Alternative analytical approaches to aid decision-making

Contact: Gerry Richardson

We explored the advantages and disadvantages of alternative analytical approaches to aid decision making in CLAHRC YH.  We identified the factors that are important in deciding which type of approach to choose, including local needs, local resources available, timelines and complexity of decision problem. This was established through a series of engagement workshops with CLAHRC members and collaborators.  We went onto identify whether there is a 'minimal' set of requirements, i.e. are there some factors essential to consider (e.g. addressing uncertainty).  We then explored the possibility of using existing techniques to identify where health economics input should be focused and whether more sophisticated approaches are required.  From this we developed a set of recommendations and a checklist to aid in choosing the choice of analytical approach.

Future related costs for Myocardial Infarction survivors

Contact: Laura Bojke or Gerry Richardson

This project looked at survivors of myocardial infarction (MI) developing other conditions in future. NICE guidance currently states that costs unrelated to the condition or technology of interest should be excluded from cost-effectiveness analysis. 

This is controversial and could have substantial impact on the results and conclusions of analyses, particularly where there is an effect on mortality. This project describes different types of cost and whether/how these might be included in cost-effectiveness analysis.

Read about our research in more detail by accessing our publication on
Which costs matter? Costs included in economic evaluation and their impact on decision uncertainty: the example of acute myocardial infarction

Costs and benefits associated with emissions: case study exploring the health impacts of West Yorkshire Low Emission Zone (Air Quality)

Contact: Laura Bojke or James Lomas
According to a 2016 Royal College of Physicians report, 40,000 deaths are attributable to exposure to outdoor air pollution, each year in the UK. There is a burgeoning availability of evidence surrounding the link between exposure to poor air quality and its effects on health, in terms of health-related quality of life and increased mortality risk.

Our research provides evidence on the value of health benefits resulting from policies that improve air quality that can be compared against the cost of the intervention itself. Specifically, if value was assessed in the same way as with a new drug, would a transport intervention, such as a low emission zone or clean air zone, be judged to be a cost-effective use of resources?

The collaboration is formed of HEOM researchers at University of York; other academics at University of Leeds and Centre de Recerca en Epidmiologia Ambiental (Barcelona); analysts from Yorkshire and Humber local authorities and Academic Health Science Network (AHSN), and academic and consultant environmental economists.

Results from our collaborative work have been used to inform applications to the Clean Bus Technology Fund and as part of a public document regarding the West Yorkshire Low Emission Zone. Our research is published in BMJ Open and this publication forms the basis of a toolkit (CAPTOR) that we have developed for use by local authorities to help provide an evidence base with which to analyse possible policies that improve air quality.

Link through to the CAPTOR toolkit, along with further information about the health benefits from policies that improve air quality.

Validity of EQ5D-5L and other measures for over-65s

Contact: Clara Mukuria

Formal and informal social care support is an important input for individuals with long term conditions (LTCs) as they can help maintain well-being even where health is not improving. Health related quality of life measures such as EQ-5D may capture some of the impact of social care but may miss out on aspects such as independence and control and new measures such as the ICECAP-O, ASCOT or well-being have been recommended as alternatives. 

The overall aim of this study was to compare the new 5 level version of EQ-5D to these new ‘beyond health measures’ in a longitudinal study in order to examine the extent to which EQ-5D already captures the ‘beyond health’ domains covered in these measures. LTCs are more prevalent in older populations therefore participants aged over 65 with and without LTCs were recruited from the South Yorkshire Cohort in 2014 (n=1749) with follow-up in 2015/16 (n=1213).

Health Economics Advice to York Clinical Commissioning Group - Rehabilitation Services

Contact: Laura Bojke or Ana Duarte
Specialist rehabilitation provides highly structured multidisciplinary care to individuals with complex disabilities following illness or injury to maximise their recovery after hospital admission and support a safe transition to the community.  York Clinical Commisioning Group (CCG) are responsible for planning and funding rehabilitation services at a local level. However, budget constraints and the numerous competing demands on health and social care impose the need for prioritising investments in health care. This process can be informed by estimates of cost-effectiveness analyses of health interventions or services.
We examined the impact of specialist rehabilitation services in North Yorkshire and Humberside on hospital length of stay (LoS) and associated costs compared to routine care.  We did this by comparing hospital (LoS) and associated costs compared to routine care.  We found that the average length of stay and duration costs were lower for the majority of patients with greater access to specialist rehabilitation compared to routine care.  The analysis suggests that specialist rehabilitation may be cost saving compared to routine care and supports the case for expansion of the existing services to improve coverage in the area.

Read about our research in more detail by accessing our publication on
Impact of specialist rehabilitation services on hospital length of stay and associated costs

Health Economics Advice to York Clinical Commissioning Group - Health Checks

Contact: Sebastian Hinde
Since their initiation in 2009 the policy of providing NHS Health Checks to 40-74 year olds has proved controversial with a poor level of coverage and overall program performance substantially below initial targets of reduction in cardiovascular disease risk factors.

