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The costs and benefits of bowel cancer service developments using discrete event simulation

Colorectal cancer includes cancerous growths in the colon, rectum and appendix and affects around 30 000 people in England each year. Maximizing health benefits for patients with colorectal cancer requires consideration of costs and outcomes across the whole service. In an era of scarce healthcare resources, there is a need to consider not only whether technologies and services may be considered clinically effective, but also whether they are cost-effective, that is, whether they represent value for money for the health service. Through the development of a whole disease model, it is possible to evaluate the cost-effectiveness of a range of options for service development consistently within a common framework. Discrete event simulation has been used to model the complete colorectal cancer patient pathway from patient presentation through to referral and diagnosis, treatment, follow-up, potential recurrence, treatment of metastases and end-of-life care. This simulation model has been used to examine the potential cost-effectiveness of different options for change across the entire colorectal cancer pathway. This paper provides an empirical demonstration of the potential application of modelling entire disease areas to inform clinical policy and resource allocation decision-making.

Estimating the direct costs of bowel cancer services provided by the National Health Service in England

OBJECTIVES Bowel cancer is the second most common cancer in England and Wales, accounting for approximately 13,000 deaths per year. Economic evaluations and national guidance have been produced for individual treatments for bowel cancer. However, it has been suggested that Primary Care Trusts develop program budgeting or equivalent methodology demonstrating a whole system approach to investment and disinvestment. The objective of this study was to provide a baseline framework for considering a whole system approach to estimate the direct costs of bowel cancer services provided by the National Health Service (NHS) in England. METHODS A treatment pathway, developed in 2005, was used to construct a service pathway model to estimate the direct cost of bowel cancer services in England. RESULTS The service pathway model estimated the direct cost of bowel cancer services to the NHS to be in excess of £1 billion in 2005. Thirty-five percent of the cost is attributable to the screening and testing of patients with suspected bowel cancer, subsequently diagnosed as cancer-free. CONCLUSIONS This study is believed to be the most comprehensive attempt to identify the direct cost of managing bowel cancer services in England. The approach adopted could be useful to assist local decision makers in identifying those aspects of the pathway that are most uncertain in terms of their cost-effectiveness and as a basis to explore the implications of re-allocated resources. Research recommendations include the need for detailed costs on surgical procedures, high-risk patients and the utilization of the methods used in this study across other cancers.

Should we invest in environmental interventions to encourage physical activity in England? An economic appraisal

BACKGROUND The Department of Health in England asked the National Institute for Health and Clinical Excellence (NICE) to develop guidance on environmental interventions that promote physical activity. The economic appraisals summarized in this study informed the development of that guidance. In view of the difficulties inherent in applying conventional health economic evaluation techniques to public health interventions, the economic appraisal employed a multi-faceted approach. METHODS The analyses comprised of three components. Two cost-utility analyses; the first used a life-time disease progression model which sought to take into account the long-term benefits of physical activity on health outcomes, whereas the second used data from a regression analysis which captured some of the short-term, process benefits of physical activity which might manifest themselves in terms of improved mental health and wellbeing. The third approach was a cost-benefit analysis that took into account benefits beyond healthcare. RESULTS The cost-utility approaches generated cost-effectiveness estimates ranging between £100 and £10 000 per QALY depending on the level of effectiveness of the intervention and the proportion of the intervention cost that was deemed to be attributable to health. The standardized cost-benefit ratio was 11:1. CONCLUSION The findings present a consistent case to support environmental interventions that promote increased physical activity in the sedentary adult population. However, some degree of caution should be taken in interpreting the findings due to the limitations of the evidence upon which they are based. Further consideration should also be given to the relative merits of alternative approaches to assessing the value of changes to the built environment that might also benefit health as a positive externality.

The feasibility of harmonizing health technology assessments across jurisdictions: A case study of drug eluting stents

OBJECTIVES There is considerable interest in the potential for harmonizing health technology assessments (HTA) across jurisdictions. This study aims to consider four HTAs of drug eluting stents to determine the degree to which the methods adopted, evidence considered, and resulting recommendations diverge. METHODS Four HTAs of drug eluting stents were selected for inclusion and evaluated using a framework developed to systematically capture information on the process adopted, the evidence considered and the recommendations of each HTA. RESULTS AND CONCLUSIONS The findings suggest that, although there is a common core data set considered by most of the agencies, differences in the approach to HTA, heterogeneity of studies, and the limited relevance of research findings to local practice meant that the core data set had only limited influence on the resulting recommendations. Of the HTA agencies considered in the analysis, many sought to generate additional primary research from local settings to help inform the development of recommendations that were relevant to local practice. This raises questions about the extent to which HTA methods can be harmonized across jurisdictions.