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.
GPs’ implicit prioritization through clinical choices – evidence from three national health services. Journal of Health Economics [RePEc] Published 7th July 2016
Through economic evaluation we inform high-level prioritisation decisions about (for example) which drugs should and should not be available. Meanwhile, GPs are able to prioritise at the individual level through their prescribing behaviour. But do they prioritise? And in what ways? This study reports on a discrete choice experiment carried out with 907 GPs in England, Scotland and Norway to try and elicit prescription behaviour in different decision making contexts. A key aspect that the study considers is the presence of a double agency problem, whereby the GP advocates both maximum patient benefit (‘patient agency’) and cost containment for society (‘social agency’). GPs were asked a generic question about prescribing either ‘Medicine A’ or ‘Medicine B’ and the DCE included 5 attributes: total costs, effect, patient costs, patient preference and physician’s experience. All else equal, GPs in all countries preferred lower total costs. There was variation both within and between countries in the extent to which GPs were willing to accept high societal costs for greater patient benefit. GPs in England seem to exhibit stronger social agency in that they were less willing to accept high costs than GPs in both Norway and Scotland. However, in regard to patient costs and patient preferences, UK GPs were willing to accept greater societal costs. The authors discuss a variety of possible reasons for these findings but suggest that strong governance reinforces social agency, while cultural aspects moderate the effect.
Unrelated future costs and unrelated future benefits: reflections on NICE Guide to the Methods of Technology Appraisal. Health Economics [PubMed] Published 3rd July 2016
NICE would prefer that we disregard UFC. That’s unrelated future costs (not Ultimate Fighting Championship) – for example, the costs of dementia care having prevented death from a heart attack. But the availability of these unrelated treatments will likely confer benefit that is not excluded from the analysis. So it’s easy to see how we could end up with suboptimal allocations of resources. In this editorial, the authors consider the arguments against the inclusion of unrelated future costs, which can be broadly considered as relating to ‘principles’, ‘practicalities’ and ‘implications’. The authors argue that current approaches in principle are no more acceptable than the inclusion of costs and exclusion of benefits, as both are inconsistent in their handling of future payoffs. Practically, the authors argue that it is simpler to incorporate projected future costs than to tease out future benefits. Some have argued that the implications are limited, but the authors highlight that issues such as the level of comorbidity could have a major impact. There’s a lot of research still to be done in this area, but for now we should at least strive for consistency in our handling of future costs and benefits.
The capability approach: a critical review of its application in health economics. Value in Health Published 29th June 2016
Friends know I’ve been guilty of a bit of ICECAP-bashing in the past. Though I like the capability approach in principle, I am not a fan of how it has been applied in health economics. Naturally, I was drawn to this “critical” review. In fact, it was published as a working paper just before I finished writing my chapter for Jeff’s book but I didn’t have time to read it let alone incorporate its findings. So here we are with the real (published) deal. The primary purpose of the review is to evaluate the extent to which current questionnaires (e.g. ICECAP) can actually capture capabilities. The article does an excellent job of concisely identifying fundamental problems in the use of current measures. One issue is that the use of terms like “able to” does not allow for trade-offs between domains. A person may have maximum capability in all domains, but not be able to achieve maximal functionings in all of them simultaneously. As such, unachievable capability sets could be defined. Another problem is that these measures do not capture all of the possible combinations of functionings, only the dominant one. Therefore, these measures fail to capture the key basis for the capability approach – the value in choice. We haven’t yet figured out how to properly value a set, rather than a single combination. The authors suggest a way forward, based on the estimation of ‘approximate capability’. This could identify dominant functionings and the degree of choice. A key benefit of this approach would be the conceptual clarity for which it allows. As I have argued, I think this is the main failure of the application of the capability approach (and indeed health state valuation more broadly) in health economics.
Clinical guidelines: a NICE way to introduce cost-effectiveness considerations? Value in Health Published 28th June 2016
Most UK health economists will be familiar with NICE clinical guidelines. They outline what should (and should not) be taking place as part of care pathways in the NHS. The production of guidelines isn’t (usually) triggered by any new intervention but rather they are designed to improve current standard of care. The recommendations take into account economic considerations. This article outlines some of the advantages of the NICE guidelines programme and describes the role of health economists. One advantage of the guideline development process is that it is a joint enterprise between NICE and the various royal colleges of medicine. But there is also tension in this relationship from an economics perspective as optimal individual patient care may be at odds with broader societal objectives (if you’ve skipped ahead, see the first article summarised above). This article identifies a key advantage of NICE guidelines as being able to make recommendations on disinvestment. A key potential that I see, which isn’t discussed here, is for whole disease modelling studies to be routinely funded as part of the guideline development process.
Photo credit: Antony Theobald (CC BY-NC-ND 2.0)