To save content items to your account,
please confirm that you agree to abide by our usage policies.
If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account.
Find out more about saving content to .
To save content items to your Kindle, first ensure firstname.lastname@example.org
is added to your Approved Personal Document E-mail List under your Personal Document Settings
on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part
of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations.
‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi.
‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
When evaluating a charity by itself, people tend to overweight overhead costs in relation to cost-effectiveness. However, when evaluating charities side by side, they base their donations on cost-effectiveness. I conducted a replication and extension of Caviola et al. (2014; Study 1) using a 3 (High Overhead/Effectiveness, Low Overhead/Effectiveness, Both) x 2 (Humans, Animals) between-subjects design. I found that the overhead ratio is an easier attribute to evaluate than cost-effectiveness in separate evaluation, and, in joint evaluation, people allocate donations based on cost-effectiveness. This effect was observed for human charities, and to a lesser extent, for animal charities.
Some charities are much more cost-effective than other charities, which means that they can save many more lives with the same amount of money. Yet most donations do not go to the most effective charities. Why is that? We hypothesized that part of the reason is that people underestimate how much more effective the most effective charities are compared with the average charity. Thus, they do not know how much more good they could do if they donated to the most effective charities. We studied this hypothesis using samples of the general population, students, experts, and effective altruists in five studies. We found that lay people estimated that among charities helping the global poor, the most effective charities are 1.5 times more effective than the average charity (Studies 1 and 2). Effective altruists, in contrast, estimated the difference to be factor 50 (Study 3) and experts estimated the factor to be 100 (Study 4). We found that participants donated more to the most effective charity, and less to an average charity, when informed about the large difference in cost-effectiveness (Study 5). In conclusion, misconceptions about the difference in effectiveness between charities is thus likely one reason, among many, why people donate ineffectively.
We describe the “evaluability bias”: the tendency to weight the importance of an attribute in proportion to its ease of evaluation. We propose that the evaluability bias influences decision making in the context of charitable giving: people tend to have a strong preference for charities with low overhead ratios (lower administrative expenses) but not for charities with high cost-effectiveness (greater number of saved lives per dollar), because the former attribute is easier to evaluate than the latter. In line with this hypothesis, we report the results of four studies showing that, when presented with a single charity, people are willing to donate more to a charity with low overhead ratio, regardless of cost-effectiveness. However, when people are presented with two charities simultaneously—thereby enabling comparative evaluation—they base their donation behavior on cost-effectiveness (Study 1). This suggests that people primarily value cost-effectiveness but manifest the evaluability bias in cases where they find it difficult to evaluate. However, people seem also to value a low overhead ratio for its own sake (Study 2). The evaluability bias effect applies to charities of different domains (Study 3). We also show that overhead ratio is easier to evaluate when its presentation format is a ratio, suggesting an inherent reference point that allows meaningful interpretation (Study 4).
Cost-effectiveness analysis needs to be considered when introducing new tools and treatments to clinical services. The number of new assessment tools in mental health has rapidly expanded, including suicide risk assessment. Such suicide-based assessments, when linked to preventative interventions, are integral to high-quality mental health care for people with severe mental illness (SMI). We examined the cost implications of implementing Oxford Mental Illness and Suicide (OxMIS), an evidence-based, scalable suicide risk assessment tool that provides probabilistic estimates of suicide risk over 12 months for people with SMI in England.
We developed a decision analytic model using secondary data to estimate the potential cost-effectiveness of incorporating OxMIS into clinical decision-making in secondary care as compared to usual care. Cost-effectiveness was measured in terms of costs per quality-adjusted life years (QALYs) gained. Uncertainty was addressed with deterministic and probabilistic sensitivity analysis.
Conducting suicide risk assessment with OxMIS was potentially cheaper than clinical risk assessment alone by £250 (95% confidence interval, −786;31) to £599 (−1,321;−156) (in 2020–2021 prices) per person with SMI and associated with a small increase in quality of life (0.01 [−0.03;0.05] to 0.01 QALY, [−0.04;0.07]). The estimated incremental cost-effectiveness ratio of implementing OxMIS was cost saving. Using probabilistic sensitivity analysis, 99.96% of 10,000 simulations remained cost saving.
