Richard Brooks

Implications for Decision-Making

We now have in place a reasonably comprehensive picture of the nature and development of health status measurement. At the outset attempts were made to answer the question concerning why health status measurement has proceeded apace in recent years. This was followed by an historical outline of the developments in health status measurement, combined with a classification and description of the nature of some of the measures themselves. It was then stressed that there are certain key methodological requirements if health status measures are to be treated seriously in health measurement and evaluation: in particular such measures should be statistically ‘sound’, reliable and valid. Before considering the actual measurement processes appropriate to health status assessment a tour was taken around the issue of quality, and as we saw this turned out be a complex and indeed often elusive concept or set of concepts. Finally measurement was considered from first principles through to the controversies surrounding whose values should be used in health status measurement.

Economic aspects of a therapy and support service for people with long‐term stroke and aphasia

BACKGROUND This paper considers some economic aspects of a therapy and support service for people with stroke and aphasia. This material was part of a broader evaluation of the service, which is reported elsewhere (van der Gaag et al. 2005, van der Gaag and Mowles 2005). AIMS The purpose of this part of the study was to investigate the feasibility of undertaking economic appraisal in a voluntary sector service providing therapy for people with aphasia and their families. METHODS & PROCEDURES The costs of delivering therapy and support services were calculated. These costs were compared with the costs of equivalent services in the National Health Service (NHS). The EQ-5D health-related quality of life instrument was used to calculate quality-adjusted life years (QALYs). OUTCOMES & RESULTS The cost of delivering therapy was lower than expected for a customized service of this nature. The study generated cost data for delivering therapy services, allowing some comparisons to be made with equivalent services in NHS settings. QALY data were generated for a sample of 25 clients on one of the programmes. CONCLUSIONS The economics of speech and language therapy service delivery have received scant attention in the published literature. The paper argues that decision-making about methods of service delivery can be aided by the explicit consideration of the costs and consequences of different programmes.

The economic framework of day surgery: a plea for appropriate appraisal

Abstract It is essential to test the ‘cost-effectiveness’ or ‘economic gains’ of day surgery by the use of appropriate economic evaluation. This paper gives an overview of economic appraisal approaches, provides a framework for appraisal which covers the perspectives of both hospital decision-makers and that of society as a whole, and considers some important issues in the economic evaluation of day surgery.

An Outline of the Development of Health Status Measures

Providing a history of the development of health status measures is not the most straightforward of tasks. In some ways the use of the term ‘health status measure’ is perhaps unhelpful since it suggests a rather narrow health-based focus. Any assessment of outcome measurement and, more generally, evaluation in health and medicine quickly leads one into a complex area populated by members of various disciplines and replete with terminologies that are not always as carefully defined as they might be. Some of the disciplines — in alphabetical order — are: economics, epidemiology, medicine, moral philosophy, political science, psychology, sociology and statistics. Amongst the terminologies are: health status indicators, indexes, measures and surveys; functional status, functional assessment; utility measurement; quality of life, and health-related quality of life. The last term has become particularly popular in the literature of health assessment. What researchers and practitioners seek are measures which capture people’s ability to function or, rather more broadly, their well-being resulting from health programmes or interventions. The last 45 years or so have seen the burgeoning of such measures. It could be argued that in essence analysts have taken up the challenge of ‘operationalising’ the all-embracing WHO definition mentioned in Chapter 1.

The Upsurge of Interest in Health Status Measurement

Why has there been such an upsurge of interest in studying and measuring health status and health-related quality of life in recent years? This book addresses this question and explores the changing issues surrounding the evaluation of resource use in health. It might be asked at the outset why this question is worth answering. After all, medical personnel deal with health status throughout their working lives. Saving people’s lives, making people feel better: what more justification is required for health intervention, for the services of doctors and nurses, the popping of pills, the strapping of injured limbs, the words of comfort, the plastercasts? Why go any further in explaining the ‘need’ for medical and other interventions which may fundamentally affect health and well-being: if medical care is needed then surely we would expect resources to be devoted to its supply?

Quality as an Issue

Quality, like beauty, may well lie in the eye of the beholder. What is meant by ‘quality’ in medicine? Does good quality medicine lie in the bedside manner or general approachability of the doctor, of the nurse and of other health personnel? Does it lie in the quality of the ‘hotel’ services provided by hospitals? Does it lie in the effectiveness of the medical techniques applied, and in that case what do we mean by ‘effectiveness’? Does it mean the quicker someone is returned to his or her normal lifestyle the higher quality the medical intervention? Does it mean the more services provided for a given level of resources the ‘better’? Does it lie in the patient’s perception of the process he or she has undergone? This series of questions gives the flavour of the complexity which attends the definition and content of the notion of quality.

The Measurement Process

It was pointed out in Chapter 2 that in developing a health status measure essentially three steps are required: 1. The choice of dimensions/items/descriptors for inclusion in the measure. 2. The ‘scaling’, measurement, or valuation of these dimensions. 3. Some ethically appropriate rule for aggregating individual valuations determined in the scaling process.

Trends and Issues

It is tempting to start this concluding chapter with the observation that health status measurement is an idea whose time has come. This would be to do an injustice to the likes of Graunt, Petty, Farr, Nightingale and Codman, whose concerns with the measurement of health and the assessment of the outcomes of medical procedures span the centuries. It would also be misleading if the impression were to be given that medical and other health personnel have not hitherto been concerned in various ways with the outcomes of their efforts. Nor would one want to imply that health status measurement is the latest fad or fashion, destined to be discarded or ignored when the next fashion comes along. Be that as it may, there is no doubt that the volume of work in health status and health-related quality of life measurement has expanded to such an extent in recent years that phrases such as ‘explosion of interest’ have been used to characterise developments in these areas. This explosion has not just been in evidence in the ‘professional’ literature: newspapers and magazines regularly contain references to such concepts as the QALY. Conferences on outcome measurement proceed apace, both for health status researchers and analysts, and for health service personnel who may be expected to become involved in such measurement.