CRITIQUING COST-EFFECTIVE RESEARCH ARTICLES
Public health economics
Master’s in Public health
S1800219
Introduction
Critical Appriasal
Health economics applies economic conceptions to understand and explain how to make informed decisions regarding their health (Kernick. 2013). “Cost-effectiveness analysis helps identify neglected opportunities by highlighting interventions that are relatively inexpensive, yet have the
potential to reduce the disease burden substantially” (Jamison et al 2006. pp. 39). Evidence of both, effectiveness on the treatment and the cost differences on both resource that would result from alternative approaches is required to choose the best treatment method (Donaldson,Currie, and Mitton, 2002).
This assignment is a critical evaluation of a cost-effective analysis. I have chosen an article related in approaches of renal stone removal treatments for the purpose of this assignment. I have selected a clinical and cost-effective analysis of retrograde intra renal surgery (RIRS) versus mini-percutaneous nephrolithotripsy (mPCNL).
I have taken Renal condition related topic due to the high prevalence rate of local context as well as globally. Ojo (2014) states that a two hundred million people have chronic kidney disease globally, and it is affecting all geographical regions. British Islands includes alarming occurrence rate of nephrolithiasis (Sohgaura and Bigoniya, 2017). Furthermore, Sohgaura and Bigoniya (2017) states that’s environmental factors and changing climates especially hot climate countries reported high incident rate. Even though in Maldives, there is not much studies done for the topic still it is evident that renal diseases are one of the major concern in public health sector of the government. Therefore, I believe there is a room for an ample of interventions to address the issue.
CHOICE OF ARTICLE
Pan, J., Chen, Q., Xue, X., Chen, Y., Xia, L., Chen, H and Huang, Y. (2013) RIRS versus mPCNL for single renal stone of 2-3 cm: clinical outcome and cost-effective analysis in Chinese medical setting.
TITLE
The title of the article clearly indicates the purpose of the study. It implies the research purpose (clinical outcome and cost-effective analysis), and comparison (RIRS versus mPCNL for single renal stone of 2-3 cm). On the other hand, study design is not stated and the study population is stated (Chinese medical setting) but very much generalized. All this information was conveyed briefly. Hence, the title is exact and clear.
Abstract
The abstract was written clearly and concisely summarize the major features of the study. The abstract provided a summary of the problem, outlined main aspects of the research design and study methods, described the study sample, summarized major findings and stated the conclusion. However, objectives of the study is not included but its relevance to clinical practice is included in the abstract.
Introduction
The article provided a short introduction along with a back ground. The article has sufficient information on the topic of research. The authors states that PCNL is a recommended as first choice of kidney stones >2 cm (Pan et al, 2013). In addition, they examined clinical and cost-effectiveness of both the procedures by stating that patients having contraindications or preference against PCNL, the RIRS could be a viable treatment solution. They go on to note “limited expenditure on public health and overloaded national medical insurance” (Pan et al, 2013 p.76), the doctors should find the most cost effective method to treat the patients along with the best clinical outcome.
Research question
The article formally does not present a research questions in a section labelled. Nevertheless, the aim and purpose of the study was stated in the last paragraph of the introduction. Authors states that the aim of the study was to compare the clinical outcome and the cost-effectiveness between
RIRS and mPCNL for single renal stone of 2–3 cm in diameter, and purpose of this study was to determine the better cost-effective treatment modality for such kidney stones in Chinese medical setting. The analysis was done based on two perspectives that’s clinical aspect and the cost effectiveness, were elaborated nicely in the article.
Method
The method section included important and useful information about how the researchers designed and implemented their study. The authors examine both cost and effectiveness of the treatment between fifty-six patients from RIRS and fifty-nine patients from mPCNL. Therefore, the sample size is adequate but not excessive and is justifiable on the basis power analysis and rationale. In their article outline a retrospective research design as well as cost effective analysis techniques involving two sample groups which were drawn from their own institute between May 2005 to February 2011, population of one hundred and fifteen patients with solitary renal calculi of two to three centimetre were treated either by RIR or mPCNL, which is sufficient time horizon to measure effectiveness of clinical and cost-effectiveness.
To maintain ethical consideration, they have taken written consent from all the patients prior intervention. On the other hand, authors do not report that the research is approved from any other authority.
All the essential and relevant costs are included but mentioned in overall costs of hospitalization, initial laboratory, and radiology test cost are included for both the procedures. “As with costs, the aim should be to be as comprehensive as possible at this stage, identifying all relevant outcomes even though it will not always be possible to measure or value them all” (Salazar). For a better understanding of the market exchange rate, all the costs are reported in US dollars.
Moreover, in this study analyse the variables using Fisher’s exact test or Chi-square test. As per Zhang (2008 p. 2) “Fisher’s Z-transformation test is more efficient when testing independence between two positive random variables”. Furthermore, they have taken written consent as to make informed decision in order to maintain ethical consideration.
