best buys, wasted buys, and controversies in non-...2019/12/04 · 5 tufts medical center, boston,...

Confidential: For Review OnlyBest Buys, Wasted Buys, and Controversies in Non-

Communicable Disease Prevention: Lessons for Better Investment in Health

Journal: BMJ

Manuscript ID BMJ-2019-050214

Article Type: Analysis

BMJ Journal: BMJ

Date Submitted by the Author: 12-Apr-2019

Complete List of Authors: Isaranuwatchai, Wanrudee; St. Michael's Hospital, Li Ka Shing Knowledge Institute, Centre for exceLlence in Economic Analysis Research (CLEAR); Royal Thai Government Ministry of Public Health, Health Intervention and Technology Assessment ProgramArcher, Rachel ; Health Intervention and Technology Assessment ProgramAnothaisintawee, Thunyarat; Mahidol University Faculty of Medicine Ramathibodi HospitalBacon, Rachel; Tufts Medical CenterBhatia , Tazeem; Public Health EnglandBump, Jesse; Harvard University T H Chan School of Public HealthChalkidou , Kalipso ; Imperial College London, Centre for Global DevelopmentElshaug, Adam; The University of Sydney, Menzies Centre for Health Policy; Brookings InstitutionKim, David; Tufts Medical Center, Center for the Evaluation of Value and Risk in Health, Institute for Clinical Research and Health Policy StudiesReddiar, Sumithra; Harvard University T H Chan School of Public HealthLuz, Alia; Health Intervention and Technology Assessment ProgramNakamura, Ryota; Hitotsubashi University, Neumann, Peter; Tufts Medical Center, Center for the Evaluation of Value and Risk in HealthSharma, Manushi; Health Intervention and Technology Assessment ProgramShichijo, Arisa; Hitotsubashi UniversitySmith, Peter; Imperial College, Imperial College Business School & Centre for Health Policy; University of YorkTeerawattananon, Yot; Health Intervention and Technology Assessment Program (HITAP), Bureau of Policy and Strategy ; National University of SingaporeCulyer, Tony; University of York

Keywords: Non-communicable disease, Best Buys, Wasted Buys, Prevention

https://mc.manuscriptcentral.com/bmj

BMJ

Confidential: For Review Only

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Best Buys and Wasted Buys in NCD prevention 1

Best Buys, Wasted Buys, and Controversies in Non-Communicable Disease Prevention: Lessons for Better Investment in Health

BMJ Series on Health, Wealth and Profits

Wanrudee Isaranuwatchai (0000-0002-8368-6065)1-3*, Rachel Archer1, Thunyarat Anothaisintawee4, Rachel Bacon5, Tazeem Bhatia6, Jesse Bump7, Kalipso Chalkidou8,9, Adam Elshaug10,11, David Kim5, Sumithra Krishnamurthy Reddiar7, Alia Luz1, Ryota Nakamura12, Peter Neumann5, Manushi Sharma1, Arisa Shichijo12, Peter Smith9,13, Yot Teerawattananon1,14,15, Anthony J Culyer13

1 Health Intervention and Technology Assessment Program, Bangkok, Thailand2 St. Michael’s Hospital, Toronto, Canada3 University of Toronto, Toronto, Canada4 Ramathibodi Hospital, Bangkok, Thailand5 Tufts Medical Center, Boston, USA6 Public Health England, London, United Kingdom7 Harvard TH Chan School of Public Health, Boston, USA8 Centre for Global Development, London, United Kingdom9 Imperial College London, London, United Kingdom10 University of Sydney, Sydney, Australia11 Brookings Institution, Washington DC, USA12 Hitotsubashi University, Tokyo, Japan13 University of York, York, United Kingdom14 National University of Singapore, Singapore15 National Health Foundation, Bangkok, Thailand

*Correspondence to:Dr. Wanrudee IsaranuwatchaiThe Health Intervention and Technology Assessment Program (HITAP), 6 th Floor, 6 th Building, Department of Health, Ministry of Public Health, Tiwanon Rd., Muang, Nonthaburi 11000, Thailand Email: [email protected] Phone: +66-63-936-5463

