Empirical challenges in the economic evaluation of health programs using quantitative and qualitative methods

Abstract

Economic evaluations are often used to assess the impacts of health programs or available technologies. However, less attention has been paid in the literature to how to obtain evidence to answer key questions such as the effectiveness, costs and long-term impact on health and quality of life, as well as the long-term impact on other healthcare uses. This thesis addresses three specific methodological challenges in economic evaluation and shows practical measures that may improve and enrich this field of research. The first challenge is one that commonly occurs in economic evaluation alongside clinical studies, namely how to deal with missing data. The advantages and the weaknesses of the available methods are explained in a synthetic and didactic way by using a case study and commenting on the on the suitability of each method. The second challenge that we addressed was how evidence for economic evaluation can be collected and synthesised in a systematic literature review. The case study focused on quantifying the costs, survival and quality of life of patients in the months and years following spinal cord injury. This review collected data from 67 longitudinal and cross-sectional studies from different countries. Heterogeneity between studies was addressed using tabulation, metaanalysis, meta-regression and graphical analyses. The third challenge we addressed was how to understand healthcare from the perspective of the patient or the user. We conducted a qualitative study to gather more in-depth evidence of factors influencing healthcare access and financing in a community of immigrants residing in Spain that are poorly understood by the host society. This study shows gaps in public health protections for migrants in Spain. The study also revealed the significance to this community of services of cultural importance, specifically options to seek care in their country-of-origin, access to traditional medicine, and burial in their country of origin. Likewise, this study was the first to provide an understanding of the community-based insurance scheme autonomously developed by this population to finance healthcare.