COVID-19—A Call to Action for Health Economics and Outcomes Researchers
Nancy J. Devlin, PhD, ISPOR President (2019-2020), Centre for Health Policy, University of Melbourne, Melbourne, Australia
I am writing this from New Zealand, where a state of emergency has been declared and I am experiencing my second week of lockdown. You will no doubt also be adapting to the new personal, family, social, and work circumstances in which we find ourselves. Having succeeded in the first challenge—figuring out good ways to work from home—the new challenge is how to cope with uncertainty about how long the pandemic will remain at crisis levels, and what the implications will be for our work and our families.
I am amazed by the spirit and resilience of my colleagues in Australia and around the world. And I am full of admiration for colleagues with young children; with childcare and schools closed, they somehow continue to work, appearing on videoconferences with partners and children in the background, all vying for use of laptops and work spaces.
I did not imagine when I began my term as ISPOR President that one of the decisions the Board of Directors would have to make this year was cancelling the ISPOR 2020 conference in Orlando (the first time in ISPOR’s 25-year existence that it has cancelled a major event). This was not a decision taken lightly, and considerable effort went into assessing the implications. But ultimately there was no option: ISPOR is committed to global health and we take seriously our duty of care for the health and well-being of our members and stakeholders.
"ISPOR is committed to global health and we take seriously our duty of care for the health and well-being of our members and stakeholders."
Beyond changing our immediate personal and working circumstances, the COVID-19 pandemic will (and should) lead us to radically rethink our world. It has revealed failures in political leadership. It has highlighted major weaknesses in public health and healthcare systems. It has brought to the fore fundamental questions about the trade-offs society is prepared to make between population health and economic activity, while also reminding us about the interconnectedness between health and wealth. There are also questions about behavioral responses to the crisis and how to strike the right balance between encouraging and compelling individuals to behave in a manner consistent with collective interests.
ISPOR is the leading international body for health economics and outcomes research (HEOR). As a community of 20,000+ HEOR professionals worldwide, we have a responsibility to consider the implications of the pandemic for our HEOR scientific priorities. We need to ensure HEOR evidence informs healthcare delivery and policy in and following the pandemic—the lessons that we can learn from this will be invaluable in planning for future, potentially much more fatal, crises.
"As a community of 20,000+ HEOR professionals worldwide, we have a responsibility to consider the implications of the pandemic for our HEOR scientific priorities."
Identifying HEOR scientific priorities for COVID-19 research
Which ethics committee signed off approval for this worldwide study into comparative public healthcare systems?
—Professor Jo Wolff, Oxford University, United Kingdom
COVID-19 and the responses to it by government, healthcare systems, businesses, and individuals generate important questions that HEOR can help to address.
The governments of the world have taken very different strategies in reacting to and managing the pandemic, creating a kind of wholesale natural experiment about restrictions on travel, gatherings, continuation of businesses and schools, and self-isolation or quarantine.
Governments have had to make rapid-fire judgments about the willingness to sustain economic harm to contain the health of people, in the presence of considerable uncertainty as to the effectiveness of those strategies, the period of time for which they will be required to be in place in order to sustain that effectiveness, and their real societal cost. Evaluation to understand the differences in effects and costs of these measures will be difficult but essential to inform economic and health policy in the post–COVID-19 world. Yet these evaluations pose methodological challenges: the options are huge in scale and far from “marginal” changes; the perspective from which to evaluate them necessarily extends beyond the narrow “healthcare perspective”; and what decision rule do we use to judge value for money in such a context?
The availability of data is a limiting factor in undertaking research at present. Differences in the availability and use of testing confounds the interpretation of and comparisons between rates of infection in the populations of different countries, and the rates of mortality among those infected. In some countries, testing and tracing was maximized; in other countries, access to testing was severely restricted, further complicating an understanding of transmission, prevalence of illness, and the relative effectiveness of strategies to limit these. What was the optimal strategy? And how much avoidable harm did the world’s nations’ deviations from that cause?
