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The matter of economic evaluations in health policy decision-making: The case of the Swedish national guidelines for heart diseases
Linköping University, Department of Medical and Health Sciences, Division of Health Care Analysis. Linköping University, Faculty of Medicine and Health Sciences.
2015 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Economic evaluations are used to inform decision makers about the efficient allocation of scarce healthcare resources and are generated with the direct intent to support decisions in healthcare. Producing guidelines is a complex process and the inclusion of health-economic aspects in the formulation of the Swedish national guidelines as a basis for the written recommendations (priority gradings), distinguishes them from their European counterparts. Despite the increased use of cost-effectiveness data in decision-making, little is known about the actual use of such data. This thesis covers issues concerning how economic evaluations matter in health policy decision-making. The thesis includes four papers based on the Swedish national guidelines for heart diseases, one of the most prominent examples in Sweden of following the notion of evidence-based policy (EBP), in order to inform explicit priority setting.

Both Papers I and II followed a qualitative case study design, based on the same data set. Paper I explored how a specific working group, the Priority Setting Group (PSG), handled the various forms of evidence and values when producing the national guidelines. Two themes were identified in reaching collective agreement in priority gradings; group facilitation activities and avoiding deadlock in the discussion. The work process involved disagreement and negotiation as part of that task. Paper I contributes to the theoretical and practical debate on EBP. Paper II focused on the use of cost-effectiveness data as decision support in the PSG work process. The paper addressed availability of cost-effectiveness data, evidence understanding, interpretation difficulties, and the reliance on evidence. Three themes were identified. The paper contributes to knowledge on how cost-effectiveness evidence was used in actual decision-making. The use of cost-effectiveness evidence was one of many tools employed to avoid deadlock in discussion and to reach a priority grading, when the overall evidence base was weak, in times of uncertainty and on the introduction of new expensive medical technologies.

Quantitative research methods were used for both Papers III and IV. Paper III explored how the PSG was presented with cost-effectiveness evidence as decision support and as a basis for their priority gradings. Cost-effectiveness ratios (ICERs) were provided, based on a  systematic literature review, as well as how the results may be conveyed and communicated, for the treatment of heart diseases using a cost-effectiveness ranking or league and providing valid information within a limited space, aiding decision makers on the allocation of healthcare resources. The thesis also includes decision support in the form of cost-effectiveness analysis on catheter ablation treatment. Paper IV provides an example of presenting evidence in the form of a decision-analytic model. The modelling approach provides an analytic framework for decision-making, specifically under conditions of uncertainty as in the introduction of new medical technology. Catheter ablation was associated with reduced cost and an incremental gain in quality adjusted life years (QALYs), and was considered a cost-effective treatment strategy compared to the medical treatment strategy in a lifetime perspective.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2015. , 119 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1440
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Other Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-121282DOI: 10.3384/diss.diva-121282ISBN: 978-91-7519-142-3 (print)OAI: oai:DiVA.org:liu-121282DiVA: diva2:853080
Public defence
2015-10-02, Eken, Ingång 65, Campus US, Linköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2015-09-11 Created: 2015-09-11 Last updated: 2015-09-11Bibliographically approved
List of papers
1. Reaching agreement in uncertain circumstances: the practice of evidence-based policy in the case of the Swedish National Guidelines for heart diseases
Open this publication in new window or tab >>Reaching agreement in uncertain circumstances: the practice of evidence-based policy in the case of the Swedish National Guidelines for heart diseases
2017 (English)In: Evidence and Policy: A Journal of Research, Debate and Practice, ISSN 1744-2648, no 4, 687-707 p.Article in journal (Refereed) Published
Abstract [en]

This paper explores the practice of evidence-based policy in a Swedish healthcare context. The study focused on how policymakers in the specific working group, the Priority-Setting Group (PSG), handled the various forms of evidence and values and their competing rationalities, when producing the Swedish National Guidelines for heart diseases that are based on both clinical and economic evidence and are established to support explicit priority-setting in healthcare. The study contributes to the theoretical and practical debate on evidence-based policy (EBP) by illustrating how the practical tensions of coming to agreement were managed, to a large extent, through deliberation and by creativity.

