Huw Lloyd-Williams

Public health economics: a systematic review of guidance for the economic evaluation of public health interventions and discussion of key methodological issues

BackgroundIf Public Health is the science and art of how society collectively aims to improve health, and reduce inequalities in health, then Public Health Economics is the science and art of supporting decision making as to how society can use its available resources to best meet these objectives and minimise opportunity cost. A systematic review of published guidance for the economic evaluation of public health interventions within this broad public policy paradigm was conducted.MethodsElectronic databases and organisation websites were searched using a 22 year time horizon (1990–2012). References of papers were hand searched for additional papers for inclusion. Government reports or peer-reviewed published papers were included if they; referred to the methods of economic evaluation of public health interventions, identified key challenges of conducting economic evaluations of public health interventions or made recommendations for conducting economic evaluations of public health interventions. Guidance was divided into three categories UK guidance, international guidance and observations or guidance provided by individual commentators in the field of public health economics. An assessment of the theoretical frameworks underpinning the guidance was made and served as a rationale for categorising the papers.ResultsWe identified 5 international guidance documents, 7 UK guidance documents and 4 documents by individual commentators. The papers reviewed identify the main methodological challenges that face analysts when conducting such evaluations. There is a consensus within the guidance that wider social and environmental costs and benefits should be looked at due to the complex nature of public health. This was reflected in the theoretical underpinning as the majority of guidance was categorised as extra-welfarist.ConclusionsIn this novel review we argue that health economics may have come full circle from its roots in broad public policy economics. We may find it useful to think in this broader paradigm with respect to public health economics. We offer a 12 point checklist to support government, NHS commissioners and individual health economists in their consideration of economic evaluation methodology with respect to the additional challenges of applying health economics to public health.

Conducting Economic Evaluations Alongside Randomised Trials: Current Methodological Issues and Novel Approaches

Trial-based economic evaluations are an important aspect of health technology assessment. The availability of patient-level data coupled with unbiased estimates of clinical outcomes means that randomised controlled trials are effective vehicles for the generation of economic data. However there are methodological challenges to trial-based evaluations, including the collection of reliable data on resource use and cost, choice of health outcome measure, calculating minimally important differences, dealing with missing data, extrapolating outcomes and costs over time and the analysis of multinational trials. This review focuses on the state of the art of selective elements regarding the design, conduct, analysis and reporting of trial-based economic evaluations. The limitations of existing approaches are detailed and novel methods introduced. The review is internationally relevant but with a focus towards practice in the UK.

Cognitive rehabiliation for Parkinson's disease demantia: a study protocol for a pilot randomised controlled trial

BackgroundThere is growing interest in developing non-pharmacological treatments to address the cognitive deficits apparent in Parkinson’s disease dementia and dementia with Lewy bodies. Cognitive rehabilitation is a goal-oriented behavioural intervention which focuses on improving everyday functioning through management of cognitive difficulties; it has been shown to be effective in Alzheimer’s disease. To date, no studies have assessed its potential efficacy for addressing the impact of cognitive impairment in people with Parkinson’s disease or dementia with Lewy bodies.Methods/designParticipants (n = 45) will be recruited from movement disorders, care for the elderly and memory clinics. Inclusion criteria include: a diagnosis of Parkinson’s disease, Parkinson’s disease dementia or dementia with Lewy bodies according to consensus criteria and an Addenbrooke’s Cognitive Examination – III score of ≤ 82. Exclusion criteria include: a diagnosis of any other significant neurological condition; major psychiatric disorder, including depression, which is not related to the patient’s Parkinson’s disease and unstable medication use for their physical or cognitive symptoms. A single-blind pilot randomised controlled trial, with concurrent economic evaluation, will compare the relative efficacy of cognitive rehabilitation with that of two control conditions. Following a goal-setting interview, the participants will be randomised to one of the three study arms: cognitive rehabilitation (eight weekly sessions), relaxation therapy (eight weekly sessions) or treatment as usual. Randomisation and treatment group allocation will be carried out by a clinical trials unit using a dynamic adaptive sequential randomisation algorithm. The primary outcomes are patients’ perceived goal attainment at a 2-months post-intervention assessment and a 6-months follow-up. Secondary outcomes include patients’ objective cognitive performance (on tests of memory and executive function) and satisfaction with goal attainment, carers’ perception of patients’ goal attainment and patients’ and carers’ health status and psychosocial well-being, measured at the same time points. Cost-effectiveness will be examined to explore the design of a larger cost-effectiveness analysis alongside a full trial.DiscussionThis pilot study will evaluate the application of cognitive rehabilitation for the management of cognitive difficulties associated with Parkinson’s disease dementia and dementia with Lewy bodies. The results of the study will inform the design of a fully powered randomised controlled trial.Trial registrationISRCTN16584442 DOI 10.1186/ISRCTN16584442 13 April 2015

