Health Economics Economic Evaluation

Economic Evaluation Assignment: Using the Drummond Criteria critically appraise the following economic evaluation which was published in the Lancet on HIV/AIDS. (1500 words). (Article attached) Full reference for the article above is: Cambiano, V. et al. (2018) Cost-effectiveness of pre-exposure prophylaxis for HIV prevention in men who have sex with men in the UK: a modelling study and health economic evaluation. Lancet Infect Dis 18: 85–94. ** In your assignment you must use an academic tone, be evidence-based and supported by relevant literature, using Harvard referencing and give more than one reference. Reading Materials: Book: (Book attached) Title: Economic Analysis in Health Care. Author(s): Morris, S., Devlin, N., Parkin, D. Date of Publication: 2012. Publisher: John Wiley & Sons. Place of Publication: Chichester.

Running head: HEALTH ECONOMICS ECONOMIC EVALUATION
Health Economics Economic Evaluation
Name of the Student’
Name of the University
Author note

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Drummond's Criteria for assessing economic evaluations
1. Was a well-defined question posed in answerable form?
1.1. Did the study examine both costs and effects of the service(s) or programme(s)?
The study examines the effect through QALYs measures after implementing pre-exposure
prophylaxis for HIV prevention in men and examines the cost through financial cost benefit
analysis. However, the estimation of the cost lacks the in-depth consideration of resources
and future values as well as type of cost. However, the effectiveness has been assessed
through QALYs which was appropriate.
1.2. Did the study involve a comparison of alternatives?
The study used only PrEP program without involving any other comparative analysis with
other alternative promotional methods. In this study the only alternation that has been
considered is no PrEP program or the absence of PrEP program. For PrEP program as well as
no-PrEP program and QALYs were assessed along with overall cost estimation.
1.3. Was a viewpoint for the analysis stated and was the study placed in any particular
decision-making context?
The qualitative and quantitative viewpoint of effectiveness assessment was made to make
decision about implementing pre-exposure prophylaxis for HIV prevention in men. However,
the study lacks cost assessment. However, the purpose of this study was to analyse the cost
effectiveness of Pre-exposure prophylaxis (PrEP) for infections in MSM, and this context has
been considered throughout the entire decision making process.

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2. Was a comprehensive description of the competing alternatives given (i.e. can you
tell who did what to whom, where, and how often)?
2.1. Were there any important alternatives omitted?
The study used only PrEP program without involving any other comparative analysis. In this
study the only alternation that has been considered is no PrEP program or the absence of
PrEP program. For PrEP program as well as no-PrEP program and QALYs were assessed
along with overall cost estimation. Since, there was no other consideration for any particular
alternative method the effectiveness of the alternative methods was not done.
2.2. Was (should) a do-nothing alternative be considered?
In order to assess the effectiveness of the PrEP program an alternative method should be
considered as control. This alternative method could be other kind of promotional method
which is currently under used by other countries or which has been already used by the
government or private organisations of UK. Comparing with the previously done alternative
method would allow this research to collect more relevant cost-effectiveness data about the
alternative method to compare with the proposed PrEP program.
3. Was the effectiveness of the programme or services established?
3.1. Was this done through a randomised, controlled clinical trial? If so, did the trial
protocol reflect what would happen in regular practice?
The data collection method of this study does not depends on the randomized control trial.
For this study considered the data sources from the Public Health England provided
surveillance data as well as nationally representative survey on a large number of population
with Natsal-3 that have been done for the assessment and evaluation of HIV. Hence the study
is entirely based on secondary data collection, where resources were based on primary.

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3.2. Was effectiveness established through an overview of clinical studies?
The effectiveness of the pre-exposure prophylaxis for HIV prevention in men has been
assessed through calibrated a dynamic, the HIV Synthesis Model, individual-based stochastic
model while utilising different data sources where the studies were conducted on HIV among
MSM parget population in the UK.
3.3. Were observational data or assumptions used to establish effectiveness? If so, what
are the potential biases in results?
This study does not have any observational data. However, for economic assessment this
study uses assumption of potential cost of the implementing the pre-exposure prophylaxis for
HIV prevention program in UK. Therefore, for this reason the only bias is the selection bias
that implies that the effectiveness assessment is only reliable for UK population.
4. Were all the important and relevant costs and consequences for each alternative
identified?
4.1. Was the range wide enough for the research question at hand?
Though the ranges of the economic assessment were not clearly discussed in the research
questions, throughout the data analysis finding and implication section all the research
questions were addressed with range of economic and financial evidences.
4.2. Did it cover all relevant viewpoints? (Possible viewpoints include the community or
social viewpoint, and those of patients and third-party payers. Other viewpoints may also
be relevant depending upon the particular analysis.)
In the discussion section, the study discussed about most of the possible viewpoint of
implementing PrEP program in men with effectiveness that include social view, community

