Background

The endogenous nature of healthcare expenditure means that instruments are often used when estimating the relationship between expenditure and mortality. Previous English studies of this relationship have largely relied on statistical tests to justify their instruments. A recent paper proposed that exogenous components of the resource allocation formula, used to distribute the national healthcare budget to local health authorities, be used as instruments.

Objectives

To estimate the relationship between healthcare expenditure and mortality by disease area for England from 2003/4 to 2012/13 using exogenous elements from the resource allocation formula as instruments for expenditure. To use these disease-specific estimates to calculate the marginal cost per quality-adjusted life year (QALY) for English NHS expenditure. To compare these estimates with those that relied on statistical tests to justify their instruments.

Methods

The two-stage least squares estimator is used to determine the annual relationship between mortality and healthcare expenditure by disease area across 151 local authorities. These disease-specific outcome elasticities are combined with information about survival and morbidity disease burden in different disease areas to calculate the marginal cost per QALY for English National Health Service (NHS) expenditure.

Results

The results suggest an annual marginal cost per QALY of between £5000 and £10,000. This is similar to that reported previously by studies that used statistical tests to justify their instruments.

Conclusion

These cost per QALY estimates are much lower than the threshold currently used by the UK’s National Institute for Health and Care Excellence (NICE) (£20,000 to £30,000) to assess whether a new pharmaceutical product should be funded by the NHS. Our estimates suggest that guidance issued by NICE is likely to do more harm than good, reducing health outcomes overall for the NHS. There may be legitimate reasons why such harms are deemed appropriate, but it is only through the type of empirical analysis in this paper that the reasons for these ‘harms’ are likely to be articulated and explicitly justified.

中文翻译：

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边际医疗保健支出的有效性如何？2003/04 至 2012/13 来自英格兰的新证据

背景

医疗保健支出的内生性意味着在估计支出与死亡率之间的关系时经常使用工具。以前对这种关系的英语研究在很大程度上依赖于统计测试来证明他们的工具是合理的。最近的一篇论文提出，将用于向地方卫生当局分配国家医疗保健预算的资源分配公式的外生成分用作工具。

目标

使用资源分配公式中的外生要素作为支出工具，估计英国 2003/4 至 2012/13 年按疾病区域划分的医疗保健支出与死亡率之间的关系。使用这些特定疾病的估计来计算英国 NHS 支出的每个质量调整生命年 (QALY) 的边际成本。将这些估计值与那些依靠统计测试来证明其工具合理性的估计值进行比较。

方法

两阶段最小二乘估计量用于确定 151 个地方当局按疾病区域划分的死亡率与医疗保健支出之间的年度关系。这些特定疾病的结果弹性与不同疾病区域的存活率和发病率疾病负担信息相结合，以计算英国国民健康服务 (NHS) 支出的每个 QALY 的边际成本。

结果

结果表明，每个 QALY 的年度边际成本在 5000 到 10,000 英镑之间。这与之前使用统计测试来证明其仪器合理性的研究报告的结果相似。

结论

这些每个 QALY 估计的成本远低于英国国家健康与护理卓越研究所 (NICE) 目前使用的阈值（20,000 至 30,000 英镑），用于评估新药品是否应由 NHS 资助。我们的估计表明，NICE 发布的指南可能弊大于利，降低了 NHS 的整体健康结果。此类伤害被认为是适当的可能有正当的理由，但只有通过本文中的实证分析类型，这些“伤害”的原因才有可能被阐明和明确证明。