Presentation by David Wonderling, Head of Health Economics at National Guideline Centre, Royal College of Physicians and Lauren Ramjee, Senior Health Economist, Royal College of Physicians.
This workshop outlines the principles of health economic evaluation for the NHS.
Getting evidence from economic evaluation into healthcare practicecheweb1
Seminar:Understanding the underutilisation of evidence from economic evaluations in healthcare: a mixed methods design. Speaker: Gregory Merlo, Australian Centre for Health Services Innovation (AusHSI), Queensland University of Technology, Brisbane, Australia.
‘In with the old, out with the new’ – In search of ways to help health economists break their addiction to technology adoption. CHE Seminar presented by Professor Stirling Bryan, Director, Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Professor, School of Population & Public Health, University of British Columbia. 17th October 2014
Remote monitoring: Direction for ResearchMarc Lange
Remote monitoring will happen! Integrating ICT in health care is about progress and who can stop the progress?
Also, patients are about to demand for it. Have in mind their current interest for mHealth and note that in a large number of trials, the feedback received from patients and their carer is positive: they feel more secure when receiving feedback on the data they sent remotely and if attention has been paid to educate them in interpreting the data they are sending, they can become a full partner of the care team!
Finally, remote monitoring services – combined with self-care – offer strategic opportunities to modernise health care systems by enabling them to become more proactive, better empower patients and citizens and, in the end, use health care resources more efficiently.
To identify future directions for research, this lecture will consider remote monitoring from three viewpoints: what evidence is still needed, how best to support decision making in favour of doing remote monitoring, and how best to support the deployment of remote monitoring in routine care. Results and lessons learned from two European Commission co-financed projects, Renewing Health and United4Health , will be used to illustrate the messages.
Getting evidence from economic evaluation into healthcare practicecheweb1
Seminar:Understanding the underutilisation of evidence from economic evaluations in healthcare: a mixed methods design. Speaker: Gregory Merlo, Australian Centre for Health Services Innovation (AusHSI), Queensland University of Technology, Brisbane, Australia.
‘In with the old, out with the new’ – In search of ways to help health economists break their addiction to technology adoption. CHE Seminar presented by Professor Stirling Bryan, Director, Centre for Clinical Epidemiology & Evaluation, Vancouver Coastal Health Research Institute, Professor, School of Population & Public Health, University of British Columbia. 17th October 2014
Remote monitoring: Direction for ResearchMarc Lange
Remote monitoring will happen! Integrating ICT in health care is about progress and who can stop the progress?
Also, patients are about to demand for it. Have in mind their current interest for mHealth and note that in a large number of trials, the feedback received from patients and their carer is positive: they feel more secure when receiving feedback on the data they sent remotely and if attention has been paid to educate them in interpreting the data they are sending, they can become a full partner of the care team!
Finally, remote monitoring services – combined with self-care – offer strategic opportunities to modernise health care systems by enabling them to become more proactive, better empower patients and citizens and, in the end, use health care resources more efficiently.
To identify future directions for research, this lecture will consider remote monitoring from three viewpoints: what evidence is still needed, how best to support decision making in favour of doing remote monitoring, and how best to support the deployment of remote monitoring in routine care. Results and lessons learned from two European Commission co-financed projects, Renewing Health and United4Health , will be used to illustrate the messages.
Health Technology Assessment (HTA) Report: Interventions to increase particip...HTAi Bilbao 2012
Health Technology Assessment (HTA) Report: Interventions to increase participation to organised cancer screening programs
Ministry of Health Grant for Applied Research
Giorgi Rossi P, Camilloni L, Ferroni E, Jimenez B, Furnari G, Guasticchi G, Borgia P.
Laziosanità – Agenzia di Sanità Pubblica della Regione Lazio
Technologies that enhance the precision and effect of therapies can make a critical contribution to ensuring value for money and improving patient care. Methods and processes for assessing value, however, still are imperfect. This presentation reviews the challenges and identifies some approaches for meeting them.
Top seven healthcare outcome measures of healthJosephMtonga1
The seven healthcare outcome measures are meant to understand the quality of health systems and how they could be measured and how quality care could be provided to clients.
Here is the slide on Healthcare economic evaluation. The content of this presentation doesn't belong to me. They are copied from several literature and internet
Recent Advances in Evidence Based Public Health PracticePrabesh Ghimire
This product is the result of compilation from various sources. I acknowledge all direct and indirect sources although they have not been mentioned explicitly in the document.
CBRT - "A Case for NHS Adoption." 05.04.13Alison Bourne
33 slides POWERPOINT : “CBRT A Case for NHS Adoption - Providing patients with structured relaxation support sessions. CBRT provides the NHS with a Value for Money, practical and unique system for physical
health, mental health and wellbeing.
• CBRT provides a ‘safe care’ and ‘right care’ solution to the ever growing requirement for
increased capacity within integrated care for patients with anxiety, mild to medium
depression and long term conditions. This need was highlighted in the report, “How Mental
Illness Loses Out in the NHS”, produced by a distinguished team of economists,
psychologists, doctors and NHS managers convened by Professor Lord Layard of the LSE
Centre for Economic Performance.
• CBRT can contribute to productive patient care and strengthen staff and patient
communication skills; CBRT is empowering.
• CBRT is a high quality, yet low cost product.
• A relaxation technique and therapeutic intervention - CBRT is a safe product. It is a potential CE Class 1 Medical Device and is made of printed matter.
• CBRT is a motivational, inclusive, non-pharmaceutical, non-invasive, non-denominational
and non-tactile intervention, for all ages and abilities.
Health technology assessment (HTA) is familiar as technique for gauging the value of specific medical technologies or approaches to care. As Adrian Towse points out, however, HTA has a much broader, ‘macro’ role in contributing to the efficiency of health care systems and supporting universal health coverage. This is particularly crucial in the face of increasing demands and limited budgets.
The Importance of measuring outcomes, including Patient Reported Outcome Measures (PROMS)
BAOT Lifelong Learning Event
10 November 2010
Dr Alison Laver-Fawcett
Head of Programme, BHSC(Hons) Occupational Therapy
York St John University
Health Technology Assessment (HTA) Report: Interventions to increase particip...HTAi Bilbao 2012
Health Technology Assessment (HTA) Report: Interventions to increase participation to organised cancer screening programs
Ministry of Health Grant for Applied Research
Giorgi Rossi P, Camilloni L, Ferroni E, Jimenez B, Furnari G, Guasticchi G, Borgia P.
Laziosanità – Agenzia di Sanità Pubblica della Regione Lazio
Technologies that enhance the precision and effect of therapies can make a critical contribution to ensuring value for money and improving patient care. Methods and processes for assessing value, however, still are imperfect. This presentation reviews the challenges and identifies some approaches for meeting them.
Top seven healthcare outcome measures of healthJosephMtonga1
The seven healthcare outcome measures are meant to understand the quality of health systems and how they could be measured and how quality care could be provided to clients.
