Publications
310 results found
Mannion R, Goddard M, Smith PC, 2019, On the limitations and pitfalls o f performance measurement systems in health care, Quality in Health Care: Strategic Issues in Health Care Management, Pages: 158-169, ISBN: 9781138724198
Formal performance measurement systems are increasingly a prominent feature of health systems concerned with raising quality and containing costs. This chapter describes the rise of performance indicators in the NHS. It then examines the role of ‘hard’ and ‘soft information in assessing hospital performance and explores the possible unintended and adverse consequences associated with the use of performance indicators. A clear and dominant theme arising from our study is that hard information, used in isolation, is seen as an inadequate and sometimes misleading indicator of Trust performance. Regional office staff reported that they examined closely the hard financial information provided by individual Trusts in order to assess whether they are meeting their targets. Informal social networks should be valued in their own right as a form of ‘social capital’ which has been shown to be a vital lubricant of complex economic relationships. The chapter advocates a cautious approach to the use of performance indicators in the NHS.
Hauck K, Morton A, Chalkidou K, et al., 2019, How can we evaluate the cost-effectiveness of health system strengthening? A typology and illustrations, Social Science and Medicine, Vol: 220, Pages: 141-149, ISSN: 0277-9536
Health interventions often depend on a complex system of human and capital infrastructure that is shared with other interventions, in the form of service delivery platforms, such as healthcare facilities, hospitals, or community services. Most forms of health system strengthening seek to improve the efficiency or effectiveness of such delivery platforms. This paper presents a typology of ways in which health system strengthening can improve the economic efficiency of health services. Three types of health system strengthening are identified and modelled: (1) investment in the efficiency of an existing shared platform that generates positive benefits across a range of existing interventions; (2) relaxing a capacity constraint of an existing shared platform that inhibits the optimization of existing interventions; (3) providing an entirely new shared platform that supports a number of existing or new interventions. Theoretical models are illustrated with examples, and illustrate the importance of considering the portfolio of interventions using a platform, and not just piecemeal individual analysis of those interventions. They show how it is possible to extend principles of conventional cost-effectiveness analysis to identify an optimal balance between investing in health system strengthening and expenditure on specific interventions. The models developed in this paper provide a conceptual framework for evaluating the cost-effectiveness of investments in strengthening healthcare systems and, more broadly, shed light on the role that platforms play in promoting the cost-effectiveness of different interventions.
Cecchini M, Smith P, 2018, Assessing the dose-response relationship between number of office-based visits and hospitalizations for patients with type II diabetes using generalized propensity score matching, PLoS ONE, Vol: 13, ISSN: 1932-6203
BackgroundWhether inpatient services can be successfully substituted by office-based services has been debated for many decades, but the evidence is still inconclusive. This study aims to investigate the effect of office-based care on use and the expenditure for other healthcare services in patients with type II diabetes (T2D).MethodsA generalized propensity score matching approach was used on pooled Medical Expenditure Panel Survey (MEPS) data for 2000–2012 to explore a dose-response effect. Patients were matched by using a comprehensive set of variables selected following a standard model on access to care.FindingsOffice-based care (up to 5 visits/year) acts as a substitute for other healthcare services and is associated with lower use and expenditure for inpatient, outpatient and emergency care. After five visits, office-based care becomes a complement to other services and is associated with increases in expenditure for T2D. Above 20 to 26 visits per year, depending on the healthcare service under consideration, the marginal effect of an additional office-based visit becomes non-statistically significant.ConclusionsOffice-based visits appear to be an effective instrument to reduce use of inpatient care and other services, including outpatient and emergency-care, in patients with T2D without any increase in total healthcare expenditure.
