Chris Sampson’s journal round-up for 20th November 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.

Effects of health and social care spending constraints on mortality in England: a time trend analysis. BMJ Open [PubMed] Published 15th November 2017

I’d hazard a guess that I’m not the only one here who gets angry about the politics of austerity. Having seen this study’s title, it’s clear that the research could provide fuel for that anger. It doesn’t disappoint. Recent years have seen very low year-on-year increases in public expenditure on health in England. Even worse, between 2010 and 2014, public expenditure on social care actually fell in real terms. This is despite growing need for health and social care. In this study, the authors look at health and social care spending and try to estimate the impact that reduced expenditure has had on mortality in England. The analysis uses spending and mortality data from 2001 onwards and also incorporates mortality projections for 2015-2020. Time trend analyses are conducted using Poisson regression models. From 2001-2010, deaths decreased by 0.77% per year (on average). The mortality rate was falling. Now it seems to be increasing; from 2011-2014, the average number of deaths per year increased by 0.87%. This corresponds to 18,324 additional deaths in 2014, for example. But everybody dies. Extra deaths are really sooner deaths. So the question, really, is how much sooner? The authors look at potential years of life lost and find this figure to be 75,496 life-years greater than expected in 2014, given pre-2010 trends. This shouldn’t come as much of a surprise. Spending less generally achieves less. What makes this study really interesting is that it can tell us who is losing these potential years of life as a result of spending cuts. The authors find that it’s the over-60s. Care home deaths were the largest contributor to increased mortality. A £10 cut in social care spending per capita resulted in 5 additional care home deaths per 100,000 people. When the authors looked at deaths by local area, no association was found with the level of deprivation. If health and social care expenditure are combined in a single model, we see that it’s social care spending that is driving the number of excess deaths. The impact of health spending on hospital deaths was less robust. The number of nurses acted as a mediator for the relationship between spending and mortality. The authors estimate that current spending projections will result in 150,000 additional deaths compared with pre-2010 trends. There are plenty of limitations to this study. It’s pretty much impossible (though the authors do try) to separate the effects of austerity from the effect of a weak economy. Still, I’m satisfied with the conclusion that austerity kills older people (no jokes about turkeys and Christmas, please). For me, the findings also highlight the need for more research in the context of social care, and how we (as researchers) might effectively direct policy to prevent ‘excess’ deaths.

Should cost effectiveness analyses for NICE always consider future unrelated medical costs? BMJ [PubMed] Published 10th November 2017

The question of whether or not ‘unrelated’ future medical costs should be included in economic evaluation is becoming a hot topic. So much so that the BMJ has published this Head To Head, which introduces some of the arguments for and against. NICE currently recommends excluding unrelated future medical costs. An example given in this article is the case of the expected costs of dementia care having saved someone’s life by heart transplantation. The argument in favour of including unrelated costs is quite obvious – these costs can’t be ignored if we seek to maximise social welfare. Their inclusion is described as “not difficult” by the authors defending this move. By ignoring unrelated future costs (but accounting for the benefit of longer life), the relative cost-effectiveness of life-extending treatments, compared with life-improving treatments, is artificially inflated. The argument against including unrelated medical costs is presented as one of fairness. The author suggests that their inclusion could preclude access to health care for certain groups of people that are likely to have high needs in the future. So perhaps NICE should ignore unrelated medical costs in certain circumstances. I sympathise with this view, but I feel it is less a fairness issue and more a demonstration of the current limits of health-related quality of life measurement, which don’t reflect adaptation and coping. However, I tend to disagree with both of the arguments presented here. I really don’t think NICE should include or exclude unrelated future medical costs according to the context because that could create some very perverse incentives for certain stakeholders. But then, I do not agree that it is “not difficult” to include all unrelated future costs. ‘All’ is an important qualifier here because the capacity for analysts to pick and choose unrelated future costs creates the potential to pick and choose results. When it comes to unrelated future medical costs, NICE’s position needs to be all-or-nothing, and right now the ‘all’ bit is a high bar to clear. NICE should include unrelated future medical costs – it’s difficult to formulate a sound argument against that – but they should only do so once more groundwork has been done. In particular, we need to develop more valid methods for valuing quality of life against life-years in health technology assessment across different patient groups. And we need more reliable methods for estimating future medical costs in all settings.

Oncology modeling for fun and profit! Key steps for busy analysts in health technology assessment. PharmacoEconomics [PubMed] Published 6th November 2017

Quite a title(!). The subject of this essay is ‘partitioned survival modelling’. Honestly,  I never really knew what that was until I read this article. It seems the reason for my ignorance could be that I haven’t worked on the evaluation of cancer treatments, for which it’s a popular methodology. Apparently, a recent study found that almost 75% of NICE cancer drug appraisals were informed by this sort of analysis. Partitioned survival modelling is a simple means by which to extrapolate outcomes in a context where people can survive (or not) with or without progression. Often this can be on the basis of survival analyses and standard trial endpoints. This article seeks to provide some guidance on the development and use of partitioned survival models. Or, rather, it provides a toolkit for calling out those who might seek to use the method as a means of providing favourable results for a new therapy when data and analytical resources are lacking. The ‘key steps’ can be summarised as 1) avoiding/ignoring/misrepresenting current standards of economic evaluation, 2) using handpicked parametric approaches for extrapolation in order to maximise survival benefits, 3) creatively estimating relative treatment effects using indirect comparisons without adjustment, 4) make optimistic assumptions about post-progression outcomes, and 5) deny the possibility of any structural uncertainty. The authors illustrate just how much an analyst can influence the results of an evaluation (if they want to “keep ICERs in the sweet spot!”). Generally, these tactics move the model far from being representative of reality. However, the prevailing secrecy around most models means that it isn’t always easy to detect these shortcomings. Sometimes it is though, and the authors make explicit reference to technology appraisals that they suggest demonstrate these crimes. Brilliant!

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