcare
Efficiency-driven approaches
Problems and proposed solutions
Healthcare and population health
Investing in Health
Equity-driven approaches
Primary health care
Conclusion
Universal Health Coverage (UHC) Day 12.12.14, NepalDeepak Karki
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A presentation for undergrad students visited Wolrd Health Organization (WHO) to understand what universal health coverage (UHC) is and how WHO works for UHC.
Presentation is about the uniqueness of Implementation Research and Role of the Government, specially in Indian context of health programme implementation.
Do height and BMI affect human capital formation? Natural experimental evidence from DNA. CHE seminar presentation by Neil Davies, University of Bristol 12 June 2020
Healthy Minds: A Randomised Controlled Trial to Evaluate PHSE Curriculum Deve...cheweb1
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Baker what to do when people disagree che york seminar jan 2019 v2cheweb1
Public values, plurality and health care resource allocation: What should we do when people disagree? (..and should economists care about reasons as well as choices?) CHE Seminar 21 January 2019
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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Quantifying the added societal value of public health interventions in reducing health inequality
1. Quantifying the added societal
value of public health
interventions in reducing health
inequality
Susan Griffin, CHE, University of York
James Love-Koh, YHEC
Rebekah Pennington, Lesley Owen, NICE
2. Overview
• Introduction
• Health inequality impacts based on aggregate data
• Available data
• Distribution of benefits
• Distribution of opportunity costs
• Quantifying and valuing inequality impacts
• Results
• Comparison to bespoke approach for estimating health inequality impact
3. Introduction
Principle 8 of NICE’s Social Value Judgements states that NICE should actively consider
reducing health inequalities when developing guidance, but there is currently no guidance on
how this should be done
• To what extent inequalities are considered in NICE public health guideline recommendations and how
this process could be formalised?
NICE commissioned two projects on health inequalities:
1. Plotting interventions from NICE public health guidelines onto the health equity impact
plane
2. A pilot study in the formal estimation of health inequality impacts using the economic
evaluation for forthcoming NICE guidance on smoking cessation
5. Part 1 – health inequality from aggregate data
• Focus on inequalities related to socioeconomic characteristics and inequality in distribution
of health in the population.
• What can we say about health inequality impact of interventions based on aggregate and
secondary data?
• What is already available?
• Economic evaluations summarise average costs and health benefits
• Know the nature of the intervention and its targeted group/disease/behaviour
• Can link groups, diseases and behaviours to socioeconomic characteristics
• Can link current healthcare utilisation to socioeconomic characteristics
• Know the current distribution of health between different socioeconomic groups
6. Stages of analysis
i. Extract incremental costs and health benefits and size of the target population;
ii. Estimate the distribution of population health benefits by age, gender and
socioeconomic status;
iii. Convert population costs into health opportunity costs;
iv. Estimate the distribution of population health opportunity cost by age, gender and
socioeconomic status;
v. Calculate the net health impact (health benefit net of health opportunity cost) for gender
and socioeconomic subgroups;
vi. Model the net health impacts onto a baseline distribution of lifetime health;
vii. Calculate inequality measures on the pre- and post-intervention health distributions to
summarise health inequality impact.
7. Data extraction
• Extracted data on interventions supported by economic evaluation within
NICE guidance up to October 2016
• Incremental costs and QALYs
• Size of target population
• Where not available we estimated from previous studies, prevalence rates, population statistics etc.