Chi Y-L, Gad M, Bauhoff S, et al., 2018, Mind the costs, too: towards better cost-effectiveness analyses of PBF programmes, BMJ Global Health, Vol: 3, Pages: e000994-e000994, ISSN: 2059-7908
Laudicella M, Martin S, Donni PL, et al., 2018, Do Reduced Hospital Mortality Rates Lead to Increased Utilization of Inpatient Emergency Care? A Population-Based Cohort Study, HEALTH SERVICES RESEARCH, Vol: 53, Pages: 2324-2345, ISSN: 0017-9124
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- Citations: 6
Laudicella M, Walsh B, Burns E, et al., 2018, What is the impact of rerouting a cancer diagnosis from emergency presentation to GP referral on resource use and survival? Evidence from a population-based study, BMC CANCER, Vol: 18, ISSN: 1471-2407
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- Citations: 7
Smith P, 2018, Advancing Universal Health Coverage: What Developing Countries Can Learn from the English Experience?, Washington DC, Publisher: World Bank
The United Kingdom has in many respects the archetypal centrally planned, publicly financed health care system in the form of National Health Service (NHS), established in 1948 in a time of great austerity after Second World War. It is largely funded from general taxation, and provides wide coverage of most mainstream health services, with little recourse to user charges. It offers strong financial protection against the costs of health care and enjoys high public approval ratings. Its principal shortcomings have been weaknesses in service quality, often in the form of long waiting times, and sometimes relating to clinical quality. This paper concentrates on the experience in England, which accounts for 84 percent of the UK population of 64.6 million. The system of health service coverage adopted in the NHS is very simple. There is no explicit requirement to enroll in an insurance plan. Instead, citizens must register with a general practitioner (GP) of their choice. GPs act as a gatekeeper to nonemergency secondary care and prescription medicines and devices. Apart from small fees for some prescription medicines (from which many citizens are exempt), patients are not directly charged for access to NHS care. Throughout most of its history, the NHS model of governance has entailed strong central control by the national ministry, with local administration responsible for detailed local planning and purchasing. The forms of local administration have varied. In the early years of the NHS they were primarily local NHS hospitals, with separate committees for oversight of primary care. Since 1974, local health authorities have assumed the role of oversight of local services, currently covering, on average, populations of 250,000.
Pires Barrenho EA, Miraldo M, Smith PC, 2017, Does global drug innovation correspond to burden of disease? The neglected diseases in developed and developing countries., ISSN: 1744-6783
While commonly argued that there is a mismatch between drug innovation and disease burden, there is little evidence on the magnitude and direction of such disparities. In this paper we measure inequality in innovation, by comparing R&D activity with population health and GDP data across 493 therapeutic indications to globally measure: (i) drug innovation, (ii) disease burden, and (iii) market size.We use concentration curves and indices to assess inequality at two levels: (i) broad disease groups; and (ii) disease subcategories for both 1990 and 2010.For some of top burden disease subcategories (i.e. cardiovascular and circulatory diseases, neoplasms, and musculoskeletal disorders) innovation is disproportionately concentrated in diseases with high burden and larger market size, whereas for others (i.e. mental and behavioural disorders, neonatal disorders, and neglected tropical diseases) innovation is disproportionately concentrated in low burden diseases.These inequalities persisted over time, suggesting inertia in pharmaceutical R&D in tackling the global health challenges.Our results highlight the priority disease areas for R&D investment in both developed and developing countries.
Thomas RA, Burger R, Harper A, et al., 2017, Differences in health-related quality of life between HIV-positive and HIV-negative people in Zambia and South Africa: a cross-sectional baseline survey of the HPTN 071 (PopART) trial, The Lancet Global Health, Vol: 5, Pages: e1133-e1141, ISSN: 2214-109X
BackgroundThe life expectancy of HIV-positive individuals receiving antiretroviral therapy (ART) is approaching that of HIV-negative people. However, little is known about how these populations compare in terms of health-related quality of life (HRQoL). We aimed to compare HRQoL between HIV-positive and HIV-negative people in Zambia and South Africa.MethodsAs part of the HPTN 071 (PopART) study, data from adults aged 18–44 years were gathered between Nov 28, 2013, and March 31, 2015, in large cross-sectional surveys of random samples of the general population in 21 communities in Zambia and South Africa. HRQoL data were collected with a standardised generic measure of health across five domains. We used β-distributed multivariable models to analyse differences in HRQoL scores between HIV-negative and HIV-positive individuals who were unaware of their status; aware, but not in HIV care; in HIV care, but who had not initiated ART; on ART for less than 5 years; and on ART for 5 years or more. We included controls for sociodemographic variables, herpes simplex virus type-2 status, and recreational drug use.FindingsWe obtained data for 19 750 respondents in Zambia and 18 941 respondents in South Africa. Laboratory-confirmed HIV status was available for 19 330 respondents in Zambia and 18 004 respondents in South Africa; 4128 (21%) of these 19 330 respondents in Zambia and 4012 (22%) of 18 004 respondents in South Africa had laboratory-confirmed HIV. We obtained complete HRQoL information for 19 637 respondents in Zambia and 18 429 respondents in South Africa. HRQoL scores did not differ significantly between individuals who had initiated ART more than 5 years previously and HIV-negative individuals, neither in Zambia (change in mean score −0·002, 95% CI −0·01 to 0·001; p=0·219) nor in South Africa (0·000, −0·002 to 0·003; p=0·939). However, scores did differ between HIV-positive individu
Miraldo M, Barrenho E, Smith P, 2017, Does global drug innovation correspond to burden of disease? The neglected diseases in developed and developing countries, Publisher: Wiley
While it is commonly argued that there is a mismatch between drug innovation and disease burden, there is little evidence on the magnitude and direction of such disparities. In this paper we measure inequality in innovation, by comparing R&D activity with population health and GDP data across 493 therapeutic indications to globally measure: (i) drug innovation, (ii) disease burden, and (iii) market size. We use concentration curves and indices to assess inequality at two levels: (i) broad disease groups; and (ii) disease subcategories for both 1990 and 2010. For some of top burden disease subcategories (i.e. cardiovascular and circulatory diseases, neoplasms, and musculoskeletal disorders) innovation is disproportionately concentrated in diseases with high burden and larger market size, whereas for others (i.e. mental and behavioural disorders, neonatal disorders, and neglected tropical diseases) innovation is disproportionately concentrated in low burden diseases. These inequalities persisted over time, suggesting inertia in pharmaceutical R&D in tackling the global health challenges. Our results confirm quantitatively assertions about the mismatch between disease burden and pharmaceutical innovation in both developed and developing countries and highlight the disease areas for which morbidity and mortality remain unaddressed.
