Sam Watson’s journal round-up for December 5th 2016

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

Choice of hospital: Which type of quality matters? Journal of Health Economics. [PubMedPublished December 2016.

We have covered a number of papers over the last few months on the relationship between hospital quality and patient choice. In one post, we discussed a paper that analysed the effect of pro-choice reforms on patient choice and outcomes in the English NHS, but argued that their measure of quality, risk-adjusted mortality rates, were not a good indicator or proxy. This article looks at the effect of quality on patient choice for patients undergoing a hip replacement. Quality is captured using the Oxford Hip Score (OHS), a hip replacement specific instrument, which measures overall health status for these patients. They find that the OHS score is only weakly correlated with readmission and mortality rates, and that hospital demand is highly elastic with respect to average OHS gain, but not mortality and readmission rates. This suggests patient respond to health gain from treatment, at least for health gain; there remains a question about how patient find out about hospital quality, although another recently featured paper may shed light on this.

Moving to Opportunity or Isolation? Network Effects of a Randomized Housing Lottery in Urban India. American Economic Review: Applied Economics. [NBER, RePEcForthcoming.

The rapid pace of urbanisation in low and middle income countries has led to the growth of slums. In response, governments have tried to implement new programs to improve the health and welfare of those living in slums. In a recent post, we documented the difficulties in the measurement of the health of people who live in slums and the evaluation of interventions. Part of the difficulty with measuring neighbourhood effects in a scientific sense is that randomisation is typically not possible. One notable example was the Moving to Opportunity experiements in the US. This article reports the long term outcomes from an Indian equivalent where a lottery was used to allocate new, improved housing built on the periphery of the slum. Interestingly, the experiment was not a success: 34% of the winners did not move, and 32% eventually exited the experiment. Part of this failure was the breakdown of community – many people became lonely or isolated. These findings clearly have implications for the design of slum upgrading programs and strategies to improve public health.

Well-being and gross national happiness for policy

In the early years of the coalition government, David Cameron lauded the measurement of happiness and well-being as an indicator of national performance. Data on life satisfaction have been collected and published by the Office for National Statistics every year since 2012. Despite this, very little is said about well-being. It is not discussed at spending or policy reviews and rarely in the media. Gross domestic product (GDP) continues to dominate the coverage of national performance and the potential impact of policies such as Brexit. Nevertheless, a precursory glance at the data can reveal an interesting picture of national well-being.


Proportion of respondents reporting their life satisfaction to be ‘high’ or ‘very high’. [Data source: ONS; .csv data; R code]

The map above plots the proportion of people reporting their life satisfaction to be ‘high’ or ‘very high’ across England and Wales. This corresponds to a score of seven or more on a ten point scale in response to the question:

Overall, how satisfied are you with your life nowadays? Where 0 is ‘not at all satisfied’ and 10 is ‘completely satisfied’.

There are clearly variations across the country, with the most obvious being the urban/rural divide. The proportion of people reporting ‘high’ or ‘very high’ life satisfaction in the UK has also increased over time, from 76.1% to 81.2% between 2012/3 and 2015/6, corresponding to a mean life satisfaction rating rising from 7.42 to 7.65.

Well-being data can also be used to evaluate the impact of policies or interventions in a cost-benefit analysis. Typically an in-depth analysis may model the impact of a policy on household incomes. But, these changes in income are only valuable insofar as they are instrumental for changes in well-being or welfare. Hence the attraction of well-being data. To derive a monetary valuation of a change in life satisfaction economists consider either compensating surplus or equivalent surplus. The former is the amount of money that someone would need to pay or receive to return them to their initial welfare position following a change in life satisfaction; the latter is the amount they would need to move them to their subsequent welfare position in the absence of a change. For example, to estimate the compensating surplus for a change in life satisfaction, one could estimate the effect of an exogenous change in income on life satisfaction. Such an exogenous change could be a lottery win, which is exactly the approach used in this report valuing the benefits of cultural and sports events like the Olympics.

Health economists have been one of the pioneering groups in the development and valuation of measures of non-monetary benefits. The quality-adjusted life year (QALY) being a prime example. However, a common criticism of these measures is that they only capture health related quality of life, and are fairly insensitive to changes in other areas of well-being. As a result there have been a growing number of broader measures of well-being, such as WEMWBS, that can be used as well as the generic life satisfaction measures discussed above. Broader measures may be able to capture some of the effects of health care policies that QALYs do not. For example, centralisation of healthcare services increases travel time and time away from home for many relatives and carers; reduced staff to patient ratios and consultation time can impact on process of care and staff-patient relationships; or, other barriers to care, such as language difficulties, may cause distress and dissatisfaction.

There are clearly good arguments for the use of broad life satisfaction and well-being instruments and sound methods to value them. One of the major barriers to their adoption is a lack of good data. The other barrier is likely to be the political willingness to accept them as measures of national performance and policy impact.


Alastair Canaway’s journal round-up for 28th November 2016

Every Monday our authors provide a round-up of some of the most recently published peer reviewed articles from the field. We don’t cover everything, or even what’s most important – just a few papers that have interested the author. Visit our Resources page for links to more journals or follow the HealthEconBot. If you’d like to write one of our weekly journal round-ups, get in touch.

