A framework for measuring the impact of HTA policy interventions. Eleanor Grieve University of Glasgow July 2015

Transcription

1 A framework for measuring the impact of HTA policy interventions Eleanor Grieve University of Glasgow July 2015

2 A methodological framework for measuring the impact of HTA policy interventions a review of the existing literature on HTA reveals a startling lack of depth, particularly on the impact HTA has had on health-care budgets, efficiency, and on societal health outcomes. Indeed one commentary noted that whereas the previous 10 years have been well-spent on building the HTA/EBM infrastructure and evidence base, the next 10 should focus on the outcomes. Reference: Straus SE (2004) in Value in Health Special Issue, Health Technology Assessment: Lessons Learnt from Around the World An Overview [Volume 12 Issue s2, Pages S1 - S5 (June 2009)]

3 Starting points Increasing investment in HTA Likely interest from policy makers about return on this investment How should we conceptualise the value of HTA? How do we generate case studies to illustrate this conceptual framework? Need for suggestions and feedback

4 What is impact? Element Area of focus What is the aim? Scope of indicators Inputs Building idsi structures A stronger idsi with meaningful partnerships and adaptable resources (partial ) Preparation for engagement Application of existing resources Building and leveraging idsi network Outputs idsi products for partners and public use Practical support, knowledge products, communications and outreach Knowledge products Targeted support to partners Establishment of institutions for priority-setting Intermediary outcomes Institutional strengthening Stronger Institutions & Processes Political commitment from stakeholders and policy-makers Improved capacity and structures for priority-setting Longer term outcomes Priority-setting decisions Better decisions Decisions adhere to idsi principles and recommendations Modelling expected impact on health and cost-effectiveness Impact Health Better health outcomes Improved health outcomes (QALYs/DALYs?) Observed impact on costeffectiveness 4

5 . Conceptual Framework for impact assessment Potential Impact Realised Impact HTA: Economic modelling population health impact full implementation Current /actual uptake Value of perfect implementation Theory based approaches 1. Critical/organisational cultural theory decision making 2. Implementation science: getting evidence into practice, dissemination, reaching the right people. Population health

6 Case Study Maternal & Child Health Voucher Scheme, Myanmar

7 Timeline May 2010 March 2011: Ex-ante evaluation (HITAP/ MoH, WHO) May 2013: MCHVS pilot programme in Yedarshey Township Jan 2014: Mid term evaluation (HITAP / MoH, WHO) 2015: Annual review (independent) 2015: Ex-post HTA + impact (University of Glasgow)

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9 . Parameters Health service utilization Baseline probability of seeking ANC with SBAs** Baseline probability of delivery with SBAs Effectiveness of CHI/elasticity of demand Average immunisation obtained per infant: Vaccinations (DPT/OPV)*** Mean (SE) 0.73 (0.03) Parameter distribution Beta Data source Community Survey 0.51 (0.04) Beta Community Survey 0.2 Nepal study, 2005 *Preimplem entatio n 1.81 average visits 0.56 *Postimplem entatio n 2.37 average visits *Mid term review 2014 and annual review 2015 **Samples had a higher rate of ANC than the national average. Myanmar health statistics indicate that the national average of ANC is 56%. ***Re-model impact of extending scheme to include MMR at 9 and 18 months Ex-ante results: introducing the voucher scheme would increase the coverage of governmentprovided MCH services from 73% to 93% for antenatal care, and increase the coverage from 51% to 71% for delivery. *Scale up impact national level

10 Full implementation: ex-ante HTA (feasibility study) and ex-post (pilot study) Ex-ante GBP Incremental cost Incremental life year saved Incremental DALY averted ICER per DALY averted GDP Myanmar (2010) 414 Threshold used = 1 GDP NHBs = ΔH - ΔC/λ Ex-post GBP Net health benefits (per person) Scaled to pilot (11532 pregnant women) 231 NHBs 576 NHBs

11 Current (actual) value of implementation With Ed = 0.2, full implementation = 76% ANC and 87% SBA coverage Mid term review of pilot reported 77% uptake SBA Current value of the HTA total patient population eligible for treatment (n) and a proportion of these patients (p) are already receiving the intervention, then the current value is defined as N * p * NHB = * 77% (of 87%) * 0.05 = 510 NHBs

12 The value of implementation Net Health Benefit: full implementation = 576 NHBs Net Health Benefit: Current implementation = 510 NHBs Additional NHB with full implementation The value of perfect implementation = 66 NHBs

13 Expected value of actual implementation The actual gains from an implementation initiative resulting from those patients receiving the intervention who would not have done so otherwise (as initiative will not necessarily result in perfect implementation). where α is the proportion treated with the initiative n * α * NHB n * p * NHB

14 Incremental net benefit of the implementation initiative An implementation initiative is worthwhile if its benefit in terms of increased utilisation of the intervention (the expected value of actual implementation ) is greater than its cost. n * α * NHB n * p * NHB - Implementation Cost / λ This can be applied to any CEA to help quantify the value of investing in resources in increasing utilisation cost-effectively thus improving impact.

15 Summary of conceptual framework What is the predicted expected gain in population health from a policy change given best evidence? What is the uncertainty and priorities for research? Has the HTA changed policy? What is the realised expected gain in population health given best evidence? How do we explain the difference between expected and actual gain in population health? What is the maximum we can pay to increase uptake? What implementation activities and policy changes can help address the gap between predicted and realised? What does additional evidence suggest about expected and actual gains in population health? Initial HTA model based on available evidence Observation of policy, best assessment of counter-factual Observation of uptake and implementation Qualitative work with relevant stakeholders; quantitative analysis Evidence on cost-effectiveness of implementation activities Update of initial HTA with further evidence from appropriately designed research

16 Acknowledgement to idsi three major funders Rockefeller Foundation Bill & Melinda Gates Foundation UK Department for International Development idsi Thank you to NICE International, Kalipso Chalkidou, MD, PhD, Director and Ryan Li, PhD, Advisor and York University (Mark Schulpher and Paul Revill) for some of these slides.

17 References How can the impact of health technology assessments be enhanced? Corinna Sorenson, Michael Drummond, Finn Børlum Kristensen and Reinhard Busse WHO Regional Office for Europe and European Observatory on Health Systems and Policies, 2008 Research report: Getting cost-effectiveness technologies into practice: the value of implementation. Authors: Walker S, Dixon S, Palmer S, Sculpher M. Policy Research Unit in Economic Evaluation of Health and Social Care Interventions, 2013 Gilson L, Raphaely N: The terrain of health policy analysis in low and middle income countries: a review of published literature Health Policy Plan 2008, 23(5): Fenwick E, Claxton K and Sculpher M. The value of implementation and the value of information: combined and uneven development. Medical Decision Making, 2008, 28, Stern et al, DFID Working Paper 28 Broadening the Range of Designs and Methods for Impact Evaluations 2012 Blamey, A., and Mackenzie M (2007) Theories of change and realistic evaluation. Evaluation 13(4), pp