There is a team of eleven health economists working in the department and eight PhD students. The focus of research is on methodological and applied projects in the field of economic evaluation.
- Developing appropriate analytical methods to address statistical issues in health economic evaluation using individual patient data: selection bias, clustering, missing data, non-compliance, etc.
- Measuring health outcomes/quality-of-life (CHILDSPLA)
- Cost-effectiveness of changing the current pathway of prostate cancer care
- Economic evaluation of kidney allocation scheme (ATTOM)
- Advancing and strengthening the methodological tools and practices relating to the application and implementation of Health Technology Assessment (ADVANCE-HTA)
The PhD students are tackling a wide range of topics including, the use of randomised and nonrandomised methods to evaluate a complex, community-based intervention in health services research, cost effectiveness of paediatric HIV diagnosis and treatment strategies in Thailand, economic evaluation of the prevention and early detection of colorectal cancer in Korea, economic analysis of improvements in environmental health, economic evaluation in decision making for prostate cancer programmes in Norway, economic analysis of kidney allocation schemes in the UK and an assessment of the efficiency of Seguro Popular in Mexico.
Service Delivery and Organisation
The Unit is also home to a growing group of researchers investigating the consequences of changes to the organisation and delivery of health services in England and the rest of the United Kingdom.
We provide the base for the scientific coordination of an evaluation programme funded by the Department of Health focused on the system reforms in the English NHS introduced since 2002. The aim of the programme is to provide independent scientific evaluation of the reforms which include patient choice, 'payment by results', practice-based commissioning and diversity of providers. These policies are operating interactively and the goal of the evaluation programme is to capture the emergent processes and their interrelated effects. Individual studies are undertaken by research teams from a number of different universities as well as from the School.
We are also carrying out a range of other studies at different levels in the health system in the UK. At the macro level of the health systems, for example, we are comparing the policies of each of the four home countries concerning the relatively new policy introduced into England of allowing patients choice of hospital. Devolution in the United Kingdom has allowed each country to make different decisions about health care policy and choice is an issue which is being approached differently in each country. At the meso level of local NHS organisations, we are investigating a wide range of issues. We are interested in how individual organisations are governed, which includes investigating the new form of NHS organisation, the NHS Foundation Trust, which is designed to be able to act more autonomously from central government while simultaneously involving local people more closely. As the range of organisations involved in NHS care becomes more diverse and organisations from the private and not for profit sectors are invited to provide care for NHS patients, we are also investigating the effect of these changes on productivity and quality of care.
We are also interested in relationships between NHS organisations, which has led us to investigate how local health economies are operating at PCT level and also the nature of NHS contractual relationships, comparing the different contracting regimes in England and Wales. At the micro level, we are looking at the effect of service modernisation on the delivery of critical care, as well as the experience of patients who are offered a choice of providers.
Establishing the value of health technologies and ways of delivering services is only of benefit if the evidence is implemented. Quality improvement encompasses the activities needed to establish criteria of good quality care, assess the actual quality being achieved and then, if necessary, intervening to make improvements. Several staff are involved in developing guidelines for the National Institute for Clinical Excellence. These have included guidance on pre-operative testing, lung cancer management and head injury care. We have also conducted a programme of research aimed at improving the validity and reliability of the consensus development methods that are commonly used to establish guidelines. We also carry out a range of national audits in various fields of surgery. Work on the development of a national Directory of Clinical Databases (DoCDat) has continued and is attracting increasing interest both in the UK and abroad.
Science: Policy Interface
Coronary heart disease policy modelling
Health policy makers need to be able to evaluate possible prevention and treatment strategies by estimating their effectiveness and affordability. A policy analysis model for coronary heart disease has been designed for the Department of Health in collaboration with the Universities of Southampton and Birmingham, using discrete event simulation. Our part of the model simulates risk factor changes and the development of coronary heart disease in a population, and the benefits and direct costs of different primary prevention strategies. The main disease events are onset of stable and unstable angina, myocardial infarction, sudden cardiac death and, as completing risks, deaths from stroke, cancer and other causes.