Cylus J, Papanicolas I, Smith PC, 2017, Using Data Envelopment Analysis to Address the Challenges of Comparing Health System Efficiency, GLOBAL POLICY, Vol: 8, Pages: 60-68, ISSN: 1758-5880
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- Citations: 18
Hauck KD, Wang S, Vincent C, et al., 2017, Healthy Life-Years Lost and Excess Bed-Days Due to 6 Patient Safety Incidents Empirical Evidence From English Hospitals, Medical Care, Vol: 55, Pages: 125-130, ISSN: 0025-7079
Background: There is little satisfactory evidence on the harm of safety incidents to patients, in terms of lost potential health and life-years.Objective: To estimate the healthy life-years (HLYs) lost due to 6 incidents in English hospitals between the years 2005/2006 and 2009/2010, to compare burden across incidents, and estimate excess bed-days.Research Design: The study used cross-sectional analysis of the medical records of all inpatients treated in 273 English hospitals. Patients with 6 types of preventable incidents were identified. Total attributable loss of HLYs was estimated through propensity score matching by considering the hypothetical remaining length and quality of life had the incident not occurred.Results: The 6 incidents resulted in an annual loss of 68 HLYs and 934 excess bed-days per 100,000 population. Preventable pressure ulcers caused the loss of 26 HLYs and 555 excess bed-days annually. Deaths in low-mortality procedures resulted in 25 lost life-years and 42 bed-days. Deep-vein thrombosis/pulmonary embolisms cost 12 HLYs, and 240 bed-days. Postoperative sepsis, hip fractures, and central-line infections cost <6 HLYs and 100 bed-days each.Discussion: The burden caused by the 6 incidents is roughly comparable with the UK burden of Multiple Sclerosis (80 DALYs per 100,000), HIV/AIDS and Tuberculosis (63 DALYs), and Cervical Cancer (58 DALYs). There were marked differences in the harm caused by the incidents, despite the public attention all of them receive. Decision makers can use the results to prioritize resources into further research and effective interventions.
Glassman A, Giedion U, Smith PC, 2017, What's In, What's Out: Designing Benefits for Universal Health Coverage, ISBN: 9781933286891
Vaccinate children against deadly pneumococcal disease, or pay for cardiac patients to undergo lifesaving surgery? Cover the costs of dialysis for kidney patients, or channel the money toward preventing the conditions that lead to renal failure in the first place? Policymakers dealing with the realities of limited health care budgets face tough decisions like these regularly. And for many individuals, their personal health care choices are equally stark: paying for medical treatment could push them into poverty. Many low- and middle-income countries now aspire to universal health coverage, where governments ensure that all people have access to the quality health services they need without risk of impoverishment. But for universal health coverage to become reality, the health services offered must be consistent with the funds available-and this implies tough everyday choices for policymakers that could be the difference between life and death for those affected by any given condition or disease. The situation is particularly acute in low- and middle income countries where public spending on health is on the rise but still extremely low, and where demand for expanded services is growing rapidly. What's In, What's Out: Designing Benefits for Universal Health Coverage argues that the creation of an explicit health benefits plan-a defined list of services that are and are not available-is an essential element in creating a sustainable system of universal health coverage. With contributions from leading health economists and policy experts, the book considers the many dimensions of governance, institutions, methods, political economy, and ethics that are needed to decide what's in and what's out in a way that is fair, evidence-based, and sustainable over time.
