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Archived Comments for: Cost-effectiveness of Multisystemic Therapy for adolescents with antisocial behaviour: study protocol of a randomized controlled trial

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  1. Productivity Loss and the Economic Evaluation of Public Health Initiatives

    Tina Olsson, Linnaeus University

    18 July 2013

    I was interested to read this recent research protocol describing an upcoming economic evaluation of Multisystemic Therapy or MST in the Netherlands [1] as I myself have advocated for the increased use of economic evaluation within public health [2, 3]. To date, comparatively little attention has been paid in the literature to the economic outcomes of behavioral health initiatives such as MST although the expansion of this line of research has clear promise for advancing the discipline [3].

    Upon reading the protocol, I was surprised to read a reference to a study of mine [4] about which the authors wrote, ¿the study of Olsson (2009) focused only on the direct costs associated with serious behavioral problems and overlooked indirect costs such as productivity loss¿ (p. 373). This is not the case. The study to which the authors referred in fact assessed the societal costs and benefits of MST, addressing productivity specifically. The study, based on a randomized controlled trial in Sweden, however, did not find any significant differences between treatment and control groups on outcomes impacting productivity (such as, delinquency, institutionalization, absenteeism, reduced capacity to engage in productive activities or presenteeism, leisure, mental health, use of social services). Therefore, incremental productivity loss was actually estimated to be zero, which is not the same as being overlooked.

    Although an extremely minor point having no bearing on the study proposed by Jansen, et al. This does raise an important point for the future of economic evaluation within public health, namely, the attention to economic theory in the application of economic analysis in public health research. The quantification and valuation of productivity loss being an important economic theoretical issue, I thought I would take this opportunity to highlight its roll in public health outcomes research.

    Productivity refers to the combined value of society¿s production output in the form of goods and services. From a health economic perspective, productivity loss occurs when production output decreases due to morbidity or mortality or when productivity changes due to changes in health status [5, 6,]. Increasingly, ¿productivity loss¿ is used to refer to indirect costs, or the time of participants (and their families, etc.) consumed or freed by the intervention under study [6, 7]. Therefore, depending on the focus of the study, investigators may choose to quantify changes in health status and/or changes in participant time (i.e., time required by the study or intervention, time incarcerated or otherwise institutionalized, time in-hospital, travel time, waiting time, etc.). In the context of effectiveness studies based on randomized controlled trials, lack of significant differences between groups on certain health outcome measures (such as crime which carries with it large productivity costs) or participant time results in negligible productivity losses associated with the intervention. In certain cases, valuing both of these changes (changes in the outcome of health status and the input of participant time) leads to double counting and does not provide an accurate picture of productivity loss [6, 7, 8].

    Valuation, or monetization, of changes in productivity can be accomplished through several methods [5, 9]. Even when quantifiable differences between intervention groups occur on certain variables, investigators must determine whether or not these changes represent a change in value, utility, to the individual and/or, benefit, to society. For example, if participants are required to take time off of work to participate in intervention or if participants are required to participate in compulsory services, work time and leisure time are likely impacted and valuation of these losses in a cost-benefit analysis may be appropriate. If time at work is not impacted and participants choose to engage in interventions during their leisure time, the appropriateness of valuation and the means for valuation becomes less straightforward. In addition, there are special considerations to take into account if these losses are over the short- or long-term [6, 10].

    These issues are not without controversy and as economic evaluation gains popularity for the assessment of public health initiatives discussion of theoretical issues and improvements in method are likely to follow. I look forward to the continued discussion within public health as well as the final results of the exciting work being undertaken by Jansen and colleagues.


    Tina M. Olson

    [1] Jensen, DEMC, Vermeulen, KM, Schuurman-Luinge, AH, Knorth, EJ, Buskens, E, Reijneveld, SA: Cost-effectiveness of Multisystemic Therapy for adolescents with antisocial behavior: study protocol of a randomized controlled trial. BMC Public Health 2013, 13: 369-282.
    [2] Olsson, TM: Economic evaluation as a component of quality effectiveness research: methodological and practical benefits. Child and Youth Care Forum 2011, 41: 137-148.
    [3] Olsson, TM, Ferrer-Wreder, L, Eninger, L.: Advancing school-based interventions through economic evaluation. New Directions for Youth Development, In prep.
    [4] Olsson, TM: MST with conduct disordered youth in Sweden: costs and benefits after 2 years. Research on Social Work Practice 2009, 20: 561-571.
    [5] Drummond, M, McGuire, A: Economic Evaluation in Health Care: Merging Theory with Practice. Oxford: Oxford University Press; 2001.
    [6] Drummond, M, Sculpher, MJ, Torrance, GW, O¿Brien, BJ, Stoddart, GL: Methods for the Economic Evaluation of Health Care Programmes, 3rd ed. Oxford: Oxford University Press; 2005.
    [7] Gold, MR, Siegel, JE, Russell, LB, Weinstein, MC: Cost-effectiveness in Health and Medicine. New York: Oxford University Press; 1996.
    [8] Shulpher, MJ: The role and estimation of productivity costs in economic evaluation. In Economic evaluation in health care: merging theory with practice. Edited by MF Drummand, A McGuire. Oxford: Oxford University Press; 2001: 94-112.
    [9] Mattke, S, Balakrishnan, A, Bergamo, G, Newberry, SJ: A review of methods to measure health-related productivity loss. The American Journal of Managed Care 2007, 13: 211-218.
    [10] Boardman, AE, Greenberg, DH, Vining, AR, Weimer, DL: Cost-Benefit Analysis: Concepts and Practice, 3rd

    Competing interests