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There is a significant backlog of patients waiting for cataract operations in the United Kingdom. In England in the first quarter of 1989, there were 74,000 patients in total on ophthalmology waiting lists, of which approximately 75% were cataract cases. Although there is currently a significant shortfall of around 225 consultant ophthalmologists, as defined by the College of Ophthalmologists' standard, the backlog is also due to the imbalance in, and inefficient use of, resources. There are a number of possible ways of clearing the backlog, including local initiatives, contracting for clinical services and the expansion of day-case surgery, which has been shown to be a cost-effective alternative to in-patient surgery. However, not only are reorganisations in the provision of surgical services required, managerial initiatives also need to be taken.

Controlled clinical trials are recognized as the best source of data on the efficacy of health care interventions and technologies. Because economic evaluation is dependent on the quality of the underlying medical evidence, clinical trials have increasingly been viewed as a natural vehicle for economic analysis. However, the closer integration of economic and clinical research raises many methodological issues. This paper discusses these issues in trial design, collection of resource use data, collection of outcome data, and interpretation and extrapolation of results. Some guidelines are suggested for economic analysts wishing to undertake evaluations alongside clinical trials.

This article reviews the methods of economic evaluation of health technology. The different forms of evaluation are outlined and the importance of assessing costs and benefits at the margin stressed. The approaches used by economists to analyze priorities for health technologies are discussed and a number of key managerial and policy issues identified. It is concluded that, while further methodological improvements can be made, a clear methodology for economic evaluation of health technologies has been established. However, attention needs to be paid to the timeliness and relevance of economic evaluation in order to ensure its maximum impact.

At the Birmingham Maternity Hospital the mean cost of caring for surviving infants who require neonatal intensive care ranges from approximately pounds 2500 (for infants above 1500 g birthweight), to pounds 5500 (for infants 1000 to 1499 g birthweight), to pounds 10 000 (for infants less than 1000 g birthweight). The mean cost of caring for non-survivors is pounds 1000 or less, with little difference between the birthweight groups. These figures are based on the lengths of stay in three treatment regimens-intensive care, high dependency care, and special care-the average daily costs of which are estimated to be pounds 235, pounds 122, and pounds 43 respectively. The survival of very low birthweight infants (less than 1500 g) at this hospital has improved from 42% to 73% since the introduction of regional funding for neonatal intensive care. This increase in survival has been brought about without undue disability in the survivors.

This paper provides some guidelines for the teaching of health economics particularly but not exclusively to non-economist personnel in the health care sector. It arose from a workshop, sponsored by WHO (Regional Office for Europe) in Copenhagen in 1982, for training a few health service personnel from various European countries in the economics of health care. The material in the guidelines is organised under eight topic headings, each followed by the main themes of each topic and some possible teaching/learning problems. Organised in this way, it would be possible to use the outline as an eight-day course on health economics or eight weekly sessions in a traditional university undergraduate or postgraduate course. The eight topics covered include: (i) What is economics? (ii) Health measurement and valuation; (iii) The patient as demander; (iv) Supply and financing of health care; (v) Setting health priorities; (vi) Assessing the costs and benefits of alternatives; (vii) Strategies for efficiency in health care; and (viii) Equity in health and health care. At a time when there is an increasing demand for economic skills and trained economists with a knowledge of the health care sector, the article emphasises that it would be unfortunate if the view were to become widespread that economics is something that only economists do. Many decision-makers in health care make decisions every day to which the principles of economics can, and should be, applied. It is with a view to introducing more of these decision-makers to the principles of economic analysis that the authors have written this article. However, while some may gain directly, the article aims to stimulate and assist those who might contribute to this process by providing ideas on how economics of health care might be taught.

In principle, economic evaluation provides a suitable framework for the assessment of the costs and benefits of health technologies. However, despite a rapid growth in the publication of cost-effectiveness and cost-benefit analysis in health care, there is little evidence that economic evaluation has yet become part of an integrated approach to technology assessment. This paper, based on the findings of a European Community project on economic appraisal of health technology, discusses how the design and conduct of economic evaluations can be improved so as to increase their relevance to health care decision making, and how policies on the diffusion and use of health technology can be devised so as to make fuller use of the economic evaluations that are carried out.

This paper considers how the economic aspects of risk assessment in chemical safety can be strengthened. Its main focus is on how economic appraisal techniques, such as cost-benefit and cost-effectiveness analysis, can be adapted to the requirements of the risk-assessment process. Following a discussion of the main methodological issues raised by the use of economic appraisal, illustrated by examples from the health and safety field, a number of practical issues are discussed. These include the consideration of the distribution of costs, effects and benefits, taking account of uncertainty, risk probabilities and public perception, making the appraisal techniques useful to the early stages of the risk-assessment process and structuring the appraisal to permit continuous feedback to the participants in the risk-assessment process. It is concluded that while the way of thinking embodied in economic appraisal is highly relevant to the consideration of choices in chemical safety, the application of these principles in formal analysis of risk reduction procedures presents a more mixed picture. The main suggestions for improvement in the analyses performed are the undertaking of sensitivity analyses of study results to changes in the key assumptions, the presentation of the distribution of costs and benefits by viewpoint, the comparison of health and safety measures in terms of their incremental cost per life-year (or quality-adjusted life-year) gained and the more frequent retrospective review and revision of the economic analyses that are undertaken.