Cost-effectiveness analysis can be conducted on risk prediction models. Implementing one such model that focuses on suicide risk in a high-risk population can lead to cost savings and improved health outcomes, especially if explicitly linked to preventative treatments.
This paper argues that cost-effectiveness analysis in the healthcare sector introduces a discrimination risk that has thus far been underappreciated and outlines some approaches one can take toward this. It is argued that appropriate standards used in cost-effectiveness analysis in the healthcare sector fail to always fully determine an optimal option, which entails that cost-effectiveness analysis often leaves decision makers with large sets of permissible options. Larger sets of permissible options increase the role of decision makers’ biases, whims, and prejudices, which means that the discrimination risk increases. Two ways of mitigating this are identified: tinkering with standards used in the cost-effectiveness analysis and outlining anti-discrimination guidelines for decision makers.
It is generally accepted that morally justified healthcare rationing must be non-discriminatory and cost-effective. However, given conventional concepts of cost-effectiveness, resources spent on disabled people are spent less cost-effectively, ceteris paribus, than resources spent on non-disabled people. Thus, it is reasonable to assume that standard cost-effectiveness discriminates against the disabled. Call this the disability discrimination problem. Part of the disability discrimination involved in cost-effectiveness stems from the way in which health-related quality of life is accounted for and measured. This paper offers and defends a patient-sensitive account of health-related quality of life, which can effectively make cost-effectiveness less discriminatory against the disabled and thus more morally justified.
To investigate whether a psychiatry-specific virtual on-call training programme improved confidence of junior trainees in key areas of psychiatry practice. The programme comprised one 90 min lecture and a 2 h simulated on-call shift where participants were bleeped to complete a series of common on-call tasks, delivered via Microsoft Teams.
Thirty-eight trainees attended the lecture, with a significant improvement in confidence in performing seclusion reviews (P = 0.001), prescribing psychiatric medications for acute presentations (P < 0.001), working in section 136 suites (places of safety) (P = 0.001) and feeling prepared for psychiatric on-call shifts (P = 0.002). Respondents reported that a virtual on-call practical session would be useful for their training (median score of 7, interquartile range 5–7.75). Eighteen participants completed the virtual on-call session, with significant improvement in 9 out of the 10 tested domains (P < 0.001).
The programme can be conducted virtually, with low resource requirements. We believe it can improve trainee well-being, patient safety, the delivery of training and induction of rotating junior doctors during the COVID-19 pandemic and it supports the development and delivery of practical training in psychiatry.
Economic evaluations of lifestyle interventions for people with mental illness are needed to inform policy makers and managers about implementing such interventions and corresponding reforms in routine mental healthcare.
We aimed to evaluate changes in healthcare costs 18 months after the implementation of a multidisciplinary lifestyle-enhancing treatment for inpatients with severe mental illness (MULTI) versus treatment as usual (TAU).
In a cohort study (n=114; 65 MULTI, 49 TAU), we retrospectively retrieved cost data in Euros on all patient sessions, ward stay, medication use, and hospital referrals in the quarter year at the start of MULTI (Q1 2014) and after its evaluation (Q3 2015). We used linear regression analyses correcting for baseline values and differences between groups, calculated quality-adjusted life years (QALY) and deterministic incremental cost-effectiveness ratios, and performed probabilistic sensitivity analyses.
Adjusted regression showed reduced total costs per patient per quarter year in favor of MULTI (B=-736.30, 95%CI: -2145.2–672.6). Corresponding probabilistic sensitivity analysis accounting for uncertainty surrounding the parameters showed MULTI was dominant over TAU with a saving in total costs of €417.48 (95%-CI: -2,873.2–2,042.1) against 0.06 improvement in QALY (95%-CI: -0.08–0.20). Costs saving estimates were statistically non-significant showing wide confidence intervals.
Regardless of cost savings, MULTI did not increase healthcare costs while improving QALY and additional previously observed health outcomes. This indicates that starting lifestyle interventions does not need to be hampered by costs. Potential societal and economic value may justify investment to support implementation and maintenance. Further research is needed to study this hypothesis.
