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Outcome Measurements in Economic Evaluations of Drug Misuse Interventions

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Outcome Measurements in Economic Evaluations of Drug Misuse Interventions Outcome Measurements in Economic Evaluations of Drug Misuse Interventions Ching-Wen Chang A thesis submitted as fulfilment for the degree of Doctor of Philosophy Department of Health Sciences University of York September 2010 To my grandfather 2 Abstract This thesis critically evaluates the measurement of outcomes in economic evaluations of drug misuse interventions. Three different aspects of measuring outcomes are examined: one focusing on non-monetary outcomes at the individual patient level; one focusing on monetary outcomes within studies using individual patient level data; and one focusing on long-term outcomes, both monetary and non-monetary. The many limitations of measuring these outcomes in existing economic evaluations of drug misuse interventions are exposed and the problems with conducting such studies are identified. The importance of this thesis is thus in providing an overview and methodological critique of the extant economic evaluations of drug misuse interventions. In addition a decision analytic model for a drug testing in schools programme is developed to illustrate how the limitations highlighted in the methodological critique might be addressed by future research. The findings of the thesis reveal the problems with using EQ-5D as a generic outcome measure for economic evaluations of drug misuse interventions, as is recommended by NICE in the UK. The nature of drug misuse problems requires that a wide range of different measures, including drug misuse specific measures, must be taken into account when evaluating drug misuse interventions. Similarly, the limitations with existing studies that attempt to estimate the monetary outcome of drug misuse interventions are exposed, as many studies fail to take into account all of the costs that will determine the monetary impact of an intervention for society. The thesis stresses the complexity of drug misuse and the need to measure the long-term outcomes of interventions, which may be best achieved by developing drug misuse modelling studies. However, these models are then revealed to be themselves limited, in part due to the lack of real-world data available to set their parameters. 3 List of contents Abstract 3 List of contents 4 List of tables 8 List of figures 10 Acknowledgement 12 Author’s declaration 12 Chapter 1 Introduction 13 1.1 Outcomes of drug misuse interventions 13 1.2 Purpose and objectives of the research 17 1.3 Structure of thesis 17 1.3.1 Non-monetary outcome measures 18 1.3.2 Dimensions of the monetary outcome 18 1.3.3 Modelling studies 19 Chapter 2 Using EQ-5D as an outcome measure in the economic evaluation of drug misuse interventions: a systematic review 21 2.1 Background 21 2.2 Objectives 22 2.3 Methods 22 2.3.1 Inclusion Criteria for this review 22 2.3.2 Data sources and search strategy 23 2.3.3 Analysis of the extracted data 23 2.4 Results 26 2.4.1 Description of included studies and outcome measures included 26 2.4.2 Outcome comparison of the included studies 32 2.5 Conclusions and Discussion 46 Chapter 3 Content comparison of EQ-5D and other outcome measures 49 3.1 Background 49 4 3.2 Objectives 50 3.3 Methods 51 3.3.1 Content comparison using ICF concepts 51 3.3.2 Correlation between questions covered by the same concepts 52 3.4 Results 53 3.4.1 Content comparison results 53 3.4.2 Results of correlation between questions in overlapping concepts 59 3.5 Conclusions and Discussion 64 Chapter 4 Systematic Review for drug misuse intervention on the individual patient level of the monetary outcome 67 4.1 Background 67 4.2 Objectives 68 4.3 Methods 69 4.3.1 Inclusion Criteria for this review 69 4.3.2 Data sources and search strategy 70 4.4 Results 71 4.4.1 Description of included studies and dimensions of monetary outcome included 71 4.4.2 Estimation methods for different dimensions of monetary outcome 84 4.5 Conclusions and Discussion 87 Chapter 5 Problems of resource use estimation in drug misuse interventions 89 5.1 Background 89 5.2 Objectives 90 5.3 Methods 90 5.3.1 Problems of using the mean average in highly skewed data 90 5.3.2 Cluster analysis 93 5.3.3 Factors related to the social costs within the subgroups 95 5.3.4 Factors related to the social costs changes 95 5.4 Results 96 5.4.1 Results at baseline 96 5.4.2 Results at the 6 month follow-up period 101 5 5.4.3 Results of the clustering for the changes 104 5.5 Conclusions and Discussion 108 Chapter 6 Systematic Review for decision analytic models in the economic evaluation of drug misuse interventions 110 6.1 Background 110 6.2 Objectives 111 6.3 Methods 112 6.3.1 Inclusion Criteria for this review 112 6.3.2 Data sources and search strategy 113 6.3.3 Quality assessment