Richard Fordham

A framework for measuring costs to society of IgE‐mediated food allergy

Both immunoglobulin E (IgE)‐mediated food allergy and food intolerance can lead to many changes in personal behaviour and health care resource use which have important economic consequences. These costs will impact directly, indirectly and intangibly on both individuals and society in general. It is important to measure the cost of illness (COI) of food allergy as a first step in developing and evaluating measures to reduce and control the burden of illness. This paper outlines a framework for assessing COI of food allergy from different viewpoints. It offers a structure for identifying the different cost impacts on allergic and nonallergic consumers, food producers and society as a whole, and for scoping, measurement and valuation of relevant costs. Within this structure, the existing literature is reviewed. This review illustrates the lack of information and clear methodology for assessing costs of food allergy. The paper concludes that there is a need for a more structured research programme to generate data essential for future evaluations of procedures and technologies for the diagnosis, treatment and management of food allergy.

Prioritizing Health Technologies in a Primary Care Trust

Background: In the English National Health Service (NHS), Primary Care Trusts (PCTs) are responsible for commissioning health-care services on behalf of their populations. As resources are finite, decisions are required as to which services best fulfil population needs. Evidence on effectiveness varies in quality and availability. Nevertheless, decisions still have to be made. Methods: We report the development and pilot application of a multi-criteria prioritization mechanism in an English PCT, capable of accommodating a wide variety of evidence to rank six service developments. Results: The mechanism proved valuable in assisting prioritization decisions and feedback was positive. Two community-based interventions were expected to save money in the long term and were ranked at the top of the list. Based on weighted benefit score and cost, two preventive programmes were ranked third and fourth. Finally, two National Institute for Health and Clinical Excellence (NICE)-approved interventions were ranked fifth and sixth. Sensitivity analysis revealed overlap in benefit scores for some of the interventions, representing diversity of opinion among the scoring panel. Conclusion: The method appears to be a practical approach to prioritization for commissioners of health care, but the pilot also revealed interesting divergences in relative priority between nationally mandated service developments and local health-care priorities.

The public health and safety benefits of the Northern Territory's Living with Alcohol programme

An evaluation is presented of the impact of a comprehensive population-based alcohol harmreduction programme in the Northern Territory funded by a levy of 5 cents per standard drink which took effect from April 1992. The proceeds of the levy supported increased treatment, public education and other prevention activities. Towards the end of the study period (the first 4 years) other positive initiatives were introduced: the lowering of the legal limit for drivers to 0.05 mg/ml and a special levy on cask wine. Indicators of alcohol-related harm were tracked from 1980 to June 30 1996 and developed from hospital, mortality and road crash data. In each case appropriate control data from the same source was employed to control for other possible confounding effects. Alcohol aetiological fractions for major alcohol-related causes of death were estimated taking account of the level of high-risk alcohol use in the Northern Territory. Multiple linear regression and time-series analyses were employed to test for any...

Screening in the community to reduce fractures in older women (SCOOP): a randomised controlled trial

BACKGROUND Despite effective assessment methods and medications targeting osteoporosis and related fractures, screening for fracture risk is not currently advocated in the UK. We tested whether a community-based screening intervention could reduce fractures in older women. METHODS We did a two-arm randomised controlled trial in women aged 70-85 years to compare a screening programme using the Fracture Risk Assessment Tool (FRAX) with usual management. Women were recruited from 100 general practitioner (GP) practices in seven regions of the UK: Birmingham, Bristol, Manchester, Norwich, Sheffield, Southampton, and York. We excluded women who were currently on prescription anti-osteoporotic drugs and any individuals deemed to be unsuitable to enter a research study (eg, known dementia, terminally ill, or recently bereaved). The primary outcome was the proportion of individuals who had one or more osteoporosis-related fractures over a 5-year period. In the screening group, treatment was recommended in women identified to be at high risk of hip fracture, according to the FRAX 10-year hip fracture probability. Prespecified secondary outcomes were the proportions of participants who had at least one hip fracture, any clinical fracture, or mortality; and the effect of screening on anxiety and health-related quality of life. This trial is registered with the International Standard Randomised Controlled Trial registry, number ISRCTN 55814835. FINDINGS 12 483 eligible women were identified and participated in the trial, and 6233 women randomly assigned to the screening group between April 15, 2008, and July 2, 2009. Treatment was recommended in 898 (14%) of 6233 women. Use of osteoporosis medication was higher at the end of year 1 in the screening group compared with controls (15% vs 4%), with uptake particularly high (78% at 6 months) in the screening high-risk subgroup. Screening did not reduce the primary outcome of incidence of all osteoporosis-related fractures (hazard ratio [HR] 0·94, 95% CI 0·85-1·03, p=0·178), nor the overall incidence of all clinical fractures (0·94, 0·86-1·03, p=0·183), but screening reduced the incidence of hip fractures (0·72, 0·59-0·89, p=0·002). There was no evidence of differences in mortality, anxiety levels, or quality of life. INTERPRETATION Systematic, community-based screening programme of fracture risk in older women in the UK is feasible, and could be effective in reducing hip fractures. FUNDING Arthritis Research UK and Medical Research Council.

To freeze or not to freeze: a cost-effectiveness analysis of wart treatment.

Background  Several general practitioner (GP)‐prescribed and over‐the‐counter therapies for warts and verrucae are available. However, the cost‐effectiveness of these treatments is unknown.