Here is the slide on Healthcare economic evaluation. The content of this presentation doesn't belong to me. They are copied from several literature and internet
Recent Advances in Evidence Based Public Health PracticePrabesh Ghimire
This product is the result of compilation from various sources. I acknowledge all direct and indirect sources although they have not been mentioned explicitly in the document.
CBRT - "A Case for NHS Adoption." 05.04.13Alison Bourne
33 slides POWERPOINT : “CBRT A Case for NHS Adoption - Providing patients with structured relaxation support sessions. CBRT provides the NHS with a Value for Money, practical and unique system for physical
health, mental health and wellbeing.
• CBRT provides a ‘safe care’ and ‘right care’ solution to the ever growing requirement for
increased capacity within integrated care for patients with anxiety, mild to medium
depression and long term conditions. This need was highlighted in the report, “How Mental
Illness Loses Out in the NHS”, produced by a distinguished team of economists,
psychologists, doctors and NHS managers convened by Professor Lord Layard of the LSE
Centre for Economic Performance.
• CBRT can contribute to productive patient care and strengthen staff and patient
communication skills; CBRT is empowering.
• CBRT is a high quality, yet low cost product.
• A relaxation technique and therapeutic intervention - CBRT is a safe product. It is a potential CE Class 1 Medical Device and is made of printed matter.
• CBRT is a motivational, inclusive, non-pharmaceutical, non-invasive, non-denominational
and non-tactile intervention, for all ages and abilities.
Health technology assessment (HTA) is familiar as technique for gauging the value of specific medical technologies or approaches to care. As Adrian Towse points out, however, HTA has a much broader, ‘macro’ role in contributing to the efficiency of health care systems and supporting universal health coverage. This is particularly crucial in the face of increasing demands and limited budgets.
The Importance of measuring outcomes, including Patient Reported Outcome Measures (PROMS)
BAOT Lifelong Learning Event
10 November 2010
Dr Alison Laver-Fawcett
Head of Programme, BHSC(Hons) Occupational Therapy
York St John University
ICN Victoria presents Dr Dashiell Gantner, research fellow at the Monash University in Melbourne. Here he talks about translating ICU research into clinical practice.
Value Based Care is a framework that helps healthcare ecosystem collaborate to provide value to patient for entire care-cycle. It also enables providers to iterate by measuring outcome and cost to maximise value over time.
> Why HEOR?
> Costs, Consequences and Perspectives
> Key Stakeholders in HEOR
> What is Health Economics and Pharmaco-economic Research?
> Economic Evaluations
> Incremental Cost Effectiveness Ratio (ICER)
> Concept of HRQoL
> Comparative Effectiveness Research (CER)
> Pragmatic Clinical Trials
> Observational Studies
> Systematic Reviews and Meta-Analysis
> Application of CER
> Health Technology Assessment (HTA)
> Real World Evidence (RWE)
> Patient Reported Outcomes (PROs)
> Patient Focused Drug Development (PFDD)
> Application of Health Economic Evaluations
> Challenges and Barriers
Policy Implications of Healthcare Associated InfectionsAlbert Domingo
On February 19, 2014 at the Ateneo School of Medicine and Public Health in Pasig City, Dr. Albert Domingo presented an introduction to the economic impact of healthcare associated infections (HAIs) as well as related concepts in health policy and management. The speaker discussed common approaches taken to ascertain the economic impact of HAIs, followed by factors/considerations in Philippine health policy and management that must be understood and adjusted in order to minimize HAIs.
Dr Brent James: quality improvement techniques at the frontlineNuffield Trust
Dr Brent James, Intermountain Institute for Healthcare Delivery Research, presents to the Health Policy Summit 2015 on delivering quality improvement techniques at the frontline.
OHE’s Professor Nancy Devlin has researched, written and spoken widely on the use of the EQ-5D, and related measures, both in her capacity as the Director of Research at the OHE and as Chair of the Executive Committee of the EuroQol Group.
In May, Nancy was invited to participate in the “Workshop on measuring patient-reported outcomes using the EQ-5D”, which was organised by the Swedish National Board of Health and Welfare in collaboration with the EuroQol Group. The workshop brought together policy makers and researchers in Sweden interested in measuring patients’ health outcomes.
Sweden has included the EQ-5D in some of its quality registries and in population health surveys for many years. The Swedish National Board of Health and Welfare now is exploring whether and how to extend use of patient reported outcomes measures in the health care system, including the EQ-5D, to both monitor the quality of providers and services and to facilitate health technology appraisal.
Nancy’s talk, shown below, introduced the EQ-5D instrument; discussed how data from it can be analysed; identified some of the challenges in analysis; and commented on the future of outcomes measurement.
Principles of Surgical Audit presented by Meeran Earfan, Kurdistan Board Trainee/General Surgery in Sulaimaniyah Teaching Hospital, As Sulaimaniyah, Iraq
Investing in specialised services - the prioritisation framework, pop up uni,...NHS England
Expo is the most significant annual health and social care event in the calendar, uniting more NHS and care leaders, commissioners, clinicians, voluntary sector partners, innovators and media than any other health and care event.
Expo 15 returned to Manchester and was hosted once again by NHS England. Around 5000 people a day from health and care, the voluntary sector, local government, and industry joined together at Manchester Central Convention Centre for two packed days of speakers, workshops, exhibitions and professional development.
This year, Expo was more relevant and engaging than ever before, happening within the first 100 days of the new Government, and almost 12 months after the publication of the NHS Five Year Forward View. It was also a great opportunity to check on and learn from the progress of Greater Manchester as the area prepares to take over a £6 billion devolved health and social care budget, pledging to integrate hospital, community, primary and social care and vastly improve health and well-being.
More information is available online: www.expo.nhs.uk
Presentations by Tawfiq Choudhury and Rocco Hadland from the second webinar of the Mastering Cholesterol webinar series on Thursday 11 May 2023, focusing on Statins.
Targeting lipids: a primary and secondary care perspectiveInnovation Agency
Presentations by Dr Sue Kemsley and Dr Gavin Galasko from the first webinar of the Mastering Cholesterol webinar series on Thursday 26 January 2023, focusing on lipid management from a primary and secondary care perspective.
Supporting the optimal detection and management of BP in Primary CareInnovation Agency
Presentation by Jane Briers, Programme Manager - Innovation Agency at the Supporting recovery in Primary Care using Proactive Frameworks for Long Term Conditions event on Thursday 15 September 2022.
Presentation by Dr Lauren Moorcroft, GP Partner - Brookvale Practice at the Supporting recovery in Primary Care using Proactive Frameworks for Long Term Conditions event on Thursday 15 September 2022.
Introduction to Supporting recovery in Primary Care using Proactive Framework...Innovation Agency
Presentation by Julia Reynolds, Associate Director for Transformation - Innovation Agency at the Supporting recovery in Primary Care using Proactive Frameworks for Long Term Conditions event on Thursday 15 September 2022.
