Introduction
Methods
Study design
Delphi panel
Steering committee
Identification and review of existing guidelines
Delphi study
Results
Literature review
Country | Perspective | Identification of costs | Measurement of costs | Valuation of costs | Discounting of future costs | List of unit costs available |
---|---|---|---|---|---|---|
Austria [28] | Societal | Healthcare, productivity | Patient level, primary level, secondary level | Opportunity costs, market prices, shadow prices, human capital method | 5% SA, higher and lower rates (e.g. 3% and 10%) | No |
Baltic states: Latvia, Estonia, Lithuania [29] | Societal, healthcare | Healthcare, social care, patient and family | – | Tariffs | 5% | No |
Belgium [5] | Healthcare | Healthcare | Patient level, primary level, secondary level | Opportunity costs, unit costs | 3% SA, not specified | Yes |
Croatia [30] | Societal, healthcare | Healthcare | – | Tariffs | 5% SA, 3–10% | No |
Denmark [31] | Societal | Healthcare, social care, patient and family, productivity, future costs | Patient level, primary level, secondary level, expert opinion | Opportunity costs, unit costs | – | No |
Finland [32] | Healthcare | Healthcare, social care, patient and family, productivity | Patient level, primary level | Unit costs, tariffs | 3% | No |
France [33] | Healthcare | Healthcare, social care, patient and family | Patient level, primary level, secondary level | Opportunity costs, tariffs | 4% SA, not specified | No |
Germany [6] | Healthcare | Healthcare, social care, productivity | Patient level, primary level | Macro costing, micro costing, diagnosis-related group, human capital method | 3% SA, 0%, 5%, 7% and 10% | No |
Societal, healthcare | Healthcare, patient and family, productivity | Patient level, primary level | Tariffs, lowest price, include VAT | 3.7% SA, 3–6% | Yes | |
Ireland [36] | Healthcare | Healthcare | Patient level, primary level, secondary level, clinical practice guidelines, expert opinion | Micro costing, macro costing | 4% SA, 0–6% | No |
Italy [37] | Societal, healthcare | Healthcare, patient and family, productivity | Patient level | Opportunity costs, micro costing, human capital method | 3 and 0% SA, 0–8% | No |
The Netherlands [10] | Societal | Healthcare, social care, patient and family, productivity | Patient level, primary level | Unit costs, standard costs, cost price calculation, friction cost method | 4% SA, not specified | Yes |
Norway [7] | Societal | Healthcare, patient and family, productivity | – | Market prices, exclude VAT | 4% | Unclear |
Poland [9] | Societal, healthcare | Healthcare, patient and family, productivity | Patient level, primary level, secondary level | Unit costs, standard costs, tariffs, cost price calculation | 5% SA, 0% | No |
Portugal [8] | Societal, 3rd-party payer | Healthcare, social care, patient and family, productivity | Patient level, primary level, secondary level | Opportunity costs, unit costs | 5% SA, not specified | No |
Spain [38] | Societal, healthcare | Healthcare, social care, patient and family, productivity | Patient level, primary level | Opportunity costs, unit costs | 3% SA, 0% and 5% | No |
Sweden [39] | Societal | Healthcare, social care, patient and family, productivity | – | Human capital method, unit costs | 3% SA, 0% and 5% | Only medication |
UK [40] | Healthcare | Healthcare, social care | – | Tariffs | 3.5% SA, 1.5% | No |
Delphi panel
Characteristics | Delphi round 1 (n = 19) | Delphi round 2 (n = 16) | Delphi round 3 (n = 16) |
---|---|---|---|
Country of residence |
n = 1: Austria, Bulgaria, Croatia, Cyprus, Czech Republic, France, Germany, Ireland, Italy, Lithuania, Poland, Slovakia, Slovenia, Spain. n = 2: Sweden. n = 3: The Netherlands |
n = 1: Austria, Bulgaria, Cyprus, Czech Republic, France, Germany, Italy, Lithuania, Poland, Slovakia, Slovenia, Spain, Sweden, UK. n = 2: The Netherlands |
