Cost-Effectiveness Analysis in Implementation Science: a Research Agenda and Call for Wider Application

Krebs, Emanuel; Nosyk, Bohdan

doi:10.1007/s11904-021-00550-5

Cited by 17 publications

(28 citation statements)

References 78 publications

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“…For example, Cidav et al (2020) advanced a theoretical framework to incorporate cost estimates into implementation evaluation [ 23 ]. Most research on this subject was recent: 12 of the 23 studies were published during the last 2 years of the review [ 17 , 18 , 22 – 25 , 27 – 32 ].…”

Section: Resultsmentioning

confidence: 99%

Economic evaluation of implementation science outcomes in low- and middle-income countries: a scoping review

et al. 2022

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Background Historically, the focus of cost-effectiveness analyses has been on the costs to operate and deliver interventions after their initial design and launch. The costs related to design and implementation of interventions have often been omitted. Ignoring these costs leads to an underestimation of the true price of interventions and biases economic analyses toward favoring new interventions. This is especially true in low- and middle-income countries (LMICs), where implementation may require substantial up-front investment. This scoping review was conducted to explore the topics, depth, and availability of scientific literature on integrating implementation science into economic evaluations of health interventions in LMICs. Methods We searched Web of Science and PubMed for papers published between January 1, 2010, and December 31, 2021, that included components of both implementation science and economic evaluation. Studies from LMICs were prioritized for review, but papers from high-income countries were included if their methodology/findings were relevant to LMIC settings. Results Six thousand nine hundred eighty-six studies were screened, of which 55 were included in full-text review and 23 selected for inclusion and data extraction. Most papers were theoretical, though some focused on a single disease or disease subset, including: mental health (n = 5), HIV (n = 3), tuberculosis (n = 3), and diabetes (n = 2). Manuscripts included a mix of methodology papers, empirical studies, and other (e.g., narrative) reviews. Authorship of the included literature was skewed toward high-income settings, with 22 of the 23 papers featuring first and senior authors from high-income countries. Of nine empirical studies included, no consistent implementation cost outcomes were measured, and only four could be mapped to an existing costing or implementation framework. There was also substantial heterogeneity across studies in how implementation costs were defined, and the methods used to collect them. Conclusion A sparse but growing literature explores the intersection of implementation science and economic evaluation. Key needs include more research in LMICs, greater consensus on the definition of implementation costs, standardized methods to collect such costs, and identifying outcomes of greatest relevance. Addressing these gaps will result in stronger links between implementation science and economic evaluation and will create more robust and accurate estimates of intervention costs. Trial registration The protocol for this manuscript was published on the Open Science Framework. It is available at: https://osf.io/ms5fa/ (DOI: 10.17605/OSF.IO/32EPJ).

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Section: Resultsmentioning

confidence: 99%

Economic evaluation of implementation science outcomes in low- and middle-income countries: a scoping review

et al. 2022

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“…Indeed, one qualitative evaluation of decision-makers operating in a range of service settings found that the costs of pre-implementation activities, including changing workflow, modifying contracts, and building infrastructure, were predominant factors in the decision of whether or not to implement various evidence-based practices [ 8 ]. Implementation costs often are overlooked in economic evaluations [ 9 ], and there are few economic evaluations that compare the value of implementation strategies, incorporating such implementation costs [ 10 , 11 ].…”

Section: Introductionmentioning

confidence: 99%

Using economic evaluations in implementation science to increase transparency in costs and outcomes for organizational decision-makers