Presentation by Paul Brain, Project Manager at the Excel in Health series - Introduction to data webinar on Monday 6 June 2022.
In this session we discussed how SMEs can use data to grow their business and access new opportunities in the market.
Presentations by Mike Kenny, Acting Co-Director of Enterprise and Growth, Innovation Agency and Dr Neil Paul, a GP and Board Member with Cheshire East ICP at the Excel in Health: Understanding the NHS Landscape webinar on Wednesday 11 May 2022.
LCR and Cheshire and Merseyside Health MATTERS networking eventInnovation Agency
Master slide deck from the LCR and Cheshire and Merseyside Health MATTERS networking event on Wednesday 24 November 2021 at Sci-Tech Daresbury Laboratory.
Master slide deck from the Excel in Health webinar series: The NHS landscape presentation.
This webinar identifies the structure of the NHS and its national priorities.
The session will cover the following topics:
Understand the structure of the NHS
Understand the national priorities of the NHS
Recognise the barriers to sale
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Title: Sense of Taste
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 structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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.
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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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
2. Who are we?
• David Wonderling, Head of health economics
• Lauren Ramjee, Senior health economist
• National Guideline Centre
– Hosted by Royal College of Physicians
– Commissioned to develop guidelines by National Institute of Health and Care
Excellence (NICE)
• NICE guidance
– Guidelines
» Clinical, public health, social care, service delivery
– Technology Appraisals
– Medical Technologies and Diagnostics
– (Interventional procedures)
5. Aims
1. Understand what health economics is about
2. Understand what an Economics Evaluation is
3. Identify different types of economic evaluation
6. Dispelling Myths
Myth 1: Health economics is about saving the government money
• Economics is the study of how to best allocate scarce resources in order to
maximise benefits to society
• Health economics helps NHS use its limited budget to maximise health
outcomes for the whole population
• Identify interventions which offer the best value for money
7. Dispelling Myths
Myth 2: A cheap intervention is cost-effective
• Surgery A costs £500 while surgery B costs £800 but…
• More re-operations after Surgery A
• And/or more complications after Surgery A
• Eventually Surgery A generates more costs
8. Dispelling Myths
Myth 3: Expensive interventions are not cost-effective
• A strategy which is very expensive might generate substantial future
savings and/or improve health substantially
– save more lives
– Fewer adverse events
– Better quality of life
9. Dispelling Myths
Myth 4: Health economics is only concerned with expensive drugs &
high technology
• Health economics is relevant for any clinical question if there could be a
difference in resource use:
– What should staff use to wash their hands?
– What is the best platform to store patient information/records?
– Should point of care tests be used?
– Should monitoring be conducted remotely (via tele medicine)?
– What sequence should tests be done?
– Should follow-up be conducted in hospital or in primary care?
– What types of rehab should be offered after stroke?
10. Challenges to the NHS
• Everyone wants better health and healthcare
• But resources are limited
– Staff e.g. doctors and nurses
– Facilities e.g. hospitals
– Equipment e.g. MRI scanners
– Consumables e.g. drugs
• The NHS does not have limitless spending therefore there is an
‘opportunity cost’ to spending i.e. the value of the best alternative use of
resources
• If the NHS spends more on one thing it has to spend less on something
else. But how can we decide?
11. Treatment A
(usual care)
Treatment B
(new treatment)
Costs
Health outcomes
Costs
Health outcomes
Economic Evaluation
• “... the comparative analysis of alternative courses of action in terms of
both their costs and consequences.” (Drummond et al. 2005)
12. Types of Economic Evaluation
Type of analysis
Value of
resources
Value of health gain
Cost-utility £ Combined index:
Quality Adjusted Life Years (QALY)
Cost-effectiveness £
Single indicator:
Weight loss (kg),
blood glucose control (HbA1c)
deaths averted,
life years saved…
Cost-consequences £ Multiple indicators
Comparative cost /
Cost minimisation
£ None
Cost-utility analysis is desirable.
Cost-consequences or cost minimisation
might be more pragmatic and sufficient
13. Cost effectiveness vs. resource/budget impact
Cost-effectiveness Resource/budget Impact
Is it value for money? How much it will cost?
Costs, savings and health outcomes Costs and savings
Inform policy / purchasing For planning & implementation
Time horizon up to lifetime Time horizon of 1 to 5 years
Cost-effectiveness ratio
e.g. Cost per quality-adjusted life-
year (QALY) gained
Cost per patient
Total cost (for Trust/CCG/England)
You might also want to conduct a budget
impact analysis
14. Conclusions
• Health economics is about the optimal allocation of scarce resources
• There is an opportunity cost for each and every decision
• Different types of economic evaluation can be conducted
• NICE prefers
– Cost-utility analyses for Guidelines and Technology Appraisals
– Cost-consequences analysis (or sometimes comparative cost analysis) for
Medical Technologies
16. Aims
1. Understand what makes a product efficient for use in the NHS
2. Understand ways that cost-savings can be achieved
17. What makes a product efficient / value for money for the NHS?
• There are four possibilities that could make a product efficient:
– Cost saving + clinical benefits
– Cost saving + clinical equivalence
– Cost neutral + clinical benefits
– ‘Cost-effective’
23. Treatment recovery is faster
= reduction in hospital length of
stay
Filling out patient records is
faster
= reduction in staff time needed
for specific activity
Time to diagnosis is faster
= reduction in costs of treating
complications prior to a diagnosis
Staff training is faster
= reduction in cost of training
staff
Faster
24. New IT system that centralises
information
= reduction in staff time required
for administrative tasks
More operation are a success
= reduction in long term health
costs
Tele-monitoring
= reduction in cost of monitoring
Less repeat tests required
= reduction in cost of diagnosis
Better
25. Fewer staff injuries
= reduction in staff costs
Fewer adverse events during
surgery
= reduction in long term health
costs
Fewer adverse events after
surgery
= reduction in long term health
costs
Lower radiation dose during
imaging
= reduction in long term health
costs
Safer
26. Conclusions
• The most attractive products for the NHS are those that improve clinical
outcomes and reduce costs
– These products DOMINATE current practice
• If your product is not dominant you will need to demonstrate the trade-off
between health gained/lost and costs increased/saved
• Products can be cost saving by being faster, better, cheaper or safer than
current practice
28. Aims
1. Specify clearly the question you want the Economic Evaluation to answer
2. Choose appropriate comparator(s)
29. Specifying the question
Population(s)
What specific patient population(s) are we interested in?
This will be our denominator for costs and effects
P
Intervention
What is our investigational intervention?
Specify dose, timing, supportive interventions, etc.
I
Comparison(s)
What are the main alternatives to compare with the product?
a) current usual practice (minimum)
b) alternative interventions that could potentially be as cost-effective as usual practice.
c) no intervention
C
Outcome(s)
What do we intend to accomplish, measure, improve or affect?
a) NHS costs (minimum)
b) patient-relevant health outcomes and/or process/resource impacts
O
30. Time horizon
• Time horizon
– Time period over which costs and benefits are measured
– Need same horizon for both costs and effects.