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AbstractThe burden from non-communicable diseases (NCDs) is huge and rising. It is essential for both health and economic reasons to make the best choices in purchasing interventions for Universal Health Coverage. The World Health Organization’s (WHO) list of Best Buys was a reflection of these considerations and, building on this work, greater understanding of Best Buys, Wasted Buys, and Contestable Buys in NCD prevention could further support smarter investment in health. Our aim is to offer some ways of thinking in order to help local managers who have responsibility for developing strategies, and for delivering Best Buys (and avoiding Wasted Buys).

Both informational and political issues impair the ability of NCD managers to promote Best Buys, avoid Wasted Buys, and resolve doubts about those that are contestable. There are no easy answers to these problems although strong leadership from the top of government is probably always a necessary condition for success, and the pathway to success is almost certain to be unique to each jurisdiction.

Systematic thinking for Evidence-based and Efficient Decision-making (SEED) provides a framework for determining whether an intervention is likely to be worthwhile in a local context. It addresses both the cost-effectiveness agenda and the second order considerations. The tool has two sections: to assist NCD managers in thinking critically about the intervention, and to provide recommendations for strengthening the evidence base. SEED additionally facilitates implementation of potential Best Buys and prepares NCD managers for swift and reasoned action whenever a window of economic, professional, and political opportunity opens.

Key words:Non-communicable disease, Best Buys, Wasted Buys, Prevention

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The burden from non-communicable diseases (NCDs) is huge and rising. It is essential for both health and economic reasons to make the best choices in purchasing interventions for Universal Health Coverage (UHC). The World Health Organization’s (WHO) list of Best Buys was a reflection of these considerations and, building on this work, greater understanding of Best Buys, Wasted Buys, and Contestable Buys in NCD prevention could further support smarter investment in health.

Best BuysThe term ‘Best Buy’, though not coined by the WHO, was adopted by it in 2017 to describe healthcare interventions that were globally recommended for treating NCDs, specifically, cardiovascular disease, diabetes, cancer and chronic respiratory disease (1).

They were selected using the following criteria: a demonstrated and quantifiable effect size; cost-effectiveness (i.e. ≤$100 per DALY averted in low-middle income countries (LMICs)); implementability (e.g. skilled resources available, collaborative resources available from other

sectors).

NCDs represent substantial epidemiological and economic burdens everywhere, influencing everyone regardless of sex and age (2, 3). The four NCDs included by the WHO accounted for over 80% of NCD deaths (1). Significant morbidity from NCDs is also attributable to mental health conditions. Elsewhere, the WHO have estimated that 4.4% of the world’s population suffer from depression (2). In 2010, the global direct and indirect economic loss attributable to mental health disorders was around US$2.5 trillion (3). In searching for Best Buys, it therefore seems desirable to include mental health disorders.

NCDs – universal diagnosis, universal prescription?While the burden of the major NCDs is ubiquitous, it does not follow that the idea of a Best Buy is similarly universal in all LMICs (4). In some societies, the costs of an intervention may be similar to one another but the outcomes of that procedure may differ, or the outcomes may be similar but the costs of achieving them are different. Some interventions may be Wasted Buys, like those with very poor outcomes, or modest outcomes achievable only at an unacceptably high cost, or outcomes readily achievable using low-cost alternatives. In any event, it seems wise to view the ideas of Best or Wasted Buys as context-sensitive and, in all cases, a matter for careful consideration rather than the application of universal formulae or simple rules of thumb or blind faith. In short, the three international criteria listed above ought to be kept in sight at the country level (where it should also be asked whether they need supplementation).

