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Paul Mitchell’s journal round-up for 25th April 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.

Cost of care for cancer patients in England: evidence from population-based patient-level data. British Journal of Cancer [PubMedPublished 12th April 2016

It is tempting to be sceptical of some of the economic costing of health conditions that is conducted in the academic literature, with often heroic assumptions made to hyperbolise the burden of disease X on society. However, the analysis conducted in this study on the costs of cancer care in England could not be labelled as one of them, and it gives a good example of making the most of routinely collected data to estimate the costs of conditions related to hospital care. By combining data from the National Cancer Data Repository and the Hospital Episode Statistics (an administrative dataset that records all hospital episodes in England), the authors are able to conduct long-term cost analysis that the authors argue has been restricted to analysis in the United States previously. The authors estimate the cost of breast, colorectal, lung and prostate cancer diagnosis in the period of 2001-2010. As well as estimating the cost per cancer per year, they also undertake a curious “phase of care” costing, broken up into three phases: 1. Initial (first six months post diagnosis), 2. Terminal (final 12 months of life) and 3. Continuum (time period between initial and terminal). The authors also conduct subgroup analysis by age (18-64 vs 65 years and older) and cancer stage, where available. In total, the authors find that the four cancers under examination cost approximately 3% (£1.5bn) of the English hospital care budget in 2010. The authors also find a higher increment in cost in treating the 18-64 age group in the initial phase post diagnosis compared to the 65 years and older age group, that the authors apportion to a higher probability of surgery in younger people. Although the authors are right to claim their costing methodology offers advances on more top-down approaches conducted previously, a number of factors remain unaccounted for in this analysis. They do acknowledge the missing primary and social care services in this analysis, but the lack of costing of pharmaceutical intervention in cancer when it is likely to make up a significant percentage of total costs is something that needs to be considered in future analysis to estimate the overall cost associated with the four cancers. Nonetheless, the analysis presented here does show what can be done by making the most of data that is currently available.

Shaping the research agenda to estimate relevant cost-effectiveness thresholds for health technology assessment decision making: report from the ABPI. OHE Consulting Reports Published 18th April 2016

The cost-effectiveness threshold for spending on the English NHS has been subject to much debate recently, with research findings led by University of York health economists suggesting the threshold should be reduced from £20,000 to £13,000 per quality-adjusted life year gained, arguing that this is a more accurate representation of the cost of displacing current health care services with new interventions (Claxton et al. 2015). Among the leading critiques of this research finding has been the Office of Health Economics, and in this study they have conducted interviews and a workshop to identify alternative ways of setting the cost-effectiveness threshold. In 2015, 15 leading UK health economists were interviewed for their views on how they felt the cost-effectiveness threshold should be set. The majority of the economists interviewed felt that the threshold should represent the shadow price opportunity cost of investment, as opposed to society’s willingness to pay for QALY gains. Only one economist felt the evidence provided in a cost per QALY economic evaluation gave sufficient evidence to make a decision, with over 1 in 3 arguing for the need to also consider some form of equity considerations. Another key finding was that half of the economists believe that cost-effectiveness should be further extended from new interventions to existing services. Although the paper has not been through a peer review process, with questionable methodology in the interview guide potentially containing leading questions, there is much still to be gained from this study for readers interested in how experienced health economists survey current practice. Particularly, it is important for any economist working in evaluations to know the limits on the generalisability of standard cost-effectiveness studies. A workshop with some of the interviewed economists was conducted following the interviews to identify key areas for improving cost-effectiveness research. I think three areas identified warrant immediate attention in the health economics community. Cost-effectiveness analysis is typically performed for national guidelines but it would be of benefit to consider how cost-effectiveness can also be made more applicable at the regional commissioning level, as well as the individual clinician level. Finally, given budget impact is not accounted for in standard economic evaluation, as highlighted by the recent example of the cost-effective but expensive hepatitis C drug, affordability is a key area of concern for the discipline supposed to deal with scarcity. Any takers?

Comprehensively measuring health-related subjective well-being: dimensionality analysis for improved outcome assessment in health economics. Value in Health [PubMedPublished 28th January 2016

One focus in the previous OHE study looked at trying to measure value beyond the QALY outcome. Recent economic attempts to incorporate broader outcome assessments have looked at measuring a person’s capability to achieve in life or an individual’s subjective wellbeing (SWB), both novel approaches drawing from different theoretical bases. On first reading, a new approach appears to be proposed in this recent study, where the authors argue instead for a focus on health-related subjective well-being (HR-SWB). Their argument for this proposal lies in the need to take greater account of the mental and social aspects of health than current measures used to generate QALYs do (e.g. EQ-5D), in order to more accurately measure health as defined in the 1940s by the WHO. In this paper, the authors test a 21 domain, 56 item HR-SWB questionnaire they have previously developed in a Dutch general population sample. They undertake factor analysis to try and pull out the distinctive aspects of health their wide ranging questionnaire is currently picking up. They test it with a large number of previously validated measures including ones of health status (EQ-5D-3L), capability (ICECAP-O) and SWB (SWLS). From the analysis undertaken, a five factor loading appears to the authors as the best fit. They state the five factors focus on “physical independence”, “positive affect/happiness”, “negative affect/feeling lost and lonely”, “autonomy”, and “personal growth”. Only one of the validated measures that focuses on emotional wellbeing was found to be associated with all five factors, with the EQ-5D not loading onto the “negative affect/feeling lost and lonely”, and both the ICECAP-O and SWLS not loading onto the “physical independence” factor. Overall, the HR-SWB measure was best explained by the SWB measure (SWLS, R2=0.71), with the EQ-5D (R2=0.45) and ICECAP-O (R2=0.53) not performing as well. When referring to SWB, the authors are not referring to it in the same way as to how welfare economists are developing the approach as a measure of individual utility (more broadly defined than health-related utility for QALY measurement). The authors now plan to reduce their lengthy questionnaire further into a HR-SWB-5D health utility instrument for generating QALYs with 5-10 items. On that basis, the authors clearly see their measure as one of health and not wellbeing more generally, so they may want to revisit the terminology they have used, as it could be easily misinterpreted.

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