Philippe Ulmann

The relationship between health care expenditure and health outcomes

The relationship between health care expenditure and health outcomes is of interest to policy makers in the light of steady increases in health care spending for most industrialised countries. However, establishing causal relationships is complex because, firstly, health care expenditure is only one of many quantitative and qualitative factors that contribute to health outcomes, and, secondly, measurement of health status is an imperfect process. This study reviews key findings and methodological approaches in this field and reports the results of our own empirical study of countries of the European Union. Our analysis examines life expectancy and infant mortality as the ‘output’ of the health care system, and various life-style, environmental and occupational factors as ‘inputs’. Econometric analyses using a fixed effects model are conducted on a panel data set for the former 15 members of the European Union over the period 1980–1995. The findings show that increases in health care expenditure are significantly associated with large improvements in infant mortality but only marginally in relation to life expectancy. The findings are generally consistent with those of several previous studies. Caveats and improvements for future research are presented.

Can economic evaluations be made more transferable

Several commentators have identified the lack of generalisability and transferability of economic evaluation results. The aims of this study were: (a) to develop a checklist to assess the level of generalisability and transferability of economic evaluations; (b) to assess the generalisability and transferability of economic evaluations between the UK and France using the checklist; (c) to identify reasons for any lack of transferability and generalisability; (d) to assess how the transferability and generalisability of economic evaluations can be improved; and (e) to outline ways in which databases of economic evaluations and journals can assist in this area. The checklist was developed using previous work and the templates of the NHS EED and CODECS databases. A sub-checklist of essential items was then derived. Validation of the two checklists was undertaken with Health Economists participating in the EURONHEED project. Economic evaluations involving the UK and France were then located and assessed using the checklist. A summary score for each study was calculated based on the percentage of correctly reported (applicable) points, and the results in the empirical analysis compared to identify differences. The extended checklist includes 42 items, and the sub-checklist 16 items. Twenty-five economic evaluations met the inclusion criteria for the empirical analysis. In the extended checklist the mean score was 66.9±13.6%. The results for the sub-checklist were very similar. The analysis revealed that costing, assessments of generalisability by the author(s), assessment of data variability, discounting, study population, and the reporting of effectiveness are areas that need more attention. Differences in cost-effectiveness results are often accounted for by price or organisational differences. The developed checklists are useful in assessing the generalisability and transferability of economic evaluations. In order to improve the generalisability and transferability of economic evaluations authors need to be more explicit and detailed in describing and reporting their studies. If they are to provide added value to their users, international databases of economic evaluations should systematically assess the generalisability and transferability of studies. Further research is in progress on producing a weighted version of the checklist.

Guidelines for completing the EURONHEED transferability information checklists

The structure and methods to complete and derive a quality score from the European Network of Health Economic Evaluation Databases (EURONHEED) transferability information checklists for published economic evaluations were reported and discussed in a previous paper (Boulenger et al. in Eur J Health Econ 6, 334–346, 2005). Within the same paper, the use of the checklists was illustrated through their application to a sample of economic evaluations conducted in France and UK. The transferability information subchecklist, consisting of 16 items from the original 42-point checklist, and methods used to derive it, were validated among 16 health economists across Europe participating in the EURONHEED project. Recent correspondence with other researchers, however, indicates that the checklists are now being utilised in empirical work and the methodology of assessing transferability and generalisability. This supplementary paper provides full details of the guidelines that have been developed and recently updated by the authors, such that the overall and subchecklists can be more widely and consistently completed and utilised. We also briefly discuss associated issues such as weighting of items in the checklists and give further clarifications regarding what we consider the most appropriate applications of the checklists to be.

The diffusion of Health economics knowledge in Europe: The EURONHEED (European Network of Health Economics Evaluation Database) Project

This paper overviews the EURONHEED (EUROpean Network of Health Economics Evaluation Databases) project. Launched in 2003, this project is funded by the EU. Its aim is to create a network of national and international databases dedicated to health economic evaluation of health services and innovations. Seven centres (France, Germany, Italy, The Netherlands, Spain, Sweden and the UK) are involved covering 17 countries. The network is based on two existing databases, the French CODECS (COnnaissance et Decision en EConomie de la Santé) database, created in 2000 by the French Health Economists Association (Collège des Economistes de la Santé), and the UK NHS-EED (NHS Economic Electronic Database), run by the Centre for Reviews and Dissemination, University of York, York, England.The network will provide bibliographic records of published full health economic evaluation studies (cost-benefit, cost-utility and cost-effectiveness studies) as well as cost studies, methodological articles and review papers. Moreover, a structured abstract of full evaluation studies will be provided to users, allowing them access to a detailed description of each study and to a commentary stressing the implications and limits, for decision making, of the study. Access will be free of charge. The database features and its ease of access (via the internet: http://www.euronheed.org) should facilitate the diffusion of existing economic evidence on health services and the generalisation of common standards in the field at the European level, thereby improving the quality, generalisability and transferability of results across countries.