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Nancy Devlin

Publications and source records attributed to Nancy Devlin.

16 recordsLinked to original sources
PubMed2006

Is there a case for using visual analogue scale valuations in cost-utility analysis?

This paper critically reviews theoretical and empirical propositions regarding visual analogue scale (VAS) valuations of health states and their use in cost-utility analysis (CUA). A widely repeated assertion in the economic evaluation literature is the inferiority, on theoretical grounds, of VAS valuations. Five common criticisms are: VAS lacks a theoretical foundation; VAS values are not 'choice based'; VAS values are not consistent with utility-under-uncertainty requirements; context and range effects observed in VAS valuation data mean that they cannot even be considered to represent measurable value functions; and when completing a VAS, people are not trying to express values. We address each of these points: the VAS does have a theoretical basis, being entirely consistent with the non-welfarist foundations of QALYs and CUA; the 'choiceless' nature of the VAS is incorrectly judged by stated preference criteria relevant to monetary rather than health state valuations, and VAS valuations do in any case involve an element of choice; because valuations are intended for use in social decision-making, it may be advantageous that VAS values are elicited under conditions of certainty; although there are measurement problems with the VAS, means such as better design and transformations of data can deal with these; and with any method of eliciting values, it is unrealistic to expect people consciously to think in terms of social science constructs such as utilities.Moreover, there are problems, both theoretical and empirical, with alternative methods. Selection of the appropriate valuation method should be based on empirical performance, and in this the VAS has important advantages. We conclude that there are strong grounds for disputing the consensus view against the VAS and challenge those who hold it to deploy more convincing arguments and evidence in favour of alternative methods. However, we identify areas where further research is required to establish and consolidate the potential of the VAS as a valuation method.

Costs and Cost Analysis↗
PubMed2006

A theoretical framework for TTO valuations of health.

This paper proposes a theoretical framework, drawing on Hicks utility theory, for the Time Trade-off (TTO) method conventionally used to value health states. We briefly describe that theory and posit four distinctive TTO valuation approaches suggested by it: each of compensating variation and equivalent variation for both gains and losses in health, with valuation of health states in each case derived from trade-offs between health and length of life. Recent developments and research on TTO valuation are placed in the context of this framework.

Attitude to Health↗
PubMed2005

Continuity through change: the rhetoric and reality of health reform in New Zealand.

New Zealand, like most other developed economies, has struggled to establish the best way of organising and delivering publicly financed health care services. Before the 1990s, hospitals and some related services were planned and provided by regionally based, locally elected health boards. This system was replaced in 1993 with a quasi-market structure in which separate organisations were responsible for the purchasing and provision of services. This in turn was replaced in 2001 by a system of locally elected boards that is remarkably similar to that which existed in the 1980s. The change to and subsequent abandonment of the quasi-market structure implies major changes to the way that health services are organised in New Zealand and suggests policy U-turns in (at least) three key areas: from cooperation to competition (and back); from integration of the roles of purchaser and provider to contractual arrangements (and back); and from local decision-making to centralised decision-making (and back). The aims of this paper are to examine the depth of system change in practice and to consider the extent to which the stated goals of reformers have disguised the degree of continuity between reform eras. We conclude that simplistic distinctions between structural approaches often fail to capture salient influences upon decision-making. New Zealand has not, in fact, been "to market and back" as the rhetoric would have us believe. Key aspects of the health system have endured throughout the reform period and these arguably have more importance for system functioning and performance than the high-level structural changes.

Health Care Reform↗
PubMed2005

A "new and improved" EQ-5D valuation questionnaire? Results from a pilot study.