• How long?
– Long enough to include all meaningful differences between the comparators
in terms of their costs and benefits
• Long time horizon (e.g. lifetime of patients)
– If there’s a difference in patient survival
– If the impact on patients is far reaching (e.g. hip replacement)
• Short time horizon
– If the impact on patients is short term
– The study follow-up was short?
– If the intervention is already cost-effective in short-term and extending the
time horizon would only make it more so.
31. Specifying the question
Are sound generators cost-saving compared to no treatment for people with
Tinnitus?
Are sound generators cost-saving
for people with Tinnitus?
compared to no treatment
Outcome
Intervention
Comparison
Population
32. Specifying the question
What is the most cost-effective way to deliver rehab for people with stroke?
What is the most cost-effective
for people with stroke?
way to deliver rehab
Outcome Intervention
Comparison
Population
33. Protocol
Is GP-AF case finding software cost effective in helping to diagnose people with
atrial fibrillation?
Population People (diagnosed and undiagnosed) with Atrial Fibrillation
Intervention GP-AF case finding software platform
Comparison Compared to opportunistic testing at general practice
Outcomes • Additional cases of atrial fibrillation detected
• Additional cases treated with anticoagulation
• Strokes avoided
• Quality adjusted life years gained
• Cost per patient
34. Conclusions
• For an economic evaluation you need to specify the:
– POPULATION(S)
– INTERVENTION
– COMPARATOR(S)
• Including usual NHS practice
– OUTCOME(S)
• Costs and benefits need to be consistently measured over a time horizon
that captures all important differences between intervention and
comparators
36. Practical
• Now frame an economic evaluation for your product
• Specifying the essentials
• What are the details of the:
– Population(s)?
– intervention?
– comparator(s)?
• What are the key impacts (Intervention vs comparator)?
• What time horizon is necessary to capture key impacts?
38. Aims
1. Understand which costs you should be considering
2. Understand how to estimate costs
3. Learn where to get information for costs from
39. Rules for conducting health economic evaluations
• England and Wales - NICE
– Methods of Technology Appraisal
https://www.nice.org.uk/about/what-we-do/our-programmes/nice-
guidance/nice-technology-appraisal-guidance/process
– Developing Guidelines
https://www.nice.org.uk/about/what-we-do/our-programmes/nice-
guidance/nice-guidelines/how-we-develop-nice-guidelines
– Medical technologies evaluation programme methods guide
https://www.nice.org.uk/about/what-we-do/our-programmes/nice-
guidance/medical-technologies-guidance/how-we-develop
• Scottish Medicines Consortium
– https://www.scottishmedicines.org.uk/making-a-submission/
• Other Countries
– https://www.ispor.org/PEguidelines/index.asp
40. Which costs should you include?
• Possible perspectives
– Trust/Practice
– CCG
– NHS (for most NICE evaluations)
– Public sector
• NHS + local authorities + central government
– Societal
• Public sector + productivity losses/gains + all other impacts
Most likely
41. NICE methods guidance for economic evaluation of drugs, medical
technologies & clinical guidelines
Non-NHS costs
Cost to other government bodies may be included in exceptional circumstances as a sensitivity
analysis.
Costs borne by patients should not be included unless they are reimbursed by the NHS
Patients productivity gains/losses should not be included, even as a sensitivity analysis, as this
would mean we would be prioritising people in work (over the elderly, chronically ill etc.).
Where a technology extends life
NHS costs related to the condition of interest and incurred in additional years of life gained as a
result of treatment should be included in the reference-case analysis. NHS Costs that are
considered to be unrelated to the condition or technology of interest should be excluded.
42. Which costs should you include?
Immediate cost of
investment + Recurrent costs
Savings from
reduced resource
use-
COSTS SAVINGS
43. How to estimate costs
1) Estimate resource use per patient for each intervention
– E.g. numbers of GP visits, outpatient visits, tests, drug use (HES data, activity
data, audit data)
– Sometimes reported in clinical trials or other studies
– May need assumptions from the Committee or other experts
2) Multiply by unit costs for each resource
– Some standard national sources (e.g. BNF for drugs)
– Sometimes available from clinical studies
– May sometimes have to use local estimates
44. Resource use for Health Economic Evaluations
Cost Type Examples
Technology costs • Medication
• Medical devices
• Diagnostic tests
• IT software
Costs of healthcare service use • Days in hospital
• Medical procedures
• Outpatient visits
• Appointments / staff time
• GP, Nurse, physio
• Emergency services
• Days in intensive care
Other costs • Healthcare consumables
• Training
• Administration
• Overheads
45. Data – How to find and use freely available national unit costs
Type of cost Source for the cost
Drugs NHS Drug tariff
http://www.nhsbsa.nhs.uk/prescriptions
British National Formulary
http://www.bnf.org
Other technologies NHS Supply Chain Catalogue
http://my.supplychain.nhs.uk/catalogue
Staff time ‘Unit costs of health and social care’
http://www.pssru.ac.uk/project-pages/unit-costs/
Hospital
procedures/stays,
outpatient visits, tests
Department of Health
Tariff and NHS reference costs
https://www.gov.uk/government/publications/payment-by-results-pbr-
operational-guidance-and-tariffs
https://www.gov.uk/government/collections/nhs-reference-costs
46. Using NHS Reference costs
https://www.gov.uk/government/collections/nhs-reference-costs
• Cost of Admission
• Cost per Excess Bed day
– Example: Total knee replacement with no comorbidities or complications
• Converting from OPCS/ICD10 to HRG
• See ‘Code to group’ Workbook for relevant year, e.g.