DIALOG+ is a digital psychosocial intervention aimed at making routine meetings between patients and clinicians therapeutically effective. This study aimed to evaluate the cost-effectiveness of implementing DIALOG+ treatment for patients with psychotic disorders in five low- and middle-income countries in Southeast Europe alongside a cluster randomised trial.
Resource use and quality of life data were collected alongside the multi-country cluster randomised trial of 468 participants with psychotic disorders. Due to COVID-19 interruptions of the trial’s original 12-month intervention period, adjusted costs and quality-adjusted life years (QALYs) were estimated at the participant level using a mixed-effects model over the first 6 months only. We estimated the incremental cost-effectiveness ratio (ICER) with uncertainty presented using a cost-effectiveness plane and a cost-effectiveness acceptability curve. Seven sensitivity analyses were conducted to check the robustness of the findings.
The average cost of delivering DIALOG+ was €91.11 per participant. DIALOG+ was associated with an incremental health gain of 0.0032 QALYs (95% CI –0.0015, 0.0079), incremental costs of €84.17 (95% CI –8.18, 176.52), and an estimated ICER of €26,347.61. The probability of DIALOG+ being cost-effective against three times the weighted gross domestic product (GDP) per capita for the five participating countries was 18.9%.
Evidence from the cost-effectiveness analyses in this study suggested that DIALOG+ involved relatively low costs. However, it is not likely to be cost-effective in the five participating countries compared with standard care against a willingness-to-pay threshold of three times the weighted GDP per capita per QALY gained.
Employment is intrinsic to recovery from mental health conditions, helping people live independently. Systematic reviews indicate supported employment (SE) focused on competitive employment, including individual placement and support (IPS), is effective in helping people with mental health conditions into work. Evidence is limited on cost-effectiveness. We comprehensively reviewed evidence on the economic case for SE/IPS programmes.
We searched PubMed/MEDLINE, EMBASE, PsycINFO, CINAHL, IBSS, Business Source Complete, and EconLit for economic and return on investment analyses of SE/IPS programmes for mental health conditions. Traditional vocational rehabilitation, sheltered work, and return to work initiatives after sickness absence of less than 1 year were excluded. Studies were independently screened by two reviewers. We assessed quality using the Consolidate Health Economic Evaluation Reporting Standards checklist. The protocol was preregistered with PROSPERO-CRD42020184359.
From 40,015 references, 28 studies examined the economic case for IPS, four IPS augmented by another intervention, and 24 other forms of SE. Studies were very heterogenous, quality was variable. Of 41 studies with quality scores over 50%, 10 reported cost per quality-adjusted life year gained, (8 favourable to SE/IPS), 14 net monetary benefits (12 positive), 5 return on investment (4 positive), and 20 cost per employment outcome (14 favorable, 5 inconclusive, 1 negative). Totally, 24 of these 41 studies had monetary benefits that more than outweighed the additional costs of SE/IPS programmes.
There is a strong economic case for the implementation of SE/IPS programmes. The economic case is conservative as evidence on long-term impacts of programmes is limited.
Care of the rapidly growing segment of older adults living longer with complex health and social needs remains fragmented, costly, and, at times, harmful. A high proportion of the total health care dollars consumed by this group is the result of preventable breakdowns in care experienced during frequent episodes of acute illness. Major changes in health and social systems are urgently needed to improve the quality of care delivered to these patients and control growth in health care spending. Widespread implementation of evidence-based transitional care interventions represents an immediate opportunity to better align care with older adults’ preferences and needs, enhance their health and quality of life, and reduce their use of high-cost services. Transitional care encompasses a time-limited, broad range of services to support patients at high risk for poor outcomes, and their families as they move between levels and settings of care.1
To examine the costs and cost-effectiveness of mirtazapine compared to placebo over 12-week follow-up.
Economic evaluation in a double-blind randomized controlled trial of mirtazapine vs. placebo.
Community settings and care homes in 26 UK centers.
People with probable or possible Alzheimer’s disease and agitation.
Primary outcome included incremental cost of participants’ health and social care per 6-point difference in CMAI score at 12 weeks. Secondary cost-utility analyses examined participants’ and unpaid carers’ gain in quality-adjusted life years (derived from EQ-5D-5L, DEMQOL-Proxy-U, and DEMQOL-U) from the health and social care and societal perspectives.
