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Assessing the costs and outcomes of healthcare

Healthcare costs are rising across the EU, and the burden is likely to intensify in future with the cost of caring for people with mental health diseases set to increase. Researchers in the PECUNIA project are developing new, more systematic, harmonised and comparable methods of assessing healthcare interventions, which could in future lead to more optimised, cost-effective care, as Professor Judit Simon explains. Many European countries spend a significant proportion of national income on healthcare, and the financial burden is set to increase further in future, with the cost of mental healthcare likely to lead to significant strain on healthcare organisations. The outlook is set to further worsen, with the COVID-19 pandemic expected to have longterm consequences on mental health amongst the general public. With governments and healthcare organisations looking to control costs while at the same time providing highquality care, it’s important to rigorously assess the costs and effects of different interventions, a topic at the heart of the PECUNIA project. “This project is addressing the issue of increasing healthcare costs,” says Judit Simon, Professor of Health Economics at the Medical University of Vienna, the coordinator of the project. Healthcare costs currently account for about 10 percent of national income across EU countries, the second highest government spending category after social protection, which Professor Simon says is the result of an enormous increase in demand for care, along with the availability and cost of new technologies. “We need this cost-effectiveness information, derived from economic evaluations, in order to provide more efficient

care across healthcare systems and achieve the best value care possible,” she continues.

PECUNIA project This is an issue Professor Simon and her colleagues from six European countries in the project are working to address by establishing a standardised approach to assessing the impact of healthcare interventions in the EU. Currently, there are not really any tools available to compare the results of economic evaluations conducted in different countries, while Professor Simon is also considering the wider importance of health in the project. “The EU published a strategy document several years ago which states that health is not just a value in itself, but is also very important for economic growth and prosperity,” she explains. The ongoing COVID-19 pandemic illustrates the importance of public health to the wider economy, but the so-called inter-sectoral consequences of healthcare interventions are often not considered in economic evaluations. “In these evaluations the health and social care costs of interventions and consequences are commonly measured, but very often healthcare interventions have a wider impact, for example on our opportunities to work and study,” points out Professor Simon.

The wider aim in the project is to develop methods and tools that enable such multisectoral, multi-national and multi-person economic evaluations, focusing in particular on mental healthcare. A mental healthcare intervention doesn’t affect just the individual concerned, but also their families and the people that care for them, while it also has an influence on the opportunities that may be open to them in future. “The treatment costs are the direct costs of healthcare, while these inter-sectoral costs fall outside the healthcare sector. For example, people may be unable to work, or to finish their studies, or there may be legal consequences,” explains Professor Simon. Researchers now aim to consider these types of costs in the project and build a deeper picture of the impact of different healthcare interventions, work which is by nature comparative. “Economic evaluations are comparative – for example you compare the cost of ‘no treatment’ to the cost of ‘treatment’, or you compare an existing medication which is already on the market and is commonly used to a newly developed medication, or you want to focus on comparing the consequences of prevention and early intervention options with different treatment options,” outlines Professor Simon.


Icons from Pickit Images,

Healthcare questionnaires and other new PECUNIA tools Researchers in the project are developing a questionnaire, the so called Resource Use Measurement (RUM) questionnaire, which would enable the collection of a wider variety of data. This covers not just the health and social care consequences of an intervention, but also the impact on other sectors, including education, employment, (criminal) justice and those for the patients and families. “An instrument is under development which could be used in different countries with different languages, opening up the opportunity to collect information and data from a variety of settings in a harmonised way with one tool. For example, we are collecting information on the care burden facing families; how many hours do they have to support a family member due to ill-health?” explains Professor Simon. By developing a comprehensive new RUM questionnaire, researchers hope to overcome issues around the fragmentation of data and the varying levels of routine data collection and data linkage opportunities across different European countries. This will then provide the foundations for more detailed and comprehensive analyses, believes Professor Simon. “We can really evaluate the broader inter-sectoral impacts of an intervention by directly collecting this information from patients,” she continues.

“Through the RUM questionnaire we collect information on, for example how many days someone was in hospital, how many times they visited their GP, or how many days they were unable to work. In order to estimate the costs, we need to know the average cost of each of these items, the so called unit costs, but this information is currently not widely available. Only a few countries have developed databases for such unit costs and it is often calculated in different ways,” says Professor Simon.

Graph © PECUNIA Consortium 2021.

calculate so called ‘Reference Unit Costs’ for the most important services. “We are developing tools which follow the basic PECUNIA Costing Concept, where we really go back to the basics of costing,” continues Professor Simon. “We have ten partners from six countries in the project. If the information that goes into calculating those costs is standardised, then in future economic evaluations you will be comparing apples with apples and not apples with oranges.”

