Inclusion of Environmental Spillovers in Applied Economic Evaluations of Healthcare Products

What are the Revealed and Stated Population Preferences for Environmental Sustainability in Healthcare? A Scoping Review

OBJECTIVE

Collective changes in healthcare practices are required to ensure real environmental gains. As patient-centred care is increasingly considered to enhance the ability of health systems to meet the expectations of the population, it is crucial for policymakers and health professionals to account for the preferences of the wider public regarding environmentally friendly healthcare. This article synthesises and appraises evidence from empirical studies to understand how people value environmental concerns when making decisions within medical-related or pharmaceutical sectors.

METHODS

We conducted electronic searches of the PubMed, Scopus, and Embase literature databases. Studies were eligible if they conducted a quantitative experiment to understand participants' preferences regarding sustainability and green initiatives in the medical sector or for pharmaceuticals.

RESULTS

Of the 1138 documents identified, 32 studies were deemed eligible. More than 60% were published since 2020. Different methods were used to elicit the revealed and/or stated preferences of participants. In most studies, respondents valued the environment positively and were willing to change their behaviour or practices to support sustainability. However, concerns such as disease severity or clinical effectiveness of medicines or medical interventions were often prioritised over environmental considerations. The wide heterogeneity in study participants emphasises the need to involve all stakeholders to achieve the transition to a greener and sustainable healthcare system.

CONCLUSION

The identified studies used various methods but were consistent in finding broad support for environmental considerations within the healthcare sector.

Cost of Carbon in the Total Cost of a Healthcare Procedure: Example of Micro-Costing Study in a French Setting

BACKGROUND

Economic evaluation aims to compare the costs and results of health strategies to inform public decision making. Although sometimes suggested, until now no national evaluation agency has recommended formally incorporating the cost of greenhouse gas (GHG) emissions generated by health interventions into the estimation of healthcare costs.

OBJECTIVE

The objective of this study was to test and discuss the feasibility of estimating and including the contribution of GHG emissions cost to the total cost of a surgical intervention, with the example of robot-assisted total knee arthroplasty (RTA), using a micro-costing approach.

METHODS

The study was conducted in June 2022 at the William Morey Hospital (France). Data regarding all of the resources (labor, medical equipment, consumables), as well as energy consumption, staff commuting and waste treatment were collected and valued from the hospital point of view. Greenhouse gas emissions were valued using a cost-effectiveness approach. Several sensitivity analyses were performed.

RESULTS

The mean cost per patient of an RTA was estimated to be €4755.65, of which €152.64 (3.21 %) would be attributable to GHG emissions. The contribution of GHG emissions in the overall cost of a health intervention was highly dependent on the convention used for the price of carbon.

CONCLUSION

Despite persistent theoretical and practical challenges, adding the estimation of GHG emission costs in the economic evaluation of health interventions may provide institutional decision makers with information that allows them to allocate the public healthcare resources more efficiently.

Intensive care unit carbon footprint: A bibliometric and document content analysis

BACKGROUND

Sustainable low-carbon health systems are among the United Nations Climate Change Conference (COP27) goals. The literature states that 4.9% of greenhouse gas emissions originate from the health sector.

AIM

This study aimed to quantify and visualize trends, citations, key terms and countries of publications about the carbon footprint of intensive care and review their contents.

STUDY DESIGN

A bibliometric analysis was conducted on 14 articles selected by searching the SCOPUS database using the keywords 'Environmental sustainability', 'Environmental footprint', 'Carbon footprint' and 'Intensive care unit'. MS Excel was used to create graphs, and VOSviewer was used to perform network analysis. Content analysis methods were used to describe the details in each document.

RESULTS

Most articles on intensive care carbon footprint and environmental sustainability were published in 2023 (n = 7, 47%), with the first publication in 2014. The article 'Environmental sustainability in anaesthesia and critical care', from the British Journal of Anaesthesia, was the most cited, with 166 citations. The carbon footprinting studies were conducted in the United Kingdom, Australia, United States and the Netherlands.

CONCLUSION

Minimizing electricity usage and waste generation (reducing, reusing and recycling more) can reduce the carbon footprint of intensive care. The number of studies on the subject was limited, and although none were specifically about nurses, sustainability and environmental impact are relevant topics for all intensive care staff.