Notwithstanding its widespread use, the standard questionnaire used to elicit visual analogue scale valuations for EQ-5D states is well known to suffer from problems with missing values (particularly for the state "dead") and logical inconsistencies. This contribution reports on efforts to redesign the questionnaire to overcome these problems and the results from its use in a pilot study. The redesigned questionnaire asks respondents to provide a numerical score for each state (instead of drawing lines to a visual analogue scale) and employs a new method for valuing "dead". A pilot study was undertaken to gauge the effects of these innovations, over and above other cosmetic changes to the questionnaire. The redesigned questionnaire was found to result in fewer missing values, fewer exclusions and fewer logical inconsistencies. Mean re-scaled values for the health states remained virtually identical. The results suggest that scoring is a better way of eliciting self-completed valuations than scaling.

Adolescent↗
PubMed2005

Do English NHS waiting time targets distort treatment priorities in orthopaedic surgery?

OBJECTIVES: To assess and quantify the impact of guarantees on maximum waiting times on clinical decisions to admit patients from waiting lists for orthopaedic surgery. METHODS: Before and after comparative study, analysing changes in waiting times distributions between 1997/8 and 2001/2 for waiting list and booked inpatients and day cases admitted for elective treatments in trauma and orthopaedics in English hospitals. RESULTS: The 2001/2 maximum waiting time target of 15 months did change the pattern of admissions for trauma and orthopaedic elective inpatients, with a net increase in admissions in that year, compared with 1997/8 (and over and above the 30,259 (7.6%) overall increase in all admissions) of patients who had waited around 15 months, of 9333. There was little indication that these additional admissions displaced shorter wait patients. In absolute and proportional terms, admissions increased for all waiting time categories except very short waiter-- one to two weeks (an absolute fall of 2901 and a relative fall of 6591), and those waiting 40--41 weeks. The latter fall was only 111 patients in absolute terms (or 577 relative to the expected increase), however. The former much larger reduction may be an indication of clinical distortions, but it is unclear why very short wait (presumably more urgent) patients should disproportionately suffer compared with longer wait (presumably less urgent) cases. In addition, there was little indication that more minor cases usurped more major cases: 57% of the increase consisted of knee and hip replacement procedures, for example. CONCLUSIONS: While the 2001/2 waiting times target demonstrably changed admission patterns (and was a major contribution to the reduction in long waits), the extent to which this represented significant and clinically relevant distortions is questionable given the lack of widely accepted admission criteria. However, as targets become progressively tougher, there is a need to monitor consultants' concerns more closely.

England↗
PubMed2004

Does NICE have a cost-effectiveness threshold and what other factors influence its decisions? A binary choice analysis.

The decisions made by the National Institute for Clinical Excellence (NICE) give rise to two questions: how is cost-effectiveness evidence used to make judgements about the 'value for money' of health technologies? And how are factors other than cost-effectiveness taken into account? The aim of this paper is to explore NICE's cost-effectiveness threshold(s) and the tradeoffs between cost effectiveness and other factors apparent in its decisions. Binary choice analysis is used to reveal the preferences of NICE and to consider the consistency of its decisions. For each decision to accept or reject a technology, explanatory variables include: the cost per life year or per QALY gained; uncertainty regarding cost effectiveness; the net cost to the NHS; the burden of disease; the availability (or not) of alternative treatments; and specific factors indicated by NICE. Results support the broad notion of a threshold, where the probability of rejection increases as the cost per QALY increases. Cost effectiveness, together with uncertainty and the burden of disease, explain NICE decisions better than cost effectiveness alone. The results suggest a threshold somewhat higher than NICEs stated 'range of acceptable cost effectiveness' of pound 20,000-30,000 British pounds per QALY--although the exact meaning of a 'range' in this context remains unclear.

Cost-Benefit Analysis↗
PubMed2004

Do patients always prefer quicker treatment? : a discrete choice analysis of patients' stated preferences in the London Patient Choice Project.