Treatment costs are the direct costs of healthcare, while inter-sectoral costs fall outside the healthcare sector. For example people may be unable to work, or to finish their studies. This limits efforts to compare economic evaluations across different countries, even in cases where the same question was being addressed, simply because the unit costs that are used have been developed with completely different methods. This is another major area of interest in the project. “In parallel to our work on RUM, we are also considering the costs of all the services and resource use items that have been identified,” outlines Professor Simon. Researchers are now developing harmonised methods to

Professor Simon and her colleagues were able to gain some deeper insights. “We came up with so-called PECUNIA Service and Resource Item Lists for each country. We noticed that because the systems are so different, the items in these lists are also extremely different,” she says. The central idea behind harmonisation in the PECUNIA Costing Concept is to move away from the name of services - and linked system dependency of services - towards units of analysis which are comparable across countries. “A healthcare service may be understood differently in different countries. We have developed these units of analysis which can be coded according to internationally recognised classifications and reflect costs more accurately,” explains Professor Simon. “This information will be included in our PECUNIA Reference Unit Cost Compendium. So when someone is working with this information, they will also know whether it is for the public sector, the private sector, or if it is a mixed estimate,” outlines Professor Simon. This is a highly complex project, and coordinating it has proved very timeconsuming and demanding, yet Professor Simon says they have made significant progress in research. “One big achievement in the project has been to highlight why current cost estimates may not be comparable,” she says. “We’ve developed new concepts and methods for costing in economic evaluations that allow harmonised costing across sectors, countries, and people.” The project’s agenda also includes assessing the outcomes of healthcare interventions, which again may not be directly comparable, as different countries may use different tools or assess the value of quality of life in different ways. “To harmonise outcome assessment, we are developing an electronic compendium of

The countries represented within PECUNIA also organise their healthcare provision differently, with varying levels of state and private sector involvement and different funding structures, which is an important consideration in terms of the project’s wider agenda. Researchers reviewed the literature, then conducted surveys about services and resources used in the different sectors in the six countries, including healthcare, social care, education, (criminal) justice and those costs directly impacting patients and families, from which

information,” explains Professor Simon. A type of measure called PROMs (Patient Reported Outcome Measures) is central to this work. “This is the cornerstone of patient-centred care – that patients are able to self-report on their quality of life and their wellbeing,” continues Professor Simon. “We are looking at the questionnaires that are currently used in healthcare to assess quality of life and well-being, often in a generic way or within the mental health context, and collect structured information so that future studies can select and use the best and most suitable methods for PROMs assessment. In addition, we developed harmonised methods for the assessment of health-related quality of life at pan-European and supra-national levels to promote the feasibility of assessment at the EU level, across multiple countries or even in a single country where national valuation is currently not available.” While the above methods have now been developed to conduct Europe-wide health economic evaluations, Professor Simon and the PECUNIA Consortium have some plans for further research beyond the end of the project. “We are very much hoping to continue together and develop these European-wide, harmonised unit costing tools further. We want to make European economic evaluations much more comparable and to improve patient access to high-quality and efficient services in all EU countries,” she says. The project’s work will provide an important resource to researchers and organisations looking to optimise healthcare provision. “It is very important that these tools are known to decision-makers, then they can be incorporated as a gold standard in future guidelines and analyses,” stresses Professor Simon. “We are moving towards piloting and testing our tools with users and bringing them to a broader audience.”

PECUNIA ProgrammE in Costing, resource use measurement and outcome valuation for Use in multi-sectoral National and International health economic evaluAtions

Project Objectives

PECUNIA aims to establish standardised costing and outcome assessment measures for optimised national healthcare provision in the European Union. The methods and tools to be developed within PECUNIA will be used to enhance efficient and evidence-based collaborative care models and intersectoral funding arrangements to improve chronic and mental health care in all EU health systems.

Project Funding

Funded by the European Union’s Horizon 2020 research and innovation programme under grant agreement No 779292.

PECUNIA Final Workshop

2nd virtual satellite workshop on 1-2 June 2021 to present the developed PECUNIA tools. More information:

Project Partners

• Medical University of Vienna (AT) • Universitätsklinikum Hamburg-Eppendorf, European Research and Project Office GmbH (Eurice) (D) • Corvinus University of Budapest (H) • Servicio Canariuo de la Salud, Asociación Científica Psicost (ES) • Maastricht University, Erasmus Universiteit Rotterdam (NL) • London School of Economics, University of Bristol (UK)

Contact Details

Prof. Dr. Judit Simon Professor of Health Economics Head of Department & Deputy Head of Center Coordinator Doctoral Program Public Health Medical University of Vienna Center for Public Health Department of Health Economics Kinderspitalgasse 15, 1090 Vienna, Austria E: W: W: : Professor Judit Simon

Judit Simon is Professor and Head of the Department of Health Economics (DHE) and Deputy Head of the Center for Public Health at the Medical University of Vienna (MUV) in Austria. She also coordinates the Doctoral Programme Public Health and leads the Health Economics Programme Line at the Ludwig Boltzmann Institute Applied Diagnostics. Previously she held positions at the LSE, UCL and University of Oxford where she remains Visiting Professor of Cognitive Health Economics at the Department of Psychiatry. © PECUNIA Consortium 2017.

© PECUNIA Consortium 2018.


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