JCPSLP Vol 21 No 2 2019 DIGITAL Edition

that make both RCTs and economic evaluations more challenging when one’s goal is to consider effectiveness and costs. Most international guidelines for economic evaluation were originally designed to assess pharmaceuticals (Tunis, Stryer, & Clancy, 2003). However, the mechanism of action for a pharmaceutical is relatively straightforward and apart from specific recruitment bias within a trial, the results are likely to be highly generalisable from the trial sample to the target population. On the other hand, for an economic evaluation to accurately assess the total impact of change in a health service at a population level or upon an alternative population, an understanding of the program’s underlying causal mechanism and explicit inclusion of this within the economic model is necessitated. While it is well established that factors such as patient or clinician preferences, or patient–clinician relationships, can influence response and compliance, rarely are such factors included in the economic evaluation of services (Husereau et al., 2014). Moreover, the impact may be dependent on difficult to quantify factors, including human resources (quality, not just quantity); the scope and scale of the service (or any given service provider); the extent to which the service is entwined with other areas of the system and/or other health service providers; and the heterogeneity of patients and their subsequent journeys. Strides have been made to accommodate these complexities within economic evaluations of health services (Lamont et al., 2016). However, it is likely that for every future proposed service intervention, new and emerging challenges will arise. But to paraphrase Winston Churchill: “We must see the opportunity in every difficulty not the difficulty in every opportunity.” If we continue to strive for transparency, evidence, and measures of patient-relevant health outcomes and costs, while avoiding myopic and tunnelled vision in our evaluations, we can begin to identify, implement and achieve value in health. References Australian Institute of Health and Welfare. (2018). Health expenditure Australia 2016–17 . Canberra, ACT: Australian Institute of Health and Welfare. Dieleman, J. L., Templin, T., Sadat, N., Reidy, P., Chapin, A., Foreman, K., … Kurowski, C. (2016). National spending

on health by source for 184 countries between 2013 and 2040. The Lancet , 387 (10037), 2521–2535. Husereau, D., Jacobs, P., Manns, B., Hoomans, T., Marshall, D., Tamblyn, R., on behalf of the IHEIHSPR Complex Interventions Working Group. (2014). Economic evaluation of complex health system interventions: A discussion paper . Edmonton, AB: Institute of Health Economics. Lamont, T., Barber, N., de Pury, J., Fulop, D., Garfield- Birkbeck, S., Lilford, R., … Fitzpatrick, R. (2016). New approaches to evaluating complex health and care systems. BMJ , 352 . i154. doi: https://doi.org/10.1136/bmj. i154 Papanicolas, I., Woskie, L. R., & Jha, A. K. (2018). Health care spending in the United States and other high-income countries. JAMA , 319 (10), 1024–1039. Porter, M. E. (2010). What is value in health care? The New England Journal of Medicine , 363 (26), 2477–2481. Productivity Commission. (2015). Efficiency in health, commission . Research Paper. Canberra, ACT: Productivity Commission. Shah, A. (2016). Value-base healthcare: A global assessment . New York, NY: The Economist Intelligence Unit. Tunis, S. R., Stryer, D. B., & Clancy, C. M. (2003). Practical clinical trials: increasing the value of clinical research for decision making in clinical and health policy. JAMA , 290 , 1624–1632. Dr Joshua Byrnes is an associate professor at the Centre for Applied Health Economics within the School of Medicine at Griffith University (Australia). He is currently the president-elect for the Australian chapter of the International Society for Pharmacoeconomics and Health Outcomes Research. He lectures frequently at local, regional, national and international conferences on topics related to value-based health.

Correspondence to: Joshua Byrnes

Centre for Applied Health Economics School of Medicine, Griffith University Nathan, QLD email: j.byrnes@griffith.edu.au

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Journal of Clinical Practice in Speech-Language Pathology