One hundred and two participants were allocated to each group; 81 mirtazapine and 90 placebo participants completed a 12-week assessment (87 and 95, respectively, completed a 6-week assessment). Mirtazapine and placebo groups did not differ on mean CMAI scores or health and social care costs over the study period, before or after adjustment for center and living arrangement (independent living/care home). On the primary outcome, neither mirtazapine nor placebo could be considered a cost-effective strategy with a high level of confidence. Groups did not differ in terms of participant self- or proxy-rated or carer self-rated quality of life scores, health and social care or societal costs, before or after adjustment.
On cost-effectiveness grounds, the use of mirtazapine cannot be recommended for agitated behaviors in people living with dementia. Effective and cost-effective medications for agitation in dementia remain to be identified in cases where non-pharmacological strategies for managing agitation have been unsuccessful.
Psychiatric mother and baby units (MBUs) are recommended for severe perinatal mental illness, but effectiveness compared with other forms of acute care remains unknown.
We hypothesised that women admitted to MBUs would be less likely to be readmitted to acute care in the 12 months following discharge, compared with women admitted to non-MBU acute care (generic psychiatric wards or crisis resolution teams (CRTs)).
Quasi-experimental cohort study of women accessing acute psychiatric care up to 1 year postpartum in 42 healthcare organisations across England and Wales. Primary outcome was readmission within 12 months post-discharge. Propensity scores were used to account for systematic differences between MBU and non-MBU participants. Secondary outcomes included assessment of cost-effectiveness, experience of services, unmet needs, perceived bonding, observed mother–infant interaction quality and safeguarding outcome.
Of 279 women, 108 (39%) received MBU care, 62 (22%) generic ward care and 109 (39%) CRT care only. The MBU group (n = 105) had similar readmission rates to the non-MBU group (n = 158) (aOR = 0.95, 95% CI 0.86–1.04, P = 0.29; an absolute difference of −5%, 95% CI −14 to 4%). Service satisfaction was significantly higher among women accessing MBUs compared with non-MBUs; no significant differences were observed for any other secondary outcomes.
We found no significant differences in rates of readmission, but MBU advantage might have been masked by residual confounders; readmission will also depend on quality of care after discharge and type of illness. Future studies should attempt to identify the effective ingredients of specialist perinatal in-patient and community care to improve outcomes.
Lemborexant has demonstrated statistically significant improvements in sleep onset and sleep maintenance compared with placebo and zolpidem tartrate extended release, measured both objectively using polysomnography and subjectively using sleep diaries, in the phase 3 clinical trial SUNRISE 1. This study evaluated the cost-effectiveness of lemborexant compared with suvorexant, zolpidem immediate release (IR), and untreated insomnia.
A decision-tree model was developed for falls, motor vehicle collisions, and workplace accidents associated with insomnia and insomnia treatments from a Japanese healthcare perspective and with a 6-month time horizon. The model extracted subjective sleep onset latency treatment responses and disutility values for non-responders from SUNRISE 1. Cost-effectiveness was assessed using incremental cost per quality-adjusted life year (QALY) gained. One-way and probabilistic sensitivity analyses were conducted to evaluate the impact of parameter uncertainty on the results.
In the base-case analysis, the mean estimated QALYs for lemborexant, suvorexant, zolpidem-IR, and untreated insomnia were 0.4220, 0.4204, 0.4113, and 0.4163, and expected medical costs were JPY 34 034, JPY 38 371, JPY 38 139, and JPY 15 383, respectively. Lemborexant saved JPY 4337 and JPY 4105 compared with suvorexant or zolpidem-IR, respectively, while conferring QALY benefits. The incremental cost-effectiveness ratio (ICER) of lemborexant compared with that of untreated insomnia was JPY 3 220 975 /QALY. Lemborexant was dominant over suvorexant and zolpidem-IR and was cost-effective when compared with untreated insomnia. Sensitivity analyses supported the results' robustness.
In a Japanese clinical practice setting, lemborexant may represent a better investment for treating insomnia in the healthcare system in Japan.