Place, publisher, year, edition, pages
Informa Healthcare, 2017
Keyword
cost-effectiveness; evidence-based policy; healthcare; national guidelines; priority setting; sense-making
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Other Health Sciences
Identifiers
urn:nbn:se:liu:diva-121280 (URN)10.1332/174426416X14788795557982 (DOI)
Available from: 2015-09-11 Created: 2015-09-11 Last updated: 2017-12-12Bibliographically approved
2. Use of cost-effectiveness data in priority setting decisions: experiences from the national guidelines for heart diseases in Sweden
Open this publication in new window or tab >>Use of cost-effectiveness data in priority setting decisions: experiences from the national guidelines for heart diseases in Sweden
2014 (English)In: International Journal of Health Policy and Management, ISSN 2322-5939, E-ISSN 2322-5939, Vol. 3, no 6, 323-332 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: The inclusion of cost-effectiveness data, as a basis for priority setting rankings, is a distinguishing feature in the formulation of the Swedish national guidelines. Guidelines are generated with the direct intent to influence health policy and support decisions about the efficient allocation of scarce healthcare resources. Certain medical conditions may be given higher priority rankings i.e. given more resources than others, depending on how serious the medical condition is. This study investigated how a decision-making group, the Priority Setting Group (PSG), used cost-effectiveness data in ranking priority setting decisions in the national guidelines for heart diseases.

METHODS: A qualitative case study methodology was used to explore the use of such data in ranking priority setting healthcare decisions. The study addressed availability of cost-effectiveness data, evidence understanding, interpretation difficulties, and the reliance on evidence. We were also interested in the explicit use of data in ranking decisions, especially in situations where economic arguments impacted the reasoning behind the decisions.

RESULTS: This study showed that cost-effectiveness data was an important and integrated part of the decision-making process. Involvement of a health economist and reliance on the data facilitated the use of cost-effectiveness data. Economic arguments were used both as a fine-tuning instrument and a counterweight for dichotomization. Cost-effectiveness data were used when the overall evidence base was weak and the decision-makers had trouble making decisions due to lack of clinical evidence and in times of uncertainty. Cost-effectiveness data were also used for decisions on the introduction of new expensive medical technologies.

CONCLUSION: Cost-effectiveness data matters in decision-making processes and the results of this study could be applicable to other jurisdictions where health economics is implemented in decision-making. This study contributes to knowledge on how cost-effectiveness data is used in actual decision-making, to ensure that the decisions are offered on equal terms and that patients receive medical care according their needs in order achieve maximum benefit.

Place, publisher, year, edition, pages
Kerman University of Medical Sciences, 2014
Keyword
Health Policy, Cost-Effectiveness, Policy Decision-Making, Priority Setting, Heart Diseases
National Category
Health Sciences
Identifiers
urn:nbn:se:liu:diva-112150 (URN)10.15171/ijhpm.2014.105 (DOI)25396208 (PubMedID)
Available from: 2014-11-17 Created: 2014-11-17 Last updated: 2017-12-05Bibliographically approved
3. Compilation of cost-effectiveness evidence for different heart conditions and treatment strategies
Open this publication in new window or tab >>Compilation of cost-effectiveness evidence for different heart conditions and treatment strategies
2011 (English)In: Scandinavian Cardiovascular Journal, ISSN 1401-7431, E-ISSN 1651-2006, Vol. 45, no 2, 72-76 p.Article, review/survey (Refereed) Published
Abstract [en]