RELEVANCE TO CLINICAL PRACTICE

Nurses and other health care professionals can improve environmental sustainability by better understanding how to reduce the carbon footprint of intensive care units.

Verso un Green Health Technology Assessment: il ruolo del Life Cycle Assessment per scelte sanitarie più sostenibili

The healthcare sector significantly contributes to global greenhouse gas emissions. Among the various strategies available, exploring the integration of environmental sustainability into Health Technology Assessment (HTA) presents a potential avenue for addressing these impacts. The HTA Core Model, widely utilized by European HTA agencies, evaluates healthcare technologies across nine domains; however, environmental considerations remain peripheral and are primarily confined to certain safety-related aspects. This paper examines the potential role of Life Cycle Assessment (LCA) in complementing HTA to better address environmental impacts. LCA offers a systematic methodology to evaluate environmental effects across the full lifecycle of a product, from raw material extraction to disposal. Through the analysis of pharmaceuticals, telemedicine, and surgical practices, the study identifies critical environmental impacts at various lifecycle stages, illustrating how LCA could support more informed and sustainable decision-making in healthcare. These findings underscore the diverse environmental impacts associated with healthcare technologies and highlight the need for tailored strategies to mitigate them. This point of view emphasizes the importance of initiating discussions on developing a framework to incorporate environmental impacts into HTA systematically, promoting healthcare decisions that prioritize both human and environmental healths.

Herpes zoster in older adults: Impact on carbon footprint in the United States

We provide estimates for (I) annual herpes zoster (HZ) cases, (II) carbon costs related to healthcare utilization, and (III) annual carbon emissions due to HZ among ≥50 years of age (YOA) United States (US) population. We estimated the annual number of HZ cases in the US based on available incidence data and demographic data of individuals ≥50 YOA. Both the healthcare resource utilization (HCRU) associated with HZ cases and the unit carbon dioxide equivalent (i.e. CO2e) costs associated with each type of HCRU in the US were estimated based on literature and studies available online. The carbon footprint associated with HZ annually among US adults ≥50 YOA was estimated by multiplying the unit carbon estimates by the HCRU. In the US population aged ≥50 YOA in 2020 (i.e. approximately 118 million), approximately 1.1 million cases of HZ occur annually assuming no vaccination. Based on 2 sources of HCRU the average kgCO2e per HZ patient ranged from 61.0 to 97.6 kgCO2e, with values by age group ranging from 40.9 kgCO2e in patients aged 50-59 to 195.9 kgCO2e in patients ≥80 YOA. The total annual HZ associated carbon ranged between 67,000 and 107,000 tons of CO2e in the US population aged ≥50 YOA. The impact of HZ on carbon footprint in the US results in considerable greenhouse gas (GHG)emissions. Assuming no vaccination, the burden of HZ is projected to rise over the coming years with the aging populations consequently worsening its impact on GHG emissions. (Figure 1).

Strategies and tactics to reduce the impact of healthcare on climate change: systematic review

OBJECTIVE

To review the international literature and assess the ways healthcare systems are mitigating and can mitigate their carbon footprint, which is currently estimated to be more than 4.4% of global emissions.

DESIGN

Systematic review of empirical studies and grey literature to examine how healthcare services and institutions are limiting their greenhouse gas (GHG) emissions.

DATA SOURCES

Eight databases and authoritative reports were searched from inception dates to November 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Teams of investigators screened relevant publications against the inclusion criteria (eg, in English; discussed impact of healthcare systems on climate change), applying four quality appraisal tools, and results are reported in accordance with PRISMA (preferred reporting items for systematic reviews and meta-analyses).

