Paul Mitchell’s journal round-up for 26th December 2016

Every Monday (even if it’s Boxing Day here in the UK) 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.

Out-migration and attrition of physicians and dentists before and after EU accession (2003 and 2011): the case of Hungary. European Journal of Health Economics [PubMedPublished 2nd December 2016

Medical staff migration is an important cross-national policy issue given the international shortage of supply of doctors to meet healthcare demand. This study uses a large administrative survey collected in Hungary from 2004-2011 and focuses on the trends of medical doctors (GPs, specialists, dentists) since Hungary joined the EU in 2004 and the introduction of full freedom of movement between Hungary with Austria and Germany in 2011. The author conducted a time-to-event analysis with monthly collection of data on a person’s occupation used as a guide for outward-migration. A competing-risks model was used to also consider medical doctors exiting the profession, becoming inactive or dying. From the 18,266 medical doctors found in this sample over the nine year period, 12% migrated, 17% exited the profession and 14% became inactive. A five-fold increase in migration was seen when the restrictions on freedom of movement between Hungary and Austria/Germany were lifted, a worrying sign of brain drain from Hungary. For those who stayed but exited the profession, relative income is argued to have been a contributory factor, with incomes increasing by on average 40% in their new line of work (although this does not account for the “thank you money” received by doctors in Hungary for healthcare access). Generous maternity leave was argued to play a key role in absence from employment. A recognised limitation in this study is the inability to conduct robust analysis on the migration patterns of new medical graduates who are likely to be more prone to migration than their established colleagues (estimated to be 40% of all medical graduates in Hungary between 2007-2010 who migrated, before restrictions on freedom of movement between Austria and Germany were lifted). Nonetheless, the study still manages to shine a light on the external (competing against countries with larger economies) but also the internal (“attrition and feminisation of workforce”) challenges to national doctor staffing policy.

Does the proportion of pay linked to performance affect the job satisfaction of general practitioners? Social Science & Medicine [PubMedPublished 24th November 2016

The impact of pay for performance (P4P) on healthcare practice has been subject to much debate surrounding the pros and cons of incentives for medical staff to achieve specific goals. This study focuses on the impact that the introduction of the Quality and Outcomes Framework (QOF) for GPs in the UK in 2004 had on their subsequent job satisfaction. Job satisfaction for GPs is argued to be an important topic area due to it having an important role in retaining GPs and the quality of care they provide to their patients. Using linked data from the the GP Worklife Survey and the QOF, that rewards GPs performance based on clinical, organisation, additional services and patient experience indicators, across three time points (2004, 2005 and 2008), the authors model the relationship between P4P exposure (i.e. the proportion of income related to performance) and job satisfaction. Using a continuous difference-in-difference model with a random effects regression, the authors find that P4P exposure has no significant effect on job satisfaction after 1 and 4 years following the introduction of the QOF P4P system. The introduction of the QOF did lead to a large increase in GP life satisfaction; this is likely to be due to the large increase in average income for GPs following the introduction of QOF. The authors argue that their findings suggest GP job satisfaction is unlikely to be affected by changes in P4P exposure, so long as the final income the GP receives remains constant. Given the generous increases on GP final income from the initial QOF, it remains to be seen how generalisable these results would be to P4P systems that did not lead to such large increases in staff income.

Country-level cost-effectiveness thresholds: initial estimates and the need for further research. Value in Health [PubMed] Published 14th December 2016

National thresholds used to determine if a health intervention is cost-effective have been under scrutiny in the UK in recent years. It has been argued on the grounds of healthcare opportunity costs that the NICE £20,000-30,000 per QALY gained threshold is too high, with an estimate of £13,000 per QALY gain proposed instead. Until now, less attention has been paid to international cost-effectiveness thresholds recommended by the WHO, who have argued for a threshold between one and three times the GDP of a country. This study provides preliminary estimates of cost-effectiveness thresholds across a number of countries with varying levels of national income. Using estimates from the recent £13,000 per QALY gain threshold study in England, a ratio between the supply-side threshold with the consumption value of health was estimated and used as a basis to calculate other national thresholds. The authors use a range of income elasticity estimates for the value placed on a statistical life to take account of uncertainty around these values. The results suggest that even the lower end of the WHO recommended threshold range of 1x national GDP is likely to be an overestimate in most countries. It would appear something closer to 50% of GDP may be a better estimate, albeit with a great amount of uncertainty and variation between high and low income countries. The importance of these estimates according to the authors is that the application of the current WHO thresholds could lead to policies that reduce instead of increase population health. However, the threshold estimates from this study rely on a number of assumptions based on UK data that may not provide an accurate estimate when setting cost-effectiveness thresholds at an international level.

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