The WHO 2017 country survey demonstrated considerable underutilisation of interventions on the Best Buys list, especially in LMICs, and noted that insufficient action was being taken to reach SDG 3.4 (5, 6). One problem is that little of the evidence on which the Best Buys list is based comes from LMICs (5). Another is that no guidance is offered as to how to implement the recommended interventions in different settings having different disease burdens, different decision-making and managerial capacities, different institutional and delivery frameworks, different cultural and historical inheritances that affect both ideas of illness and the acceptability of types of intervention, and different capacities to translate international research findings into locally relevant research information (7). It therefore seems appropriately cautious to use a third category, besides ‘Best’ and ‘Wasted’, to cover cases where, at the national or regional level, it is hard to reach an unambiguous conclusion. We term these ‘Contestable’ Buys.

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Many NCD interventions are preventive. Prevention requires acting on the determinants of disease, including changes to current lifestyles, and addressing conflicts between stakeholders having rival vested interests. These two are self-evidently contingent on local culture and circumstance. For example, tobacco taxation is widely considered to be a Best Buy and is included in the WHO’s list. However, in India, the tax on cigarette products did not appear to reduce smoking even though there was international evidence and strong political buy-in supporting the implementation. This ineffectiveness was in part because the tax did not influence the consumers of local tobacco (bidi), which accounted for about 85% of smokers in the country (8). Despite the evidence, tobacco taxation remains a severely underused policy.

Analysis of case studies implementing NCD preventive policies in LMICs and the literature (9) highlights important contextual (second order) considerations for review when implementing Best Buys:

1) relevance to the community of interest; 2) ethical acceptability;3) cross-sectoral collaboration;4) community and stakeholder engagement;5) affordability, feasibility and sustainability; 6) leadership, governance, compliance and monitoring.

Claims about Best and Wasted Buys should be tested. Our aim is to offer some ways of thinking in order to help local managers who have responsibility for developing strategies, and for delivering Best Buys (and avoiding Wasted Buys), to sharpen their skills at interrogating technical literatures and experts in the fields of clinical epidemiology and health economics, so as to engage intelligently with issues of prioritization and delivery, in ways that are publicly defensible if challenged.

Best Buys – International or local?The principal criterion for Best Buys is cost-effectiveness (Figure 1). However, global evidence of cost-effectiveness may be insufficient to reach a Best Buy conclusion. Much evidence is presented as if it were context-free, or somehow universally applicable. That is not the case. There are usually many other considerations, which we term ‘second order’, that can influence whether the policy intervention is cost-effective in a specific setting. A shortlist of potentially important considerations includes: population characteristics, other priorities for social spending, disease resistance and other epidemiological and demographic factors, relative prices, health systems capacities, political and cultural acceptability, affordability, and scalability. The list is easy to supplement.

Policymakers when allocating resources need to balance setting national spending priorities fairly and efficiently while at the same time safeguarding an individual’s right to health. An approach that seeks to maximise health benefits across a population can conflict with efforts to achieve equity (10). Achieving equity can be costlier as it means reaching less accessible, often marginalised groups; thus potentially deeming the intervention cost-ineffective. For example, delivering a prevention programme in a dispersed, rural area, even if the effectiveness is the same, will be costlier than implementing the programme in a densely packed, urban area. Exclusion of hard to reach populations raises philosophical questions on what is a just distribution of health. Structural policies that seek to promote health should not only consider their impact on health inequalities but look for means to reduce inequalities. For example, in settings with a commercial alcohol market rather than home brewed, implementing a minimum unit price on alcohol could have more impact on health inequalities than simply raising alcohol taxes (11). It is possible for a cost-ineffective intervention to be deemed a successful intervention if it delivers sufficiently strong equity outcomes.

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Transferability of economic evidence to local settings A major challenge concerns the transferability of economic evidence generated elsewhere to local settings (12-14). We propose a decision chart for transferability assessment that starts with an initial screening of study characteristics based on the location of the economic evidence (e.g. from formal cost-effectiveness analysis), followed by a data transferability assessment (Appendix A and B). Five study-level elements to be examined include:

1) study perspective; 2) intervention and its comparator(s); 3) analytic time horizon; 4) the discount rate; 5) study quality.

