Health Economics and Finance

You are asked to find a published economic evaluation and critically appraise the work using two popular checklists. Further details follow.

Step 1: Find your economic evaluation
Choose a published evaluation of cost-effectiveness or cost-utility of a health intervention that interests you.

Tip: In making your selection, bear in mind the definition of economic evaluation as a comparison of two or more options in terms of their costs and their benefits.

Tip: A google search will be more than adequate. I suggest you choose an article published in a public health or medical journal rather than an economics journal. And please obtain a pdf copy of your article that you can send to me.

Step 2: Critically appraise the evaluation
Use Drummond’s ten-step checklist to structure your critical appraisal of the article. A copy of the checklist is attached to this document, or it can be found here:
Please use only this ten-question version. There are longer ‘tick-box’ versions of the checklist available (see the reference to Drummond and Jefferson for example), which should not be used. I’ve included the Drummond and Jefferson paper because it provides useful information about what to consider in your review.
Feel free to use the 10 main questions as section headings to structure your review. The sub-questions should just be used as prompts to guide what to consider under each section heading.

Tip: See the example by Chris Doran for what I have in mind, but note there will be no marks for anyone choosing the same article to critique as the one that Chris reviews! Note also that I am not endorsing his review. He may be wrong in what he says!

When you have finished your critique assign a score from 0-100 to reflect your subjective assessment of the study’s quality … give it a mark! Please do this before you consider step 3.

Step 3: Score the article formally using the QHES
The Quality of Health Economic Studies instrument is closely related to Drummond’s ten-step checklist but it also allows you to score the quality of the study more formally. There are sixteen questions that you answer yes/ no according to whether you think the article meets the criteria.

Each question then has a weight (see Table 1 in the article by Offman). Each yes answer scores 1 and you compute a total quality score for the article by multiplying each yes answer by the weight assigned to that question and summing the result.

Step 4: Compare the results of your two assessments
This step is optional – it is not part of the assignment, but may be an interesting exercise. Compare your assessment of the article’s merits in step 2 with the score that you arrive at in step 3. If there is a big difference, perhaps share your reflections on what might be causing it.

Chiou CF et al. Development and validation of a grading system for the quality of cost-effectiveness studies. Medical Care 2003; 41: 32-44.

Doran C. Critique of an economic evaluation using the Drummond checklist. Applied Health Economics and Health Policy 2010; 8: 357-359.

Drummond M et al. Methods for the Economic Evaluation of Health Care Programmes. 2nd ed. Oxford. Oxford University Press. 1997.

Drummond MF, Jefferson TO. Guidelines for authors and peer reviewers of economic submissions to the BMJ. The Economic Evaluation Working Party. British Medical Journal 1996; 313: 275-283.

Offman JJ et al. Examining the value and quality of health economic analyses: implications of utilizing the QHES. Journal of Managed Care Pharmacy 2003; 9: 53-61.

Checklist for the Economic Evaluation of Health Care Programmes1

1. Was a well-defined question posed in answerable form?
1.1. Did the study examine both costs and effects of the service(s) or programme(s)?
1.2. Did the study involve a comparison of alternatives?
1.3. Was a viewpoint for the analysis stated and was the study placed in any particular decision-making context?

2. Was a comprehensive description of the competing alternatives given (i.e. can you tell who did what to whom, where, and how often)?
2.1. Were there any important alternatives omitted?
2.2. Was (should) a do-nothing alternative be considered?

3. Was the effectiveness of the programme or services established?
3.1. Was this done through a randomised, controlled clinical trial? If so, did the trial protocol reflect what would happen in regular practice?
3.2. Was effectiveness established through an overview of clinical studies?
3.3. Were observational data or assumptions used to establish effectiveness? If so, what are the potential biases in results?

4. Were all the important and relevant costs and consequences for each alternative identified?
4.1. Was the range wide enough for the research question at hand?
4.2. Did it cover all relevant viewpoints? (Possible viewpoints include the community or social viewpoint, and those of patients and third-party payers. Other viewpoints may also be relevant depending upon the particular analysis.)
4.3. Were the capital costs, as well as operating costs, included?

5. Were costs and consequences measured accurately in appropriate physical units (e.g. hours of nursing time, number of physician visits, lost work-days, gained life years)?
5.1. Were any of the identified items omitted from measurement? If so, does this mean that they carried no weight in the subsequent analysis?
5.2. Were there any special circumstances (e.g., joint use of resources) that made measurement difficult? Were these circumstances handled appropriately?

6. Were the cost and consequences valued credibly?
6.1. Were the sources of all values clearly identified? (Possible sources include market values, patient or client preferences and views, policy-makers’ views and health professionals’ judgements)
6.2. Were market values employed for changes involving resources gained or depleted?
6.3. Where market values were absent (e.g. volunteer labour), or market values did not reflect actual values (such as clinic space donated at a reduced rate), were adjustments made to approximate market values?
6.4. Was the valuation of consequences appropriate for the question posed (i.e. has the appropriate type or types of analysis – cost-effectiveness, cost-benefit, cost-utility – been selected)?
7. Were costs and consequences adjusted for differential timing?
7.1. Were costs and consequences that occur in the future ‘discounted’ to their present values?
7.2. Was there any justification given for the discount rate used?

8. Was an incremental analysis of costs and consequences of alternatives performed?
8.1. Were the additional (incremental) costs generated by one alternative over another compared to the additional effects, benefits, or utilities generated?

9. Was allowance made for uncertainty in the estimates of costs and consequences?
9.1. If data on costs and consequences were stochastic (randomly determined sequence of observations), were appropriate statistical analyses performed?
9.2. If a sensitivity analysis was employed, was justification provided for the range of values (or for key study parameters)?
9.3. Were the study results sensitive to changes in the values (within the assumed range for sensitivity analysis, or within the confidence interval around the ratio of costs to consequences)?

10. Did the presentation and discussion of study results include all issues of concern to users?
10.1. Were the conclusions of the analysis based on some overall index or ratio of costs to consequences (e.g. cost-effectiveness ratio)? If so, was the index interpreted intelligently or in a mechanistic fashion?
10.2. Were the results compared with those of others who have investigated the same question? If so, were allowances made for potential differences in study methodology?
10.3. Did the study discuss the generalisability of the results to other settings and patient/client groups? 10.4. Did the study allude to, or take account of, other important factors in the choice or decision under consideration (e.g. distribution of costs and consequences, or relevant ethical issues)?
10.5. Did the study discuss issues of implementation, such as the feasibility of adopting the ‘preferred’ programme given existing financial or other constraints, and whether any freed resources could be redeployed to other worthwhile programmes?

(1) Drummond M et al. Methods for the Economic Evaluation of Health Care Programmes. 2nd ed. Oxford. Oxford University Press. 1997.

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