This work aimed to assess the cost-effectiveness evaluation of the NHS Health Checks in their current form using the impact of the policy on reducing the long term risk factors associated with obesity, one of the primary factors associated with many of the targeted diseases.  This focused analysis sought to answer the question: has the reduced level of obesity caused by NHS Health Checks, been sufficient to justify the cost of the entire policy to the NHS? The analysis employs a publicly available economic evaluation toolkit to estimate how an observed reduction in the mean BMI in the target population impacts long term population health and costs to the NHS. 

Read further about how the NHS health checks are given a clean bill of health.  The research is discussed in our publication The Cost-Effectiveness of Population Health Checks: have the NHS Health Checks been unfairly maligned?


Establishing regional research priorities to improve the effectiveness and cost-effectiveness of treatment pathways for heart attack patients (Cardiovascular prioritisation)

Contact: Laura Bojke

To understand why differences in care pathways for cardiovascular disease occur at a local level we have worked to develop a list of priority topics for the future. This will encourage locally driven, needs-led research to be prioritised, with a view to improving the health of heart attack patients in Yorkshire & Humber. 

This project resulted from a collaboration formed through CLAHRC YH between HEOM researchers at York, academic cardiologists at Leeds and Sheffield Universities and the Vale of York CCG. The list of priority topics was generated through a review of the literature and then further refined at a regional workshop.

This long list of topics was prioritised using a web survey with the wider academic, clinical and commissioning communities. The web survey results have been analysed and a journal publication written.

RCF funding has been awarded to explore one of the priority topics (multiple versus staged stenting for elective PCI).

Assessment of the EQ-5D-5L compared to EQ-5D-3L and generation of population norms in England

Contact: Clara Mukuria

Comparing EQ-5D-5L and EQ-5D-3L data in the United Kingdom using the GP Patient Survey (GPPS). The study will also generate population norm data for the EQ-5D-5L. EQ-5D-5L was developed to address concerns with the discriminative properties of EQ-5D-3L. Results will add to the growing body of knowledge on the performance of EQ-5D-5L as well as population norm data that can be used by researchers in the UK.

MICA: Going beyond health related quality of life - towards a broader QALY measure for use across sectors

Contact: Clara Mukuria

The aim of this project is to develop a broad generic measure of quality of life that is valued on the zero to one scale necessary to calculate Quality Adjusted Life Years (QALYs) for use in economic evaluation. Three key distinctions between existing generic health and wellbeing measures and this new instrument are: the need to be applicable across a number of sectors (health, social care, carers, and public health); the explicit role of broader wellbeing aspects within the instrument; and its intended use in economic evaluation. The project contains six stages:

Stage 1: Establishing the domains for the QoL instrument
Identifying the domains for the instrument will draw from a number of strands of qualitative and quantitative work.
Stage 2: Generate a list of potential items
Stage 3: Test the face validity of candidate items
Stage 4: Psychometric testing of items
A large survey will be conducted to generate data for psychometric testing of the final item pool from Stage 3 (30-40 items). This will identify the final items for inclusion in the classification system to be valued. We will survey five groups to achieve an overall sample of 2,000 and ensure we cover all the groups of interest.
Stage 5: Valuation
The valuation of the instrument involves two components. A large TTO valuation exercise with a representative sample of the general public and a deliberative exercise with members of NICE Citizens Council to generate an alternative valuation and better understand the results of the TTO.
Stage 6: Implementation, dissemination, and impact

Synthesising registry data (psoriatic arthritis)

Contact: Laura Bojke

In recent years, an increasing number of biologic therapies have been made available for the treatment of psoriatic arthritis (PsA). Biologics are particularly effective at controlling the symptoms of PsA and have been shown to delay disease progression in terms of joint erosion. However, these treatments are expensive, and within resource constrained systems, their value for money has been assessed by health technology assessment (HTA) agencies to determine whether they should be approved for reimbursement in public health care systems.

Many HTA agencies require robust evidence demonstrating that a drug therapy is cost-effective, as well as clinically effective, to receive a positive reimbursement decision. As a result, cost-effectiveness evidence has come to play a prominent role in decisions regarding the approval of biologic treatments in many settings. Unfortunately, the development of robust cost-effectiveness evidence for PsA treatments has often been hindered by deficiencies in the evidence base. The short-term nature of many phase 3 trials in this area means that assumptions regarding the long-term efficacy of biologics are required to investigate the cost-effectiveness of biologic therapies over the remaining lifetime of an average patient. Consequently, this can impose additional uncertainty surrounding the results and, ultimately, reduce confidence in a decision to accept or reject a treatment for reimbursement.

We aimed to explore the extent to which existing registry data can be used to inform cost-effectiveness analysis studies involving biologic therapies for the treatment of PsA. The second aim was to identify how data collection in PsA registries might be improved to inform future cost-effectiveness analysis research.

Read about our research in more detail by accessing our publication on How to appropriately extrapolate costs and utilities in cost-effectiveness analysis?