Improving the relevance and suitability of cost-effectiveness analyses to inform local commissioning decisions, a worked case-study of cardiac rehabilitation in England

Economic evaluations of healthcare interventions are conventionally framed to inform national decision-making processes, with a focus on the expected cost-effectiveness of interventions to impact narrowly defined costs and outcomes over a long time horizon. However, a significant proportion of commissioning decisions are made at more localised levels. Research has shown that the current means of conducting and disseminating cost-effectiveness analysis is not impacting decision making at this level. This thesis explores the relevance of the conventional framework of cost-effectiveness analysis to local decision makers and how it can be adapted to increase it. This is achieved through a combination of methodological and applied analyses using a case-study developed to inform commissioning decisions regarding the cost-effectiveness of cardiac rehabilitation (CR) for people recovering from surgery for a cardiac event. The first element of this thesis interrogates the conventional framework of cost-effectiveness analysis, specifically whether the approach becomes inappropriate when the commissioning decision is made by a more localised decision maker. This element identifies five areas pertaining to the conventional framework which require adaptation or disaggregation to ensure their relevance to local commissioning decisions, with recommendations provided in each case. The second element presents the development of a case study decision model to assess the cost-effectiveness of CR. As an intervention subject to national targets and with an international literature on its cost-effectiveness, but commissioned at a sub-national level, CR represents a good example on which to explore the impact of the proposed adaptations to the conventional framework of cost-effectiveness. Finally, the five elements where the standard framework are argued to require adaptation are applied to the CR case-study, demonstrating the value of a more pragmatic approach to the conducting of cost-effective analysis rather than the normative framework typically applied.