https://digital.nhs.uk/services/national-casemix-office/downloads-groupers-and-tools/costing-
hrg4-2017-18-reference-costs-grouper
Currency
Description
Cost Unit cost
Very Major Knee
Procedures for Non-
Trauma with CC
Score 0-1
Non Elective long
stay £5692
Excess bed day
£315
47. Using ‘Unit costs of health and social care’
http://www.pssru.ac.uk/project-pages/unit-costs/
Cost Value Source
GP appointment £37 (£31 without
qualifications)
PSSRU (Curtis 2017)
(p172)
Example
48. Unit costs – other sources
• Published studies
– HEED (health economics evaluation database up to 2014), HTAs
• https://www.crd.york.ac.uk/CRDWeb/
– Medline/Embase
• Manufacturers
• Trusts
49. Discounting
• Different interventions give rise to costs and benefits incurred at different
time points
• People prefer benefits today and costs in the future
– Costs and benefits incurred today are therefore valued higher than those in
the future
• We “discount” costs and benefits to account for this time preference
– we can calculate the ‘present value’ of future costs and benefits
• NICE discounts both costs and health benefits at 3.5% per annum
– For example, a cost of £1,035 incurred in one years time would be valued at
£1,000 today (£1,000 is therefore the present value)
50. Annuitizing costs
• Products have an upfront costs and expected lifetimes
• As we are interested in cost per patient we need to
– annuitize the upfront costs – calculate the implicit rental value
– divide by the expected caseload / output
• Example
– GP-AF case finding software platform costs £1,000 upfront
– Expected lifetime = 5 years (after which a new licence needs to be purchased)
– Software can help identify 10 people with AF per year
• Annuitize, accounting for the discount rate (3.5%)
– Cost of software per year = £221
• Divide by the outcome
– Cost per case detected = £22
51. Formulae for discounting / annuitizing
• Net present value of cost occurring in future
– 𝑁𝑃𝑉 = 𝐶
1
(1+r) 𝑡
– Where C=cost incurred at time t; r=discount rate (time preference, e.g. 3.5%)
• Annual equivalent cost of up-front expenditure
– Annuity factor: 𝐴 =
1−(1+r)−𝑡
r
• Where t=life expectancy of equipment; r=discount rate
– Annual equivalent cost= 𝐴𝐸𝐶 =
K−(S/(1+r) 𝑡)
A
• Where t=life expectancy of equipment, K=cost at time of purchase;
S=resale value at time t; r=discount rate; A= annuity factor
52. Conclusions
• Costs include both resource use (number of times used) and the cost itself
• Costs included should reflect the perspective of the target audience
• There are available sources for many NHS unit costs
• Costs that occur in the future need to be discounted
• Up-front costs need to be annuitized
54. Aims
• Understand what health outcomes you should be measuring
• Understand whether you can calculate quality adjusted life years
• Understand the decision rules of economic evaluations
55. Measuring health gain
Type of analysis
Value of
resources
Value of health gain
Cost-utility £ Combined index:
Quality Adjusted Life Years (QALY)
Cost-effectiveness £
Single indicator:
Weight loss (kg),
blood glucose control (HbA1c)
deaths averted,
life years saved…
Cost-consequences £ Multiple indicators
Comparative cost /
Cost minimisation
£ None
56. Quality Adjusted Life Years
QALYs =
Life expectancy
(life years)
x Quality of life
(utility)
• A measure of overall effectiveness (overall health)
– Length of life
– Quality of life (utility): 0 (death) to 1 (full heath) scale
• 2 years in full quality of life = 2 x 1.0 = 2 QALYs
• 2 years at 50% quality of life = 2 x 0.5 = 1 QALY
• Life-years can be calculated using life tables or Markov models
57. Utility weights for QALYs
• A common measure used in Economic Evaluations and NICE’s preferred
measure is the EQ-5D health state valuation tool
• 5 dimensions of health
– MOBILITY
– SELF-CARE
– USUAL ACTIVITIES
– PAIN / DISCOMFORT
– ANXIETY / DEPRESSION
58. Sources for utility weights
• EQ-5D is NICE’s preferred method of health related quality of life in adults
– https://euroqol.org/
• You can sometimes source utility weights from published literature
– http://healtheconomics.tuftsmedicalcenter.org/cear4/SearchingtheCEARegistry/SearchtheCEARegist
ry.aspx
– https://www.scharrhud.org/
• When EQ-5D data is not available the data can sometimes be estimated by
mapping from other health-related quality of life measures
59. Decision rules of cost effectiveness analysis
• An intervention is considered to be cost-effective compared to the best
alternative if:
– It improves health and costs less (is dominant)
– The incremental cost effectiveness ratio (ICER) is less than the threshold
• ICER = the difference in mean costs / the difference in mean QALYs
If an intervention requires additional resources these rules
ensure too much health will not be displaced elsewhere in
the health system in order to fund the intervention
Thresholds
-NICE uses £20,00-£30,000 per QALY for most treatments
-DHSC uses £15,000 per QALY for Impact assessments
61. Measuring health gain
Type of analysis
Value of
resources
Value of health gain
Cost-utility £ Combined index:
Quality Adjusted Life Years (QALY)
Cost-effectiveness £
Single indicator:
Weight loss (kg),
blood glucose control (HbA1c)
deaths averted,
life years saved…
Cost-consequences £ Multiple indicators
Comparative cost /
Cost minimisation
£ None
62. Cost-consequences / cost-effectiveness analyses
• The intervention /product improves all clinical outcomes and reduces
costs compared to current practice
– Then it DOMINATES current practice and should be recommended for use in
the NHS
• The intervention/product improves some clinical outcomes but not others
and reduces costs OR
• The intervention/product improves all/some clinical outcomes but
increases costs
– Then an informal judgement needs to be made about the ‘cost-effectiveness’
and whether it is considered ‘value for money’
E.g. £100 per stroke avoided vs. £1,000,000 per stroke avoided
63. Measuring health gain
Type of analysis
Value of
resources
Value of health gain
Cost-utility £ Combined index:
Quality Adjusted Life Years (QALY)
Cost-effectiveness £
Single indicator:
Weight loss (kg),
blood glucose control (HbA1c)
deaths averted,
life years saved…
Cost-consequences £ Multiple indicators
Comparative cost /
Cost minimisation
£ None
Sometimes it is not possible or necessary to
estimate health gain and then a costing
analysis might be the most appropriate!
64. Evidencing the impact of a product
• For the main effects (health and resource use) you will need good
evidence (ideally from comparative studies):
– E.g. reduction in major adverse events
• Other effects may be modelled using case series or national statistics
– E.g. length of stay associated with the adverse event
– E.g. proportion of the adverse events that are fatal
• Economic evaluation best practice
– Baseline event rates from large case series
– Relative treatment effects from pragmatic randomised controlled trials
• Where you use observational data for relative treatment effects, you
should attempt to control for differences in baseline confounding variables
using regression analysis
65. Hierarchy of evidence for relative treatment effectiveness
Meta-analysis of RCTs
RCTs
Cohort studies
Case series
Expert opinion
Lower risk of bias
Sometimes better
- Larger studies
- More generalisable
- Longer time horizon
Might be the best we can do
66. Sensitivity analysis
• Threshold analyses
– How much of a change in a key outcomes is needed in order to make the
intervention cost saving/cost-effective
• One-way and n-way sensitivity analyses
– Vary individual parameters within plausible ranges
– Or to extremes
• Probabilistic sensitivity analyses
– Vary all parameters simultaneously within plausible ranges
67. Conclusions
• Cost-utility analyses are the preferred method of economic evaluation for
NICE but are not always feasible
– EQ-5D is the preferred health state valuation tool
• The results of cost-effectiveness analyses and cost-consequences analyses
require informal judgements to be made to determine whether the
product/intervention is considered ‘value for money’
• Comparative cost analyses do not estimate a value of health gain
• Observational evidence typically has a higher risk of bias but might be the
best we can do
• Sensitivity analysis should be conducted to deal with parameter
uncertainly
69. 3. Case Studies
NICE Medical Technologies guidance
• A technology is likely to be selected if:
– relevant* technology with a CE marks (or equivalent regulatory approval) or is expected to get
one within 12 months
– substantial benefits to patients or the health and care system compared with current practice
• easily understood, clearly described, plausible, supported by evidence.