Healthcare has recently seen numerous exciting applications of artificial intelligence, industrial engineering, and operations research. This book, designed to be accessible to a diverse audience, provides an overview of interdisciplinary research partnerships that leverage AI, IE, and OR to tackle societal and operational problems in healthcare. The topics are drawn from a wide variety of disciplines, ranging from optimizing the location of AEDs for cardiac arrests to data mining for facilitating patient flow through a hospital. These applications highlight how engineering has contributed to medical knowledge, health system operations, and behavioral health. Chapter authors include medical doctors, policy-makers, social scientists, and engineers. Each chapter begins with a summary of the health care problem and engineering method. In these examples, researchers in public health, medicine, and social science as well as engineers will find a path to start interdisciplinary collaborations in health applications of AI/IE/OR.
This chapter explains the concepts of effectiveness and inclusion as key determinants of the successful performance of public services. Effectiveness is assessed in terms of social benefits (as a function of service “quality”) relative to costs, while the assessment of inclusion observes whether disadvantaged populations have access to quality services. Alternative methods to compare policy options are presented: utilitarianism (the creation of social value whereby benefits must surpass service costs) and social contractualism (when inclusion is taken as a priority), with critical implications for the choice of private versus public delivery.
The public debate is rife with polarized views of how to deliver essential services such as education, health, and security. While some tout privatization as a way to supplant bad governments, others warn that private firms maximize profits at the expense of socially oriented service attributes. In reality, all forms of service delivery—public, private and hybrid public private-collaborations—have merits and flaws. This book scrutinizes the menu of delivery forms in public services and the conditions that should make them work. It argues that privatization benefits from capable government units committing to well-defined policy objectives, mobilizing critical resources, and incentivizing effective and inclusive delivery. Societies counting on capable governments can also reject single solutions and experiment with plural paths of improvement, where public and private organizations co-exist and learn from each other. This book will appeal to students, academics, managers and policy makers interested in examining the public-private boundary and the many ramifications of this focal issue.
To assess the cost-effectiveness of prophylactic Zn supplementation for preventing diarrhoea in young children in Tanzania.
Cost-effectiveness analysis using decision-analytic modelling. Cost-effectiveness ratios were calculated as the incremental cost (2019 USD) per disability-adjusted life year (DALY) averted, from a societal perspective, and with a 3 % discount rate applied to future outcomes. Sensitivity analyses were performed to test the robustness of results to alternative assumptions.
A hypothetical cohort of 10 000 children aged 6 weeks to 18 months.
The intervention costs of Zn supplementation were estimated as $109 800 (95 % uncertainty interval: 61 716, 171 507). Zn supplementation was estimated to avert 2200 (776, 3737) diarrhoeal episodes, 14 080 (4692, 25 839) sick days, 1584 (522, 2927) outpatient visits, 561 (160–1189) inpatient bed days, 0·51 (0·15, 1·03) deaths and 19·3 (6·1, 37·5) DALY (discounted at 3 % per year). Zn supplementation reduced diarrhoea care costs by $12, 887 (4089, 25 058). The incremental cost per DALY averted was $4950 (1678, 17 933). Incremental cost-effectiveness ratios (ICER) estimated from a health system perspective were similar to the results from the societal perspective. ICER were substantially lower (more favourable) when future outcomes were not discounted, but all ICER were above contemporary thresholds for cost-effectiveness in this setting.
Prophylactic Zn reduced diarrhoea incidence and associated healthcare utilisation; however, it did not appear to be cost-effective for prevention of childhood diarrhoea in the scenario examined in this study. Reducing intervention costs, or identifying high risk groups for intervention targeting, may be needed to improve cost-effectiveness in this setting.
There are many structural problems facing the UK at present, from a weakened National Health Service to deeply ingrained inequality. These challenges extend through society to clinical practice and have an impact on current mental health research, which was in a perilous state even before the coronavirus pandemic hit. In this editorial, a group of psychiatric researchers who currently sit on the Academic Faculty of the Royal College of Psychiatrists and represent the breadth of research in mental health from across the UK discuss the challenges faced in academic mental health research. They reflect on the need for additional investment in the specialty and ask whether this is a turning point for the future of mental health research.