Smith P, 2017, Introduction: Putting pen to paper: Methods to select a bene ts plan that works, What's In, What's Out: Designing Benefits for Universal Health Coverage, Pages: 109-114, ISBN: 9781933286891
Glassman A, Giedion U, Smith PC, 2017, Introduction: The health benefits package: Bringing universal health coverage from Rhetoric to reality, Pages: 1-18, ISBN: 9781933286891
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- Citations: 37
Smith PC, Chalkidou K, 2017, Should Countries Set an Explicit Health Benefits Package? The Case of the English National Health Service, VALUE IN HEALTH, Vol: 20, Pages: 60-66, ISSN: 1098-3015
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- Citations: 4
Hauck KD, Thomas R, Smith P, 2017, Beyond Cost Effectiveness: Health Systems Constraints to Delivery of a Health Benefits Package, What's in What's out: Designing Benefits for Universal Health Coverage, Editors: Glassman, Giedion, Smith, Publisher: Center for Global Development, Pages: 201-213
Cylus J, Papanicolas I, Smith PC, 2016, Health system efficiency: how to make measurement matter for policy and management, Copenhagen, Publisher: World Health Organization, ISBN: 9789289050418
Efficiency is one of the central preoccupations of health policy-makers and managers, and justifiably so. Inefficient care can lead to unnecessarily poor outcomes for patients, either in terms of their health, or in their experience of the health system. What is more, inefficiency anywhere in the system is likely to deny health improvement to patients who might have been treated if resources had been used better. Improving efficiency is therefore a compelling policy goal, especially in systems facing serious resource constraints.The desire for greater efficiency motivates a great deal of decision-making, but the routine use of efficiency metrics to guide decisions is severely lacking.To improve efficiency in the health system we must first be able to measure it and must therefore ensure that our metrics are relevant and useful for policy-makers and managers. In this book the authors explore the state of the art on efficiency measurement in health systems and international experts offer insights into the pitfalls and potential associated with various measurement techniques.The authors show that1. The core idea of efficiency is easy to understand in principle - maximizing valued outputs relative to inputs, but is often difficult to make operational in real-life situations2. There have been numerous advances in data collection and availability, as well as innovative methodological approaches that give valuable insights into how efficiently health care is delivered3. Our simple analytical framework can facilitate the development and interpretation of efficiency indicatorsThe authors use examples from Europe and around the world to explore how policy-makers and managers have used efficiency measurement to support their work in the past, and suggest ways they can make better use of efficiency measurement in the future.
Hofmarcher MM, Simon J, Peric N, et al., 2016, Priority setting methods in health information, Publisher: OXFORD UNIV PRESS, Pages: 202-202, ISSN: 1101-1262
Hofmarcher MM, Simon J, Peric N, et al., 2016, Indicators for structured monitoring of health system performance, Publisher: OXFORD UNIV PRESS, Pages: 149-149, ISSN: 1101-1262
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- Citations: 1
Hauck K, Martin S, Smith PC, 2016, Priorities for action on the social determinants of health: Empirical evidence on the strongest associations with life expectancy in 54 low-income countries, 1990-2012, SOCIAL SCIENCE & MEDICINE, Vol: 167, Pages: 88-98, ISSN: 0277-9536
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- Citations: 23
Morton A, Thomas R, Smith PC, 2016, Decision rules for allocation of finances to health systems strengthening, JOURNAL OF HEALTH ECONOMICS, Vol: 49, Pages: 97-108, ISSN: 0167-6296
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- Citations: 16
Driffield T, Smith PC, 2016, A real options approach to watchful waiting: Theory and an illustration, MEDICAL DECISION MAKING, Vol: 27, Pages: 178-188, ISSN: 0272-989X
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- Citations: 24
Laudicella M, Walsh B, Burns E, et al., 2016, Cost of care for cancer patients in England: evidence from population-based patient-level data, British Journal of Cancer, Vol: 114, Pages: 1286-1292, ISSN: 1532-1827
background: Health systems are facing the challenge of providing care to an increasing population of patients with cancer. However, evidence on costs is limited due to the lack of large longitudinal databases.methods: We matched cost of care data to population-based, patient-level data on cancer patients in England. We conducted a retrospective cohort study including all patients age 18 and over with a diagnosis of colorectal (275 985 patients), breast (359 771), prostate (286 426) and lung cancer (283 940) in England between 2001 and 2010. Incidence costs, prevalence costs, and phase of care costs were estimated separately for patients age 18–64 and greater than or equal to65. Costs of care were compared by patients staging, before and after diagnosis, and with a comparison population without cancer.results: Incidence costs in the first year of diagnosis are noticeably higher in patients age 18–64 than age greater than or equal to65 across all examined cancers. A lower stage diagnosis is associated with larger cost savings for colorectal and breast cancer in both age groups. The additional costs of care because of the main four cancers amounts to £1.5 billion in 2010, namely 3.0% of the total cost of hospital care.conclusions: Population-based, patient-level data can be used to provide new evidence on the cost of cancer in England. Early diagnosis and cancer prevention have scope for achieving large cost savings for the health system.