Some of these criteria are context-free, e.g. “discounting” as a procedure to be adopted; others are context-sensitive, e.g. the choice of a specific discount rate(s). It is the context-sensitive elements that are critical for consideration when assessing transferability (15, 16). After the initial screening, evaluators can determine whether the original evidence can be directly applicable to a local setting or require further modification based on factors such as:

1) baseline risk in the original study (compared with local settings); 2) treatment effects; 3) unit costs/prices; 4) resource utilization and substitutions; and5) health state preference weights.

The assessment can help decision-makers or program managers organize their thinking about the transferability of existing economic evidence. A pre-established hub of local or regional technical expertise would greatly aid these aspects of transferability assessment (17). When the epidemiological and economic evidence of alleged Best Buys is not transferable to the specific local setting, it could mean either that there is the lack of localized evidence to support the implementation or that intervention could actually be a Wasted Buy. Further research may be necessary to determine which is the case.

Wasted BuysA Wasted Buy could be an intervention that:

1) has no benefit; or2) is costlier than the willingness-to-pay threshold in the given setting (Figure 1); or3) has limited effectiveness or its costs are not proportional to the benefits; or4) may have uncertain benefit or cost-effectiveness; or5) is cost-ineffective and contributes nothing to equity objectives.

Conditional coverage with evidence development or only in research with subsequent review is one approach to uncertainty that has been used elsewhere (18, 19). Exploring real world evidence generation post coverage through, for example, coverage with evidence development approaches and then using the new information to improve practice is another possibility (19-21).

Wasted Buys are often rooted in conflicted motives, misinformed beliefs, the political economy realities, and social issues that proliferate in the policy design and implementation sphere of NCD management. Some common pitfalls are:

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1) believing that all preventive interventions are Best Buys; 2) believing that clinical guidelines can be context-free;3) believing that evidence-based policy making is the same as policy-based evidence making (one

seeks to do what is right, and the other seeks to prove that what was done was right);4) selective implementation of interventions that introduces hidden biases and misses possible

interactions between options;5) applying equity criteria regardless of opportunity cost;6) choosing a decision-making threshold (cost per QALY) that is too high – this guarantees that

more technologies will be included than are budgeted for.

ChallengesNCD managers face challenges on several fronts. We highlight two in particular: informational and political. Keeping up with information in health care is not easy. Seventy-five trials and 11 systematic reviews are published daily (22). NCD managers have to find ways of identifying likely relevant information to implement in their areas. An expert hub of the sort mentioned above can be an instrument for gathering and filtering relevant information as well as for reviewing it and supporting health technology assessment (HTA) processes.

The need for effective inter-ministry collaboration may be a factor accounting for the underutilization of Best Buys in NCD prevention (23) since nearly all systems of public administration are vertical and tend to act as decision-making silos. Interventions to address social determinants often require collaborations with other sectors as well as government departments., e.g. education, housing, and the corporate sector. There are no ready models to follow through numerous attempts exist, such as Chicago’s Inter-Departmental Task Force on Childhood Obesity. From the health sector perspective, cross-sectoral projects should be evaluated in the same way as all other uses of health sector funds. That is, to be acceptable, the financial contribution of the health sector to a cross-sectoral project should yield sufficient health benefits to make the project cost-effective. The cost-effectiveness threshold will indicate the health sector’s maximum willingness-to-pay for a cross-sectoral project’s implementation (24, 25). Decisions ought to allow the full participation of sectoral partners. In systems that favor short term planning and silo budgets, we tend not to prioritise actions whose benefits are realized in the future and in sectors who did not initiate the original spend. Both informational and political issues impair the ability of NCD managers to promote Best Buys, avoid Wasted Buys, and resolve doubts about those that are contestable. There are no easy answers to these problems although strong leadership from the top of government is probably always a necessary condition for success (26), and the pathway to success is almost certain to be unique to each jurisdiction.

