Prospective Graduate Students / Postdocs
This faculty member is currently not actively recruiting graduate students or Postdoctoral Fellows, but might consider co-supervision together with another faculty member.
Craig Mitton
Professor
Research Classification
Research Interests
Health Policies
Health care resource allocation
Relevant Thesis-Based Degree Programs
Affiliations to Research Centres, Institutes & Clusters
Research Methodology
Health technology assessment
priority setting
Economic evaluation
Graduate Student Supervision
Doctoral Student Supervision
Dissertations completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest dissertations.
Development and application of economic learning health systems - a forecasting and simulation based analysis of home health for seniors (2022)
The task of providing high quality care has become increasingly difficult as pressure mounts on both the funding and demand side of the provision equation. Health leaders have simultaneously had to contend with a decreasing availability of resources along with rising expenditures in part due to an aging population and the development of new innovations in care delivery. Health system transformation and improvement are crucial to addressing these challenges. To spur such transformation, Learning Health Systems (LHS) have been posited as a framework to enable health organizations to generate and apply knowledge in a manner that delivers higher performance and greater value. Despite the opportunities afforded by LHS, published literature has identified several impediments to adoption including: data management, prioritization, and evaluation.This thesis built upon existing LHS theoretical models by incorporating health economic methods to address the aforementioned challenges and create a novel model for economic learning health systems (eLHS). Practically, the first steps of an eLHS model were carried out and documented including an auto-regressive integrated moving average (ARIMA) forecasting analysis, and simulation analysis using Markov modelling. These analyses were conducted in partnership with a local health organization within the context of providing home health services for seniors.Results from the analyses forecasted growing community and acute expenditure on care for senior home health patients, set target thresholds for innovations designed to reduce dependence on acute care, and found that two possible home health interventions were cost-effective using simulation with a decision analytic Markov model. Recommendations for future stages of the eLHS process in this context were made as well as applications of the eLHS frameworks in other domains of care.
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Economic evaluation of the Community-Level Interventions for Pre-eclampsia (CLIP) in Sindh, Pakistan (2018)
Background: Hypertensive disorders of pregnancy, particularly pre-eclampsia and eclampsia (PE/E), can lead to life-threatening complications or even the death of a mother or a newborn. Because there are few clinical trials of community-based interventions for PE/E, there is little evidence about the cost-effectiveness of these interventions. The aim of this dissertation is to conduct an economic evaluation of the Community-Level Interventions for Pre-eclampsia (CLIP) combined with routine pregnancy care, compared to routine pregnancy care alone, in Sindh, Pakistan.Methods: A mixed-methods (i.e., qualitative and quantitative) approach to economic evaluation was undertaken alongside the CLIP Trial. A literature review of published epidemiological and economic studies was carried out to document evidence on PE/E interventions and guide the design of the economic model. Data were collected through focus groups, a structured questionnaire embedded into CLIP Trial surveillance, a cross-sectional survey of health facilities, and program budgetary reviews. The cost-effectiveness analysis was performed using a societal perspective. Probabilistic analysis was applied to estimate incremental cost-effectiveness ratios (ICERs), and sensitivity analysis was done to characterize uncertainties.Results: The literature review found economic studies mainly in developed countries and focused only on costs to the health system. Focus groups revealed a large burden of out-of-pocket spending and productivity losses to pregnant women and families. Health care providers and decision makers identified upfront technology costs as a key challenge for the health system. Maternal and newborn care costs varied significantly between and within public and private sectors. In the probabilistic analysis of the base case, the incremental cost of the intervention as compared to control was $20,438, while the years of life lost was -37 (i.e., negative health gains), indicating a wide range of statistical uncertainty around ICERs. Overall, the probability that ICERs fell below the country-specific threshold was less than 30%.Conclusion: This dissertation highlights knowledge gaps for costs and cost-effectiveness of PE/E interventions in low- and-middle-income countries (LMICs). The economic analysis indicates that CLIP is not a cost-effective strategy, compared to routine pregnancy care. More research is needed to conduct the process evaluation to inform policy decisions on resource allocation in Sindh, Pakistan.
