How, why and when to include implementation costs in health economic evaluation: Case study of major system change

Abstract:

Implementation of new health care interventions and services can be thought of as a spectrum. At the more complex end, for example major system change, where services are reorganised and behaviours and processes must change, substantial upfront costs (staff, equipment, facilities) are often required to plan and implement the new system and ensure its success. Conversely, simpler changes, for example dose reduction of an existing medication, require no new staff hiring or training, and no purchasing of new equipment or  facilities.

High quality economic evaluations in health care require consideration of all relevant costs and consequences. Different decision makers consider different aspects to be relevant, depending on whose budget is footing the bill among other criteria. Implementation costs are often neglected as too complex, sunk costs, or somebody else’s problem in the first instance described above, or as minimal and therefore unworthy of attention in the second simpler scenario. However, many evaluations fall between the two extremes described above, and care must be taken to ensure that appropriate stakeholders are consulted, and realistic implementation processes and costs are considered.

As health economists, we need to consider these different perspectives and provide meaningful information to aid transparent decision-making in order to improve health. The case study of the RESPECT-21 study programme will be presented as an example of how to calculate the cost of implementing a major system change, and how to incorporate the implementation cost in the overall cost-utility analysis.

Drawing on work from:
• Clarke CS, Vindrola-Padros C, Levermore C, Ramsay AIG, Black GB, Pritchard-Jones K, Hines J, Smith G, Bex A, Mughal M, Shackley D, Melnychuk M, Morris S, Fulop NJ, Hunter RM; “How to Cost the Implementation of Major System Change for Economic Evaluations: Case Study Using Reconfigurations of Specialist Cancer Surgery in Part of London, England”; Applied Health Economics and Health Policy (2021), 19(6): 797-810; https://doi.org/10.1007/s40258-021-00660-6
• Clarke CS, Melnychuk M, Ramsay AIG, Vindrola-Padros C, Levermore C, Barod R, Bex A, Hines J, Mughal MM, Pritchard-Jones K, Tran M, Shackley D, Morris S, Fulop NJ, Hunter RM; “Cost-Utility Analysis of Major System Change in Specialist Cancer Surgery in London, England, Using Linked Patient-Level Electronic Health Records and Difference-in-Differences Analysis”; Applied Health Economics and Health Policy (2022), 20:905–917; https://doi.org/10.1007/s40258-022-00745-w
• Panel session at the HTAi Annual Meeting in June 2022, Utrecht, Netherlands, led by Dr Robert Heggie, titled, “A Lifecycle Approach to HTA: The Role of Implementation Alongside Economic Evaluation”. The title of my talk was, “When should we consider implementation?”