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Background: Economic evaluations are being conducted with increasing frequency in the maternity care setting, with more randomized controlled trials containing a health economic component. Key emerging criticisms of economic evaluation in maternity care are lack of robust data collection and measurement, inconsistencies in methodology, and lack of adherence to reporting guidelines. Methods: This article provides a guide to the design of economic evaluations alongside clinical trials in maternal health. We include economic concepts and considerations for the maternity setting and provide examples from the UK and Australia. Results: There are many important considerations for the design of economic evaluations alongside clinical trials. To be effective, researchers must select types of economic evaluation, which align with their study objectives; choose an appropriate evaluation perspective, time horizon, and discount rate; and identify accurate ways to measure and evaluate health outcomes and costs. Discussion: This guide is written for noneconomists and can be used for designing economic evaluations to be conducted as a part of clinical trials. We seek to improve the quality, consistency, and transparency of economic evaluations in maternal health. [ABSTRACT FROM AUTHOR]

One of the main drivers for change towards delivering value-based healthcare is to improve clinical and managerial culture and engagement within organisations. The relationships between clinicians and managers in an organisation are often considered to be either an enabler or disabler towards successful engagement to develop strategies towards better value healthcare. Successful engagement is dependent on effective and transformational leadership that can impact on organisational value in healthcare. The aim of this research was to explore the relationships, behaviours and perceptions between managers and clinicians towards value-based healthcare in the National Health Service in the United Kingdom. A qualitative research methodology of semi-structured in-depth interviewing on a sample consisting of hospital consultants, senior managers and board executives from a diverse group were conducted. A thematic analysis was used to analyse the data using a systematic approach. The study findings identified areas of potential barriers to engagement for clinicians and managers which were related to regulatory burden, financial challenges and workforce shortages. Key recommendations on what will be required to improve clinicians and managers engagement and the leadership approaches towards improving value-based healthcare are discussed. [ABSTRACT FROM AUTHOR]

Background: Patients with a weakened immune system were considered at high risk for severe infection with Covid-19 and associated complications.1,3 In March 2020 patients with haematological malignancies were classified as extremely clinically vulnerable and advised to shield.2 NICE produced guidance on treatment prioritisation and modifications to usual service to reduce exposure to these patients, including using or switching to oral Systemic Anti-Cancer Treatment (SACT) and introducing home delivery of medications.4 NHS England supported this by providing interim Covid-19 funding pathways.5 Consequently, where appropriate, NBT preferentially selected oral-based SACT regimens; introduced telephone consultations; and the pharmacy department established a medication delivery service. Objectives: This patient satisfaction survey aimed to determine the perceived quality and value of the delivery service and identify any improvements, in order to establish the benefit of continuation. Methodology: Over a period of four weeks from the 16th August 2021, the pharmacy team distributed the patient satisfaction survey to haematology patients having their medication delivered. Patients were provided with a pre-paid postage envelope and requested to return the questionnaire by the 24th September 2021. 87 surveys were sent out. Results: The survey response rate was 66%. Patients were also asked to compare to the waiting service (79% much better, 5% better, 3.5% same, 0% worse or much worse, 12.5% not circled) and for their perceived value of long-term continuation of the delivery service (96% valuable, 2% neutral, 0% not valuable, 2% not circled). Comments were evaluated by qualitative analysis and divided into themes: description of overall service; advantages for delivery service continuation; barriers to delivery service continuation; comparison to waiting; staff feedback; service improvement. Patients appreciated the reduced time in the hospital waiting for medications and travelling/parking costs. Patients raised concerns over the cost of the service to the NHS. Descriptions of the overall service and staff feedback were positive. Improvements related to a delayed delivery as there was no stock of medication and a patient not being informed of a change in the strength of their supportive medication. Discussion and conclusion: The results demonstrate the value of the delivery service, indicating that it is worthwhile continuing as it has improved patient experience and reduced the risk of potential exposure to infection for a vulnerable cohort of patients. Limitations • Patients who newly started treatment during the pandemic had no experience with the previous waiting service. In hindsight, a ‘not applicable’ answer should have been provided. • Patients started having blood in advance with their GP to reduce time in the clinic and facilitate telephone appointments. This previously delayed processing and increased waiting times. • Specialist pharmacists now screen the prescriptions, rather than a dispensary rota where pharmacists were not always ChemoCare trained causing delays and increased waiting times. Recommendations • Continue taking blood in advance to aid the timely processing of prescriptions. • Funding was sourced to continue offering the delivery service. Some patients may choose to collect when attending face-to-face appointments but continue to deliver following telephone consultations. • Counsel on medication changes over the telephone, if not seeing patients face-to-face. • Prepare for clinics in advance to appropriately manage stock levels. [ABSTRACT FROM AUTHOR]