of the included models 114 6.4 Results 115 6.4.1 Quality assessment of the included models: dimensions related to the model structure 129 6.5 Conclusions and Discussion 141 Chapter 7 Drug testing in schools: illustration of outcomes in modelling studies 145 7.1 Background and objectives 145 7.2 Structure of the model 147 7.2.1 Simulated random drug testing regime 148 7.2.2 Control group model: no drug testing in schools 150 7.2.3 Outcome domains and end states 151 7.2.4 Time period and scope 151 7.3 Building the random drug testing in schools model 152 7.3.1 No drug testing model 152 7.3.2 Random drug testing in schools model 154 7.4 Parameters of the model 159 7.4.1 Estimating the costs of drug testing 159 7.4.2 Parents’ time and travel cost 161 7.4.3 Cost of truancy and exclusion 163 7.5 Costs of different outcomes 164 7.5.1 Drug domain outcome: cost and transition of different groups 164 6 7.5.2 Education domain outcome 165 7.5.3 The 6 final outcomes 166 7.6 Probability Parameters 167 7.6.1 Parameters: description 167 7.6.2 Parameters: deterrent effect 171 7.7 Results 172 7.7.1 Comparing cost and outcomes of the two scenarios 172 7.7.2 Sensitivity analysis 177 7.8 Conclusion and discussion 186 Chapter 8 Conclusion 190 8.1 Summary of findings 190 8.2 Limitations of research and implications for future research 196 8.3 Conclusions, discussion and the implications for policy makers 199 Appendices 203 References 269 7 List of tables Table 2.4.1 Description of included studies 28 Table 2.4.2 List of outcome measure categories in the included studies, using dimensions suggested by Rehm and colleagues (2000) 31 Table 2.4.3 Result of included studies: HEPC 34 Table 2.4.4 Result of included studies: Carpentier et al, 2009 37 Table 2.4.5 Result of included studies: Dutch prescribed heroin trial 38 Table 2.4.6 Result of included studies: UKCBTMM 41 Table 2.4.7 Result of included studies: COBRA 45 Table 3.4.1 Kappa coefficient of inter-observer agreement 54 Table 3.4.2 Content comparison results 57 Table 3.4.3 Kappa coefficient of inter-observer agreement in RESULT 59 Table 3.4.4 Overlapping concepts covered by the outcome measures in RESULT 59 Table 3.4.5 Correlation between EQ-5D and CORE questions which cover the same concept (ICF b152 Emotional functions) at baseline and follow-up 62 Table 3.4.6 Correlation between EQ-5D, CORE and SCL questions which cover the same concept (ICF b280 Sensation of pain) at baseline and follow-up 62 Table 3.4.7 Correlation between EQ-5D, LDQ and SSQ questions which cover the same concepts (ICF d230 Carrying out daily routine, d760 Family relationships, d850 Remunerative employment, d920 Recreation and leisure) at baseline and follow-up 63 Table 4.4.1 Description of included studies 73 Table 4.4.2 List of dimensions of the monetary outcome in the included studies 82 Table 4.4.3 Estimation of societal resource use in the included studies 86 Table 5.3.1 Description of the sample at baseline 92 Table 5.3.2 Description of the sample at 6 month follow-up 92 Table 5.4.1 Patient characteristics within each cluster at baseline 99 Table 5.4.2 Mean costs within each cluster at baseline 100 Table 5.4.3 Patient characteristics within each cluster at follow-up 102 Table 5.4.4 Mean costs within each cluster at follow-up 103 Table 5.4.5 Patient characteristics within each cluster at 6 month change 106 Table 5.4.6 Mean costs within each cluster at 6 month change 107 8 Table 6.4.1 Description of the included studies 117 Table 7.4.1 Unit cost of drug test 161 Table 7.4.2 Cost of parents’ involvement 162 Table 7.4.3 Travel cost 163 Table 7.4.4 Cost of truancy and exclusion 164 Table 7.4.5 Cost of random drug testing in schools 164 Table 7.5.1 Drug domain outcome 165 Table 7.5.2 Education domain outcome 166 Table 7.5.3 Final outcomes 167 Table 7.6.1 Parameters 170 Table 7.6.2 Parameters: deterrent effect 172 Table 7.7.1 Total cost and outcomes of baseline model 175 Table 7.7.2 Total cost and outcomes of model with a deterrent effect of 24% 176 Table 7.7.3 Sensitivity analysis: deterrent effect on number of pupils 179 Table 7.7.4 Sensitivity analysis: deterrent effect on net benefits 179 Table 7.7.5 Sensitivity analysis: number of pupils applied different prevalence with no deterrent effect 180 Table 7.7.6 Sensitivity analysis: net benefits applied different prevalence with no deterrent effect 181 Table 7.7.7 Sensitivity analysis: number of pupils applied different prevalence with 24% deterrent effect 182 Table 7.7.8 Sensitivity analysis: net benefits applied different prevalence with 24% deterrent effect 183 Table 7.7.9 Sensitivity analysis: different self-exclusion rate with no deterrent effect 184 Table 7.7.10 Sensitivity analysis: different self-exclusion rate with 24% deterrent effect 185 9 List of figures Figure 2.4.1 Standard mean scores and SEM (Standard Error of mean=SD/√n) bar of outcome measures
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