The cost-effectiveness of antibiotic prophylaxis for patients at risk of infective endocarditis. Circulation [PubMed] Published 13th November 2016

Did NICE get it wrong? In 2008 NICE recommended stopping antibiotic prophylaxis (AP) for those at risk of infective endocarditis (IE). For those unfamiliar with this research area, AP refers to the use of antibiotics or similar to prevent infection complications. IE is an infection of the endocardial surface of the heart which can have severe, and potentially fatal consequences. NICE stopped the recommendation of AP for those at risk of IE whilst undergoing dental procedures citing lack of evidence of efficacy and cost-effectiveness. This paper sought to fill the void in evidence and conduct an economic evaluation of AP using the latest estimates of efficacy and resource use. The paper constructed a decision analytic model to estimate costs and benefits. Both resource use and adverse event rates were sourced through Hospital Episode Statistics. The results were pretty conclusive: AP was less costly and more effective (than no AP) for all patients at risk of IE. Scenario analyses suggested that AP would have to be substantially less effective than estimated for it to fail on grounds of cost-effectiveness. The paper estimated that the annual savings of reintroducing AP in England would be between £5.5m and £8.2m with a health gain of over 2600 QALYs. Given the low costs of AP, the consequent cost saving and health improvements, perhaps NICE will be persuaded to reconsider their decision.

Maximizing health or sufficient capability in economic evaluation? A methodological experiment of treatment for drug addiction. Medical Decision Making [PubMed] Published 17th November 2016

The standard normative framework for economic evaluation within the UK is extra-welfarism, specifically, using health as the maximand (typically measured using QALYs). Thus, the evaluative space is health, with maximisation as the decision rule. Arguments have been made that health maximisation is not always the most appropriate framework. It has been suggested that the evaluative space be broadened to include capability wellbeing (based on the work of Sen), whilst a minimum threshold approach has been touted as an alternative approach to decision making. Such an approach is egalitarian and aims to ensure all members of society achieve a ‘sufficient’ level of capability wellbeing. This paper reports a pilot trial for the treatment of drug addiction to explore how i) changing the evaluative space to that of capability wellbeing, and ii) switching the decision-making principle to sufficient capability, impacts upon the decisions made. The drug addiction context is particularly pertinent due to non-health spill over impacts to the patient and others. The intervention considers three treatments: treatment as usual (TAU), TAU with social behaviour and network therapy (SBNT) and TAU with goal setting (GS). The two measures of interest within this study are the EQ-5D-5L and the ICECAP-A (capability measure for adults), QALYs and years of full capability (YFC) were calculated. Additionally, years of sufficient capability (YSC) were also calculated, sufficient capability was determined by a score of 33333: ‘a lot’ on each dimension of the ICECAP-A instrument. The study examined four situations: i) broadening the costing perspective from NHS/PSS to government, ii) broadening the evaluative space from QALYs to YFC, iii) broadening both costing perspective and evaluative space, and iv) changing the decision making rule to years of sufficient capability (YSC). The study found that changing from health maximisation to capability maximisation changed the treatment decision, as did changing the perspective: treatment recommendation is sensitive to choice of evaluative space and perspective. In the YSC analysis, the decision remained the same as the YFC analysis. The authors note a number of limitations with their study. The biggest for me, was the sample size of 83 – unsurprising given this was a pilot trial. As a result of the small numbers in each arm (30, 27, and 26) there is a surfeit of uncertainty, and just a handful of extreme cases in any one arm has the potential to change the results, and so it is difficult to draw any firm conclusions from this study. This paper however does provide a good starting point for the novel YFC approach, I’d be very interested in seeing this operationalised in a larger trial.

Does the EQ-5D capture the effects of physical and mental health status on life satisfaction among older people? A path analysis approach. Quality of Life Research [PubMed] Published 19th November 2016

This study sought to identify whether the EQ-5D captures impacts of mental and physical health on life satisfaction (LS) of older adults. This involved a retrospective cohort of 884 patients in Ireland. Path analysis was used to evaluate the direct and indirect effects. The EQ-5D-3L was used to measure health-related quality of life, whilst life satisfaction was measured with the life satisfaction index (LSI). Various specific measures of health status were also measured, e.g. co-morbidity level, activity limitation, and anxiety and depression. Within the analysis a number of assumptions were required, specifically around causation. The overall findings suggest that the EQ-5D-3L sufficiently captures the impact of physical health on life satisfaction, but not mental health. The author’s reflect that this may be due to a fundamental incommensurability of the general public’s preferences (who value the health states for the EQ-5D) and those who experience these health states. The authors conclude that the EQ-5D-3L should be used with caution within economic evaluations, and the use of the EQ-5D will underestimate benefits of treatment to mental health. The authors suggest alternative measures: HUI-3, AQoL and the ICECAP, and advocate their use alongside the EQ-5D within economic evaluation to better capture mental health impacts. A lot of this boils down to existing issues of debate: who should do the valuing (patient vs society), what are we trying to maximise (health vs well-being, or minimum threshold) and are existing measures doing the job they are supposed to be doing (is the EQ-5D fit for purpose). All these are interesting areas and it’s nice to see these issues being pushed to the fore once more.