The London Patient Choice Project (LPCP) was established to offer NHS patients more choice over where and when they receive treatment, and to reduce waiting times. The LPCP offered those patients waiting around 6 months for elective procedures a choice of treatment at an alternative NHS or private hospital, or treatment at an overseas hospital.The aim of this article is to investigate the following questions regarding patients' response to choice: (a) What are the factors that patients consider when deciding whether to accept the alternatives they are offered? (b) What is the relative importance to patients of each factor when making their choices, i.e. what trade-offs are patients prepared to make between time waited and other factors? (c) Are there any systematic differences between subgroups of patients (in terms of their personal, health and sociodemographic characteristics) in their response to choice?Patients' preferences were elicited using a discrete choice experiment. Patients eligible to participate in the LPCP were recruited prior to being offered their choice between hospitals and each presented with seven hypothetical choices via a self-completed questionnaire. Data were received from 2114 patients. Thirty percent of respondents consistently chose their 'current' over the 'alternative' hospital. All the attributes and levels examined in the experiment were found to exhibit a significant influence on patients' likelihood of opting for an alternative provider, in the expected direction. Age, education and income had an important effect on the 'uptake' of choice. Our results suggest several important implications for policy. First, there may be equity concerns arising from some patient subgroups being more predisposed to accept choice. Second, although reduced waiting time is important to most patients, it is not all that matters. For example, the reputation of the proffered alternatives is of key importance, suggesting careful thought is required about what information on quality and reputation can/should be made available and how it should be made available to facilitate informed choice.

Adolescent↗
PubMed2003

WHO evaluates NICE.

Explore the source record for details and available documents.

Academies and Institutes↗
PubMed2003

Waiting times. Catch up, keep up.

Trusts vary greatly on their progress in achieving waiting-list targets, particularly for 2005. A study of trusts with a range of performances identified four key criteria: information use, managerial focus, capacity and long-term efficiency. Actions that help a trust 'catch up' rarely help them 'keep up; strategies may need to change once waiting lists have fallen markedly. Flexibility, forward planning and 'expecting the unexpected' are characteristics of successful trusts.

Efficiency, Organizational↗
PubMed2003

Prioritizing patients for elective surgery: a prospective study of clinical priority assessment criteria in New Zealand.

OBJECTIVES: Many hospitals in New Zealand have been using clinical priority assessment criteria (CPAC) to select and prioritize patients for access to publicly funded elective surgery. CPAC usually consist of clinical, patient-experienced, and social measures. The objective of this study was to determine how robust patient rankings were and the extent to which the patients selected were those who benefited the most from surgery. METHODS: Patients prioritized for cataract (n = 101), prostate (n = 103), and hip or knee joint replacement (n = 137) surgery according to CPAC were assessed using the EQ-5D, SF-12, and condition-related patient-experienced health status measures before and after treatment. Correlations between the rankings of patients on the CPACs and the alternative instruments were explored. RESULTS: For each surgery group, the CPAC ranking of patients was not strongly correlated with rankings obtained using their before-treatment EQ-5D (valued) profiles or the SF-12, although there was some correlation with rankings according to the condition-related measures. Improvements in the health status of patients who were operated on, as measured by the change in their EQ-5D values, were poorly correlated with equivalent changes on the SF-12 and condition-related measures. Patients' baseline health status according to the CPAC, the EQ-5D, and the SF-12 patient-experienced measures was only slightly related to the magnitude of benefit following surgery. The strongest predictors of improvement in health status were the baseline condition-related measures. CONCLUSIONS: The current method of prioritizing patients in New Zealand requires reconsideration, although a gold standard method for prioritization is not immediately apparent from these results.

Arthroplasty, Replacement↗
PubMed2003

Funding fertility: issues in the allocation and distribution of resources to assisted reproduction technologies.

