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      Health care input constraints and cost effectiveness analysis decision rules

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          Results of cost effectiveness analyses (CEA) studies are most useful for decision makers if they face only one constraint: the health care budget. However, in practice, decision makers wishing to use the results of CEA studies may face multiple resource constraints relating to, for instance, constraints in health care inputs such as a shortage of skilled labour. The presence of multiple resource constraints influences the decision rules of CEA and limits the usefulness of traditional CEA studies for decision makers. The goal of this paper is to illustrate how results of CEA can be interpreted and used in case a decision maker faces a health care input constraint.

          We set up a theoretical model describing the optimal allocation of the health care budget in the presence of a health care input constraint. Insights derived from that model were used to analyse a stylized example based on a decision about a surgical robot as well as a published cost effectiveness study on eye care services in Zambia.

          Our theoretical model shows that applying default decision rules in the presence of a health care input constraint leads to suboptimal decisions but that there are ways of preserving the traditional decision rules of CEA by reweighing different cost categories. The examples illustrate how such adjustments can be made, and makes clear that optimal decisions depend crucially on such adjustments.

          We conclude that it is possible to use the results of cost effectiveness studies in the presence of health care input constraints if results are properly adjusted.


          • Health care input constraints affect cost effectiveness analysis decision rules.

          • However, if ICERS are adjusted traditional CEA decision rules can be preserved.

          • In specific cases it is possible to adjust conventional ICERs.

          • ICER adjustments require detailed reporting of cost effectiveness results.

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          Most cited references 21

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          Discounting and decision making in the economic evaluation of health-care technologies.

          Discounting costs and health benefits in cost-effectiveness analysis has been the subject of recent debate - some authors suggesting a common rate for both and others suggesting a lower rate for health. We show how these views turn on key judgments of fact and value: on whether the social objective is to maximise discounted health outcomes or the present consumption value of health; on whether the budget for health care is fixed; on the expected growth in the cost-effectiveness threshold; and on the expected growth in the consumption value of health. We demonstrate that if the budget for health care is fixed and decisions are based on incremental cost effectiveness ratios (ICERs), discounting costs and health gains at the same rate is correct only if the threshold remains constant. Expecting growth in the consumption value of health does not itself justify differential rates but implies a lower rate for both. However, whether one believes that the objective should be the maximisation of the present value of health or the present consumption value of health, adopting the social time preference rate for consumption as the discount rate for costs and health gains is valid only under strong and implausible assumptions about values and facts. 2010 John Wiley & Sons, Ltd.
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            The effectiveness and cost implications of task-shifting in the delivery of antiretroviral therapy to HIV-infected patients: a systematic review.

            Human resource shortages are a challenge to the rollout of antiretroviral therapy (ART) for HIV-infected patients, particularly in sub-Saharan Africa. Task-shifting has been recommended as an approach to reduce the impact of human resource shortages. We conducted a systematic review of randomized controlled trials and quasi-experimental studies to assess the effectiveness of task-shifting, and its impact on costs of ART provision. We searched MEDLINE, EMBASE, PSYCINFO, Cochrane Library, Web of Knowledge and the Current Controlled Trials Register for articles published up to January 2011. We included studies evaluating any task-shifting model against any other intervention using any of the following outcomes: mortality (all causes); occurrence of new AIDS-defining illness; virological outcomes; CD4 cell count; adherence to ART medicines (e.g. self-report and pill counts); hospital admissions; clinic visits; toxicity or adverse events; quality of life indicators; costs and cost-effectiveness. We did not pool the results because of high levels of clinical heterogeneity. We identified six effectiveness studies including a total of 19 767 patients. Non-inferior patient outcomes were achieved with task-shifting from doctors to nurses, or from health care professionals to mid-level workers or lay health workers. However, most of the identified studies were underpowered to detect any difference. Three studies were identified on the cost implications of task-shifting. Task-shifting resulted in substantial cost and physician time savings. The reviewed evidence suggests that task-shifting from doctors to nurses, or from health care professionals to lay health workers can potentially reduce costs of ART provision without compromising health outcomes for patients. Task-shifting is therefore a potentially effective and cost-effective approach to addressing the human resource limitations to ART rollout. However, most of the studies conducted were relatively small and more evidence is needed for each task-shifting model as it is currently limited.
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              Accounting for future costs in medical cost-effectiveness analysis.

               David Meltzer (1997)
              Most medical cost-effectiveness analyses include future costs only for related illnesses, but this approach is controversial. This paper demonstrates that cost-effectiveness analysis is consistent with lifetime utility maximization only if it includes all future medical and non-medical expenditures. Estimates of the magnitude of these future costs suggest that they may substantially alter both the absolute and relative cost-effectiveness of medical interventions, particularly when an intervention increases length of life more than quality of life. In older populations, current methods overstate the cost-effectiveness of interventions which extend life compared to interventions which improve the quality of life.

                Author and article information

                Soc Sci Med
                Soc Sci Med
                Social Science & Medicine (1982)
                1 March 2018
                March 2018
                : 200
                : 59-64
                [a ]Erasmus University Rotterdam, Erasmus School of Health Policy & Management, Rotterdam, The Netherlands
                [b ]University of Strathclyde, Department of Management Science, Glasgow, United Kingdom
                Author notes
                []Corresponding author. vanbaal@
                © 2018 The Author(s)

                This is an open access article under the CC BY license (



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