• Nature of target population in terms of targeted risk factor, disease or particular group
• Whether intervention was recommended by the PHAC
• Obtained data for 134 interventions
8. Distribution of population health benefits
• Target population was broken down into subgroups according to gender and
socioeconomic status
• Socioeconomic status in terms of IMD = area based measure of deprivation
• For interventions targeting specific diseases this was done on the proportion of health care utilisation in
HES by gender, IMD and ICD code
• For interventions targeting risk factors or health behaviours this was based on published prevalence and
incidence data linked to socioeconomic status
• For interventions targeting disadvantaged groups these were mapped to IMD quintiles
• We then calculated population health benefit (incremental QALYs * target population) and
apportioned this according to the size of the subgroups
9. Population costs to distribution of opportunity costs
• We calculated incremental population costs (incremental costs * target population)
• Converted these into health opportunity costs based on the amount of health that could be
generated with an alternative use of those funds
• One QALY per £20,000 for base case analysis (wide range in sensitivity analysis)
• In line with lower bound in guidance on which PHAC based any recommendations
• Gender, and socioeconomic distribution of health opportunity cost was estimated by
extending a previous study that estimated the relationship between a marginal change in
NHS expenditure and QALYs
• Making use of proportion of health care utilisation in HES by IMD and ICD
10. Distribution of
opportunity costs
Men Women
IMD1 (worst off) 0.14 0.12
IMD2 0.12 0.10
IMD3 0.12 0.10
IMD4 0.09 0.07
IMD5 0.08 0.06
• NHS spend benefits most deprived more
than least deprived
• Opportunity cost disproportionately falls to
most deprived
11. Net health impacts
• Information from stages i-iv
combined to estimate, for each
intervention, net health impact
for subgroups
12. Pre and post intervention distribution of health
• Used published estimate of quality adjusted life expectancy by gender and socioeconomic
status as pre intervention baseline distribution of health
• After adding distribution of net health impact, this provides post intervention distribution of
quality adjusted life expectancy
• Ordering the distribution from least to most healthy provides a univariate distribution of
health
• Distributions are in terms of the whole population in England and Wales (53.5 million) as
health opportunity costs can fall on any citizen
• Changes can appear small given that interventions typically target fraction of population and/or harms
that occur in only fraction of population
15. Summarising health inequality impacts
1. Quantify using common measures: slope index of inequality (SII) and relative index of
inequality (RII)
• SII = slope or gradient of line fit to health distribution; RII = SII / mean health
• SIl of 7 means most healthy has 7 more QALYs compared to least healthy
• RII of 0.07 means most healthy has 7% more QALYs than least healthy
2. Summarise and value in societal welfare terms using Atkinson and Kolm indices
• Calculated based on inequality aversion parameter
• The extent of preference for an equal distribution based on the amount of social welfare that could be gained
by redistributing an outcome equally
• Index shows extent by which social welfare reduced by relative (Atkinson) or absolute (Kolm) inequality
3. Summarise and value in health terms using Equally Distributed Equivalent (EDE)
• Atkinson and Kolm index combine with mean health to calculate EDE
• EDE is the level of an outcome that, if given to all individuals in a population, generates the same
amount of societal wellbeing as the current distribution
17. Inequality impact – Atkinson index and EDE
• Inequality aversion parameter ε=10.95
• General population survey Robson et al. (2016)
• Atkinson index, A(ε) ≈ 0.02
• Current inequality reduces societal welfare by
about 2%
• Would sacrifice ~2% current health to achieve
equal distribution
• Change in Atkinson index (lower better) and
change in EDE (higher better)
• Compare net health impact to change in EDE
• ∆EDE > ∆NHB for health inequality reducing
interventions
𝐸𝐷𝐸 =
1
𝑁
ℎ𝑖
1−𝜀
1
1−𝜀
𝐴 𝜀 = 1 −
𝐸𝐷𝐸
ℎ
69.8
68.3
0.48
0.6
68
69
69
70
70
71
Average health EDE
Pre intervention + Post intervention
19. Health equity impact plane - interventions
Axes subject to an inverse hyperbolic sine transformation and with reduction in SII multiplied by 104. This is necessary to allow all interventions to be
displayed on a single plane given the large variation and right skew in both incremental population health benefit and reduction in SII
Recommended by PHAC Not recommended by PHAC
20. Impact on decision making
Impact R NR %R
Increases total health and
reduces inequality
59 12 84
Increases total health and
increases inequality
12 3 86
Reduces total health and
reduces inequality
2 2 50
Reduces total health and
increases inequality
12 32 26
Overall 85 49 63
• Estimates do not reflect PHAC considerations about
quality of evidence, other factors etc.
• Few trade offs
• Moderate positive correlation between cost-effectiveness
and reduction in health inequality
• Pearson correlation coefficient 0.44
• 71 (53%) improve total health AND reduce inequality
• 44 (34%) reduce total health AND increase inequality
• 19 (14%) trade-off
R = Recommended; NR = Not recommended
21. Health equity impact plane – recommendations by guideline
Potential cumulative impact
• 23,227,018 QALYs
• Reduce SII by 0.44
• QALE gap reduced from 13.78 to
13.34 QALYs
• 28,603,577 EDE QALYs
• Inequality reduction equivalent in
value to further 5.4m QALYs
• Societal value 23% higher than
increase in average health alone
Axes subject to an inverse hyperbolic sine transformation and with reduction in SII multiplied by 104. This is necessary to allow all interventions to be
displayed on a single plane given the large variation and right skew in both incremental population health benefit and reduction in SII
Physical activity
Older people in own home
Domestic violence
CHD
T2DSmoking
Alcohol
22. What may be missed?
• Approach based on aggregate data divides incremental QALY according to proportion in
population.
