Chris Sampson’s journal round-up for 6th February 2017

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.

A review of NICE methods and processes across health technology assessment programmes: why the differences and what is the impact? Applied Health Economics and Health Policy [PubMed] Published 27th January 2017

Depending on the type of technology under consideration, NICE adopts a variety of different approaches in coming up with their recommendations. Different approaches might result in different decisions, which could undermine allocative efficiency. This study explores this possibility. Data were extracted from the manuals and websites for 5 programmes, under the themes of ‘remit and scope’, ‘process of assessment’, ‘methods of evaluation’ and ‘appraisal of evidence’. Semi-structured interviews were conducted with 5 people with expertise in each of the 5 programmes. Results are presented in a series of tables – one for each theme – outlining the essential characteristics of the 5 programmes. In their discussion, the authors then go on to consider how the identified differences might impact on efficiency from either a ‘utilitarian’ health-maximisation perspective or NICE’s egalitarian aim of ensuring adequate levels of health care. Not all programmes deliver recommendations with mandatory funding status, and it is only the ones that do that have a formal appeals process. Allowing for local rulings on funding could be good or bad news for efficiency, depending on the capacity of local decision makers to conduct economic evaluations (so that means probably bad news). At the same time, regional variation could undermine NICE’s fairness agenda. The evidence considered by the programmes varies, from a narrow focus on clinical and cost-effectiveness to the incorporation of budget impact and wider ethical and social values. Only some of the programmes have reference cases, and those that do are the ones that use cost-per-QALY analysis, which probably isn’t a coincidence. The fact that some programmes use outcomes other than QALYs obviously has the potential to undermine health-maximisation. Most differences or borne of practicality; there’s no point in insisting on a CUA if there is no evidence at all to support one – the appraisal would simply not happen. The very existence of alternative programmes indicates that NICE is not simply concerned with health-maximisation. Additional weight is given to rare conditions, for example. And NICE want to encourage research and innovation. So it’s no surprise that we need to take into account NICE’s egalitarian view to understand the type of efficiency for which it strives.

Economic evaluations alongside efficient study designs using large observational datasets: the PLEASANT trial case study. PharmacoEconomics [PubMed] Published 21st January 2017

One of the worst things about working on trial-based economic evaluations is going to lots of effort to collect lots of data, then finding that at the end of the day you don’t have much to show for it. Nowadays, the health service routinely collects many data for other purposes. There have been proposals to use these data – instead of prospectively collecting data – to conduct clinical trials. This study explores the potential for doing an economic evaluation alongside such a trial. The study uses CPRD data, including diagnostic, clinical and resource use information, for 8,608 trial participants. The intervention was the sending out of a letter in the hope of reducing unscheduled medical contacts due to asthma exacerbation in children starting a new school year. QALYs couldn’t be estimated using the CPRD data, so values were derived from the literature and estimated on the basis of exacerbations indicated by changes in prescriptions or hospitalisations. Note here the potentially artificial correlation between costs and outcomes that this creates, thus somewhat undermining the benefit of some good old bootstrapping. The results suggest the intervention is cost-saving with little impact on QALYs. Lots of sensitivity analyses are conducted, which are interesting in themselves and say something about the concerns around some of the structural assumptions. The authors outline the pros and cons of the approach. It’s an important discussion as it seems that studies like this are going to become increasingly common. Regarding data collection, there’s little doubt that this approach is more efficient, and it should be particularly valuable in the evaluation of public health and service delivery type interventions. The problem is that the study is not able to use individual-level cost and outcome data from the same people, which is what sets a trial-based economic evaluation apart from a model-based study. So for me, this isn’t really a trial-based economic evaluation. Indeed, the analysis incorporates a Markov-type model of exacerbations. It’s a different kind of beast, which incorporates aspects of modelling and aspects of trial-based analysis, along with some unique challenges of its own. There’s a lot more methodological work that needs to be done in this area, but this study demonstrates that it could be fruitful.

“Too much medicine”: insights and explanations from economic theory and research. Social Science & Medicine [PubMed] Published 18th January 2017

Overconsumption of health care represents an inefficient use of resources, and so we wouldn’t recommend it. But is that all we – as economists – have to say on the matter? This study sought to dig a little deeper. A literature search was conducted to establish a working definition of overconsumption. Related notions such as overdiagnosis, overtreatment, overuse, low-value care, overmedicalisation and even ‘pharmaceuticalisation’ all crop up. The authors introduce ‘need’ as a basis for understanding overconsumption; it represents health care that should never be considered as “needed”. A useful distinction is identified between misconsumption – where an individual’s own consumption is detrimental to their own well-being – and overconsumption, which can be understood as having a negative effect on social welfare. Note that in a collectively funded system the two concepts aren’t entirely distinguishable. Misconsumption becomes the focus of the paper, as avoiding harm to patients has been the subject of the “too much medicine” movement. I think this is a shame, and not really consistent with an economist’s usual perspective. The authors go on to discuss issues such as moral hazard, supplier-induced demand, provider payment mechanisms, ‘indication creep’, regret theory, and physicians’ positional consumption, and whether or not such phenomena might lead to individual welfare losses and thus be considered causes of misconsumption. The authors provide a neat diagram showing the various causes of misconsumption on a plane. One dimension represents the extent to which the cause is imperfect knowledge or imperfect agency, and the other the degree to which the cause is at the individual or market level. There’s a big gap in the top right, where market level causes meet imperfect knowledge. This area could have included patent systems, research fraud and dodgy Pharma practices. Or maybe just a portrait of Ben Goldacre for shorthand. There are some warnings about the (limited) extent to which market reforms might address misconsumption, and the proposed remedy for overconsumption is not really an economic one. Rather, a change in culture is prescribed. More research looking at existing treatments rather than technology adoption, and to investigate subgroup effects, is also recommended. The authors further suggest collaboration between health economists and ecological economists.

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