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To What Extent Should the Public be Involved in Health Disinvestment Decision Making: A Mixed Methods Investigation into the Views of Health Professionals in the English NHS (2016)
Demand for health services is growing, but funding is often failing to keep pace. To ensure that budgets are balanced and that delivered services continue to be high quality, decision makers are having to set priorities, removing funding from some services- this is disinvestment. This thesis details research incorporating a literature review followed by a two stage empirical investigation into the way that disinvestment decisions are made and whether or not the public should be involved. The first stage is a Q-Methodology study, the second is in-depth interviews. The population for the study is NHS health professionals (including managers and clinicians). 55 participants took part in the Q-study, and of these, 20 took part in follow-up interviews. The study highlighted three distinct perspectives, all of which supported public involvement. One was unequivocal in its support, another highlighted some potential disadvantages to involving the public and the third suggested that the public should have the freedom to choose whether they became involved. The follow up interviews re-iterated participants’ support for involvement but suggested that the public should become involved earlier and to a greater extent in those disinvestment decisions which affected more patients and/or resulted in a tangible loss of services.
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Identifying disinvestment options to increase the impact of priority setting in health care organizations (2011)
Choices about what to fund and what not to fund are necessary in health care because claims on resources always exceed those available. Moreover, the choices faced by decision-makers are often between or amongst a wide range of difficult to compare programs or interventions. It is no surprise, then, that processes that inform those choices are of considerable interest. Yet, we know that existing priority setting processes have found limited practical use and when used, are rarely used to their full potential. The objective of the current research was to produce new knowledge that would facilitate the use of formal priority setting processes in decision-making on resource allocation in health care. Based on a detailed review of the literature, a decision was made to focus on one particular aspect of priority setting in health care that has long been recognized as a significant barrier to the successful implementation of priority setting processes: the identification of disinvestment options. Building on initial exploratory research, a proposed procedural change to the Program Budgeting and Marginal Analysis (PBMA) priority setting process was designed to address challenges in identifying disinvestment options. The proposed procedural change was then evaluated in a case study as part of a real-world priority setting exercise. The key finding of this research project was that adding a step -- that focused on the determination and communication of acceptable service reductions, at the outset of process implementation -- to the standard PBMA process, has the potential to assist in ‘disarming’ organizational incentives that have been found to work against the identification of disinvestment options. This key finding is of critical importance because without practical disinvestment options, priority setting processes are likely to have limited impact on decision-making and therefore limited practical appeal. Further, without formal, structured priority setting processes that actually work in practice, resource allocation decisions will continue to follow historical patterns, leading to incremental growth without explicit consideration of return on investment. As such, this study makes a novel contribution to the literature in an area that is highly relevant to the everyday challenges faced by health care decision-makers.
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Master's Student Supervision
Theses completed in 2010 or later are listed below. Please note that there is a 6-12 month delay to add the latest theses.
The cost of school food programs in British Columbia (2023)
BACKGROUND: Canada is currently the only OECD country without a national school food program. The Government of Canada recently committed to working with different levels of government, Indigenous partners, and stakeholders towards a national school food policy. However, limited data on the costs of running a program in Canada is an evidence gap for making informed policy decisions. OBJECTIVES: This project aimed to synthesize published literature on the full costs of producing school lunches, estimate these costs in the BC provincial context, and gain stakeholder insights on the context and costs of existing programs in BC. METHODS: A literature review through Ovid MEDLINE, Web of Science, CAB Direct, ERIC (EBSCO), and additional grey literature gathered evidence on the costs of producing school lunches. Through a subsequent costing exercise, these costs were estimated in BC and a novel interactive costing tool was developed. Interviews (n=9) then highlighted perspectives of school district staff, government representatives, those directly involved in school food programs, and those with expertise on programs costs. These perspectives offered insights and contextualized the existing school food programs in BC, as well as the estimates and the interactive costing tool from the costing exercise. RESULTS: The literature (n=6 studies) reported costs associated with school lunches in the US, Norway, and Wales. The ensuing costing exercise produced a range of $2.79 to $5.18 for the estimated cost of preparing lunches in BC schools, while an array of input variables – including school characteristics (e.g., number of students), staffing information, additional costs, and revenue – were used to build the interactive costing tool. Stakeholders responded positively to the tool and highlighted its value for program planning, while providing insights into the major cost categories (e.g., food, human resources, infrastructure) and the policy considerations relevant to the BC context. DISCUSSION: This novel interactive costing tool is the key contribution of this research project. It simultaneously addresses the knowledge gap (of the missing evidence on school food program costs) while allowing the user to define the costing parameters using real numbers when estimating the costs of preparing school lunches in BC.
