Applied economic evaluations

HERG has become an External Assessment Centre for the NICE MedTEP programme. This involves evaluating evidence on the effectiveness and cost-effectiveness of medical devices, and facilitating the further development of evidence on selected technologies. HERG is a joint centre with Prof Richard Lilford and the Birmingham Clinical Research Academy at Birmingham University.

Funding body: National Institute for Health and Clinical Excellence (NICE)
Contact: Dr Catherine Meads

This project which is being jointly conducted between researchers at HERG and at the Royal Free Hospital will assess the cost-effectiveness of the non-invasive assessment and monitoring of liver fibrosis and cirrhosis in patients with suspected or established chronic liver disease. The evaluation will be based secondary data analysis and economic modelling. It builds on previous collaborative research conducted at HERG in the clinical area of liver disease.

Funding body: NIHR HTA Programme
Contacts: Dr Louise Longworth (PI: Prof Andrew Burroughs, Royal Free Hospital)

The aim of this thesis is to establish the relevance of an economic evaluation produced for one geographic area to another location of interest. This aim is achieved by analysing the assumption of ‘exchangeability’ of cost-effectiveness data across geographic domains. Multivariate multilevel modelling is being used to integrate secondary cost-effectiveness data, facilitating the assessment of ‘contextual effects’ on country level whilst controlling for ‘baseline characteristics’ of the studies included in the dataset. Currently, the first of two empirical exercises is carried out on the cost-effectiveness of statins in the primary and secondary prevention of coronary artery disease.

The aim of the thesis is: firstly, to conduct a cost-consequences analysis of two referral modes in providing specialist advice for foetal cardiology; secondly, to conduct a cost-effectiveness analysis of a screening service with telemedicine versus a screening service without telemedicine in foetal cardiology; and finally to address some of the economic issues relating to telemedicine services such as selection bias, patient costs, and the calculation of QALYs.

PhD Research: Completed 2011
Contact: Dr Hema Mistry – now at Birmingham University (Supervisor: Prof Martin Buxton)

NICE clinical guidelines make recommendations for the care of people with specific diseases and conditions by the NHS in England and Wales. Health economists working on NICE guidelines do not assess the cost-effectiveness of the whole clinical pathway, but instead prioritise selected issues for evaluation. This is pragmatic, but may neglect important questions and interconnections across the pathway. In this project we are testing the feasibility of building whole pathway models for two NICE guidelines; prostate cancer and atrial fibrillation. We will use the models to address key cost-effectiveness questions and survey NICE guideline stakeholders to assess the usefulness of the model results.

Funding body: Medical Research Council (MRC)

Contacts: Dr Joanne Lord (Chief Investigator)

Informed patient choice is an important part of health care. Guidelines for the treatment of low back pain, produced by NICE recommend that patients are offered a choice of manual therapy, exercise or acupuncture. Current evidence suggests that these treatments have similar health benefits and costs to the NHS. However, this does not mean that everyone will do equally well on each treatment. This study, led by clinical researchers at Warwick University, aims to develop and pilot a Decision Support Package to help patients, in partnership with a physiotherapist, to make more informed choices of therapy. Methods used to develop the package include literature review, patient questionnaires and focus groups, and consensus techniques with physiotherapists. The package will be tested in a pilot randomised controlled trial, which will include an economic evaluation to assess the value of information associated with the collection of further evidence.

Funding body: National Institute for Health Research (NIHR)
Contacts: Dr Joanne Lord (Principal Investigator: Prof Martin Underwood, Warwick Medical School)

Low back pain is a common and costly disorder. Therapies with evidence of effectiveness and cost-effectiveness include acupuncture, exercise, manipulation, and psychological treatments. The average benefit from these treatments is small, since although some patients gain substantial benefit, most patients receive no benefit. If we could predict which patients would be most likely to benefit from which treatment, effectiveness and cost-effectiveness could be improved. This study aims to develop a repository of individual patient data from clinical trials of therapist-delivered interventions for low back pain, and then to use this database to identify which patient characteristics, if any, predict clinical response to and cost-effective outcomes of the different treatments. The economic contribution to this study includes development of methods to record resource use and cost data within the repository; estimation of individual patient costs and Quality Adjusted Life Years (QALYs); and econometric analysis to identify baseline characteristics which act as moderators for the cost-effectiveness of the different treatments.