"The availability of data is a limiting factor in undertaking research at present."
Economic damage from lockdown measures will not be equally distributed—it is likely the misery from this will fall disproportionately on the poor and those in secondary labor markets, including “gig economy” workers, who are pushed into poverty. Given what we know about the socioeconomic determinants of health, the health consequences of these economic measures will therefore also be unequally distributed—and will have implications for health well beyond the immediate crisis. We need evidence on that, so effective policy measures can be targeted.
Meanwhile, what is happening to supply, demand, and access to other health services during the pandemic in the world’s healthcare systems? What health needs and healthcare utilization have been deferred, and what will be the consequences of that in the post-COVID world? How have morbidity and mortality from non-COVID infectious diseases (and from noninfectious causes) been affected by isolation and lockdowns? Presumably some will have been avoided altogether (eg, car crash fatalities), and some may worsen (eg, domestic abuse fatalities and injuries, alcoholism), while other health problems will be “stored up” (eg, mental health problems, cancers), and future outcomes will be worse, due to delayed diagnosis and missed treatment opportunities.
What are the implications for the health and quality of life of those for whom this period of enforced isolation has disrupted the delivery of essential services, such as those with mental health problems and those with disabilities? What are the effects of isolation and lockdown on the quality of life of those without pre-existing mental health problems, but who are now struggling with anxiety, depression, and uncertainty? How has the lockdown affected vulnerable populations, including elderly people in residential care?
"What are the implications for the health and quality of life of those for whom this period of enforced isolation has disrupted the delivery of essential services, such as those with mental health problems and those with disabilities?"
How are prioritization decisions being made when demand exceeds capacity in healthcare systems during the peaks of the COVID-19 crisis—particularly in systems where “rationing” has not previously been accepted? Who is making these decisions—are they being made consistently—and on what basis? Who is benefiting and what is being sacrificed?
The pandemic has also revealed different levels of preparedness among healthcare systems: lack of personal protective equipment (PPE) for frontline staff may itself have led to a considerable avoidable burden of ill health. What are the cost and benefits of improved PPE? What are the supply or other constraints that have led to PPE not being available for frontline clinical staff during COVID-19? More broadly, what is the appropriate balance between spare capacity and technical efficiency in healthcare provision?
This is far from an exhaustive account of the kinds of questions HEOR could usefully address. ISPOR now has a new and important role to facilitate us working together collectively as an HEOR community to establish the research priorities. And each of us, as ISPOR members, should consider how to pivot our research agendas, to use our skills to address the new and emerging research needs.
"ISPOR now has a new and important role to facilitate us working together collectively as an HEOR community to establish the research priorities."
ISPOR’s role
As I write, ISPOR is working hard to develop its first online conference program to take the place of the in-person event in Orlando. In addition to the plenaries and panel sessions which had already been planned, we will add an online preconference session where HEOR aspects of the COVID-19 situation and their implications for future research priorities will be discussed. I encourage all ISPOR members to log in, tune in, and engage. We welcome your ideas about how ISPOR can help to mobilize HEOR efforts now and over the coming year to produce better data, better evidence, and real solutions. It is important we learn as much as we can from this crisis—and the enormous human and economic cost that has and is still to be incurred—to better prepare us for the future.
At the start of the year, ISPOR embarked on an important new project to establish HEOR research priorities. That project has made excellent progress and is well positioned to incorporate new research topics relating to COVID-19. ISPOR leaders will meet in the coming months to establish ISPOR’s HEOR science priorities for the next 5 years, informed by results of that work.
ISPOR and its member groups will organize special webinars and discussions around COVID-19 and will continue to support its members with the latest information on this rapidly changing situation. ISPOR is committed to its mission and to serving its members and the broader healthcare audience during the extraordinary global healthcare crisis that COVID-19 presents. The field of HEOR has never been more important.
"The field of HEOR has never been more important."
Wherever you are, I hope you, your family, and your community stay safe and stay well. Be kind to each other.