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Describing sources of uncertainty in cancer drug formulary priority setting across Canadian provinces (2021)
Introduction: Over the years, there have been significant advances in oncology. However, the rate that therapeutics come to market have increased while the strength of evidence has decreased - leaving decision makers with more uncertainty than ever before. Currently, there is limited understanding about how this uncertainty is understood and managed in provincial funding decisions for cancer therapeutics. Methods: A qualitative, two-phase study approach was employed. Phase I comprised of semi-structured key-informant interviews (n=6) with senior officials from four Canadian provinces (BC, AB, QC and ON). In part II, a document review of the uncertainties found in clinical evidence in the pan-Canadian Oncology Drug Review (pCODR) assessments was conducted. Interviews in part I were audio-recorded and transcribed verbatim. Results: Participants included stakeholders from British Columbia (BC) (n=1), Alberta (AB) (n=1), Quebec (QC) (n=3) and Ontario (ON) (n=1) whom held a variety of roles in ministries of health, cancer agencies and national health technology assessment (HTA) organizations that evaluate evidence and make funding recommendations. Participants reported considerable uncertainty related to a lack of solid clinical evidence (early-phase clinical trials: generalizability, immature data and the use of unvalidated surrogate outcomes). Clinical uncertainty was exacerbated with high costs and accelerated approvals. Other sources of uncertainty were related to external influences. Proposed strategies to deal with the uncertainty included risk-sharing agreements, collection of real-world evidence (RWE) and ongoing collaboration between federal groups and provinces. The document review added to the reported uncertainties by classifying them into five main categories: trial validity, population, comparators, outcomes and intervention. Conclusion: This study highlights that decision makers have to deal with more uncertainty in funding decisions for cancer drugs than ever before and that this uncertainty generally stems from clinical trials. Since only one decision maker could identify a deliberative priority setting process and cancer drugs are rarely reassessed, this situation might leave ineffective drugs in the health system. These drugs can incur opportunity costs. There is a critical need for transparent priority setting processes and mechanisms to reevaluate drugs to ensure benefit given the high level of uncertainty of novel therapeutics.
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Multi-criteria decision analysis comparing agricultural production methods: protocol for analyzing British Columbia blueberries (2020)
INTRODUCTION: Methods such as Multi-criteria decision analysis (MCDA) are often applied to assess how preferences to make rational choices are applied. This thesis aims to examine how farmers balance environmental and social factors of sustainability and health with economic factors (e.g. costs) by assessing their preference for applying alternative agricultural approaches (e.g. conventional, agro-ecological/organic, and integrated farming/mixed-methods).METHODS: First, a systematic bibliometric review of studies that used MCDA techniques for agricultural purposes was conducted to consider the ways that the analytical approach was being applied in this area. The review was restricted to all English language studies of farm-based agricultural studies that considered cost in their analysis. Studies from the Web of Science, CAB Direct, and Agriculture & Environmental Science databases were reviewed to identify publication trends that helped situate the objectives the thesis’ own MCDA feasibility study. Second, a small group (9) of BC Blueberry farmers were interviewed using an Analytic Hierarchy Process (AHP) MCDA technique to elicit their preferred production system while considering potential constraints. The costs of agricultural production systems were divided by the aggregate value scores of the AHP, and systems ranked on their cost-benefit ratio.RESULTS: MCDAs in agriculture have become increasingly popular over time, particularly AHPs in Europe and Asia, and in fruit, vegetable, and nuts farming sectors. Most studies considered costs as one of the criteria in the analysis, most often as a production/operating cost. Health was not mentioned extensively in these studies. The MCDA study showed that organic farming is the most preferred method without the consideration of costs, but conventional farming was the most preferred in the cost-benefit ratio.CONCLUSION: Farmers prefer to be more mixed-methods or ecological (without the consideration of costs), constraints (specifically costs) prevent them from practicing their preferences. As a novel approach in agriculture, the MCDA-CBA is a feasible tool to understand farmer preferences and how they can be advocated for to achieve more sustainable and healthy processes in policy. MCDA-CBA has potential for understanding health and sustainability as connected with similar, if not the same, goals and criteria.