Saldana

Ritzwoller

Campbell

et al. 2022

Implement Sci Commun

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Background Economic evaluations frequently are utilized to compare the value of different interventions in medicine and health in concrete terms. Implementation science also would benefit from the incorporation of economic evaluations, but such studies are rare in the literature. The National Cancer Institute has supported a special collection of articles focusing on economic evaluations in implementation science. Even when interventions are supported by substantial evidence, they are implemented infrequently in the field. Implementation costs are important determinants for whether organizational decision-makers choose to adopt an intervention and whether the implementation process is successful. Economic evaluations, such as cost-effectiveness analyses, can help organizational decision-makers choose between implementation approaches for evidence-based interventions by accounting for costs and succinctly presenting cost/benefit tradeoffs. Main text This manuscript presents a discussion of important considerations for incorporating economic evaluations into implementation science. First, the distinction between intervention and implementation costs is presented, along with an explanation of why the comprehensive representation of implementation costs is elusive. Then, the manuscript describes how economic evaluations in implementation science may differ from those in medicine and health intervention studies, especially in terms of determining the perspectives and outcomes of interest. Finally, referencing a scale-up trial of an evidence-based behavioral health intervention, concrete case examples of how cost data can be collected and used in economic evaluations targeting implementation, rather than clinical outcomes, are described. Conclusions By gaining a greater understanding of the costs and economic impact associated with different implementation approaches, organizational decision-makers will have better transparency for future replication and scale-up. The use of economic evaluations can help to advance this understanding and provide researchers, purveyors or third-party intermediaries, and organizational decision-makers with essential information to facilitate implementation.

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“…Further economic evaluations of public health implementation interventions have emerged since this review [45][46][47][48][49][50]; however, the field of work remains small and studies are highly variable by topic, research design, setting and outcome measure(s). Cost evaluations of public health implementation interventions, especially via cost-effectiveness estimates, are needed to enhance understanding and ultimately to increase the uptake of evidence-based practices across settings [41,43,51,52]. Given the established evidence base demonstrating the cost-effectiveness of increasing physical activity in schools [18][19][20][21][22], we sought to determine the efficiency of the additional investment required to increase policy implementation.…”

Section: Introductionmentioning

confidence: 99%

Economic evaluation of a multi-strategy intervention that improves school-based physical activity policy implementation

et al. 2022

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Background Internationally, government policies mandating schools to provide students with opportunities to participate in physical activity are poorly implemented. The multi-component Physically Active Children in Education (PACE) intervention effectively assists schools to implement one such policy. We evaluated the value of investment by health service providers tasked with intervention delivery, and explored where adaptations might be targeted to reduce program costs for scale-up. Methods A prospective trial-based economic evaluation of an implementation intervention in 61 primary schools in New South Wales (NSW), Australia. Schools were randomised to the PACE intervention or a wait-list control. PACE strategies included centralised technical assistance, ongoing consultation, principal's mandated change, identifying and preparing in-school champions, educational outreach visits, and provision of educational materials and equipment. Effectiveness was measured as the mean weekly minutes of physical activity implemented by classroom teachers, recorded in a daily log book at baseline and 12-month follow-up. Delivery costs (reported in $AUD, 2018) were evaluated from a public finance perspective. Cost data were used to calculate: total intervention cost, cost per strategy and incremental cost (overall across all schools and as an average per school). Incremental cost-effectiveness ratios (ICERs) were calculated as the incremental cost of delivering PACE divided by the estimated intervention effect. Results PACE cost the health service provider a total of $35,692 (95% uncertainty interval [UI] $32,411, $38,331) to deliver; an average cost per school of $1151 (95%UI $1046, $1236). Training in-school champions was the largest contributor: $19,437 total; $627 ($0 to $648) average per school. Educational outreach was the second largest contributor: $4992 total; $161 ($0 to $528) average per school. The ICER was $29 (95%UI $17, $64) for every additional minute of weekly physical activity implemented per school. Conclusion PACE is a potentially cost-effective intervention for increasing schools implementation of a policy mandate. The investment required by the health service provider makes use of existing funding and infrastructure; the additional cost to assist schools to implement the policy is likely not that much. PACE strategies may be adapted to substantially improve delivery costs. Trial registration Australia New Zealand Clinical Trials Registry ACTRN12617001265369; Prospectively registered 1st September 2017 https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373520

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Cost-Effectiveness Analysis in Implementation Science: a Research Agenda and Call for Wider Application

Cited by 17 publications

References 78 publications

Economic evaluation of implementation science outcomes in low- and middle-income countries: a scoping review

Economic evaluation of implementation science outcomes in low- and middle-income countries: a scoping review

Using economic evaluations in implementation science to increase transparency in costs and outcomes for organizational decision-makers

Economic evaluation of a multi-strategy intervention that improves school-based physical activity policy implementation

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