Given the shortage of resources in the NHS clinicians are increasingly being asked to search for more cost-effective treatment strategies. This requires consideration not only of the cost consequences to the NHS but also the impact on quality of care and patients' costs. This paper reports two studies of the cost effectiveness of alternative practices within a contact lens department. They show that, for the hospital concerned, both the internal production of, and more extensive stocking of, lenses are cost-effective strategies. Moreover it is argued that cost-effectiveness analysis might have wider applications within ophthalmology as a whole.

An economic appraisal of different methods of long-term treatment with oxygen in the home has shown that the oxygen concentrator is the cheapest and most convenient one. The only method at present generally available in the National Health Service, the use of small oxygen cylinders, is the most expensive and least convenient of those studied. There is need for a more flexible administrative system which will allow patients and the Health Service to benefit from the economies which are offered by technical advances.

In most countries, there are concerns about health care utilization and costs. Therefore, those arguing for more funds to be devoted to eye health care need economic data in support of their claims. This article examines the methods for estimating the economic effect of blindness and discusses the approaches to economic evaluation of health care interventions in the field of cataract. Some suggestions are also given for undertaking economic analysis alongside clinical trials in the field of ophthalmology.

Studies in which clinicians' therapeutic plans are determined before and after application of a new test offer an attractive alternative to randomized trials as a strategy for establishing the usefulness of diagnostic technologies. To maximize scientific credibility such studies should include a number of design features: specific clinical questions should be addressed; consecutive patients presenting with a clinical problem should be entered; the test's accuracy should be assessed; and changes in therapy should be described in sufficient detail to allow an estimate of the impact on patient outcome. Even with attention to these issues, the validity of before-after studies of therapeutic impact is limited by possible discrepancies between clinicians' stated plans and actual behavior, and by the often tenuous link between change in therapy and patient benefit. Before-after designs will be most useful in primary investigations which, if positive, should be followed by more rigorous studies to establish patient benefit.

There is currently interest in the effectiveness and cost of the intraocular lens as compared with other methods of correcting aphakia following cataract extraction. We have undertaken a retrospective review of patients undergoing cataract surgery by the extracapsular method at Moorfields Eye Hospital during the period January 1982 to July 1983. From the total population we selected at random two groups of patients, having their aphakia corrected either by means of a contact lens or an intraocular implant. Patients under the age of 60 years and those with complicating illnesses were excluded from the study. Using case notes, we followed the sample patients from the time of referral until one year after the operation, and recorded a number of clinical and economic variables such as waiting time for operation, length of inpatient stay, incidence of per- and post-operative complications, number of follow-up visits, final visual acuity and (for the contact lens patients) waiting time for lens issue and average daily wearing time. We found that the visual acuities obtained, and the total costs to society, were similar for the two groups.

Given the increasing interest in the economics of health care, the incorporation of economic analysis in clinical trials is more often being considered, both by medical researchers and by research funding bodies. This article proposes criteria for judging the appropriateness of including economic analysis in a given trial, suggests how that analysis could be phased in order to minimize the work involved, and discusses the wider implications for medical research of more frequent attention to economic concepts.

Between 2% and 9% of patients with cancer present with metastatic nonsquamous cell carcinoma of unknown primary origin. Traditionally, a series of investigations is undertaken to locate the primary origin of the tumour, although many of these tests are often painful or distressing to patients, unsuccessful in locating the primary site and costly to the health care system. Moreover, even if a tumour is found it usually cannot be treated surgically. However, a small number of cancers of unknown primary origin can be cured, arrested or effectively palliated with systemic treatment. This study compares the costs and outcomes of the current practice of comprehensively searching for the primary tumour with those of an alternative, limited approach that identifies only the primary tumours for which relatively effective systemic therapy exists. Decision trees were constructed for the two diagnostic approaches and their associated therapeutic options. Costs and probabilities were integrated with published data on the survival of patients with each type of cancer. The results indicate that the comprehensive diagnostic strategy may increase 1-year survival rates from 11.0% to 11.5%. On the basis of Ontario cost data it is calculated that the additional costs of a comprehensive search for 1000 patients will range from approximately $2 million to $8 million, depending on the subsequent treatment strategy.

This paper discusses the relevance of quality of life measurement in clinical and epidemiological research to resource allocation decisions in health care. The discussion concentrates on economic evaluations, the form of health services research which most directly pertains to decisions about the allocation of resources, and the use of the quality-adjusted life-year in economic evaluation. Three key issues are addressed: whose assessments of quality of life are relevant and how should these be obtained; should one search for a generalizable quality of life measure; is it right to construct "league tables" of health care interventions in terms of cost per quality-adjusted life-year?