The emergence of the COVID-19 pandemic has had a profound impact on the delivery of health and social care in the UK. Services have been forced to adopt unconventional ways of working to prepare for a world in which we must coexist with COVID-19. These unprecedented challenges have highlighted the need to explore alternative methods of delivering safe and effective shared care regardless of knowledge, training and specialist wound care skills. The aim of this evaluation was to document initial clinical experiences of Alprep Pad® and record the cleansing and debriding and performance. The evaluation would also explore patient reported outcome measures (PROMs) and record their personal experience of using the product between clinic visits. The findings demonstrated a 49% reduction in wound surface area over the 4-week evaluation period. One patient achieved complete healing and there was a 52% increase in the mean proportion of healthy granulation tissue documented at the wound bed, and 100% reduction in bioburden, slough and non-viable tissue. Sixty per cent of patients reported that they found Alprep Pad to be easy and convenient to use in the home setting. The remaining 40% found the product both easy and convenient to use in the home setting without the support of a healthcare professional. Overall, the PROMs demonstrated very high levels of satisfaction with the performance of Alprep Pad, with 100% of respondents expressing a preference to use the product in the future. In terms of delivering safe and effective shared care, Alprep Pad could be considered as a cost-effective intervention from a value-based healthcare perspective. Thus, reducing the need for frequent visits to the wound clinic for sharp debridement and minimising waiting times for treatment. [ABSTRACT FROM AUTHOR]

Key content Continuing financial constraints on the UK's National Health Service means the need for clinicians to provide high‐quality care in a cost‐effective way has never been greater.While the medical education system equips doctors with skills to provide safe clinical care, it should also provide an understanding of healthcare costs and cost‐effectiveness analysis.Value‐based care is becoming a key paradigm in women's health services, where clinicians must employ strategies for delivering value, rationalising costs and capitalising on the use of emerging technologies.The calculation of value of an intervention for providers and service users may differ; care must be taken to ensure this concept is adapted for, and not imposed on healthcare systems.Engaging trainees in systems transformation and embedding the concepts of 'do no financial harm' are essential to ensure sustainable healthcare services. Learning Objectives: To understand the principles of value‐based health care.To highlight the importance of adopting 'cost‐conscious' care within daily clinical practice.To learn the differences between 'cost', 'charge', 'price' and 'reimbursement.To encourage developing value‐based competencies for future medical workforce through utilising out of programme placements and digital resources. Ethical Issues: The ethical obligation of clinicians to consider cost may encompass justice and equity. However, the impact of practicing value‐based health care is yet to be evaluated. [ABSTRACT FROM AUTHOR]

SUMMARY: In value-based healthcare (VBHC) value is defined as outcomes that matter to patients divided by the cost of achieving these outcomes. Value is measured for discrete medical conditions across the whole cycle of care. Data on the value achieved by different providers is openly shared. Providers increase value using quality improvement (QI) techniques to improve outcomes, reduce costs or both. Patients or commissioners choose the provider achieving the greatest value. Units should compete regionally or nationally. There are challenges to implementing such ideas in the mental health services in the UK. However, measuring outcomes, understanding costs and using QI to drive up value may be possible without adopting the complete model that has developed in the context of a North American and acute hospital healthcare system. [ABSTRACT FROM AUTHOR]

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Purpose Research suggests that 85 per cent of health research is avoidably wasted. The research and development management community has an important role in the research process and can contribute to improving the quality and value of research. Al-Shahi Salman et al. (2014) identified ways in which the community can contribute towards the reduction of research waste by increasing the efficiency of recruitment and retention of research participants, data management and data sharing in studies, and promoting the integration of research into practice. The paper aims to discuss these issues.Design/methodology/approach A project undertaken between May 2016 and May 2017 explored the perspective, and contribution, towards reducing research waste amongst the research and development management community. The study identified those categories of research waste the community felt were the most important and of the most value to address. It also examined spheres of influence and barriers to addressing research waste.Findings The most important and highest value categories of research waste to address were: implementation of research in practice, prioritisation of research, and design, conduct and analysis of research. The research and development management community’s level of influence in those areas was low. The categories where the community felt they had most influence, with the exception of design, conduct and analysis of research, were generally those they thought were less important and valuable, i.e. research taking place to time and target, public and patient involvement, and administration.Originality/value Waste in research is a significant area of waste in health care expenditure. This study has provided a better understanding of research waste for the research management community. The research and development management community can take a leadership role in formulating an action plan and identifying measures of success in reducing waste in research. [ABSTRACT FROM AUTHOR]