Vaccination policy modelling
With collaborators in Bangladesh, Peru and WHO, and funding from DfID and WHO, we have developed decision-support models to investigate the cost-effectiveness of some of the relatively costly new vaccines for children in middle and low income countries. These include a dynamic micro-simulation model for rotavirus, Hib and hepatitis B, and simpler Markov models for rotavirus, Hib and pneumococcal. These models involve data on adherence to the national vaccination schedules, and after seeing our analysis of vaccination timeliness in 45 low and middle income countries, WHO has embarked on a major review of their recommended schedules the evidence that underpins them. LSH&TM will be playing a leading role in this.
Resource allocation formulae
Budgets for primary care trusts in England are based on local demographic, socioeconomic and cost factors. The formulae involved are under continual review, and as part of a group led from the Nuffield Trust we have been commissioned by the Department of Health to identify new predictors of health care costs using the characteristics of individuals in the population served rather than small areas. We are particularly concerned with taking account of unmet need, the effect of local variations in the quality of information, and on the use of standard cost weights.
Economics of Infectious Disease
The work on economics of infectious disease is multidisciplinary; it draws together microbiologists, epidemiologists, clinical and public health professionals and health services researchers. Recent work with vetinerary scientists on zoonosis includes studies on brucellosis in Mongolia, E.coli O157, avian flu and salmonella. Other research focuses on health care acquired infection building on earlier work in this field. The programme includes work on MRSA, handhygiene and faster testing methods and a review of isolation facilities. An international review of healthcare related infections is being undertaken for the National Audit Office and further research in this area is being funded by the Department of Health. As part of an ESRC programme grant we are working on a project related to the prevention of E.coli O157 in rural Britain. Close contacts are maintained with the Health Protection Agency. A recent publication, Economics of Infectious Disease. brings together many of the themes and developments in infectious disease, including methodology, evaluation, governance and regulations.
Health Outcomes: Measurement and Evaluation
We are involved both in developing new measures and in researching their implementation and use. The Unit is home to the LSHTM Outcomes Group, internationally recognised for its work on patient-reported outcomes (PROs). The importance of patients’ views in health care evaluation and in audit has led to the need for scientifically robust tools to ensure rigorous measurement of PROs such as quality of life, symptoms and treatment satisfaction. Working with government, industry, regulatory bodies, professional societies and scientists nationally and internationally, our broad and diverse programme of research ranges from methodological work to develop and validate measures to evaluate health outcomes across a wide range of conditions (e.g. dementia, stroke, DVT, pressure ulcers), treatments (e.g. anticoagulation, surgery) and vulnerable groups (e.g. carers of people with severe mental health problems, the oldest old, children with musculoskeletal impairments in Malawi) to studies to inform policy about the routine use of PROs for evaluating patient benefit in assessing new health technologies and treatments (e.g. MR-guided focused ultrasound for uterine fibroids, elective surgery, oral anticoagulants for venous thromboembolism and atrial fibrillation).
We are also involved in pioneering the widespread routine use of patient reported outcomes in the NHS in England (Patient-Reported Outcome Measures (PROMs) for routine use in Treatment Centres: recommendations based on a review of the scientific evidence.) Having demonstrated the feasibility of routine use of such measures in a pilot study, we are implementing the use of disease-specific and generic measures in hip and knee replacement, hernia repair and varicose vein surgery in over 50 NHS trusts and in independent providers. This is also enabling us to explore several methodological issues including the relationship between disease-specific and generic measures and the development of rigorous methods for comparing the performance of hospitals.
Health and Health Systems in Transition
Our major focus is the European region including the former Soviet Union. We are interested in understanding the reasons for the changing patterns of health and disease and in identifying the social and economic determinants of inequalities in health across countries in the region, including a major project on obesity. This work has for example led to important new insights on the contribution of alcohol, nutrition, injuries and poor quality medical care to a continued east-west gap in mortality. Research on health systems includes international comparisons of health care systems, health system performance assessment and the production of the 'Health System Reviews' series of publications, providing in-depth analysis of over 30 countries.