‘Make do and mend’ after redundancy at Anglesey Aluminium: critiquing human capital approaches to unemployment

This article tracks workers’ responses to redundancy and impact on the local labour market and regional unemployment policy after the closure of a large employer, Anglesey Aluminium (AA), on Anglesey in North Wales. It questions human capital theory (HCT) and its influence on sustaining neo-liberal policy orthodoxy – focused on supplying skilled and employable workers in isolation from other necessary ingredients in the policy recipe. It is concluded that HCT and associated skills policy orthodoxy are problematic because supply of particular skills did not create demand from employers. Ex-AA workers faced a paradox of being highly skilled but underemployed. Some workers re-trained but there were insufficient (quality) job opportunities. In picking up the pieces after redundancy many workers found themselves part of a labour ‘precariat’ with little choice but to ‘make do and mend’.

Age and Work‐Related Health: Insights from the UK Labour Force Survey

Data from the UK Labour Force Survey (LFS) are used to examine two methodological issues in the analysis of the relationship between age and work-related health. First, the LFS is unusual in that it asks work-related health questions to those who are not currently employed. This facilitates a more representative analysis than that which is constrained to focus only on those currently in work. Second, information in the LFS facilitates a comparison of work-related health problems that stem from current employment to a more encompassing measure that includes those related to a former job. We find that accounting for each of these sources of bias increases the age work-related health risk gradient, and suggest that ignoring such effects will underestimate the work-related health implications of current policies to extend working lives.

Sample size calculation in trials of public health interventions: a discussion of implications for health economists

Abstract Background Statistical analysis enables ascertainment of whether or not there are interesting differences in effects between two or more groups and allows inferences to be made about the population from which a sample comes. For those of us interested in these differences, to be able to report on their statistical significance is useful to help us remark on the confidence we have in our results. However, careful consideration should be given to the choice of sample size. We investigated recent developments in the methodological considerations surrounding issues of identification of an appropriate sample size for a study, investigating first the issue in the context of clinical trials before going on to discuss the issue in terms of public health. Methods In this discussion piece, we highlight recent developments in the area of sample size calculation. We then offer two case studies that provide examples of sample size estimation under different scenarios: when no power or sample size calculations have been mentioned and when power or sample size calculations have been done properly. The first was done by the UK prospective diabetes study group (1998) in which the sample size was 1148, although there was no explicit mention of how this sample size was calculated. The second case study was an example by Briggs and Gray (1998) on the study of intracranial aneurysms. They plotted the sample size requirements as a function of the maximum cost-effectiveness ratio. One can then, for a given level of cost effectiveness, work out the sample size needed for different levels of power. Findings Although clinical trials calculate sample sizes on the basis of clinical outcomes, we show that these sample sizes might not provide enough power for any economic assessment we might want to undertake, because economic assessments deal with both costs and treatment effects. Usually, economic assessment relates to estimation rather than hypothesis testing. Therefore, calculations of power and sample size in economic assessment are done in relation to some value of maximum willingness to pay (WTP) for a unit of treatment effect. The upper confidence limit of the incremental cost-effectiveness ratio of a cost-effective treatment must fall below the value of the maximum WTP and the sample size must provide enough power for this to be possible. Further, in economic assessment of public health interventions, the effective sample size might be less than the actual sample size used because of intra-cluster correlation and so the sample size must be corrected for this factor. Interpretation We argue that a systematic review of the published work is needed to highlight the state of play with regard to sample size estimation, especially in economic assessment of public health interventions. By methodically collating the available evidence, the case for best practice in choosing the appropriate sample size can be put forward and progress can be made in increasing the number of studies that are sufficiently powered. Funding None.

Labour precariousness and make do and mend after redundancy at Anglesey Aluminium: critiquing Human Capital Theory

This paper tracks workers experiences of and responses to redundancy, and the impact on the local labour market, following the closure of a large employer, Anglesey Aluminium (AA), on Anglesey in North Wales. We draw on these findings to produce a critical challenge to Human Capital Theory (HCT) and its influence on sustaining neo-liberal policy orthodoxy with its focus on supplying skilled and employable workers in isolation from other necessary ingredients in the policy recipe. We conclude that HCT and associated policy orthodoxy has contributed to market failure. Ex-AA workers faced a paradox of being overqualified but underemployed. Some workers re-skilled but there were insufficient (quality) job opportunities commensurate with the employment they had left. In picking up the pieces following redundancy, many workers found themselves part of an expanding labour precariat with little choice but to make do and mend.