– developing guidance would mean faster and more consistent adoption of the technology.
• Relevance
– Detailed and transparent
– Lower threshold of evidence than medicines or guidelines
• QALYs not necessary
• Less sophisticated modelling
– Approved by a national committee
* a medical device (under EC directive 2007/47/EC or 93/42/EEC)
an active medical device (under EC directive 90/385/EEC)
an active implantable medical device, (under EC directive 90/385/EEC)
an in vitro diagnostic medical device (under EC directive 98/79/EC).
70. Case study 1 – SecurAcath for securing percutaneous catheters
https://www.nice.org.uk/guidance/mtg34
Published June 2017
71. PICO
• Population: Patients requiring peripherally inserted central
catheters (PICC)
• Intervention: SecurAcath – a single-use device used to secure
percutaneous catheters in position on the skin
• Comparator: StatLock – standard care
• Outcomes:
• NHS costs
• Catheter-related complications
72. Model essentials
• Economic evaluation type: Comparative cost analysis
• Model type: Simple decision tree
• Time horizon: 25 days
• Discounting: Not necessary - short time horizon
• Perspective: NHS hospital costs (England)
73. Technology costs
• StatLock – standard care
– Unit cost £3.47
– Needs replacing weekly
– Nurse time for placement 40.8 minutes x£0.60=£24.48
– Cost over 25 days=£3.47x4+£24.48=£38.36
• SecurAcath
– Unit cost £16
– Does not need replacing
– Nurse time 20.5 minutes x£0.60=£12.30
– Cost over 25 days =£16+£12.30=£28.30
Faster
Better
74. Benefits
• Reduced need for PICC replacement
• Slightly reduced risk of catheter-related infection
Probability of
complication over 25
days Cost of
treating
complicationSecurAcath StatLock
PICC migration 0.0040 0.0593 £250
PICC malposition 0.0166 0.1097 £250
PICC occlusion 0.1435 0.1200 £250
Thrombosis 0.0369 0.0369 £250
Infection 0.0036 0.0037 £9,900
Sources
Effects
1xRCT (n=105)
2x cohort studies
4x case series
Unit costs
3x published studies
Safer
75. Decision tree - SecurAcath
£28
SecurAcath
PICC migration
PICC malposition
PICC occlusion
Thrombosis
Infection
0.0040
0.0166
0.1435
0.0369
0.0036
No complication
0.7954
£278
£278
£278
£278
£9,928
£114
Multiply the cost of each endpoint with the probability of getting there
(0.7954x28)+(0.0040x278)+(…….. =
78. Other Analyses
• Sensitivity analyses did not change outcome
– Device cost +/-20%
– Complications +/-20% and no difference
– Shorter SecurAcath placement time
• Other population - alternative time horizons
– 5 days and 25 days
– Threshold analysis – SecurAcath is cost saving for PICC use over 15 days
• Other population - CVC instead of PICC
– Alternative comparator – sutures
– SecurAcath was not cost saving
79. Recommendations
• “SecurAcath should be considered for any PICC with an anticipated
medium- to long-term dwell time (15 days or more).”
• “Estimated cost savings range from £9 to £95 per patient for dwell times
of 25 days and 120 days, respectively.”
• “Annual savings across the NHS in England from using SecurAcath are
estimated to be a minimum of £4.2 million.”
81. Case study 2
• PleurX peritoneal catheter drainage system for vacuum-assisted drainage
of treatment-resistant, recurrent malignant ascites
Published March 2012
Model updated February 2018
https://www.nice.org.uk/guidance/mtg9
82. PICO
• Population: People with treatment resistant, recurrent malignant
ascites (accumulation of fluid in the peritoneal cavity)
• Intervention: PleurX peritoneal catheter drainage system for
vacuum-assisted drainage
• Comparator: Repeated large-volume paracentesis (needle drainage
of fluid) inpatient procedures
• Outcomes: Technical success, resolution of symptoms, perception
of body image, quality of life, adverse events, drainage
frequency, resource use, cost per patient
83. Model essentials
• Economic evaluation type: Comparative cost analysis
• Model type: Simple decision tree
• Time horizon: 26 weeks
• Discounting: Not necessary - short time horizon
• Perspective: NHS hospital costs (England)
84. Claimed Benefits
• Greater patient independence
• Better symptom control
• Reduced need for repeated large-volume
paracentesis procedures
• Resource savings through a reduced need for hospital
physician and nurse time, outpatient visits and
hospital bed days
Cheaper
Better
86. Clinical variables
Parameter LVP PleurX Source
Mean survival
(weeks)
8.45 8.45 Mullan et al
(2011a)
Parameter LVP PleurX Source
Probability of
infection (LVP)
4.5% 2.5% Rosenberg
(2004)
Probability of
catheter
failure (LVP)
3.0% 5.0% Rosenberg
(2004)
Survival
Complications
87. Healthcare recourse use
Parameter Value Source
Bed days for LVP per session 2.8 Mullan (2011a)
Frequency of repeated LVP (per month) 1.22 Mullan (2011a)
Large volume paracentesis
PleurX
Parameter Value Source
Bed days for catheter placement 1.0 Assumed based on Mullan
(2011a)
Probability of re-intervention 4.0% Rosenberg (2004)
Proportion who are self-managed 73.0% Courtney (2008)
Length of nurse visit (hours) 0.25 Assumed
Nurse visits for catheter use training 2 Questionnaire
Nurse visits per week 3.5 Assumed
Number of drainage kits used (per week) 3.5 6.4.5
88. Healthcare Costs
Parameter Value Source
Hospital bed day £355.00 NHS reference cost 2015-
16
Infection £198.97 NHS reference cost 2015-
16; BNF*
Catheter failure £405.73 NHS reference cost 2015-
16, BNF**
Catheter re-intervention £790.96 Assumed***
Cost per home visit (assisted) £67.89 PSSRU 2016
Cost of travel per visit (assisted) £1.58 Assumed
*Includes: A medical oncology consultant led first attendance visit:
£197; 7 day course of antibiotics (Ciprofloxacin) £1.97
**Includes: A medical oncology consultant led first attendance visit:
£197; vial of Streptokinase: £16.73; Ultrasound lasting <20 minutes:
£51.00; contrast fluoroscopy lasting <20 minutes: £141.00
*** Assumed to be cost of 1st catheter procedure + 1 hospital bed day
89. Costs of consumables
Large Volume Paracentesis
Parameter Value Source
Catheter and pack £33.64 Uplifted from Mullan et al
Connector £7.22 Uplifted from Mullan et al
Drain £5.19 Uplifted from Mullan et al
2L Drainage Bag £0.67 Uplifted from Mullan et al
Procedure costs/sundries £127.21 Uplifted from Mullan et al
Parameter Value Source
Catheter and pack £245.00 Provided by manufacturer
2L Drainage Bag and 1L drainage
kit
£63.75 Provided by manufacturer
Procedure costs/sundries £127.21 Uplifted from Mullan et al
Drainage kit box (10 units) £637.50 Provided by manufacturer
PleurX
90. Key Model Assumptions
• Effects
– No change in survival rate in both arms of the model
– Drainage volume of 9.2 litres per procedure in patients who have large-
volume paracentesis
– Average drainage volume of 3.5 litres per week using PleurX