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view and target population’s view. However, the view of third party stakeholders or tertiary
stakeholders like government was not discussed adequately.
4.3. Were the capital costs, as well as operating costs, included?
In order to assess the overall cost of developing and implementing PrEP program
successfully only overall cost are considered without any specific consideration for capital
costs as well as operating costs individually.
5. Were costs and consequences measured accurately in appropriate physical units
(e.g. hours of nursing time, number of physician visits, lost work-days, gained life
years)?
5.1. Were any of the identified items omitted from measurement? If so, does this mean
that they carried no weight in the subsequent analysis?
The major limitation of this study is that the study completely omitted the financial
assessment part where it should address the details expenditure measurement. Therefore, it
reduces the weight of subsequent cost effectiveness analysis.
5.2. Were there any special circumstances (e.g., joint use of resources) that made
measurement difficult? Were these circumstances handled appropriately?
The assessment could have included the consideration of stakeholder involvement risk in the
measurement process where the any special circumstances such as lack of supplier of the
program equipment, lack of professionals to execute the program could be addressed. .
However, these type of circumstances were not handled appropriately.
6. Were the cost and consequences valued credibly?

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6.1. Were the sources of all values clearly identified? (Possible sources include market
values, patient or client preferences and views, policy-makers’ views and health
professionals’ judgements)
The major limitation of the cost analysis of this study is that the study only done an overall
financial estimation of the cost where the cost requires for different sources were not
addressed with details in the expenditure measurement. At the same time, no sources of
values was identified in the effectiveness measurement that could include the market value
and client preference.
6.2. Were market values employed for changes involving resources gained or depleted?
As it has been discussed in previous questions the market value or the preferences of the
target population was not considered in this paper and therefore this study is not relevant to
the subject of market value employment for changes for gained resources.
6.3. Where market values were absent (e.g. volunteer labour), or market values did not
reflect actual values (such as clinic space donated at a reduced rate), were adjustments
made to approximate market values?
The market values are absent in this paper. In this paper only the effectiveness has been
measured considering their value points. However, when it comes to considering the values
of market, the paper does not have any relevant information about it.
6.4. Was the valuation of consequences appropriate for the question posed (i.e. has the
appropriate type or types of analysis – cost-effectiveness, cost-benefit, cost-utility – been
selected)?
The study examines the effect through QALYs measures after implementing pre-exposure
prophylaxis for HIV prevention in men and examines the cost through financial cost benefit

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analysis. At the same time the valuation of consequences of the implementation are
appropriately presented in this paper under cost effectiveness economic assessment model.
7. Were costs and consequences adjusted for differential timing?
7.1. Were costs and consequences that occur in the future ‘discounted’ to their present
values?
The consequence of implementation of the chosen program was done by assessing the QULY
values for 80 years. Therefore, QULY will not change or discounted in the future. However,
the overall cost that has been considered to analyse cost effectiveness is entirely done on the
present market values. Therefore, the cost of the implementation plan which has been
measured will be discounted in future.
7.2. Was there any justification given for the discount rate used?
As it has been discussed before, the chosen paper does not consist of any consideration of
discount rate for the estimated expenditure for even near future. Therefore, there was no
justification about this issue present in this paper as well.
8. Was an incremental analysis of costs and consequences of alternatives performed?
8.1. Were the additional (incremental) costs generated by one alternative over another
compared to the additional effects, benefits, or utilities generated?
The study used only PrEP program without involving any other comparative analysis with
other alternative promotional methods. The only alternative consideration was the absence of
PrEP program where, no additional or incremental cost would be required. Therefore, there
was not cost incremental cost comparison has been done compared with the alternative
method.

