In this blog Dr Ruth Abrams and Professor Heather Gage share their thoughts about working on realist evaluations with a health economic (HE) component…
There is often an absence of exploring cost-effectiveness within broader evaluations despite this being a crucial component in understanding service sustainability. For realist evaluations, exploring cost-effectiveness requires reflection on the implications of differing perspectives for data collection, analysis and presentation.
Economic evaluations focus on costs (based on resource use) and measures of effect (that could be beneficial or negative) to establish value-for-money (i.e. cost effectiveness). It is usually a relatively precise process involving quantification, although there is a spectrum and narrative presentation of findings is possible. Establishing cost-effectiveness always involves a comparator, i.e. an intervention can only be cost effective in comparison to another intervention or the status quo.
There is no reason why a realist analysis (of what works, for whom and under what circumstances) cannot be applied to questions about costs and cost effectiveness. Realist evaluations and economic evaluations are potentially complementary but there are two key differences between economic evaluations and realist approaches:
Firstly, outcomes: In realist terms, outcomes are not pre-defined in the same way that an economic evaluation requires them to be. Realist outcomes can be what you are working towards determining as part of the realist process and, whilst in some cases might already ‘exist’, they can also arise inductively. Within a realist evaluation, space needs to be given to this process of discovery. Economic evaluation usually involves data collection on specific and valid outcomes, determined at the outset of an evaluation and this can be a tricky distinction to iron out initially.
Secondly, effectiveness. When we consider effectiveness in realist terms, it is done at the level of interpretation. This is largely due to the underpinning philosophy of realism which constitutes that whilst there is a ‘reality’ ‘out there’ it can only ever be accessed through individual interpretations. However, for an economic evaluation, effectiveness is often quantifiable, deterministic, and size of effect is important.
Is there an interface? Anderson and Hardwick (2016) argue that there is and the REEM study led by Sonia Dalkin and Angela Bate is designing guidelines to cover this. Integration is a live challenge being faced by an increasing number of realist researchers. For example, Ruth is currently leading a realist evaluation of the dementia care coordinator service which has an embedded economic component led by Heather. Strides are also being made by Tomasina Oh working on the D-PACT project,. This is an area of huge potential and it is an exciting space to watch.
Please cite this blog as: Abrams, R and Gage, H. (2023) Realist work and Health economics: working across interfaces, Realist Health & Social Care SIG, Dec. Available at: https://rabrams0.wixsite.com/realistworkforce-sig/post/realist-work-and-health-economics-working-across-interfaces
References
Anderson, R., & Hardwick, R. (2016). Realism and resources: Towards more explanatory economic evaluation. Evaluation, 22(3), 323 - 341. https://doi.org/10.1177/1356389016652742
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