Abstract: Aim: To compare drug recovery outcomes in commissioning areas included in a ‘payment by results’ scheme with all other areas. Design: Observational and data linkage study of the National Drug Treatment Monitoring System, Office for National Statistics mortality database and Police National Computer criminal records, for 2 years before and after introduction of the scheme. Pre–post controlled comparison compared outcomes in participating versus non‐participating areas following adjustment for drug use, functioning and drug treatment status. Setting: Drug services in England providing publicly funded, structured treatment. Participants: Adults in treatment (between 2010 and 2014): 154 175 (10 716 in participating areas, 143 459 non‐participating) treatment journeys in the 2 years before and 148 941 (10 012 participating, 138 929 non‐participating) after the introduction of the scheme. Intervention: Scheme participation, with payment to treatment providers based on patient outcomes versus all other areas. Measurements: Rate of treatment initiation; waiting time (> or < 3 weeks); treatment completion; and re‐presentation; substance use; injecting; housing status; fatal overdose; and acquisitive crime. Findings: In participating areas, there were relative decreases in rates of: treatment initiation [difference‐in‐differences odds ratio (DID OR) = 0.17, 95% confidence interval (CI) = 0.14, 0.21]; treatment completion (DID OR = 0.60, 95% CI = 0.53, 0.67); and treatment completion without re‐presentation (DID OR = 0.63, 95% CI = 0.52, 0.77) compared with non‐participating areas. Within treatment, relative abstinence (DID OR = 1.50, 95% CI = 1.30, 1.72) and non‐injecting (DID OR = 1.32, 95% CI = 1.10, 1.59) rates were improved in participating areas. No significant changes in mortality, recorded crime or housing status were associated with the scheme. Conclusion: Drug addiction recovery services in England that are commissioned on a payment‐by‐results basis tend to have lower rates of treatment initiation and completion but higher rates of in‐treatment abstinence and non‐injecting than other services. [ABSTRACT FROM AUTHOR]

The U.S. must assess its pricing and reimbursement system for prescription drugs. The current system is attracting intense scrutiny for various reasons. Drug pricing and reimbursement mechanisms used in other countries are described to assess what an optimal system should entail. [ABSTRACT FROM AUTHOR]

Carer quality of life is increasingly considered alongside patient quality of life in economic evaluation. Important questions remain about how to value carer and patient quality of life effects alongside one another. In this study, we estimated the relative social value of two conceptualisations of carer quality of life (health-related and care-related) compared to patient quality of life. Relative valuations were estimated using a person trade-off (PTO) study with 990 representative members of the UK public. Participants chose between hypothetical services that improved the quality of life of carers and patients, iterating to a point of indifference. Overall 84% of participants completing the task were willing to trade patient and carer quality of life effects. Relative to a reference point of 1 for patient health-related quality of life, we estimated a social value of 0.74 for carer health-related quality of life effects and 0.69 for carer care-related quality of life effects. In conclusion, public preferences appear to support the inclusion of carer quality of life effects within economic evaluation. The results provide a means to value different carer quality of life outcomes in economic evaluation, where such values are needed and deemed appropriate. • Person trade-off assessed relative value of carer and patient QoL. • 84% of participants trade-off carer and patient QoL. • Social value for health-related QoL for carers estimated to be 0.74. • Social value for care-related QoL for carers estimated to be 0.69. [ABSTRACT FROM AUTHOR]

Steve Chaplin examines NICE's proposals to introduce two weighting systems into its technology appraisal process in order to better reflect the value of new treatments. [ABSTRACT FROM AUTHOR]

Background: This paper addresses the question of what a reasonable price for an orphan drug is. The research proposes a way to adjust an established payer/HTA body incremental cost-effectiveness threshold (CET) to take account of differences in patient populations and costs of research and development in order to sustain prices that generate rates of return from investments in developing orphan drugs that are no greater than the industry average. Methods: We investigated the cost of conducting research for orphan drugs as compared to non-orphan drugs, as well as patient population sizes targeted by orphans and non-orphans. We provided an empirical illustration based on novel drug approvals of orphan and non-orphan drugs of the FDA between 2011 and 2015 (N = 182). Results: Using, for illustration, the NICE incremental CET (£20 K per QALY) as an anchor and adjusting by R&D costs and expected market revenue, we estimated the adjusted reasonable CET for orphan drugs to be £39.1 K per QALY at the orphan population cut-off and £78.3 K per QALY at the orphan population mid-point. For ultra-orphan drugs the adjusted CET was £937.1 K. Conclusions: We propose one general method for establishing a reasonable price for an orphan drug, based on the proposition that rates of return for investments in developing orphan drugs should not be greater than the industry average. More research is required on data and assumptions, but with the data and assumptions we use, we find that in order to secure such a reasonable price for an orphan drug, the CET for orphans would need to be higher. This could be one approach for establishing the maximum allowable price society should be willing to pay, although decision-makers may still wish to negotiate a lower price, or refuse to pay such a premium over the value-based price in order to treat these groups of patients. [ABSTRACT FROM AUTHOR]