• Efficacy and uptake can be socioeconomically patterned
• Uptake can be incorporated in approach based on aggregate data
• Differential intervention impact less straightforward
• Even if relative treatment effect constant across socioeconomic groups, different baseline risks will confer different
absolute benefit
• If include distributional concerns from outset can search for and incorporate evidence with
subgroup analysis
• Differential efficacy
• Differential access and uptake
• Impact of differential comorbidity in terms of costs, quality of life and absolute benefit of treatment
23. Distributional cost effectiveness analysis smoking cessation
• Existing model for smoking cessation guideline constructed to estimate incremental costs and quality adjusted life
years per average recipient of each intervention
• Retrospectively adapted to include evidence on how model inputs vary by socioeconomic status
• Impact of socioeconomic patterns in all cause mortality and quality of life
• Differential baseline risk of death to which relative risk reduction of quitting smoking applied
• Different baseline quality of life to which quality of life benefit of quitting smoking applied
• Differential risk of comorbidity in terms of smoking related disease
• Evidence that deprivation level independently influences risk of smoking related disease
• Differential probability of successful quit attempt
• Overall by socioeconomic status – lower probability of quit in more deprived across all interventions
• By socioeconomic status and intervention type – socioeconomic variation in probability of quit different for one to one vs closed group
interventions
• Uptake of intervention
• Lower proportional uptake in more deprived
24. Differential inputs by socioeconomic status
• Implicit assumption of equal uptake would
overestimate health inequality benefit if
uptake greatest in least deprived
• Failure to incorporate differential all cause
mortality and risk of smoking related
disease (baseline risk) would
underestimate health inequality benefit
• Failure to incorporate differential efficacy
will overestimate health inequality benefit
if efficacy lower in more deprived
• Overall, bespoke analysis produced
smaller health inequality impact
compared to aggregate approach, but
same quadrant on health equity plane
25. Differential inputs by intervention type
• Aggregate data may
fail to differentiate
between interventions
for same indication
• Limited data to
characterise this within
bespoke approach
26. Discussion
• Aggregate approach simple, feasible and provides additional information on which to base recommendations
• Takes account of the fact that existing public health spending likely benefits the most disadvantaged
• Consideration of the socioeconomic distribution of the health opportunity cost is vital to ensure that
• New investments perform better than existing activities for the most disadvantaged
• Targets for disinvestment represent the least worst option
• From NICE guideline example, focus on average net health benefit routinely and significantly undervalues
investment in public health interventions from a social welfare perspective
• Aggregate approach omits differential inputs, but bias can work in either direction
• Formal bespoke economic evaluation is feasible within the existing NICE appraisal process
• In smoking cessation example quantifying health inequality impacts did not affect the rank order of the interventions
• Adapting the design of economic evaluations to formally estimate net health inequality impact likely more useful for
• Interventions that are cost increasing
• That have different socioeconomic patterns of efficacy and uptake across the set of interventions being compared
• Where population level interventions (e.g. taxation or price) are compared against individual level interventions
27. Selected references
• M. Asaria, S. Griffin, R. Cookson, S. Whyte, and P. Tappenden, “Distributional Cost-Effectiveness Analysis of Health Care Programmes -
A Methodological Case Study of the UK Bowel Cancer Screening Programme,” Health Econ., vol. 24, pp. 742–754, 2015.
• M. Asaria, S. Griffin, and R. Cookson, “Distributional Cost-Effectiveness Analysis: A Tutorial,” Med. Decis. Mak., pp. 1–12, 2015
• K. Claxton, S. Martin, M. Soares, N. Rice, E. Spackman, S. Hinde, N. Devlin, P. C. Smith, and M. Sculpher, “Methods for the estimation of
the National Institute for Health and Care Excellence cost-effectiveness threshold,” Health Technol. Assess. (Rockv)., vol. 19, no. 14, pp.
1–504, 2015.
• J. Love-Koh, R. Cookson, K. Claxton, and S. Griffin, “Does public healthcare spending reduce inequality? Estimating the socioeconomic
distribution of health gains and losses from marginal changes to NHS expenditure in England,” in Winter 2016 Health Economists’ Study
Group Meeting, 2016.
• J. Love-Koh, M. Asaria, R. Cookson, and S. Griffin, “The Social Distribution of Health: Estimating Quality-Adjusted Life Expectancy in
England,” Value Heal., vol. 18, pp. 655–662, 2015.
• M. Robson, M. Asaria, R. Cookson, A. Tsuchiya, and S. Ali, “Eliciting the level of health inequality aversion in England,” Health Econ.,
2016