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9. Was allowance made for uncertainty in the estimates of costs and consequences?
9.1. If data on costs and consequences were stochastic (randomly determined sequence of
observations), were appropriate statistical analyses performed?
This study did an estimated observation over the changes of effectiveness through QALY
measures. The observation estimation was done for 10year to 80 year taking 10 year as
intermediate gap. The data has been presented in a tabular form. In this case, Regression
analysis could have been done for analysing the variance of changes for consequent years.
This type of statistical analysis has not been done in the chosen study.
9.2. If a sensitivity analysis was employed, was justification provided for the range of
values (or for key study parameters)?
In this study a probabilistic sensitivity analysis has been done with range of range of
univariate sensitivity analyses. The purpose of this analysis was to evaluate the effectiveness
of the implementation of a PrEP programme for MSM with sexual event-based use of two
differnet drugs namely emtricitabine and tenofovir For the probabilistic sensitivity analysis
22 key parameters were used. Therefore, the key consideration of sensitivity assessment done
in this study us adequate.
9.3. Were the study results sensitive to changes in the values (within the assumed range
for sensitivity analysis, or within the confidence interval around the ratio of costs to
consequences)?
The key parameters in sensitivity assessment were not clearly presented in the sensitivity
assessment. Therefore, due to insufficient information in sensitivity result it cannot be stated
clearly that if the study result is sensitive enough to changes in values of cost and
effectiveness.

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10. Did the presentation and discussion of study results include all issues of concern to
users?
10.1. Were the conclusions of the analysis based on some overall index or ratio of costs
to consequences (e.g. cost-effectiveness ratio)? If so, was the index interpreted intelligently
or in a mechanistic fashion?
The conclusion of this study is based on cost verses Quality of Life Years score estimation of
the per million men population in UK. The ratios are presented and discussed with other
supportive evidences and alternative views. However, the interpretations are not clear and
intelligent. The numerical findings of this study are presented in mechanic fashion in the
conclusion section.
10.2. Were the results compared with those of others who have investigated the same
question? If so, were allowances made for potential differences in study methodology?
The study results are presented with other researchers where some of them are supportive to
the authors view and some of them are argumentative. However, in discussion section the
findings or results of other researchers that have been considered are not presented with the
details discussion of used methodologies and the potential differences amongst their
approaches.
10.3. Did the study discuss the generalisability of the results to other settings and
patient/client groups?
This study concluded with the effect through QALYs measures after implementing pre-
exposure prophylaxis for HIV prevention in men for the population of UK. The discussion
section consists only the settings and population group taken in this research initially and no
other potential settings and target population are considered. Therefore, this study lacks the
discussion about the generalizability of the results and findings.

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10.4. Did the study allude to, or take account of, other important factors in the choice or
decision under consideration (e.g. distribution of costs and consequences, or relevant
ethical issues)?
In the methodological discussion the study considered the ethical issues associated with data
collection procedures. However, in the conclusion section this research only discussed the
associated factors with the cost and effectiveness of after implementing pre-exposure
prophylaxis for HIV prevention that are considered initially. Therefore, no additional or other
important factors in the choice and decisions have been considered in the conclusion section.
10.5. Did the study discuss issues of implementation, such as the feasibility of adopting
the ‘preferred’ programme given existing financial or other constraints, and whether any
freed resources could be redeployed to other worthwhile programmes?
In the discussion section the study discussed about the feasibility of the implementing the
pre-exposure prophylaxis for HIV prevention for men in United Kingdom, considering
constraints of current healthcare facilitations, health promotional infrastructure and others.
However, the current financial constraints and the potential financial constraints are not
discussed adequately. There was not consideration about the freed resources for other
worthwhile programmes in the discussion and conclusion section of the paper.

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Reference:
Cambiano, V., Miners, A., Dunn, D., McCormack, S., Ong, K.J., Gill, O.N., Nardone, A.,
Desai, M., Field, N., Hart, G. and Delpech, V., 2018. Cost-effectiveness of pre-exposure
prophylaxis for HIV prevention in men who have sex with men in the UK: a modelling study
and health economic evaluation. The Lancet Infectious Diseases, 18(1), pp.85-94.