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.



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