RESULTS
This article reports that there is no statistically significant difference found in the patients in both the groups in terms of clinical aspects. on the other hand, the details of cost effective analysis show that effective quotient (EQ) for mPCNL were greater than that for RIR. Other than post-operative OPD visit cost, all other costs were high in mPCNL though the most clinically effective and recommended method is mPCNL (Pan et al, 2013). Furthermore, they have highlighted all the important and relevant out comes for each procedure. For example, high risk of urosepsis in RIRS group and bleeding in mPCNL group.
As this is a cost-effective analysis, cost as well as the clinical outcome effectiveness must be studied s to support policymakers in the development of prioritization (Woods, Revill, Sculpher and Claxton. 2016). For example, the authors states that “since the resources for public health are relatively limited in Chinese medical setting, the urologists should find out the most cost-effective option to offer the patients best clinical outcome with lower expenditure” (Pan et al, 2013 p.76). Clinical aspect of both procedures are described well and cost incurred for both the procedures separately mentioned in a table and explained well.
In contrast, sensitivity analysis and discounting is not clearly reported in the study. However, discounting applies for the costs and health outcomes if there is a delay in identifying the results of the procedures if not will shows less cost-effectiveness (Zhang 2008).
Furthermore, authors reported that mPCNL is an effective treatment method for the patients who are having single stone of 2 – 3 cm, implying generalization among the population of same disease condition.
The researchers have discussed about the limitations of the study and suggested a prospective randomized study in future researches to reduce biases. Stone composition might influence surgery time leading a bias in statistics.
Conclusion
Conclusion followed from the data reported stating that the effective method is mPCNL however RIR is also a reliable procedure for the patients who are contraindicated or preferred against mPCNL. Finally, the authors states that they do not have any potential conflict of interest to declare.
It is difficult to evaluate the effectiveness and cost-effectiveness of complex public health interventions in the community.
There are several challenges on the path of public health interventions in the community due to various reasons. Effectiveness of the intervention and the cost- effectiveness is mainly performing in health care interventions as a tool. To make informed decision it is vital to provide a good evidence on cost-effectiveness of the intervention or the program of choice (Weatherly et al., 2009). Public health interventions are often aimed to the general public than aiming to the individual so it is not feasible to undertake randomised control trials (Weatherly et al., 2009). Many researchers identified in different evaluation methods to evaluate the difficulties evaluating and applying health economics public health interventions. For example, Weatherly et al. (2009) identified four methodological difficulties and they are; attribution of effects: randomised control studies are aimed in representing effectiveness but it may not be feasible to conduct in public health. Measuring and valuing outcomes: it is frequently values by means of the quality adjusted life-years. Identifying inter-sectoral costs and consequences: it comes under different sectors making a health service perspective inadequate. Incorporating equity considerations: in public health services can be accessible without being discriminated. However, it is difficult to go in details of several researcher’s methods in such a short essay.
In this paper the authors highlighted some of the challenges in regard of the two procedures they compared. The main challenge in any health promotion aspect is the resources mainly financially. In this studies Pan et al (2013) states that “In the context of limited expenditure on public health and overloaded national medical insurance, the urologists should find out the most cost-effective option to offer the patients best clinical outcome”. Woods, Revill, Sculpher and Claxton states that see that the utilization of health values are more in terms of health care resource needed to develop health (2016).
To give a glance to our country situation, all the health care burden is taking care of government insurance company where millions are spending on health care cost from government budget (Maldives National Health Accounts 2011. 2013) specially on curative aspects like kidney diseases of nephrolithiasis.
One main reason of spending a huge budget on medical insurance is that most of the advance procedures are not available locally like renal transplant and mPCNL and RIR. However, to provide basic life saving measures is a responsibility of government and when it is not available locally, government decided to transfer the patient abroad for the treatments which is unavailable locally via the universal health insurance coverage in Maldives. The main goal is to improve public health status of all nation via a health system that assures universal coverage for Maldivians (Maldives National Health Accounts 2011, 2013).
In order to provide a safe and cost effective method insurance company may need to seek the most cost effective method for the patients along with effective treatments. Woods, Revill, Sculpher, and Claxton (2017) states that every organization face some restrictions in terms of resource availability for health care and if these resources spend for one intervention, then there is no enough fund for other sectors.
Renal diseases are one of the main public concern for the public as well as the government as even in Maldives non- communicable diseases are taking over the communicable diseases as per the Global burden of disease study 2010. A large percentage of health sector budget is going for curative rather than preventive measures which has to be the other way round and the researchers has a role to study the issues and the outcome measures to bring a healthy change in our health sector.
Another challenge researchers coming across are the time frame of measuring effectiveness. Pan et al (2013) states that the limitation was done the study as a retrospective nature rather than prospective randomize method which is highly recommended in their study. Most of the time researches need to complete within the time frame with the limited resources, lacking the quality of research in terms of effectiveness due inadequate time period and unable to evaluate result of frequent attempts. In contrast, effectiveness of the cost and clinical outcomes varies due to individual’s risky behavior. Pan et al (2013) highlighted that severe bleeding due to excessive physical activities soon after surgery which is not allowed for the initial days, and the urine infection and sepsis develops after the surgery will impact the result of the effectiveness.