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Home telemonitoring technology for heart failure patients; a cost-consequence analysis and narrative systematic review (2019)
Introduction: Heart failure (HF) is a costly health condition and a major public health problem.2%-3% of the population in developed countries has heart failure, and the prevalence increasesto 8% among patients 75 years and above.¹⁰ Home telemonitoring is a form of non-invasive,remote patient monitoring that aims to improve patient care and management.¹ Telehealth forEmergency-Community Continuity of Care Connectivity via Home- Telemonitoring(TEC4Home) implements and evaluates a home monitoring protocol to support seniors withHeart Failure as they transition from the ED to home.²Methods: A cost-consequence analysis of the TEC4home pilot study was conducted, assessingthe costs of the home monitoring platform relative to usual care and costs related to healthcareutilization during the 90-day post-discharge period. Additionally, a systematic review of theeffects of home monitoring technology to evaluate the effect of telemonitoring on healthcareutilization and quality of life of Heart Failure patients.Results: The overall results from systematic review showed a generally positive trend, withpatients in the telemonitoring arm experiencing reductions in health care utilization. However,the variations in study outcomes, technology design, study protocol, etc. make it difficult tomake a definitive conclusion on the efficacy of telemonitoring technology in heart failurepatients. However, variations in study outcomes, technology design, study protocol, etc. make itdifficult to make a definitive conclusion. Economic analysis of the TEC4home pilot studyshowed a positive trend in cost savings for patients using TEC4home.Conclusion: The systematic review component of this study highlighted the fact there is somelevel of uncertainty regarding the efficacy of telemonitoring in heart failure patients. In line withthe advantages of conducting an economic analysis alongside a feasibility study, the economicanalysis of the TEC4home pilot study facilitated the piloting of patient questionnaires and it hasalso informed the methodology for the full clinical trial which is currently underway in BC.
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Describing practices of priority setting in publicly funded health care systems of high-income countries (2018)
Spending in health care have grown considerably over the last decades in all developed countries. Aging populations and novel technologies are usually deemed as the main drivers for such unsustainable trend in the finances of health systems. In this scenario, setting priorities for investments becomes a central concern. Making hard choices in a rational, evidence-informed, systematic, transparent, legitimate, and fair manner has constituted an increasingly important target. Notwithstanding the voluminous body of literature in this area, most of work focus on developing and improving prescriptive approaches as well as presenting case studies. The present work aimed to describe existing practices of priority setting and resource allocation within the context of publicly funded health care systems of high-income countries. An online qualitative survey was used with decision makers and academics from 18 countries. Four hundred and fifty individuals were invited and 58 answered the survey questionnaire. We found that resource allocation in health care has been still largely done based on historical patterns and through ad hoc decisions, despite the wide understanding that decisions must be formally based on multiple explicit criteria. Health technology assessment (HTA) was the tool most commonly indicated by participants as a formal strategy of priority setting. Several approaches have been tested and published, with special emphasis on Program Budgeting and Marginal Analysis (PBMA), but there is limited evidence of their continuous and systematic use by health organizations across countries. A point of increasing convergence is the reliance of multiple types of evidence to judge the value of investment options. Disinvestment frameworks are very rare and the topic itself has only started to appear with any regularity. This work represents the first attempt to identify existing practices of priority setting in a systematic way through a qualitative descriptive study. Despite its methodological limitations, it provides a better understanding of the current scenario of policy making and research in this field.
