Chris Sampson’s journal round-up for 3rd July 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.

Role of cost on failure to access prescribed pharmaceuticals: the case of statins. Applied Health Economics and Health Policy [PubMed] Published 28th June 2017

Outside work, I find that people often like to tell me how to solve health economics problems. A common one is the idea that the NHS could save a load of money by enforcing prescription charges. It’s a textbook life-ain’t-that-simple situation. One of the reasons it isn’t that simple is that, if you start charging for prescriptions, people will be less likely to take their meds. That’s probably bad news for patients and for doctors. “But it’s only a few quid”. Well… As in many countries, Australians have to cough up a co-payment to fill their prescriptions. The size of the copayment depends on i) whether or not the patient is concessional (e.g. a pensioner) and ii) whether or not a threshold has been reached for total family prescription expenditure in one year. Concessional patients have a lower co-payment, a lower threshold and no co-payment once the threshold is met. This study looks at statin use in this context for 94,000 over-45s in New South Wales from 2005-2011. Separate logistic regressions are run for each of the 4 groups (concessional/non-concessional, pre-threshold/post-threshold) to predict statin adherence, controlling for a good range of sociodemographic and health-related variables. The size of the copayment comes out as the biggest barrier to adherence. More than 75% of people who weren’t adherent before reaching their threshold became so after reaching it – that is, once their co-payment was either much-reduced or zero. Poorest adherence was observed in non-concessional low-income people who hadn’t reached the threshold, who faced the highest co-payment. Income, age group and holding private insurance were also important determinants. In short, charging people for their statins, even if it isn’t much money, reduces the likelihood that they will take them. There is the possibility that adherence is correlated with the likelihood of having reached the threshold, which could undermine these results. I’m not entirely convinced that the analysis cuts the mustard, but I’ll let the more econometrically minded amongst you figure that out.

Conceptualizations of the societal perspective within economic evaluations: a systematic review. International Journal of Technology Assessment in Health Care [PubMed] Published 23rd June 2017

In my last round-up, I included a study looking at resource use measures for intersectoral costs and benefits; costs and benefits that occur outside the health sector. This week we have a study looking at how the inclusion of intersectoral costs and benefits influences results, and how researchers have interpreted the ‘societal perspective’. A systematic review was conducted for economic evaluations purporting to use a societal perspective, published since the CHEERS statement was released, including 107 studies. Only 74 provided a conceptualisation of the societal perspective. Reported conceptualisations of the societal perspective were grouped according to the specificity of their definition – 18 general, 50 specific, 6 both – and assessed using content analysis. Of these, 25 referred to a guideline or other source in their conceptualisation. A total of 10 general and 56 specific clusters of conceptualisations were identified, demonstrating major inconsistency. For some studies – namely trial-based economic evaluations in musculoskeletal or mental disorders – the authors dug deeper and extracted additional information. In both cases, where data were adequately reported, the intersectoral costs tended to make up more than 50% of total costs. But in general the specific intersectoral items were not fully reported and relevant costs (e.g. in education or criminal justice) were not identified. It probably won’t come as a surprise that the general impression is that a lot of researchers interpret the societal perspective – in practice, if not in theory – as health costs plus productivity losses. And usually, that’s not really good enough.

Annual direct medical costs associated with diabetes-related complications in the event year and in subsequent years in Hong Kong. Diabetic Medicine [PubMed] Published 21st June 2017

There are a lot of high-quality decision models built for the evaluation of interventions in diabetes. See Mt Hood. But some are still a bit primitive when it comes to estimating the costs associated with the many clinical pathways and complications associated with diabetes, especially when multimorbidity can be important. So studies like this are very welcome. This study contributes cost estimates for a wide range of complications (13, to be precise) for what should be a representative sample of (Chinese) people with diabetes. It includes public health care expenditure for more than 120,000 people with diabetes in Hong Kong, with 5-year follow-up. For private health care costs, a cross-section of 1275 people was recruited through other studies and provided information about service use by telephone. Fixed effects panel data regressions were used for the public medical costs. During the follow-up, 17% developed at least one complication. The models estimate the impact on total cost of new disease and existing disease separately, in order to identify first-year and subsequent-year cost estimates. Generalised linear models were used for the private health care costs. The base case of a 65-year old with no complications was US$1500/year in costs to the public purse. The biggest effect on costs was a first-year multiplier of 9.38 for lower limb ulcer (1.62 in subsequent years). Other costly complications were stroke, heart failure, end-stage renal disease and acute myocardial infarction. Private costs were much smaller, at $187 for the base case. These figures may prove useful to decision modellers, even outside the Hong Kong setting.

Financing and distribution of pharmaceuticals in the United States. JAMA [PubMed] Published 15th May 2017

The purpose of this article seems to be to demonstrate the complexity of the financing and distribution of pharmaceuticals in the US. It describes distributors, retailers and patients on the distribution side, and pharmacy benefit managers and health insurers on the financing side, with manufacturers in the middle. But the system that is shown in the article’s figure strikes me as surprisingly simple for an industry in which such vast amounts of money are sloshing around. It’s far more straightforward than any diagram you might see relating to the organisation of NHS services. I would imagine that a freer market would be associated with more complexity as upstarts might muscle-in on smaller corners of the market and become new intermediaries. But the article is still enlightening. It outlines some of the features of the market, particularly the high levels of concentration, characteristics of the key players and the staggering sums of money changing hands.

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