Using economic evaluation and preference elicitation methods to inform decisions about how best to reorganise services :a case study of the redesign of emergency medical services

Abstract

The aim of this thesis was to evaluate the centralisation of emergency medical services (EMS) in different local hospitals into a single specialised emergency care hospital in terms of costs and quality of care. It also aimed to investigate preferences and trade-offs that individuals’ were willing to make to receive treatment at the centralised specialised emergency hospital. The economic evaluation method builds upon a systematic review of economic evaluation methods and types of economic evaluation that have been used to assess the performance of centralised healthcare specialities. A discrete choice experiment (DCE) was used to investigate preferences for centralised EMS and the trade-offs individuals were willing to make to receive treatment at the centralised hospital. The DCE identified preferences for: shorter travel times to the hospital; shorter waiting times; fewer days in hospital; low risk of death; low risk of readmission; and outpatient follow-up care in local hospitals. However, people were willing to trade-off increased travel time and waiting time for higher quality of specialised emergency medical care in the centralised hospital. A Markov model was developed to evaluate the costs and effectiveness of centralisation of EMS compared with non-centralised care. Multiple sensitivity analyses were carried out to assess whether centralisation had an impact on cost, quality and cost-effectiveness over the short and longer term. The incremental cost per QALY at one year (deterministic estimate £1,004 per QALY) and 10 years (deterministic estimate £636 per QALY) were both well below the threshold used by the National Institute for Health and Care Health Excellence (£20,000-£30,000 per QALY). There were fewer deaths in the centralised EMS compared with noncentralised services (deterministic estimate: 31.47 fewer deaths at 1 year, 31.57 fewer deaths at 10 years). Discounting the costs and outcomes at different rates did not alter conclusions. The economic evaluation suggested that centralisation of EMS into fewer more specialised units could be cost-effective, although cost-effectiveness may vary in specific population sub-groups. Sub-group analyses suggest that centralised EMS would be more cost-effective for elderly patients, the most economically deprived patients and those presenting with diseases of the circulatory system. These findings ii support the recommendations to centralise urgent and EMS in England. However, a cost benefit analysis that incorporated the results of the DCE into the economic evaluation suggested that centralised EMS could have negative societal value when compared with services provided in local hospitals. The implications of these findings, potential limitations of the methods used in this thesis and recommendations for future research are discussed.