n = 1: Bulgaria, Croatia, Cyprus, France, Germany, Lithuania, Poland, Slovakia, Slovenia, Spain, Sweden, UK. n = 2: Austria, The Netherlands |
Primary employment | |||
University | 9 (47%) | 5 (31%) | 4 (25%) |
Government institution | 6 (31%) | 7 (44%) | 9 (57%) |
Healthcare and/or research institute | 2 (11%) | 2 (13%) | 1 (6%) |
Pharmaceutical company | – | 1 (6%) | 1 (6%) |
Consulting company | 2 (11%) | 1 (6%) | 1 (6%) |
Mean number of years of experience in HTA | 14.1 (range 1–40) | 12.4 (range 1–40) | 10.5 (range 1–16) |
Delphi results
Component/topic | Delphi round 1 (n = 19) | Delphi round 2 (n = 16) | Delphi round 3 (n = 16) | Steering committee (n = 4) |
---|---|---|---|---|
Inclusion | Inclusion | Inclusion | Inclusion | |
Perspective | ||||
Healthcare sector |
96%
| |||
Societal |
88%
| |||
Governmenta
| 40% | |||
Healthcare payer(s)a
|
86%
| |||
Health insurance–public fundsa
|
87%
| |||
Social servicesa
|
67%
| |||
Identification of costs (societal perspective) | ||||
1. Healthcare services | ||||
Hospitalization; ICU; emergency visits; medical specialist at an outpatient clinic; diagnostic services; medical devices; treatment procedures; day treatment in a hospital; medication; allied healthcare providers; mental healthcare services; preventive care; general practitioner visits; institutionalized care; palliative care; home care |
94–100%
| |||
Supportive care; social care/welfare; respite care |
73–89%
| |||
Complementary therapists | 50% | 63% |
75%
| |
E-healtha
|
71%
| |||
2. Intervention costs | ||||
Administration; planning; implementation; supervision and monitoring |
67–80%
| |||
Development | 50% | 40% |
25% | |
Training | 60% | 60% |
100%
| |
Donated items (such as drugs, vaccines, supplies or equipment) | 60% |
71%
| ||
3. Patient and family costs | ||||
Patient-out-of-pocket expenses; patient time; travel costs; informal caregivers time (not fully compensated); informal caregivers time (fully compensated) |
76–94%
| |||
4. Lost productivity costs | ||||
Absenteeism; reduced productivity while at work (i.e. presenteeism) |
83–100%
| |||
Absenteeism from unpaid labour such as household activities, education, voluntary work | 44% |
27%
| ||
5. Future costs | ||||
Future healthcare costs incurred for disorders related to the intervention |
100%
| |||
Future healthcare costs incurred for disorders unrelated to the intervention | 53% | 50% |
100%
| |
Future non-healthcare expenditures (e.g. food, clothes, and housing) | 39% |
19%
| ||
VAT | ||||
Including VAT | 50% |
79%
|
Inclusion | Panel ranking | Most suitable | Most suitable | |
---|---|---|---|---|
Measurement of resource use | ||||
1. Healthcare services | ||||
Patient-level data: patient-based reports (resource use questionnaires and interviews, self-reported activity logs, cost diaries etc.) |
94%
|
1
| 50% |
75%
|
Patient-level data: observer/care provider-based reports (medical records, time and motion records, etc.) |
94%
| 3 | ||
Secondary-level data: local registers |
89%
| 6 | ||
Secondary-level data: national registers |
89%
| 4 | ||
Secondary-level data: national insurance fund utilization databases |
89%
|
2
| 50% |
25%
|
Secondary-level data: hospital information system |
89%
| 5 | ||
Estimates based on clinical practice guidelines |
78%
| 7 | ||
Expert opinion |
67%
| 8 | ||
2. Travel costs | ||||
Standard distances |
100%
|
1
|
100%
| |
Patient-reported distances | 65% |
2
| ||
Public transport should be valued by market prices and travelling by car using standard costs per kilometre/milea
| 86% | |||
3. Absenteeism from paid labour | ||||
Company registered data for sick leave |
81%
|
1
| 50% | 0% |
Self-reported sick leave due to the disease under study |
81%
|
2
| 50% |
100%
|
Self-reported sick leave due to general health | 63% | 4 | – | – |