Likewise, the cost of the interventions is high and the effectiveness can be seen in a later stage makes more difficult to convince decision makers as well as the individuals to make a quality choice. For example, in renal stones people may not be aware of the difference between the two procedures and the cost-effectiveness. In order to implement advanced or a new procedure, researchers need to convince the health sector investors as they are the decision makers and it is vital to convince them to establish an effective and cost-effective intervention in clinically. Researchers need to prove that by doing an in depth research on the effectiveness as well as the cost- effectiveness. Researchers can study a cost utility analysis is to evaluate the effectiveness of an intervention’s effect on both the quantitative and qualitative methods of health (Palmer, Byford, and Raftery. 1999).
An additional challenge of evaluating effectiveness and cost-effectiveness is methods to measure the intervention in clinical and cost-effectiveness. The existing studies are done mostly in developed countries which is very much different from our settings. In terms of effectiveness, “interventions need to be researched and evaluated for effectiveness, economic, ethical, and accountability reasons” (Waters et al, 2006, pp. 285). Furthermore, Waters et al (2016) states that the aim should to be communities and the procedures should to be complex. In addition, cost-effective analysis weakens due to evaluating multiple intervention outcomes. For instance, Pan et al. (2013) studied effectiveness of RIR and mPCNL, stating that both the procedures are effective. In a public health perspective individual may confuse choosing the best intervention. Moreover, to evaluate effectiveness on the treatment and the cost differences, it is essential to study the local context considering the local public health perspectives.
Equity is also a challenge to measure the effectiveness of the intervention and cost-effectiveness. Many study done on cost-effectiveness and rarely researchers talk about who gets the opportunity to access and who is not. “The cost-effectiveness analysis studies, rarely provide information about who gains and who loses from health programs or about trade-offs between cost-effectiveness and equity in the distribution of health-related outcomes (Cookson et al 2017 pp. 206). Furthermore, it is very important to study socio-economic outcomes, which may include improved social interactions and increased support for family members as “equity- informative economic evaluation is an input into decision makers” (Cookson et al., 2017 pp. 206). Therefore, health economic studies must be focus on the well-being of the whole community rather than an individual or an organization (Byford and Raftery, 1998).
To conclude the essay, though there are challenges on the path of measuring effectiveness in clinical and economically, cost-effective and clinical effective studies are essential to make informed decisions.
Reference
Byford, S., & Raftery, J. (1998). Perspectives in economic evaluation. BMJ : British Medical Journal, 316(7143), 1529–1530.
Palmer, S., Byford, S., & Raftery, J. (1999). Types of economic evaluation. BMJ : British Medical Journal, 318(7194), 1349.
Cookson, R, Mirelman, A. J., Griffin, S., Asaria, M., Dawkins, B., Norheim, O. F., Verguet, S. and Culyer, A. J (2017). Using Cost-Effectiveness Analysis to Address Health Equity Concerns. Value in Health. [Online]. 20(2), pp. 206-212. [Accessed 1 May 2018].
Waters, E., Doyle, J., Jackson, N., Howes, F., Brunton, G., & Oakley, A. (2006). Evaluating the effectiveness of public health interventions: the role and activities of the Cochrane Collaboration. Journal of Epidemiology and Community Health, 60(4), 285–289. http://doi.org/10.1136/jech.2003.015354
Maldives National Health Accounts 2011 (2013) Health Economic Unit, Policy Planning Division Ministry of Health, Maldives http://www.searo.who.int/maldives/hsd-mav-1.pdf?ua=1 [Accessed 10 May 2018].
Woods B., Revill P., Sculpher, M., and Claxton, K. (2017) Country-Level Cost-Effectiveness Thresholds: Initial Estimates and the Need for Further Research. Values in Health. [Online]19(8), PP. 929-935 [Accessed on 10 May 2018].
Zhang, Z. (2008) Quotient Correlation: A Sample Based Alternative to Pearson’s Correlation. The Annals of Statistics [online]. 36, p. 1007–1030. [Accessed 13 April 2018].
Misra R, R, Jamison , D.T., Breman , J.G. and Measham Et Al, A.R. (2008) Priorities in Health. Washington (Dc): The International Bank For Reconstruction and Development / the World Bank.
Jamison DT, Breman JG, Measham AR, et al., editors. Priorities in Health. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2006. Chapter 3, Cost-Effectiveness Analysis. Available from: https://www.ncbi.nlm.nih.gov/books/NBK10253/
Kernick DP Introduction to health economics for the medical practitioner Postgraduate Medical Journal 2003;79:147-150.
Jamison DT, Breman JG, Measham AR, et al., editors. Priorities in Health. Washington (DC): The International Bank for Reconstruction and Development / The World Bank; 2006. Chapter 3, Cost-Effectiveness Analysis. Available from: https://www.ncbi.nlm.nih.gov/books/NBK10253/
Donaldson, C., Currie, G., & Mitton, C. (2002). Cost effectiveness analysis in health care: contraindications. BMJ : British Medical Journal, 325(7369), 891–894.
Woods, B., Revill, P.,Sculpher, M. and Claxton, K (2016) Country-Level Cost-Effectiveness Thresholds: Initial Estimates and the Need for Further Research. Values in Health. [Online] 19 pp. 929-935. [Accessed 02 May 2018].