SEED – A tool for practical thinkingHTA is not only a collection of technical methods. It is also a way of thinking. It necessarily involves the academic disciplines of biostatistics, economics, epidemiology, and ethics, together with the professional disciplines of medicine. Systematic thinking for Evidence-based and Efficient Decision-making (SEED) (Figure 2) provides a framework for determining whether an intervention is likely to be worthwhile in a local context. It addresses both the cost-effectiveness agenda and the second order considerations. The tool has two sections: the inner circle aims to assist NCD managers in thinking critically about the intervention, while the outer boxes provide recommendations for strengthening the evidence base. In the inner circle, the tool highlights the following:

1) a sound theoretical basis;2) good quality evidence;3) transferability to the implementation setting;

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4) reasonable cost;5) sufficient political commitment.

SEED collates and summarizes information. Moving clockwise round the circle takes one through a logical sequence of factors for consideration, which we hope increase the probability of finding Best Buys. Depending on context, however, it may sometimes be advantageous to address issues in a different order to reach the right decisions – provided that no step is completely missed. SEED additionally facilitates implementation of potential Best Buys and prepares NCD managers for swift and reasoned action whenever a window of economic, professional, and political opportunity opens.

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Summary boxes

What is already known on this topic: The burden from non-communicable diseases is huge and rising, making it essential for both

health and economic reasons to make the best choices in purchasing interventions for Universal Health Coverage.

The World Health Organization’s list of Best Buys was a reflection of these considerations and, building on this work, greater understanding of Best Buys, Wasted Buys, and Contestable Buys in non-communicable disease prevention could further support smarter investment in health.

What this study adds: Our aim is to offer some ways of thinking in order to help local managers who have

responsibility for developing strategies, and for delivering Best Buys (and avoiding Wasted Buys).

Systematic thinking for Evidence-based and Efficient Decision-making (SEED) provides a framework for determining whether an intervention is likely to be worthwhile in a local context, addressing both the cost-effectiveness agenda and the second order considerations (i.e., relevance to the community of interest; ethical acceptability; cross-sectoral collaboration; community and stakeholder engagement; affordability, feasibility and sustainability; and leadership, governance, compliance and monitoring).

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Figure Legends

Figure 1. Cost-effectiveness plane to show Best Buys and Wasted Buys Legend: Cost-effectiveness (represented on this graph) highlights part of the definitions for Best

Buys and Wasted Buys including controversies. There are other considerations to consider when identifying and implementing Best Buys and Wasted Buys such as context and political economy including equity considerations (which could be as or more important than cost-effectiveness).

Figure 2. SEED tool This tool provides a framework for determining whether an intervention is likely to be

worthwhile in a local context. The tool has two sections: the inner circle aims to assist NCD managers in thinking critically about the intervention, while the outer boxes provide recommendations for strengthening the evidence base.

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DeclarationsContributor and guarantor informationAll authors work in health technology assessment and health systems and policy research. All authors approved the version to be published and agreed to be accountable for all aspects of the work. WI, RA, TA, TB, JB, KC, AE, DK, SK, AL, RN, PN, MS, PS, YT, and AJC provided substantial contributions to the conception or design of the work and drafted the work.

All authors provided substantial contributions to the acquisition, analysis, or interpretation of data for the work. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. WI is the guarantor of the article.

Copyright/license for publicationThe Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive licence (or non exclusive for government employees) on a worldwide basis to the BMJ Publishing Group Ltd ("BMJ"), and its Licensees to permit this article (if accepted) to be published in The BMJ's editions and any other BMJ products and to exploit all subsidiary rights, as set out in BMJ’s licence.

Competing interests The authors have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

FundingPrince Mahidol Award Foundation, Thai Health Promotion Foundation, and International Decision Support Initiative

AcknowledgementsWe would like to acknowledge the support from Ms. Waranya Rattanavipapong, Dr. Olaa Mohamed-Ahmed, Dr. Suchita Bhattacharyya, Prof. Kanchan Mukherjee, and Dr. Rohan Jayasuriya. The Health Intervention and Technology Assessment Program (HITAP) is funded by the Thailand Research Fund (TRF) under a grant for Senior Research Scholar (RTA5980011). HITAP’s International Unit is supported by the International Decision Support Initiative (iDSI) to provide technical assistance on health intervention and technology assessment to governments in low- and middle-income countries. iDSI is funded by the Bill & Melinda Gates Foundation [OPP1134345], the UK’s Department for International Development, and the Rockefeller Foundation. The findings, interpretations, and conclusions expressed in this article do not necessarily reflect the views of the funding agencies.