Use of published estimates of previous studies |
71%
| 3 | – | – |
4. Presenteeism | ||||
Self-reported perceived performance during working hours due to the disease under study |
80%
|
2
|
27%
| – |
Self-reported perceived performance during working hours due to general health | 47% | 4 | ||
Self-reported comparative performance (how an employee’s performance differs from that of others or from his/her usual performance) | 40% | 3 | ||
Self-reported rating of both the quantity and quality of the work (quantity and quality method) |
79%
|
1
|
73%
| |
Self-reported unproductive time while at work |
67%
| 5 | ||
Valuation of resource use | ||||
1. Unit costs to value healthcare utilization | ||||
Average of available European unit costs |
29%
| |||
Lowest available of European unit costs |
12%
| |||
Highest available of European unit costs |
12%
| |||
Use of costs from 1 or more other countries and their conversion with use of power purchasing parities | 47% |
2
| ||
Country-specific unit costs |
100%
|
1
|
100%
| |
2. Healthcare services | ||||
Standard/unit costs |
100%
|
1
|
23%
| |
Market prices | 60% | 4 | ||
Tariffs | 46% | 6 | ||
Bottom-up/micro costing estimation of unit costs |
87%
|
3
| ||
Top-down/macro costing estimation of unit costs | 40% | 7 | ||
Diagnosis-related groups (payment weight based on the average resources used to treat patients in that diagnosis-related group) |
75%
| 5 | ||
Country-specific standardized valuesa
| – |
2
|
77%
| |
3. Supportive care/social care services | ||||
Standard/unit costs |
94%
|
1
|
23%
| |
Market prices |
69%
| 4 | ||
Tariffs | 40% | 5 | ||
Bottom-up cost price calculation |
81%
|
3
| ||
Top-down cost price calculation | 44% | 6 | ||
Country-specific standardized valuesa
|
2
|
77%
| ||
4. Patient out-of-pocket expenses | ||||
Patient-reported costs |
75%
|
1
|
75%
| |
Standard/unit costs |
81%
|
2
|
25%
| |
Market prices |
75%
| 3 | ||
Tariffs | 47% | 5 | ||
Bottom-up cost price calculation |
69%
| 4 | ||
Top-down cost price calculation | 44% | 6 | ||
5. Patient time/informal care | ||||
National average wages of unskilled labour | 59% | 3 | ||
National average wages of unskilled labour sex/age specific | 44% |
2
| 46% | 50% |
National minimum wages of the population as a whole |
25%
| |||
National minimum wages of the population as a whole sex/age specific |
31%
| |||
Specific (self-reported) wages | 35% | 4 | ||
Shadow prices (opportunity costs when the actual price is not known or difficult to calculate) |
73%
|
1
| 54% | 50% |
National average wages to reflect the value of leisure timea
| 5 | |||
6. Travel costs | ||||
Patient-reported costs | 61% |
2
| ||
Standard/unit costs |
94%
|
1
| ||
Market prices |
76%
| 3 | ||
7. Absenteeism (1) approach | ||||
Friction cost approach |
82%
|
1
|
73%
| |
Human capital approach | 59% |
2
|
27%
| |
8. Absenteeism (2) proxy measure | ||||
National average wages of unskilled labour |
31%
| |||
National average wages of unskilled labour sex/age specific |
31%
| |||
National average wages of the population as a whole |
65%
|
2
|
7%
| |
National average wages of the population as a whole sex/age specific |
71%
|
1
|
93%
| |
Specific (self-reported) wages |
63%
| 3 | ||
National minimum wages |
19%
| |||
9. Presenteeism | ||||
National average wages of unskilled labour |
27%
| |||
National average wages of unskilled labour sex/age specific |
27%
| |||
National average wages of the population as a whole | 60% |
2
|
8%
| |
National average wages of the population as a whole sex/age specific |
67%
|
1
|
92%
| |
Specific (self-reported) wages | 53% | 3 | ||
National minimum wages |
13%
| |||
10. Unpaid labour | ||||
National average wages of unskilled labour | 47% |
2
| ||
National average wages of unskilled labour sex/age specific | 47% | 3 | ||
National average wages of the population as a whole |