RESULTS

Of 33 737 publications identified, 32 998 (97.8%) were excluded after title and abstract screening; 536 (72.5%) of the remaining publications were excluded after full text review. Two additional papers were identified, screened, and included through backward citation tracking. The 205 included studies applied empirical (n=88, 42.9%), review (n=60, 29.3%), narrative descriptive (n=53, 25.9%), and multiple (n=4, 2.0%) methods. More than half of the publications (51.5%) addressed the macro level of the healthcare system. Nine themes were identified using inductive analysis: changing clinical and surgical practices (n=107); enacting policies and governance (n=97); managing physical waste (n=83); changing organisational behaviour (n=76); actions of individuals and groups (eg, advocacy, community involvement; n=74); minimising travel and transportation (n=70); using tools for measuring GHG emissions (n=70); reducing emissions related to infrastructure (n=63); and decarbonising the supply chain (n=48).

CONCLUSIONS

Publications presented various strategies and tactics to reduce GHG emissions. These included changing clinical and surgical practices; using policies such as benchmarking and reporting at a facility level, and financial levers to reduce emissions from procurement; reducing physical waste; changing organisational culture through workforce training; supporting education on the benefits of decarbonisation; and involving patients in care planning. Numerous tools and frameworks were presented for measuring GHG emissions, but implementation and evaluation of the sustainability of initiatives were largely missing. At the macro level, decarbonisation approaches focused on energy grid emissions, infrastructure efficiency, and reducing supply chain emissions, including those from agriculture and supply of food products. Decarbonisation mechanisms at the micro and meso system levels ranged from reducing low value care, to choosing lower GHG options (eg, anaesthetic gases, rescue inhalers), to reducing travel. Based on these strategies and tactics, this study provides a framework to support the decarbonisation of healthcare systems.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42022383719.

Accounting for planetary boundaries in health economic evaluation

INTRODUCTION

Health economic evaluation (HEE) provides guidance for decision-making in the face of scarcity but ignores ecological scarcities as long as they involve external costs only. Following the imperative to account for planetary health, this study explores how this blind spot can be addressed.

AREAS COVERED

The study is based on a critical review of relevant work, particularly in the fields of HEE and life cycle assessment (LCA). LCA can provide information on a technology's environmental impacts which can be accounted for on both the effect and cost sides of HEE. Cost-benefit analyses can incorporate environmental impacts in case vignettes used for eliciting consumers' willingness to pay. Existing LCA impact models can be used to estimate human health risks associated with environmental impacts and add them to the health benefits in cost-utility analyses. Many jurisdictions offer lists of shadow prices that can be used to incorporate environmental impacts on the cost side of HEE. Also, environmental impacts can be reported in a disaggregated manner.

EXPERT OPINION

Accounting for planetary boundaries is likely to become a key field of methodological innovation in HEE. Decision relevance is likely to be highest for technologies with similar cost-effectiveness but different ecological impacts.

Cost of Carbon in the Total Cost of Healthcare Procedures: A Methodological Challenge

Economic evaluations aim to compare the costs and the results of health strategies to guide the public decision-making process. Cost estimation is, thus, a cornerstone of this approach. At present, few national evaluation agencies recommend incorporating the cost of greenhouse gas (GHG) emissions from healthcare actions into the calculation of healthcare costs. Our main goal is to describe and discuss the methodology for integrating the cost of GHG emissions into the field of applied economic evaluations. To estimate this cost, three steps are required: (1) identifying and quantifying the physical flows linked to the production and management of the outputs of healthcare interventions, (2) estimating the quantity of GHG that can be attributed to each physical flow, and (3) valuing these GHG emissions in monetary terms. Integrating the cost of GHG emissions into the calculation of the costs of healthcare interventions is both useful and relevant from a perspective of collective intergenerational well-being. This approach has been made possible thanks to the existence of accounting and monetary valuation methods for emissions. Agencies specialized in health economic evaluations could take up this issue to resolve ongoing questions, thus providing researchers with a methodological framework and public decision-makers with some key insights.