As cancer drug prices rise, it remains unclear whether the cost of new interventions is related to their beneficial impact for patients at a societal-level. Using data for 2003–2015 from the IQVIA MIDAS® dataset, the relationship between cancer drug costs and drug clinical benefits was studied in four countries with different approaches to drug pricing. Summary measures of drug clinical effects on overall survival, quality of life, and safety were obtained from a review of health technology assessments. Mean total drug costs for a full course of treatment were estimated using standard posology for each medicine and in each country. Regression analysis was used to test whether, at a societal-level, the cost of recently licensed drugs is related to their beneficial impact for patients. Across all eligible medicines, average treatment costs were lowest in France and Australia and highest in the UK and US. Compared with Australia, France, and the UK, cancer medicines were on average between 1.2 and 1.9 times more expensive in the US, where the average total per patient cost for treatment was $68,255.17. Costs for new cancer medicines are high and, at best, only weakly associated with drug clinical benefits. The strength of this relationship nevertheless varied across countries. Some new cancer drugs—particularly in the US—may be neither affordable nor clinically beneficial over existing treatments. While all countries can benefit from strategies that more robustly align price with therapeutic benefit in cancer drugs, the US stands out in its opportunity to improve both affordability and value in cancer drug treatment. • We examine drug treatment costs and their relationship to clinical benefits within a multi-country framework. • Cancer drug treatment costs are high and, at best, only weakly associated with clinical benefits, especially in the US. • New anti-cancer drugs may be neither affordable nor clinically beneficial over existing treatments. • Countries share in the opportunity to improve value-for-money in cancer drug spending. • Governmental intervention may play an appropriate economic role in the pricing of anti-cancer medicines. [ABSTRACT FROM AUTHOR]

Really good businesses are built from an aggregation of marginal gains, a concept that was made famous by Sir Dave Brailsford, general manager of the GB Cycling Team. all too often we focus on one part of the ‘sale’, ie. the appointment, and miss other opportunities to generate additional earnings, frequently for very little extra effort. stock sales is one of those marginal gains that can end up making you thousands in extra revenue, every year. This article details how this opportunity can be put into practice by any therapist or practice. [ABSTRACT FROM AUTHOR]

The authors offer comments on the challenges posed by changes in population, health service reforms and funding reviews on the entire health sector of Great Britain, with a focus on physiotherapy. Topics covered include the role of physiotherapy in the effective management of long-term conditions, independent prescribing for non-medical professions and the emerging roles for specialist physiotherapists.

This case study demonstrates the benefits of early intervention and a proactive approach for a patient with chronic oedema living in the community. These benefited the patient and also supported value-based healthcare in the NHS. The patient's health and wellbeing significantly improved with an assessment of his chronic oedema and a management plan consisting of skincare, an exercise and movement programme and the introduction of a class 1 British standard compression garment.

Adoption of new technologies, including diagnostic tests, is often considered not to deliver the expected return on investment. The reasons for this poor link between expectation and outcome include lack of evidence, variation in use of the technology, and an inability of the health system to manage the balance between investment and disinvestment associated with the change in care pathway. The challenges lie in the complex nature of healthcare provision where the investment is likely to be made in the jurisdiction of one stakeholder while the benefits (as well as dis-benefits) accrue to the other stakeholders. A prime example is found in the field of laboratory medicine and the use of diagnostic tests. The current economic tools employed in healthcare are primarily used to make policy and strategic decisions, particularly across health systems, and in purchaser and provider domains. These tools primarily involve cost effectiveness and budget impact analyses, both of which have been applied in health technology assessment of diagnostic technologies. However, they lack the granularity to translate findings down to the financial management and operational decision making at the provider department level. We propose an approach to translational health economics based on information derived from service line management and time-driven activity-based costing, identifying the resource utilisation for each of the units involved in the delivery of a care pathway, before and after adoption of new technology. This will inform investment and disinvestment decisions, along with identifying where the benefits, and dis-benefits, can be achieved for all stakeholders.