Patient and public involvementNot applicable

DisseminationNot applicable

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FilesFile Name File Format DescriptionFigure1 JPG Figure 1: Cost-effectiveness plane to

show Best Buys and Wasted BuysFigure2 JPG Figure 2: SEED toolSupplementaryFile_BBsandWBsOfNCDPrevention

MS Word Figure: Framework for transferability assessmentTable: Checklist for transferability assessment

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References1. World Health Organization. Noncommunicable diseases: Key facts 2018 [Available from: http://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases.2. World Health Organization. Depression and other common mental disorders: global health estimates. World Health Organization; 2017.3. Trautmann S, Rehm J, Wittchen HU. The economic costs of mental disorders: Do our societies react appropriately to the burden of mental disorders? EMBO reports. 2016;17(9):1245-9.4. Mehndiratta A, Sharma S, Gupta NP, Sankar MJ, Cluzeau F. Adapting clinical guidelines in India—a pragmatic approach. bmj. 2017;359:j5147.5. Allen LN, Pullar J, Wickramasinghe KK, Williams J, Roberts N, Mikkelsen B, et al. Evaluation of research on interventions aligned to WHO ‘Best Buys’ for NCDs in low-income and lower-middle-income countries: a systematic review from 1990 to 2015. BMJ global health. 2018;3(1):e000535.6. World Health Organization. Assessing national capacity for the prevention and control of noncommunicable diseases: report of the 2017 global survey. 2018.7. World Health Organization. ‘Best buys’ and other recommended interventions for the prevention and control of noncommunicable diseases: Tackling NCDs: World Health Organization,; 2017 [Available from: https://apps.who.int/iris/bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf;sequence=1.8. The Tobacco Institute of India. Tobacco taxation 2017 [Available from: https://www.tiionline.org/industry-issues/taxation/.9. Ng E, de Colombani P. Framework for selecting best practices in public health: a systematic literature review. Journal of public health research. 2015;4(3).10. Rumbold B, Baker R, Ferraz O, Hawkes S, Krubiner C, Littlejohns P, et al. Universal health coverage, priority setting, and the human right to health. The Lancet. 2017;390(10095):712-4.11. The University of Sheffield. Minimum unit pricing and strength-based taxation have larger impacts on health inequalities than increasing current alcohol taxes 2016 [Available from: https://www.sheffield.ac.uk/news/nr/alcohol-tax-taxation-minimum-pricing-1.552930.12. Drummond M, Barbieri M, Cook J, Glick HA, Lis J, Malik F, et al. Transferability of economic evaluations across jurisdictions: ISPOR Good Research Practices Task Force report. Value in health. 2009;12(4):409-18.13. Wilkinson T, Sculpher MJ, Claxton K, Revill P, Briggs A, Cairns JA, et al. The international decision support initiative reference case for economic evaluation: an aid to thought. Value in health. 2016;19(8):921-8.14. Li R, Ruiz F, Culyer AJ, Chalkidou K, Hofman KJ. Evidence-informed capacity building for setting health priorities in low-and middle-income countries: a framework and recommendations for further research. F1000Research. 2017;6.15. Lomas J, Culyer T, Mccutcheon C, Law S, Tetroe J. Final Report-Conceptualizing and Combining Evidence for Health System Guidance. Ottawa: Canadian Health Services Research Foundation; 2005.16. Culyer AJ, Lomas J. Deliberative processes and evidence-informed decision making in healthcare: do they work and how might we know? Evidence & Policy: A Journal of Research, Debate and Practice. 2006;2(3):357-71.17. Glassman A, Chalkidou K. Priority-setting in health: building institutions for smarter public spending. Washington, DC: Center for Global Development. 2012.18. ten Brink D, Gad M, Ruiz F. Malaria innovations: pursuing value in an evolving market. The Lancet Global Health. 2018;6(2):e138-e9.19. Chalkidou K, Hoy A, Littlejohns P. Making a decision to wait for more evidence: when the National Institute for Health and Clinical Excellence recommends a technology only in the context of research. Journal of the Royal Society of Medicine. 2007;100(10):453-60.