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The Influence of a Pediatric Palliative Care Program on Health Care Utilization and Costs (2015)
Pediatric palliative care program (PPCP) is believed to increase system efficiency. British Columbia (BC) relies on a free-standing hospice-based PPCP, and its effects on health care utilization and costs remain an outstanding question. This study aimed to gather evidence in a combined analysis of data from literature and BC PPCP. A systematic review was conducted through an electronic search of Medline, Embase, CINAHL, LILACS, and grey literature. Comparative studies reporting admissions, length of stay, and health care costs between PPCP users and usual care were included. Additionally, a similar comparison was applied to the data from BC PPCP using a retrospective matched-pairs cohort design (matched by ICD code and age at death) with a 3-year observational period prior to death. Data were obtained from Canuck Place Children’s Hospice and BC Children’s Hospital databases, and complemented by estimates from Canadian Institute for Health Information. A cost impact of the overall inpatient care provided by the hospice was presented. The review did not demonstrate a decrease in utilization by PPCP users yet suggested a shift to other health care settings, and potential cost saving in the Canadian context (1 article). The cohort study (n=11 pairs), suggests that children in both groups had similar upward trends in inpatient utilization and cost. However, PPCP users showed more inpatient care in the last year of life (especially critical care in the last 2 months), compared to their controls and to the period prior to referral. Post-referral, a shift in health care setting utilization from hospital to hospice was observed, representing approximately 50% of the costs. Without this shift PPCP users would have cost 32% more with a median monthly increment of $7,163 per child. All inpatient care provided by the hospice in the fiscal year 2011-2012 represented a potential cost saving ranging from approximately $1.1M to $4.3M. The findings of this study suggest that PPCP users may present higher health care needs, and that the shift of inpatient care to the hospice optimized resource use, offering a more holistic approach to EOL care, relieving hospital resources to meet other demands.
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Development and implementation of a priority setting and resource allocation evaluation tool for achieving high performance (2013)
Objective: Canadian healthcare decision makers are facing greater pressure in setting priorities and allocating resources. However, recent studies suggest that only about 50% of healthcare organizations follow a formal priority setting process, and that even fewer are evaluating their processes to achieve ongoing improvement. This research developed an evaluation tool to help organizations identify the strengths and weaknesses of their process, and performed a meta-evaluation of the tool itself to inform future refinements.Methods: A high performance framework for priority setting and resource allocation formed the foundation for this research. The framework was operationalized into an evaluation tool that took the form of a semi-structured interview. The tool was then implemented in test organization. Data from this application were analyzed using template and content analysis, and organizational strengths and weaknesses were identified. At the end of each evaluation interview, debriefs with participants were used to inform refinements for future applications of the tool.Results: The evaluation tool was successfully developed from the high performance framework, and was implemented through interviews with 27 members of the test organization. Strengths of the organization’s process included involvement of a strong leadership team and use of a proposal assessment tool. Weaknesses included lack of training, and the presence of proposals that circumvented the formal process. Refinements to the tool involved formatting of interview questions as well as the addition of a new element and a new sub-element.Conclusion: This research represents the first attempt at creating an evaluation tool using the high performance framework, and is novel in its application at a macro level within the test healthcare organization. Based on feedback from participants and the ability of the tool to capture relevant strengths and weaknesses of the organization’s process, further application is warranted. Future implementation will also serve to further refine the tool itself.
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The development of a disinvestment framework to guide resource allocation decisions in health care service delivery organizations (2012)
Objective: Within publicly funded health care, there is an urgent need to reduce spending while maximizing benefits; however, processes to guide so-called disinvestment decisions are lacking. The purpose of this research is to develop a framework that will provide decision-makers with a more equitable approach to meeting budgetary constraints than current practices.Methods: Through a systematic review of the health care literature and a scoping review of the public sector and business literatures, a knowledge synthesis of disinvestment approaches was created, including analyses of current strategies and the modeling of appropriate processes. From this synthesis, a disinvestment framework has been developed. In collaboration with Chief Financial Officers from across Western Canada and an external reference group comprised of international researchers, the framework has been critiqued in keeping with current resource allocation practices. Results: Evidence from the two reviews revealed that while budgetary cutbacks are experienced across government, non-profit and the private sector, very few processes have been developed to identify and implement disinvestment options. In cases of budget re-allocation, program budgeting and marginal analysis (PBMA) was the most relevant framework described. However, PBMA fails to address stand-alone disinvestment requirements. Within the public sector and business literatures, cutback management and policy termination research offered strategies to mitigate barriers and facilitate implementation, however, details were absent. Drawing elements from the approaches identified in the reviews, and in collaboration with decision-makers and other researchers, a seven-step disinvestment framework was developed that can be incorporated into on-going priority setting practices or applied as a stand-alone activity. Conclusion: This work addresses a critical knowledge gap in how health service organizations approach disinvestment activities. The proposed framework provides detailed steps to equip health care decision makers with a clear and defined disinvestment process. Such a process will help to ensure limited funds are allocated based on evidence rather than across-the-board cuts or historical practices.
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