Objectives. Despite the continuing interest in health economic research, we could find no accessible data set on cost-effectiveness, useful as practical information to decision makers who must allocate scarce resources within the cardiovascular field. The aim of this paper was to present cost-effectiveness ratios, based on a systematic literature search for the treatment of heart diseases. Design. A comprehensive literature search on cost-effectiveness analyses of intervention strategies for the treatment of heart diseases was conducted. We compiled available cost-effectiveness ratios for different heart conditions and treatment strategies, in a cost-effectiveness ranking table. The cost-effectiveness ratios were expressed as a cost per quality adjusted life year (QALY) or life year gained. Results. Cost-effectiveness ratios, ranging from dominant to those costing more than 1,000,000 Euros per QALY gained, and bibliographic references are provided for. The table was categorized according to disease group, making the ranking table readily available. Conclusions. Cost-effectiveness ranking tables provide a means of presenting cost-effectiveness evidence. They provide valid information within a limited space aiding decision makers on the allocation of health care resources. This paper represents an extensive compilation of health economic evidence for the treatment of heart diseases.

Place, publisher, year, edition, pages
Informa Healthcare, 2011
Keyword
Cost, cost-effectiveness, rankings, heart disease, priority setting, evidence-based medicine
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-67153 (URN)10.3109/14017431.2011.557438 (DOI)000288326200002 ()
Note
Original Publication: Nathalie Eckard, Magnus Janzon and Lars-Åke Levin, Compilation of cost-effectiveness evidence for different heart conditions and treatment strategies, 2011, Scandinavian Cardiovascular Journal, (45), 2, 72-76. http://dx.doi.org/10.3109/14017431.2011.557438 Copyright: Informa Healthcare http://informahealthcare.com/ Available from: 2011-04-01 Created: 2011-04-01 Last updated: 2017-12-11
4. Cost-Effectiveness of Catheter Ablation Treatment for Patients with Symptomatic Atrial Fibrillation
Open this publication in new window or tab >>Cost-Effectiveness of Catheter Ablation Treatment for Patients with Symptomatic Atrial Fibrillation
2009 (English)In: Journal of Atrial Fibrillation, ISSN 1941-6911, Vol. 1, no 8, 461-470 p.Article in journal (Refereed) Published
Abstract [en]

Background:  Atrial Fibrillation is the most common cardiac arrhythmia.  It increases the risk of thromboembolic events and many atrial fibrillation patients suffer quality of life impairment due to disturbed heart rhythm.  Pulmonary vein isolation using radiofrequency catheter ablation treatment is aimed at maintaining sinus rhythm ultimately improving quality of life.  Randomized clinical trial have shown that catheter ablation is more effective than antiarrhythmic drugs for the treatment of atrial fibrillation, but its impact on quality of life and cost-effectiveness has not been widely studied.  Aims:  To assess the cost-effectiveness of radiofrequency ablation (RFA) vs. antiarrhythmic drug (AAD) treatment, among symptomatic atrial fibrillation patients not previously responding to AAD.  Methods:  A decision-analytic Markov model was developed to assess costs and health outcomes in terms of quality adjusted life years (QALYs) of RFA and AAD over a lifetime time horizon.  We conducted a literature search and used data from several sources as input variables of the model.  One-year rates of atrial fibrillation with RFA and AAD, respectively, were available from published randomized clinical trials.  Other data sources were published papers and register data.  Results:  The RFA treatment strategy was associated with reduced costs and an incremental gain in QALYs compared to the AAD treatment strategy.  The results were sensitive to whether long-term quality of life improvement is maintained for the RFA treatment strategy and the risk of stroke in the different atrial fibrillation health states.  Conclusion:  This study shows that the short-term improvement in atrial fibrillation associated with RFA is likely to lead to long-term quality of life improvement and lower costs indicating that RFA is cost-effective compared to AAD. 

Keyword
Cost, cost-effectiveness, decision-analytic model, ablation, atrial fibrillation, cardiovascular disease
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-20923 (URN)10.4022/jafib.v1i8.543 (DOI)
Available from: 2009-09-25 Created: 2009-09-25 Last updated: 2015-09-11

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