Smith PC, 2016, Health system design and performance: what can other countries learn from the Nordic experience?, Nordic Journal of Health Economics, Vol: 4, Pages: 84-91
Nordic health systems are amongst the strongest in the developed world. This paper discusses their strengths and lessons for other health systems under five headings: sources of finance, provider payment, organization, regulation, and persuasion. It attributes the good performance of Nordic systems to good governance of the institutions of health care, the behaviour and attitude of citizens, and high levels of cooperation in Nordic countries. The paper notes that there is only modest use of competition or payment incentives in the provider market. It suggests that improving information on the performance of providers and other institutions is an important priority for the future.
Smith PC, Yip W, 2016, The design and financing of health systems: an economic perspective, Oxford Review of Economic Policy, Vol: 32, Pages: 21-40, ISSN: 1460-2121
There has been much rhetoric in global health about the need to consider the health sector as a ‘system’, defined by the World Health Organization as all the activities whose primary purpose is to improve health. The need to adopt a system-wide perspective arises from the complexity of the processes for delivering effective health services, and the important interdependencies between elements of the health system. However, there have hitherto been very few contributions from an economic perspective that explicitly address these issues. This paper argues that an economic paradigm of constrained optimization adapted to the systemic nature of the health sector could provide an analytical and practical approach to policy-makers in assessing their health systems and deriving solutions. The paper therefore discusses the objectives of the health system, the factors that constrain optimization, and the decision variables, in the form of policy levers. Economic approaches that could contribute to the associated research agenda include institutional economics, micro-simulation, and option pricing theory. The important feature of such methods is that they offer the possibility of developing tractable methods for addressing the complexity and interconnectedness of the health system.
Glassman A, Giedion U, Sakuma Y, et al., 2016, Defining a Health Benefits Package: What Are the Necessary Processes?, Health Systems and Reform, Vol: 2, Pages: 31-50, ISSN: 2328-8604
There is immense interest worldwide in the notion of universal health coverage (UHC). A major policy focus in moving toward UHC has been on the key policy question: what services should be made available and under what conditions? In this article we are concerned with how a feasible set of UHC services can be explicitly defined to create what is commonly known as a “health benefits package” (HBP), a set of services that can be feasibly financed and provided under the actual circumstances in which a given country finds itself. We explain why an explicit statement of the HBP is important and then describe a framework that includes ten core elements that are indispensable if a coherent and sustainable process for setting the HBP is to be established.
Hauck KD, Thomas R, Smith PC, 2016, Departures from cost-effectiveness recommendations: The impact of health system constraints on priority setting, Health Systems & Reform, Vol: 2, Pages: 61-70, ISSN: 2328-8604
The methods and application of cost-effectiveness analysis have reached an advanced stage of development. Many decision makers consider cost-effectiveness analysis to be a valid and feasible approach towards setting health priorities, and it has been extensively applied in evaluating interventions and developing evidence based clinical guidelines. However, the recommendations arising from cost-effectiveness analysis are often not implemented as intended. A fundamental reason for the failure to implement is that CEA assumes a single constraint, in the form of the budget constraint, whilst in reality decision-makers may be faced with numerous other constraints. The objective of this paper is to develop a typology of constraints that may act as barriers to implementation of cost-effectiveness recommendations. Six categories of constraints are considered: the design of the health system; costs of implementing change; system interactions between interventions; uncertainty in estimates of costs and benefits; weak governance; and political constraints. Where possible -and if applicable- for each class of constraint, the paper discusses ways in which these constraints can be taken into account by a decision maker wishing to pursue the principles of cost-effectiveness.
Smith PC, 2016, INTERNATIONAL EXPERIENCE WITH HEALTH SYSTEM PERFORMANCE ASSESSMENT, MANAGING A CANADIAN HEALTHCARE STRATEGY, Editors: Carson, RichardNossal, Publisher: MCGILL-QUEENS UNIV PR, Pages: 81-100
Savedoff W, Smith PC, 2015, Measuring governance for accountability, management and research, Strengthening Heath Governance Better Policies, Stronger Performance, Editors: Greer, Wismar, Figueras, ISBN: 9780335261345
This book is designed for health policy makers and all those working or studying in the areas of public health, health research or health economics.
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