• Resource use
– Need for 2 nurse visits to train patients to self-manage drainage at home using
PleurX
– Nurse visit length of 15 minutes for PleurX help with drainage
– One nurse visit per litre of fluid drained using PleurX
– Similar levels of treatment monitoring needs in both arms
91. Results
Intervention/Comparator Cost per patient
Inpatient large-volume paracentesis £3,146
PleurX peritoneal catheter drainage system £2,466
Savings = £680 per patient when PleurX catheter
drainage system is used
92. Sensitivity Analysis
• One-way deterministic sensitivity analysis
• All variables were tested except population size
• Variables were analysed using 20% variance regardless of level of
confidence in an input
• Six key drivers were identified and subjected to further deterministic
threshold analysis to identify point at which PleurX became more costly or
cost saving
93. Key drivers
• Cost of a hospital bed day
• Number of bed days per LVP procedure per month
• Number of bed days for PleurX catheter placement
• Cost of drainage kit box (10 units)
• Number of drainage kits used per week per patient
94. PleurX became more costly compared to inpatient LVP when:
• the cost of an excess bed day is reduced to less than £220 per day
• the frequency of an inpatient large-volume paracentesis procedure is
reduced to fewer than one per month
• the average length of inpatient stay after the LVP is decreased to 2.1
days
• the number of inpatient bed days following the PleurX catheter
insertion is increased to more than 3.1 days
• the cost of the PleurX drainage kit is increased to more than £915
(per 10 units)
• more than 5.1 drainage kit units are needed per week
Findings of the Threshold Analyses
95. Recommendations
• “The PleurX peritoneal catheter drainage system should be considered for
use in patients with treatment-resistant, recurrent malignant ascites.”
97. Conclusion: Key things to remember
• Appropriate comparators should include usual care
• NHS cost perspective should not cover patient costs or productivity
gains/losses
• Find evidence for impact on health care resource use
• Unit costs from standard sources
• Appropriate time horizon to capture costs and benefits
• Accounting for time preference, through discounting/annuitizing
• Types of economic analysis, e.g. cost-consequences analysis
• Health outcomes to include
• Simple models, e.g. decision trees, can help
• Deal with uncertainty through sensitivity analysis
• Parameter estimates, sources, pathways and assumptions should be
transparent
98. Health economic evaluation resources
• Textbooks
– Drummond et al Methods for the Economic Evaluation of Health Care Programmes
(4th edition) 2015
– Briggs et al Decision Modelling for Health Economic Evaluation 2006
• Short courses
– Oxford University – one day
• https://www.herc.ox.ac.uk/herc-short-courses/introduction-to-health-
economic-evaluation
– Brunel University – 3 day
• https://www.brunel.ac.uk/research/Institutes/Institute-of-Environment-
Health-and-Societies/Health-Economics/Short-Courses
– York University
• https://www.york.ac.uk/che/news/news-2018/che-short-courses/
• Good practice guides
– https://www.ispor.org/workpaper/practices_index.asp
100. Practical
• Costs
• What are the technology costs?
• Are there upfront costs? Can you calculate cost per patient?
• Cost savings? (Faster, better, cheaper, safer)
– What is the evidence?
• What cost perspective? Who is the evaluation for?
• What unit costs?
• Health gain
• Does it improve health?
– What is the evidence?
• What kind of health economic analysis is required? (e.g. cost-
consequences analysis)
108. Repeat for each intervention and calculate ICER
A B Difference
Expected cost £1,394,575 £2,250,404 £855,830
Expected QALYs 9,286 9,345 59
ICER (£ per QALY) = £14,466
5%
1%
75%
5%
£100 pa
QoL=1
£0 pa
QoL=0
£1,000 pa
QoL=0.6
Intervention A
4%
1%
78%
5%
£200 pa
QoL=1
£0 pa
QoL=0
£1,100 pa
QoL=0.6
Intervention B
109. Limitations
• Must assume that each ‘state’ is mutually exclusive, i.e. For one person,
they cannot be in both states at once
• Models usually have no ‘memory’:
– Feasible that one person in the model could have multiple events i.e. 6 heart
attacks
– Assumes that transition values, costs and QALYs are the same (so if you have
the 1st heart attack, same costs and QALYs as 7th)
– There are ways to solve this issue
111. Cirrhosismodelsstructure F3-TN F3-FP
Comp-
TP*
Comp-
FN*
Var-
Un*
VarTP-
Pr*
Var-
FN*
Decomp
*
Bleed
Trans
2
dcVar
Un*
dcVar
Pr*
Post -
Trans
Dead
i) Shaded states relate to test results
ii) States with an asterisk have a corresponding hepatocellular carcinoma (HCC) 5
year state attached to them (not shown)
iii) From an HCC state patients can either die or get a transplant Non-transplant HCC
survivors either return to their state of origin or if that was a FN to the
corresponding TP state (not shown)
iv) All states transit to death
v) Dashed arrows represent the additional transitions during a cirrhosis retest cycle
112. Steatosis model structure
<F3–<F3
<F3 TN*
<F3 – F3
<F3 FP
F3 - F3
F3 TN*
F3 - <F3
F3 FN
F4 – F3
Comp FN
F4 – F4
Comp TP
F3 – F4
F3 FP
<F3 – F4
<F3 FPc
Cirr test
Cirr test +
Progress
Fib test
i) The first component of the first name depicts the true health state
whereas the second is the fib/cirr test results
e.g. F3 – <F3 = patients with advanced fibrosis identified by the test
as not having advanced fibrosis. (The second name underneath is as it
appears in the spreadsheet).
ii) All states transit to dead
iii) F4 states transit to cancer and decompensated cirrhosis; Varices
states transit to bleed. See NAFLD cirrhosis model
<F3 as true state F3 as true state F4 as true state Retesting for advanced fibrosis
F4 – <F3
Comp FN+
Cirr test
Cirr test +
Progress
F4V – F3
Var FN
F4V– F4 pr
Var TPpr
Cirr test +
Progress
F4V– <F3
Var FN+
Cirr test F4V – F4
VarTPun
Var test + progress
Fib test +
Progress
Fib test +
Progress
Fib test +
Progress
Fib test
Fib test
Fib test
Cirr test
Fib test +
regress
Var test
Non-<F3
Non-FP
<F3-Non
<F3-FN
F3-Non
F3FN+
F4-Non
CompFN++
Non-Non
Non-TN
F4V – Non
Var FN++
Steat test
Non-F3
Non-FPf3
Steat test
Steat test
Steat test
Steat test
Steat test +
Progress
Steat test +
Progress
Steat test +
Progress
Steat test +
Progress
Fib test +
Progress
Fib test
No NAFLDas true state
Steat test +
regress
Cirr test +
regress
Cirr test +
Progress
Editor's Notes
Delete graphics if preferred
Delete graphics if preferred
This definition of economic evaluation (from Drummond, Stoddart & Torrance) has two key aspects:
EE should always compare one health care intervention with one or more alternative interventions for the same population group.