The appropriate level and source of funds for assisted reproduction technologies (ARTs), in particular IVF, have been controversial in most developed economies. Funding of fertility services internationally is characterized by low public (or other third party) funding, a greater reliance on user-pays than in most other health services, and variations in funding and provision. This article describes the characteristics of infertility as a condition and its treatment that have been used as a rationale for its exclusion from an otherwise comprehensive coverage of health services. The challenges these characteristics pose for the use of economic evaluation to inform resource allocation are discussed. Most economic evaluations have focused on the cost effectiveness of alternative infertility treatments. These evaluations provide important information, but do not inform the real issue at stake: what is the appropriate allocation of funds to ARTs, given that it involves sacrificing improvements in health in other areas? Cost utility analysis - the method of economic appraisal preferred by most agencies charged with making such decisions (including the National Institute of Clinical Excellence in the UK) - is ill-equipped to deal with the benefits produced by ARTs. Alternative methods are available, but require decision makers to weigh up very different sorts of evidence. Demonstration of the willingness to pay for the benefits of ARTs can be used to support public decisions but, conversely, also implies that those who can pay will pay in a private market. Ultimately, decisions about the inclusion or otherwise of ARTs in collectively funded health systems probably rest as much on judgments about equity in access as value for money. Given that this is the case, public funding of IVF should be accompanied by the development of agreed criteria for the prioritization of potential recipients, to ensure treatment is targeted at those for whom it is most effective and that access is consistent and fair.

Adult↗
PubMed2003

Patients' views of explicit rationing: what are the implications for health service decision-making?

Patient groups in England and Wales have expressed concerns about the decision-making processes of the National Institute for Clinical Excellence (NICE), the body responsible for explicit rationing. Five key issues were identified by the Multiple Sclerosis Society regarding NICE appraisals and guidance: they focus too narrowly on costs to the National Health Service; quality-adjusted life-years are an inadequate measure of health gain, particularly for long-term conditions; NICE takes too conservative a view of long-term benefits; NICE's cost-effectiveness threshold is inappropriate; and NICE evaluations fail to capture patients' personal experiences of their condition and treatments. We question the veracity of some of these arguments and, where appropriate, suggest ways in which NICE's processes might be strengthened.

Academies and Institutes↗
PubMed2002

Internal Marker. This little piggy....

The government's proposals for a new fixed-price market could mean that many trusts will make significant losses. Policy must balance the need to protect some trusts from the effects of fixed prices with the desire for financial incentives with 'bite'. The basis on which prices are struck is crucial. Quality will need careful monitoring.

Economic Competition↗
PubMed2002

Preventing injuries in older people by preventing falls: a meta-analysis of individual-level data.

OBJECTIVES: Our falls prevention research group has conducted four controlled trials of a home exercise program to prevent falls in older people. The objectives of this meta-analysis of these trials were to estimate the overall effect of the exercise program on the numbers of falls and fall-related injuries and to identify subgroups that would benefit most from the program. DESIGN: We pooled individual-level data from the four trials to investigate the effect of the program in those aged 80 and older, in those with a previous fall, and in men and women. SETTING: Nine cities and towns in New Zealand. PARTICIPANTS: One thousand sixteen community dwelling women and men aged 65 to 97. INTERVENTION: A program of muscle strengthening and balance retraining exercises designed specifically to prevent falls and individually prescribed and delivered at home by trained health professionals. MEASUREMENTS: Main outcomes were number of falls and number of injuries resulting from falls during the trials. RESULTS: The overall effect of the program was to reduce the number of falls and the number of fall-related injuries by 35% (incidence rate ratio (IRR) = 0.65, 95% confidence interval (CI) = 0.57-0.75; and, respectively IRR = 0.65, 95% CI = 0.53-0.81.) In injury prevention, participants aged 80 and older benefited significantly more from the program than those aged 65 to 79. The program was equally effective in reducing fall rates in those with and without a previous fall, but participants reporting a fall in the previous year had a higher fall rate (IRR = 2.34, 95% CI = 1.64-3.34). The program was equally effective in men and women. CONCLUSION: This exercise program was most effective in reducing fall-related injuries in those aged 80 and older and resulted in a higher absolute reduction in injurious falls when offered to those with a history of a previous fall.

Accidental Falls↗