29%
| |||
National average wages of the population as a whole sex/age specific | 41% | 5 | ||
Specific (self-reported) wages | 53% | 4 | ||
Shadow prices (opportunity costs when the actual price is not known or difficult to calculate) |
73%
|
1
| ||
National minimum wages |
29%
|
– | Inclusion | Most suitable | Inclusion | |
---|---|---|---|---|
Discounting | ||||
European average discount rate | 54% | |||
Lowest European discount rate |
8%
| |||
Highest European discount rate |
8%
| |||
Country-specific discount rate |
80%
| |||
Study design | ||||
Model based (outcomes of an average patient are assessed) |
86%
| |||
Trial based (outcomes of an individual patient are assessed) |
86%
|
Recommendations
Component/topic | Recommendation | Arguments |
---|---|---|
Perspective | Societal perspective | It is likely that relevant costs are missed when a narrower perspective is used, because often sectors other than healthcare may incur costs or costs savings as a result of the intervention |
Identification of costs | Depending on the nature of the disorder, intervention and treatment under study. Costs of healthcare services and social care services, intervention costs, patient and family costs, lost productivity costs, and future healthcare costs (See Appendix 1 in the electronic supplementary material for more details) | Relevant cost categories |
Measurement of resource use | ||
Healthcare services | Patient-level data | Patient self-report methods are preferred over national databases because not all services are covered in these databases |
Patient-out-of-pocket expenses | Patient-reported expenses | Most reliable source to obtain these data |
Patient time costs | Patient-reported time | Most reliable source to obtain these data |
Travel costs | Standard distances | To avoid random differences between groups |
Informal care costs | Self-report of informal caregivers | Most reliable source to obtain these data |
Absenteeism from paid labour | Self-reported sick leave due to the disease under study | Can be more accurately attributed to the disorder under study and may more easily be available than reports from many individual employers |
Presenteeism | Obtain ratings of both the quantity and the quality of work performed in a standardized way | Standardized method |
Valuation of resource use | ||
Healthcare services | Country-specific standard/unit costs | Representative of the situation in the country under study |
Supportive care/social care services | Country-specific standard/unit costs | Representative of the situation in the country under study |
Patient out-of- pocket expenses | Patient-reported costs | Large variations between patients |
Patient time/informal care | National average wages of unskilled labour sex/age specific | |
Travel costs | Use of standard distances between the patient’s home and the healthcare provider Travel by public transport: tariffs Travel by car: standard costs per kilometre/mile | Tariffs are closely related to market prices, and are expected to resemble opportunity costs adequately Standard costs per kilometre/mile to avoid random differences between groups |
Absenteeism | Friction cost approach. National sex/age-specific average wages of the population as a whole | Human capital approach, an alternative, is expected to lead to overestimation of productivity losses |
Presenteeism | National sex/age-specific average wages of the population as a whole | |
VAT | Include VAT | Part of the true costs of healthcare |
Discounting | Country-specific discounting rates Sensitivity analysis: lowest and highest European discounting rates | Representative of the situation in the country under study |
Study design | Both a model-based approach and a trial-based approach are appropriate depending on the research question under study |