Applying visual models for
priority setting
CAMHS EBPU
UCL & Anna Freud Centre
7 July 2013
Gwyn Bevan
Department of Management
SyMPOSE
 Systems Modelling for Performance
Optimisation & Service Equity
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Mara Airoldi
Gilberto Montibeller
Alec Morton
Chiara de Poli
Samantha Roberts
Laura Schang
Jenifer Smith
http://www2.lse.ac.uk/management/research/initiatives/sympose/home.aspx
Applying visual models for
priority setting
 Cost-effectiveness analysis (CEA) &
Burden of Disease (BoD)
 Cost-effective  impact on BOD?
 Making horse & rabbit stew taste
good
Visual model from early
Research into Operations
Visual model from early
Research into Operations
Merchantmen
F(area)
Defence
F(perimeter)
Lord Blackett
Head of Physics Department of
Imperial College (1953 -63)
Nobel Prize in Physics 1948
‘most versatile & best loved
physicist of his generation’
Value for Money (VfM) Triangles
Value
Population
benefit
Benefit
/ person
Numbers who benefit
costs
Prioritisation by marginal
analysis: biggest bang / buck
QALYs
A
B
C
Order by slope of line
VfM = QALY/cost 
1. A
2. B
3. C
4. D
D
Costs
A theory of priority setting
against budget constraint?
QALYs
E
D
C
A
B
Size of
triangle matters
Budget
constraint
DA
Costs
Cost-effectiveness analysis (CEA)
& Burden of Disease (BoD)
CEA
 Health gain in
Quality-Adjusted Life
Years (QALYs)
 Set priorities in terms
of cost / QALY
Ignores scale &
transaction costs of
making changes
BoD
 Years of life lost
(YLLs)
 Years lived with a
Disability (YLDs)
Ignores what is
‘avoidable’ & costs
Does reduction of BoD in DALYs = health gain in QALYs?
ΔQALYs
QoL
1
.8
30*.5 = 15
.5
QALYs gained
QoL 0.8 drops dead age 35
Intervention  30 years QoL 0.5
0
35
65
age
ΔDALYs
30*.5 = 15 DALYs
avoided
QoL 1
.8
BoD
.5
QoL 0.8 drops dead age 35
Intervention  30 years QoL 0.5
0
35
65
85
age
DALY methods of estimation
Current BoD?
 Fixed reference age
(e.g. 85) arbitrary
 no benefit
treating over 85s
 YLLs from life tables
better
ΔDALYs?
 Life tables  bizarre
results

ΔDALYs not ΔQALYs
 Fixed reference age

ΔDALYs = ΔQALYs
Visual Models of Health Gain
Average DALY / QALY loss
per person
Observed BoD
Average QALY gain per person
Population
Avoidable BoD
benefit
Numbers (‘000s )
Applying visual models for
priority setting
 Burden of Disease (BoD) & Costeffectiveness analysis (CEA)
 Cost-effective  impact on BOD?
 Making horse & rabbit stew taste
good
Cost-effective & BoD?
stroke treatment
 Massive annual BoD
 deaths + disability = 0.5m QALYs lost
 ‘must dos’ (highly cost-effective)
 Stroke Unit: 54%  100%
 Thrombolysis: 9% < 3 hours onset
 Achieve ‘must dos’:  BoD from
stroke?
Cost-effective & BoD?
Average QALY loss/person
QALYs
Costeffective
Costs
BoD?
Numbers
Impact on BoD from stroke
(England)
5
Average QALY*/ person
4
3
2
1
Stroke units (6%)
10
Thrombolysis (0.4%)
50
Numbers (‘000s )
110
Treatment & prevention of stroke in
Isle of Wight
 Stroke unit
 50%  100%
 Thrombolysis
 9% patients < 3 hours stroke onset
 Prescribed first-line antihypertensive
 BP(55)> 55 years
 BP(140/90): blood pressure > 140/90
 Na2
  sodium content in bread & cereals
Impact on BoD from stroke
(IoW)
Mean QALY gain
'Avoidable' DALYs
4.00
Na2
3.50
3.00
BP (55)
BP(140/90)
2.50
Stroke
units
2.00
1.50
1.00
0.50
0
10
20
Thrombolysis
30
40
50
60
70
80
Numbers
Applying visual models for
priority setting
 Burden of Disease (BoD) & Costeffectiveness analysis (CEA)
 Cost-effective  impact on BOD?
 Making horse & rabbit stew taste
good
Horse & rabbit stew: take one
horse & one rabbit
Sheffield PCT: eating disorders
 Two one day
meetings
 20 participants
 Data-pack each
service:
 Benefits
 How many?
 How much?
 Inequalities?
 Costs?
PCT
managers
Providers
managers
Patients
and carers
Public rep
Clinicians
Assessing QoL for mild eating
disorders around anchors
Benefit / person (QoL):
intensive residential care
Stay
Worsen
same
(QoL =
(QoL =
0.05)
0.1)
Little
improve
ment
(QoL =
0.12)
Become
Recover
moderate
Average
(QoL =
(QoL =
QoL
1)
0.5)
After 1
year, if
admitted
0%
25%
0%
33%
42%
0.61
After 1
year, if
not
admitted
10%
30%
50%
10%
0%
0.15
Benefit = 0.46 Quality-Adjusted Life
Years (QALYs) / person
Intensive residential care
Value
Population
benefit = 7.36
Benefit
/ person =
0.46
Numbers who benefit
= 16
costs
Good or poor VfM?
Population
health gain
Poor VfM
Good
VfM
-ve VfM
Costs
VfM triangles pathway for
treatment of eating disorders
Value
?
Residential intensive care
80% costs & 13% benefits
Costs
VfM for eating disorders
Lower
budget
More benefit
Star tool – launched May 2013
To download:
http://www.health.org.uk/areas-of-work/star/
Applying visual models for priority
setting
Thank you!