Funding body: National Institute for Health Research (NIHR)
Contacts: Dr Joanne Lord (Principal Investigator: Prof Martin Underwood, Warwick Medical School)

Rheumatoid Arthritis (RA) commonly affects the hands and wrists with inflammation, deformity, pain, weakness and restricted mobility leading to reduced function. The effectiveness of exercise for RA hands is uncertain, although evidence from small scale studies is promising. The Strengthening And Stretching for Rheumatoid Arthritis of the Hand (SARAH) trial is a multi-centre randomised controlled trial evaluating the clinical and cost effectiveness of adding an optimised exercise programme for hands and upper limbs to usual care for patients with RA. 480 participants with problematic RA hands have been recruited and randomised to either usual care or standard care supplemented with an individualised exercise programme. Patients are being followed up at four and 12 months. An economic evaluation is being conducted alongside this study, using individual patient data on quality of life (EQ-5D) and healthcare resource use and costs. The analysis will include a regression-based within-trial analysis and modeling to extrapolate costs and effects over the longer term.

Funding body: National Institute for Health Research (NIHR)
Contacts: Dr Joanne Lord (Principal Investigator: Prof Sarah Lamb, Warwick Clinical Trials Unit)

The UK has seen a resurgence of tuberculosis (TB) since the late 1980s. Most cases arise from reactivation of latent infection, acquired from contact with an infectious person possibly many years previously. The identification and prophylactic treatment of individuals with latent TB infection who are at high risk of developing active TB, is therefore an important method for controlling the impact and spread of this disease. The objective of this cohort study is to assess the prognostic value of new Interferon Gamma Release Assay (IGRA) tests compared with the standard Mantoux Tuberculin Skin Test (TST) for predicting the development of active tuberculosis amongst contacts of active cases and new entrants from high incidence countries. 10,000 participants are being recruited from 12 hospitals and a network of GP surgeries in London. All participants will have a TST and IGRA tests at baseline, and will then be followed up for an average of 24 months to determine whether they develop tuberculosis. A cost-effectiveness analysis will be performed to estimate the costs and health effects (QALYs) of alternative screening strategies: no screening; each test on its own; and two-step strategies including both TST and IGRA tests in series. The economic evaluation will use individual patient data from the cohort study, and a transmission dynamic model to predict the impact of the different strategies on healthcare costs and outcomes (QALYs).

Funding body: National Institute for Health Research (NIHR)
Contacts: Dr Joanne Lord (Principal Investigator: Dr Ibrahim Abubakar, Health Protection Agency and UCL)

The National Tuberculosis (TB) Strain Typing Service (STS) was established by the Health Protection Agency (HPA) as a result of the re-emergence of TB as a public health issue in the UK. It is a three-year initiative to provide DNA fingerprinting of Mycobacterium tuberculosis isolates from every TB case in England. The TB STS aims to prevent the spread of TB by better targeting of public health control activity (contact tracing and cluster investigations), by allowing the detection of recent transmission, and by ruling out assumed links between clustered cases where true links do not exist. The HPA has convened an independent Evaluation Group to conduct a full evaluation of the service and its impact on public health and TB control. The evaluation will consist of five main components: a descriptive component outlining the structures and processes comprising the STS; a before-after survey of service users (TB nurses, physicians and Health Protection Unit staff); an investigation into the usefulness of strain typing for identifying false positive TB diagnosis; a mathematical model of disease transmission; and a cost effectiveness model.

Funding body: Health Protection Agency (HPA)
Contacts: Dr Joanne Lord (Chair of the Evaluation Group: Pam Sonnenberg)

Multi-drug resistant (MDR) and extensive-drug resistance (XDR) tuberculosis (TB) are relatively rare in the UK. However, their impact on the individual, their close contacts, and the health care economy is disproportionably large. Tests which can rapidly detect genetic markers of drug resistance have the potential to reduce this impact. This study will investigate the clinical impact and cost-effectiveness of a range of rapid molecular biology-based tests detecting genetic markers of antibiotic resistance, compared with conventional culture and drug susceptibility testing. It will include a systematic review of evidence on the diagnostic accuracy of these tests. In order to determine the clinical impact of earlier diagnosis, a transmission dynamic model will be developed to predict the number of infections averted with the genetic marker tests. This information will then be used to estimate the value for money potentially derived from earlier diagnosis and also to investigate the economics of alternative models of service delivery (centralised versus distributed testing).

Funding body: National Institute for Health Research (NIHR)
Contacts: Dr Joanne Lord (Principal Investigator: Prof Francis Drobniewski, Queen Mary College and Health Protection Agency)