EE should include both the costs and consequences of interventions - the resources that they consume and the health outcomes that they produce.
Note that the choice of comparator is crucial – should include all relevant options for a group of patients (including ‘do nothing’ and ‘current practice’).
Analysis should be conducted separately for each subgroup of patients.
Different types of economic evaluation are defined by the choice of outcome unit.
CUA is the preferred option for NICE – but sometimes QALY estimation is difficult, so CEA may be used.
Most likely that they will want to conduct cost-consequences analyses
We will come back to this concept later on in the session!!!!!!!
Other examples
Mobile ultrasound (MDI medical) iPhone size device with DICOM image standards. Need to model benefit of less hospital referrals and more GP practice/home based scans for a wide range of conditions not just pregnancy
Point of care testing (eBiogen) Point of care rapid (nearly real time) testing of lactate (and other) analytes in blood. Lactate is a strong indicator of sepsis
Pick out the cost of an average GP appointment from the document
The ICER is illustrated by the slope of a line through the origin and the IE/IC point for an intervention.
Compare this with the ‘threshold’ cost-effectiveness ratio – assume around £20,000 to £30,000 per QALY for NICE decisions.
SOMETIMEES A SIMPLE COSTING MIGHT BE THE MOST APPROPERIATE
Clinical outcomes
technical success of catheter insertion and drainage procedure
resolution of symptoms (bloating, nausea, acid reflux, reduced appetite, negative
perception of body image and resulting psychological distress)
quality of life outcomes
adverse events (catheter site infections, peritonitis, catheter occlusion, and haemorrhage or bowel perforation when the device is inserted)
drainage frequency
resource use outcomes, for example re-admission rates, re-interventions and duration of hospital stay.
Cost model submitted by the sponsor
Malignant ascites is a sign of peritoneal carcinomatosis, the presence of malignant cells in the peritoneal cavity. While survival in this patient population is poor, averaging about 20 weeks from time of diagnosis, quality of life can be improved through palliative procedures
The conventional management of treatment-resistant, recurrent malignant ascites involves repeated large-volume paracentesis (LVP) procedures that are carried out in hospital. Most commonly this is done as an inpatient procedure, although some centres are able to offer paracentesis as a day-case procedure.
Inpatient paracentesis is carried out when patients have developed troublesome symptoms from recurrent ascites. This can entail someresult in delay while waiting for admission, during which the patient continues to experience symptoms.
The PleurX peritoneal catheter drainage system (UK Medical Ltd) is designed to remain in place indefinitely and patients and carers are trained to perform fluid drainage when needed by attaching the vacuum bottle to the catheter. The use of the PleurX peritoneal catheter drainage system may allow greater patient independence, and lead to resource savings through a reduced need for repeated LVP procedures and hospital bed days.
Clinical outcomes
technical success of catheter insertion and drainage procedure
resolution of symptoms (bloating, nausea, acid reflux, reduced appetite, negative
perception of body image and resulting psychological distress)
quality of life outcomes
adverse events (catheter site infections, peritonitis, catheter occlusion, and haemorrhage or bowel perforation when the device is inserted)
drainage frequency
resource use outcomes, for example re-admission rates, re-interventions and duration of hospital stay.
Give brief detail on the studies Rosenburg and Mullan
Rosenberg (2004) was the one comparative case series study
Limitation is that variables were analysed using a 20% variance regardless of level of confidence in an output
Management with PleurX may result n cost savings of £679 per patient when compared with inpatient large-volume paracentesis. 7.4 hospital bed days saved per patient but 23.5 more community nurse visits needed
Key drivers
Cost of a hospital bed day
Number of bed days per LVP procedure per month
Number of bed days for PleurX catheter placement
Cost of drainage kit box (10 units)
Number of drainage kits used per week per patient
Cost savings of PleurX are heavily dependent on a reduction in hospital stay.
The health economic information booklet explains key concepts and HE methods
NICE run free introductory workshops on health economic methods. Please let us know if you would like to attend one of these
Complete feedback forms
1) Markov models are based on a series of health states that a patient can occupy at a given point in time.
2) The arrows represent possible transitions:
We allocate members of a population to one of a finite number of ‘states’ (e.g. ‘well’, ‘sick’ and ‘dead’).
We then specify the probabilities of moving between the states in consecutive time periods.
3) The probability of a patient occupying a particular state is assessed over a series of time periods called cycles – need to choose the appropriate cycle length, this which will depend on the disease and interventions.
NB Death is a ‘absorbing’ state - there is no way out of it!
Now that we have the structure set up we can add data:
1) For example the probabilities of transitioning between the different states have been defined.
2) Also we need to attach costs and QoL values to each of the states.
So just like in the decision tree, these will be used to calculate the expected value.
SO let’s say our cycles are yearly and we have assumed a time horizon of 10 years.
Therefore each year patients can move between different health states, which health state they move to depends on the transition probabilities.
Given that we now know how many patients are in each state per cycle, It is a simple case of multiplying the number of patients in each state by the costs and QALYs of each state.
We then sum the costs of each cycle and the QALYs, this will then give us the total costs and total QALYs for each intervention.
In state transition models:
We allocate members of a population to one of a finite number of ‘states’ (e.g. ‘well’, ‘sick’ and ‘dead’).
We then specify the probabilities of moving between the states in consecutive time periods.
NB Death is a ‘sink’ state - there is no way out of it!
In state transition models:
We allocate members of a population to one of a finite number of ‘states’ (e.g. ‘well’, ‘sick’ and ‘dead’).
We then specify the probabilities of moving between the states in consecutive time periods.
NB Death is a ‘sink’ state - there is no way out of it!
If one person has multiple events, then the same costs and QALYs are applied if you had the first event or a recurrent event.
Going back to our previous example – a person could get sick multiple times, however they would still have the same probability of going into that sick state, as well as the same cost and same QALY assigned to that state – however in reality, someone who has their 7th heart attack for example may have a different decrease in their QoL compared to someone who had their 1st heart attack.
In summary when someone in a model has an adverse event, the model doesn’t know if they have had any previous adverse events or what state they have come from – which is why it is memoryless.