SECOND OPINION:Media fuss over rejection of breast tests betrays ignorance
IRISH PEOPLE are so unused to thinking about health services in economic terms that the report from the National Centre for Pharmacoeconomics (NCPE), which did not recommend paying more than €3,000 for a new breast cancer test, evoked a predictable response.
The media coverage stressed the fact that private patients can avail of the test but not public patients. The most important finding, that “there is currently no direct evidence that the use of leads to improvement in health outcomes”, received little or no attention. The implication is that this is only about money, whereas in fact an economic appraisal is about the costs versus the benefits of a particular intervention. The response to the NCPE report shows that many people do not understand the meaning of cost-effectiveness research.
Until the publication of this study, few people had heard of the NCPE, which has been in existence since 1998 and is funded by the Department of Health. Among other things, the NCPE endorsed the universal vaccination of Hepatitis B in infants, which was implemented. Economic appraisals are relatively new in Ireland and are part of the Health Information and Quality Authority’s (Hiqa’s) brief. Hiqa recommended the new HPV vaccination programme for girls, and is currently exploring the cost effectiveness of robot-assisted surgery.
Health economics has been around for a long time, but the vast majority of services provided by the HSE and others have not been subjected to any economic appraisals. For example, extra staff will be appointed during 2011 to implement the recommendations in the Ryan report, at a total cost of €18 million. No economic appraisal has been carried out on this development. Economics does not influence health service planning decisions other than on an ad-hoc basis.
Many different kinds of economic analyses can be carried out, including cost analysis, cost-benefit analysis (CBA) and cost-effectiveness analysis (CEA). Cost analysis is the simplest and most frequently used in the Irish health services; this is where all costs are added up, including pay and non-pay (rent, office supplies and travelling expenses), and matched with activities such as the numbers of people who attend for day surgery.
This level of analysis, while necessary, is the least useful. It takes no account of outcomes for service users or whether there are alternative, less expensive services that will deliver the same results. CBA is used to decide whether a programme is worth doing. All the costs of a particular treatment or intervention are added together and compared with the health and economic benefits, which are assigned a monetary value. CEA is expressed as a ratio of benefits versus costs, where the higher the ratio the more worthwhile the intervention.
The extent to which the HSE uses economic appraisals to plan and deliver health services is exemplified by its approach to smoking cessation. Brief interventions by health professionals for the treatment of tobacco dependence are very effective. In fact, brief interventions are the most cost-effective of all known healthcare interventions, and the cost per life year gained is 10 times less than standard medical interventions for diseases caused by smoking.
In spite of the negligible cost of brief interventions, a recent report from the Irish Society for Quality and Safety in Healthcare showed that only one in five smokers admitted to hospital for treatment received help to quit. The HSE is already €200 million overspent, and the cost of health services will continue to increase until economic appraisals are routinely used in health service planning.
Many people believe money should not influence decisions about the provision of health services, and the usual argument is that if one life can be saved it’s worth doing. This is pie in the sky and a denial of reality.
Money already influences the health of Irish citizens to a massive extent, with hundreds of people dying prematurely every day because of poverty, lack of education and health inequalities. These hundreds die unnoticed, yet one person dying because a hospital is closed provokes a huge response. Roll on more Hiqa and NCPE reports. Maybe we will eventually have health service planning based on scientific evidence and not just “it seemed like a good idea at the time”.
Dr Jacky Jones is a former regional manager of health promotion with the HSE