Chris Sampson’s journal round-up for 24th February 2020

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.

Should health economic evaluations undertaken from a societal perspective include net government spending multiplier effects? Applied Health Economics and Health Policy [PubMed] Published 4th February 2020

Any mention of “macroeconomics” usually causes my eyes to glaze over and my mind to return to 2007 and to ECN202. With some luck, I might scrape through the conversation as I did my second year of undergrad. Perhaps other health economists share my affliction, and that’s why fiscal multipliers haven’t been paid much attention. This paper seeks to redress the balance by considering the possible importance of accounting for the general effects of health expenditure on the economy.

The title of the paper raises the question of ‘should‘, but it’s really more about the ‘could‘. The authors start out by reminding us what a fiscal multiplier is and how it is commonly used and estimated. In short, it’s the amount of expansion we might expect to see in an economy relative to government expenditure. So, with a fiscal multiplier of 1.5, the government spending £1 would expand the economy by £1.50. This study is conducted in the Australian context, so the authors do a bit of groundwork to identify a multiplier for Australia of 1.1. Then, the authors proceed to use this multiplier for domestic expenditure in health care, to demonstrate the potential importance of its use in estimating the societal benefits of health care expenditure.

Two previously conducted economic evaluations are used as test cases. One case study is for a pharmaceutical intervention and the other is for physiotherapy. The key difference between the two – as far as this analysis is concerned – is that the pharmaceutical is produced outside of Australia, with 77% of the expenditure falling outside of the country. Physiotherapy is largely based in expenditure on domestic labour, with only 3% of expenditure falling outside of Australia. What this means is that the effective cost-effectiveness of the pharmaceutical is reduced, while the cost-effectiveness of the physiotherapy is increased. The difference in the case of the pharmaceutical is quite large, with the incremental cost-effectiveness ratio shifting from $31,244 to $47,311 per QALY. Clearly, this could affect decision-making, with implications for cost-effectiveness thresholds.

Personally, I’m a societal perspective sceptic. So, from my position, the main value of considering fiscal multipliers is not from using them to estimate the cost-effectiveness of individual interventions, but rather to help to determine industrial policy. As the authors explain, this approach can be used to identify the value of having health care industries base their operations within a country. Perhaps we could get to the point where a pharmaceutical manufacturer enjoys a higher threshold in a given country if they also pay more taxes. From a (national) societal perspective, there’s a satisfying logic in that.

Whom should we ask? A systematic literature review of the arguments regarding the most accurate source of information for valuation of health states. Quality of Life Research [PubMed] Published 3rd February 2020

For many years, there has been debate about ‘patient’ vs ‘public’ values when it comes to preferences for health states. Gradually, researchers are realising that this is not a useful distinction, as all patients are members of the public and the public are all past and future patients. Nevertheless, there is a useful distinction between valuing a health state based on one’s own current experience and valuing a hypothetical health state. Which should be used to generate quality-adjusted life years (QALYs) to inform resource allocation decisions? In this paper, the authors review the arguments that have been made in the literature.

A literature search was conducted and studies were included in the review if they contained arguments about the source of health state valuations, with 82 articles included. The authors conducted a descriptive qualitative content analysis, grouping arguments into themes at three levels of granularity. The arguments favouring ‘patient’ values related to issues such as the superiority of patient knowledge, adaptation, and patient interests. Arguments in favour of ‘public’ values related to issues such as valuation difficulties for patients, socially directed values, and practical advantages.

This study provides a valuable review of a complex literature, but I believe it is flawed in its conception. There is no such thing as “the most accurate source of information” in this context. For this to be the case, there would need to be some true value that we were seeking to identify. But the value that is most close to the truth depends on our conception of value. Therefore, the answer to the question “which is most accurate?” and “whom should we ask?” are one in the same. This is easily demonstrated by the unanswerable question “how do we define accuracy?” The authors’ attempt to separate the two inevitably fails. Arguments that they frame as ‘irrelevant’ are only irrelevant if we accept the premise that value and decision-making imperatives are separable. The authors’ concluding argument in favour of patient values is both pre-determined by their conception of ‘accuracy’ and groundless.

Nevertheless, I like the paper a lot, as it digests a large amount of information and provides a taxonomy of quotations that will be extremely valuable to researchers developing ideas in this context. My only complaint is that they did not include blog posts in their review!

Health-related quality of life in neonates and infants: a conceptual framework. Quality of Life Research [PubMed] Published 29th January 2020

I’m working on an evaluative study in the context of newborns, and it’s the first time I’ve worked on an intervention where consideration of health-related quality of life (in the short term) – let alone QALYs – is barely even on the table. Yet many interventions and support services for newborns might reasonably be expected to have huge impacts on their quality of life. This study attempts to bring us closer to a world where we can identify QALYs for newborns and infants.

A qualitative study was conducted in a Toronto hospital with two focus groups and five interviews with caregivers of children with intestinal failure and with 14 health care professionals. The focus groups and interviews used open-ended questioning, allowing participants to state what they saw as the most important factors. Fourteen different factors arose, including things like sleep, feeding needs, safety, hygiene, and physical abilities. The authors arranged these into four levels, relating to i) basic needs, ii) non-basic needs, iii) caregivers and family, and iv) society and community.

Much the same dimensions were identified for neonates (0-28 days) and infants (up to one year), but the weighting attributed to the dimensions differed. The importance of non-basic needs increased with age. One implication of this is that time in hospital, where basic needs can be met but other aspects of HRQoL may be limited, may be very good for a neonate but not so good for an older infant. As a result of this, the authors suggest that a weighting algorithm according to age or developmental status may be appropriate. An interesting characterisation of HRQoL that comes out of the study is as a surrogate for the effort required by caregivers to obtain some degree of normalcy in the child’s life. The HRQoL of the individual and of the caregiver(s) is clearly inseparable. But the authors aren’t able to offer much guidance on how this affects measurement.

The authors set out from the position that measuring health-related quality of life in this cohort is important. I don’t know the ethics literature well enough to disagree, so I have to take their word for it. But it does seem that it might be OK for clinical decision-making in this context to be guided by a very different set of criteria to those used in older populations. Whatever the right solution, it will be guided by this important study.

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  • Founder of the Academic Health Economists' Blog. Principal Economist at the Office of Health Economics. ORCID: 0000-0001-9470-2369

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