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http://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases

https://apps.who.int/iris/bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf;sequence=1

https://apps.who.int/iris/bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf;sequence=1

https://www.tiionline.org/industry-issues/taxation/

https://www.sheffield.ac.uk/news/nr/alcohol-tax-taxation-minimum-pricing-1.552930



20. Group BR. Better Outcomes through Learning, Data, Engagement, and Research (BOLDER)–a system for improving evidence and clinical practice in low and middle income countries. F1000Research. 2016;5.21. English M, Irimu G, Agweyu A, Gathara D, Oliwa J, Ayieko P, et al. Building learning health systems to accelerate research and improve outcomes of clinical care in low-and middle-income countries. PLoS medicine. 2016;13(4):e1001991.22. Bastian H, Glasziou P, Chalmers I. Seventy-five trials and eleven systematic reviews a day: how will we ever keep up? PLoS medicine. 2010;7(9):e1000326.23. Niessen LW, Mohan D, Akuoku JK, Mirelman AJ, Ahmed S, Koehlmoos TP, et al. Tackling socioeconomic inequalities and non-communicable diseases in low-income and middle-income countries under the Sustainable Development agenda. The Lancet. 2018.24. Remme M. Cross-sectoral co-financing: Taking a multi-payer perspective in the financing and economic evaluation of structural HIV interventions. London, UK: London School of Hygiene & Tropical Medicine; 2018.25. Ochalek J, Lomas J, Claxton K. Estimating health opportunity costs in low-income and middle-income countries: a novel approach and evidence from cross-country data. BMJ global health. 2018;3(6):ee000964.26. Melkas T. Health in all policies as a priority in Finnish health policy: A case study on national health policy development. Scandinavian Journal of Public Health. 2013;41(11_Suppl):3-28.

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Figure 1: Cost-effectiveness plane to show Best Buys and Wasted Buys

184x139mm (96 x 96 DPI)

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Figure 2: SEED tool

241x146mm (220 x 220 DPI)

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Appendix A. Decision Chart for Assessing Transferability and Evidence Review

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Appendix B. Transferability assessment checklist

Step 1: Initial assessment of study designEvaluation questions for each criterion

Criteria Q1: Is the listed study characteristic aligned with local decision-making context? (If No, go to Q2)

Q2: Is the original study still informative to the decision problem?

Decision Question: Considering your evaluation for each criterion, is the original study warranted for the further assessment?

Study Perspective Intervention and its comparator(s)

Time horizon

Discounting

Study quality

A. No, reject the external evidence

B. No, but the external evidence can be used with caution

C. Yes, proceed to data transferability assessment

Step 2: Data transferability assessment

Evaluation questions for each data input?

Major considerationsQ1: Are the original input data applied to the local setting?(If No, go to Q2)

Q2: Is local data on the specific input available?(If Yes, go to Q3 If No, go to Q4)

Q3: Is appropriate adjustment for local data input possible?(If No, go to Q4)

Q4: Is the data input used in the original study still informative to the local context?

Decision Question: Considering your evaluation for each criterion, is the original evidence transferable to your local setting?

Baseline risk

Treatment effects

Unit costs/prices

Resource utilization

Health-state preference weight

A. No, reject the external evidence

B. No, but the external evidence can be used with caution

C. Yes, but only after appropriate adjustments for local data input

D. Yes, apply the external evidence as it is

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best buys, wasted buys, and controversies in non-...2019/12/04 · 5 tufts medical center, boston,...

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