Getting cost-effective technologies into practice: the value of implementation. Report on framework for valuing implementation initiatives

Getting cost-effective health technologies into practice is one of the priorities for the NHS identified in Innovation, Health andWealth [1]. This involves not only identifying cost-effective technologies, which is the responsibility of the National Institute of Health and Care Excellence (NICE), but also understanding the potential barriers to the uptake of these technologies and evaluating possible solutions to these barriers (implementation initiatives). The research presented here sets out a framework for examining the latter (i.e. the solutions to the barriers), in a manner consistent with the estimation of value of the technologies by NICE.

The aim of this research is not to create an additional barrier (or “fifth hurdle”) for health care technologies to get into regular use in the NHS but instead to set out a formal analytic framework to allow for the evaluation of different implementation initiatives in a manner consistent with those methods currently employed for health technology assessment by NICE in England and Wales. The use of this framework recognises that the different types of barriers identified and the range of possible implementation approaches that maybe considered appropriate will invariably be associated with different resource implications and potential outcomes. Consequently, it will be important to ensure that the type and intensity of the implementation approach adopted is commensurate with the anticipated value to the NHS.

1.2 NICE and cost-effectiveness

 The value of the new health care technology to the NHS is established by the Appraisal

Committee after reviewing evidence.

 The value of the new technology, in terms of an incremental cost per QALY, is then compared to the cost-effectiveness threshold (k) to see if it represents a cost-effective use of resources.

 Alternatively, but equivalently, the net value to the NHS of treating a patient with the technology can be calculated in terms of monetary or health benefits.

In 1999 the National Institute of Health and Clinical Excellence (NICE) was created with the aim of ensuring that everyone have equal access to medical treatments and high quality care from the UK National Health Service (NHS) [2]. Further, it aimed to maximise the health produced by the NHS (i.e. to use resources efficiently). These objectives are, however, constrained by the budget allocated to the NHS by the government. One of the ways NICE accomplishes these objectives is through their Medical Technology Evaluation Programme [3], which provides recommendations on the use of new and existing medicines and treatments within the NHS. Recommendation decisions are based on the value of treatments and the uncertainty around that value. Importantly, these decisions require an assessment of both the costs and health effects of a new intervention, as well as the health effects of activities that will have to be displaced elsewhere in the NHS in order to fund any new (and more costly) health care technology.

The methods recommended by NICE provide standardised and systematic ways to evaluate the overall cost and health effects of new health care technologies [3]. Health effects contain both changes in the quality and length of life. NICE recommends measuring health effects in quality adjusted life-years (QALY) using the EQ-5D instrument [4]. The use of a generic measure of quality of life is important both in ensuring consistency in decision making across different treatments and diseases, as well as ensuring that decisions are consistent with the objective of maximising health gain within a fixed NHS budget. The current perspective used by NICE considers the impact of a new intervention on the resource use and costs on the NHS and Personal Social Services [3].

A new health care technology is considered valuable if it provides more overall health than it displaces as a result of any additional cost displacing other health care interventions elsewhere in the NHS. In other words, there are two types of outcomes to be considered when deciding whether to fund a new health care technology. The first is the effect on the patient receiving the health care technology. The second is the effect on others who must then be treated from a reduced budget.

Currently NICE assumes the value of displaced treatments is between £20,000 and £30,000 per QALY. This suggests that the marginal treatment in the NHS (i.e. the treatment that would no longer be funded to release resources to fund a new treatment) provides 1 additional QALY for an additional £20,000-£30,000 spent. To ensure that the funding of a new intervention is consistent with the objective of maximising health gain subject to a budget constraint, new health care technologies must, therefore, provide an incremental cost per QALY compared to current care of less than £20,000-£30,000 per QALY. The incremental cost per QALY of a health care technology is referred to as its incremental cost-effectiveness ratio, or ICER.