Estimating cost-effectiveness in public health: a summary of modelling and valuation methods

It is acknowledged that economic evaluation methods as they have been developed for Health Technology Assessment do not capture all the costs and benefits relevant to the assessment of public health interventions. This paper reviews methods that could be employed to measure and value the broader set of benefits generated by public health interventions. It is proposed that two key developments are required if this vision is to be achieved. First, there is a trend to modelling approaches that better capture the effects of public health interventions. This trend needs to continue, and economists need to consider a broader range of modelling techniques than are currently employed to assess public health interventions. The selection and implementation of alternative modelling techniques should be facilitated by the production of better data on the behavioural outcomes generated by public health interventions. Second, economists are currently exploring a number of valuation paradigms that hold the promise of more appropriate valuation of public health interventions outcomes. These include the capabilities approach and the subjective well-being approach, both of which offer the possibility of broader measures of value than the approaches currently employed by health economists. These developments should not, however, be made by economists alone. These questions, in particular what method should be used to value public health outcomes, require social value judgements that are beyond the capacity of economists. This choice will require consultation with policy makers, and perhaps even the general public. Such collaboration would have the benefit of ensuring that the methods developed are useful for decision makers.

The economic benefit of hip replacement: a 5-year follow-up of costs and outcomes in the Exeter Primary Outcomes Study

Objectives To assess changes in quality of life and costs of patients undergoing primary total hip replacement using the Exeter prosthesis compared with a hypothetical ‘no surgery’ group. Design The incremental quality of life, quality-adjusted life years (QALYs) and cost of Exeter Primary Outcomes Study patients was compared with hypothetical ‘no surgery’ group over 5 years. Scores from annual SF-36 assessments were converted into utility scores using an established algorithm and the QALY gains calculated from pre-operative baseline scores. Costs included implant costs and length of stay. Setting Secondary care hospitals. Participants Patients receiving a primary Exeter implant enrolled in five of seven Exeter Primary Outcomes Study centres. Results On average, patients gained around 0.8 QALYs over 5 years. Younger and male patients or those with lower body mass index and poorer Oxford Hip Scores were significantly associated with increased QALYs. Treatment costs for a primary episode of care were just over £5000 (95% CI £4588 to £5812) per patient. Compared with ‘no surgery’, the cost per QALY was £7182 (95% CI £6470 to £7678), and this remained stable when key cost parameters were varied. The most likely cost per QALY was between £7058 and £7220. Older patients (age 75+) cost more, mainly due to longer average hospital stays and had a higher cost per QALY, although this remained below £10 000. Conclusions 85% of cases had a cost of <£20 000 per QALY (with 70% having a cost per QALY under £10 000) compared with no surgery. Cases would be considered cost-effective under currently accepted thresholds (£25 000–£30 000) compared with ‘no surgery’. However, depending on age and severity, younger patients and more severe patients had below average cost per QALYs. These results help to confirm the long-term benefits and cost-effectiveness of total hip replacement in a wide variety of patients using well-established implant models such as the Exeter. However, further and ongoing economic appraisal of this and other models is required for comparative purposes.

Using economic analyses for local priority setting: The population cost-impact approach

IntroductionStandard methods of economic analysis may not be suitable for local decision making that is specific to a particular population.BackgroundWe describe a new three-step methodology, termed ‘population cost-impact analysis’, which provides a population perspective to the costs and benefits of alternative interventions. The first two steps involve calculating the population impact and the costs of the proposed interventions relevant to local conditions. This involves the calculation of population impact measures (which have been previously described but are not currently used extensively) — measures of absolute risk and risk reduction, applied to a population denominator. In step three, preferences of policy-makers are obtained. This is in contrast to the QALY approach in which quality weights are obtained as a part of the measurement of benefit.MethodsWe applied the population cost-impact analysis method to a comparison of two interventions — increasing the use of β-adrenoceptor antagonists (β-blockers) and smoking cessation — after myocardial infarction in a scaled-back notional local population of 100 000 people in England. Twenty-two public health professionals were asked via a questionnaire to rank the order in which they would implement four interventions. They were given information on both population cost impact and QALYs for each intervention.ResultsIn a population of 100 000 people, moving from current to best practice for β-adrenoceptor antagonists and smoking cessation will prevent 11 and 4 deaths (or gain of 127 or 42 life-years), respectively. The cost per event prevented in the next year, or life-year gained, is less for β-adrenoceptor antagonists than for smoking cessation. Public health professionals were found to be more inclined to rank alternative interventions according to the population cost impact than the QALY approach.DiscussionThe use of the population cost-impact approach allows information on the benefits of moving from current to best practice to be presented in terms of the benefits and costs to a particular population. The process for deciding between alternative interventions in a prioritisation exercise may differ according to the local context. We suggest that the valuation of the benefit is performed after the benefits have been quantified and that it takes into account local issues relevant to prioritisation. It would be an appropriate next step to experiment with, and formalise, this part of the population cost-impact analysis to provide a standardised approach for determining willingness to pay and provide a ranking of priorities.ConclusionOur method adds a new dimension to economic analysis, the ability to identify costs and benefits of potential interventions to a defined population, which may be of considerable use for policy makers working at the local level.

The indirect cost due to pulmonary Tuberculosis in patients receiving treatment in Bauchi State-Nigeria.

ObjectiveTo determine the time spent and income lost by patients and their households for seeking tuberculosis diagnosis and treatment in Bauchi State-Nigeria.MethodA cross sectional study where 242 TB patients were sampled from 27 out of 67 facilities providing TB services in a north-eastern state of Nigeria. Sampling was stratified based on facility type, patients’ HIV status and gender.ResultsThe income lost among the hospitalized group was estimated at

Direct costs of pulmonary tuberculosis among patients receiving treatment in Bauchi State, Nigeria.

156/patient and about