Rita Faria’s journal round-up for 15th April 2019

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.

Emulating a trial of joint dynamic strategies: an application to monitoring and treatment of HIV‐positive individuals. Statistics in Medicine [PubMed] Published 18th March 2019

Have you heard about the target trial approach? This is a causal inference method for using observational evidence to compare strategies. This outstanding paper by Ellen Caniglia and colleagues is a great way to get introduced to it!

The question is: what is the best test-and-treat strategy for HIV-positive individuals? Given that patients weren’t randomised to each of the 4 alternative strategies, chances are that their treatment was informed by their prognostic factors. And these also influence their outcome. It’s a typical situation of bias due to confounding. The target trial approach consists of designing the RCT which would estimate the causal effect of interest, and to think through how its design can be emulated by the observational data. Here, it would be a trial in which patients would be randomly assigned to one of the 4 joint monitoring and treatment strategies. The goal is to estimate the difference in outcomes if all patients had followed their assigned strategies.

The method is fascinating albeit a bit complicated. It involves censoring individuals, fitting survival models, estimating probability weights, and replicating data. It is worthy of a detailed read! I’m very excited about the target trial methodology for cost-effectiveness analysis with observational data. But I haven’t come across any application yet. Please do get in touch via comments or Twitter if you know of a cost-effectiveness application.

Achieving integrated care through commissioning of primary care services in the English NHS: a qualitative analysis. BMJ Open [PubMed] Published 1st April 2019

Are you confused about the set-up of primary health care services in England? Look no further than Imelda McDermott and colleagues’ paper.

The paper starts by telling the story of how primary care has been organised in England over time, from its creation in 1948 to current times. For example, I didn’t know that there are new plans to allow clinical commissioning groups (CCGs) to design local incentive schemes as an alternative to the Quality and Outcomes Framework pay-for-performance scheme. The research proper is a qualitative study using interviews, telephone surveys and analysis of policy documents to understand how the CCGs commission primary care services. CCG Commissioning is intended to make better and more efficient use of resources to address increasing demand for health care services, staff shortage and financial pressure. The issue is that it is not easy to implement in practice. Furthermore, there seems to be some “reinvention of the wheel”. For example, from one of the interviewees: “…it’s no great surprise to me that the three STPs that we’ve got are the same as the three PCT clusters that we broke up to create CCGs…” Hum, shall we just go back to pre-2012 then?

Even if CCG commissioning does achieve all it sets out to do, I wonder about its value for money given the costs of setting it up. This paper is an exceptional read about the practicalities of implementing this policy in practice.

The dark side of coproduction: do the costs outweight the benefits for health research? Health Research Policy and Systems [PubMed] Published 28th March 2019

Last month, I covered the excellent paper by Kathryn Oliver and Paul Cairney about how to get our research to influence policy. This week I’d like to suggest another remarkable paper by Kathryn, this time with Anita Kothari and Nicholas Mays, on the costs and benefits of coproduction.

If you are in the UK, you have certainly heard about public and patient involvement or PPI. In this paper, coproduction refers to any collaborative working between academics and non-academics, of which PPI is one type, but it includes working with professionals, policy makers and any other people affected by the research. The authors discuss a wide range of costs to coproduction. From the direct costs of doing collaborative research, such as organising meetings, travel arrangements, etc., to the personal costs on an individual researcher to manage conflicting views and disagreements between collaborators, of having research products seen to be of lower quality, of being seen as partisan, etc., and costs to the stakeholders themselves

As a detail, I loved the term “hit-and-run research” to describe the current climate: get funding, do research, achieve impact, leave. Indeed, the way that research is funded, with budgets only available for the period that the research is being developed, does not help academics to foster relationships.

This paper reinforced my view that there may well be benefits to coproduction, but that there are also quite a lot of costs. And there tends to be not much attention to the magnitude of those costs, in whom they fall, and what’s displaced. I found the authors’ advice about the questions to ask oneself when thinking about coproduction to be really useful. I’ll keep it to hand when writing my next funding application, and I recommend you do too!

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