On spillovers in economic evaluations: definition, mapping review and research agenda

An important issue in economic evaluations is determining whether all relevant impacts are considered, given the perspective chosen for the analysis. Acknowledging that patients are not isolated individuals has important implications in this context. Increasingly, the term "spillovers" is used to label consequences of health interventions on others. However, a clear definition of spillovers is lacking, and as a result, the scope of the concept remains unclear. In this study, we aim to clarify the concept of spillovers by proposing a definition applicable in health economic evaluations. To illustrate the implications of this definition, we highlight the diversity of potential spillovers through an expanded impact inventory and conduct a mapping review that outlines the evidence base for the different types of spillovers. In the context of economic evaluations of health interventions, we define spillovers as all impacts from an intervention on all parties or entities other than the users of the intervention under evaluation. This definition encompasses a broader range of potential costs and effects, beyond informal caregivers and family members. The expanded impact inventory enables a systematic approach to identifying broader impacts of health interventions. The mapping review shows that the relevance of different types of spillovers is context-specific. Some spillovers are regularly included in economic evaluations, although not always recognised as such, while others are not. A consistent use of the term "spillovers", improved measurement of these costs and effects, and increased transparency in reporting them are still necessary. To that end, we propose a research agenda.

Methods to Include Environmental Impacts in Health Economic Evaluations and Health Technology Assessments: A Scoping Review

OBJECTIVES

The environmental impacts of healthcare are important factors that should be considered during health technology assessments. This study aims to summarize the evidence that exists about methods to include environmental impacts in health economic evaluations and health technology assessments.

METHODS

We identified records for screening using an existing scoping review and a systematic search of academic databases and gray literature up to September 2023. We screened the identified records for eligibility and extracted data using a narrative synthesis approach. The review was conducted following the JBI Manual for Evidence Synthesis and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses Extension for Scoping Reviews checklist.

RESULTS

We identified 2898 records and assessed the full text of 114, of which 54 were included in this review. Ten methods were identified to include environmental impacts in health economic evaluations and health technology assessments. Methods included converting environmental impacts to dollars or disability-adjusted life years and including them in a cost-effectiveness, cost-utility, or cost-benefit analysis, calculating an incremental carbon footprint effectiveness ratio or incremental carbon footprint cost ratio, incorporating impacts as one criteria of a multi-criteria decision analysis, and freely considering impacts during health technology assessment deliberation processes.

CONCLUSIONS

Methods to include environmental impacts in health economic evaluations and health technology assessments exist but have not been tested for widespread use by health technology assessment agencies. Further research and implementation work is needed to determine which method can best aid decision makers to choose low environmental impact healthcare interventions.

Health technology assessment and healthcare environmental sustainability: Prioritizing effort and maximizing impact

The growing global focus on and sense of urgency toward improving healthcare environmental sustainability and moving to low-carbon and resilient healthcare systems is increasingly mirrored in discussions of the role of health technology assessment (HTA). This Perspective considers how HTA can most effectively contribute to these goals and where other policy tools may be more effective in driving sustainability, especially given the highly limited pool of resources available to conduct environmental assessments within HTA. It suggests that HTA might most productively focus on assessing those technologies that have intrinsic characteristics which may cause specific environmental harms or vulnerabilities, while the generic environmental impacts of most other products may be better addressed through other policy and regulatory mechanisms.

How environmental impact is considered in economic evaluations of critical care: a scoping review

PURPOSE

Health care is a major contributor to climate change, and critical care is one of the sector's highest carbon emitters. Health economic evaluations form an important component of critical care and may be useful in identifying economically efficient and environmentally sustainable strategies. The purpose of this scoping review was to synthesise available literature on whether and how environmental impact is considered in health economic evaluations of critical care.

METHODS

A robust scoping review methodology was used to identify studies reporting on environmental impact in health economic evaluations of critical care. We searched six academic databases to locate health economic evaluations, costing studies and life cycle assessments of critical care from 1993 to present.

RESULTS

Four studies met the review's inclusion criteria. Of the 278 health economic evaluations of critical care identified, none incorporated environmental impact into their assessments. Most included studies (n = 3/4) were life cycle assessments, and the remaining study was a prospective observational study. Life cycle assessments used a combination of process-based data collection and modelling to incorporate environmental impact into their economic assessments.

CONCLUSIONS

Health economic evaluations of critical care have not yet incorporated environmental impact into their assessments, and few life cycle assessments exist that are specific to critical care therapies and treatments. Guidelines and standardisation regarding environmental data collection and reporting in health care are needed to support further research in the field. In the meantime, those planning health economic evaluations should include a process-based life cycle assessment to establish key environmental impacts specific to critical care.