3.6 How do you assess costs associated with implementation?

Economic evaluation within healthcare generally compares two or more intervention options in relation to their cost and consequences. Commonly used methods include cost effectiveness, cost-utility and cost- benefit analysis.

Assessing the economics of an implementation strategy poses slightly different questions.An implementation strategy generally comes with additional costs. Therefore, the key economic question is whether the relative costs associated with the implementation strategy lead to a justifiable level of enhanced outcome as compared to usual/routine methods.(98) If enhanced implementation can be shown to lead to improved service delivery and also result in improved client outcomes, then these may be more cost effective than usual care. Such information is crucial for policy- and decision-makers, managers and service providers.

The total costs of the intervention are estimated as a ratio of the outcome. This has been described using the following ratio:(98)

\[\mathrm{\substack{Implementation \ Cost \\ \mathrm{effectiveness \ ratio}}} = \frac {\mathrm {Cost_{\mathrm {Implementation \ strategy}}} - \mathrm {Cost_{\mathrm {Usual \ strategy}}}} {\mathrm {Outcome_{\mathrm {Implementation \ strategy}}} - \mathrm {Outcome_{\mathrm {Usual \ strategy}}}}\]

‘Cost’ may include:

  • direct labour costs – costs associated with consumer- or implementer- contact (e.g. the time cost of having a clinician coach a consumer through a new health app or deliver a training programme to service delivery staff);
  • indirect labour costs – additional costs associated with the consumers and implementers which do not require direct contact (e.g. developing resources or planning for the intervention);
  • non-labour costs – additional overheads and resource costs associated with the intervention (e.g. building space, printing of resources, etc.).

‘Outcome’ may include:

  • consumer-level health outcomes;
  • implementer-level outcomes – associated with the intervention (e.g. enhanced communication, collaboration  and/or  service delivery).

Additional benefits may be seen in the timeliness of care.

Systematic implementation incurs costs above that of the intervention itself, with the bulk of this cost currently being borne by implementers (e.g. provider organizations). However, economic evaluation is relatively new to the field of implementation and there is a paucity of literature on the topic. The research base around economic evaluation of implementation therefore needs to be developed. If studies reveal added benefits of a particular implementation strategy above usual practice, then policy- and decision- makers will need to think about getting additional resources to successfully implement the strategy.(98)