Alastair Canaway’s journal round-up for 20th March 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.

The use of quality-adjusted life years in cost-effectiveness analyses in palliative care: mapping the debate through an integrative review. Palliative Medicine [PubMed] Published 13th February 2017

February saw a health economics special within the journal Palliative Medicine – the editorials are very much worth a read to get a quick idea of how health economics has (and hasn’t) developed within the end of life care context. One of the most commonly encountered debates when discussing end of life care within health economics circles relates to the use of QALYs, and whether they’re appropriate. This paper aimed to map out the pros and cons of using the QALY framework to inform health economic decisions in the palliative care context. Being a review, there were no ground-breaking findings, more a refresher on what the issues are with the QALY at end of life: i) restrictions in life years gained, ii) conceptualisation of quality of life and its measurement, and iii) valuation and additivity of time. The review acknowledges the criticisms of the QALY but concludes that it is still of use for informing decision making. A key finding, and one which should be common sense, is that the EQ-5D should not be relied on as the sole measure within this context: the dimensions important to those at end of life are not adequately captured by the EQ-5D, and other measures should be considered. A limitation for me was that the review did not include Round’s (2016) book Care at the End of Life: An Economic Perspective (disclaimer: I’m a co-author on a chapter), which has significant overlap and builds on a number of the issues relevant to the paper. That aside, this is a useful paper for those new to the pitfalls of economic evaluation at the end of life and provides an excellent summary of many of the key issues.

The causal effect of retirement on mortality: evidence from targeted incentives to retire early. Health Economics [PubMed] [RePEc] Published 23rd February 2017

It’s been said that those who retire earlier die earlier, and a quick google search suggests there are many statistics supporting this. However, I’m unsure how robust the causality is in such studies. For example, the sick may choose to leave the workforce early. Previous academic literature had been inconclusive regarding the effects, and in which direction they occurred. This paper sought to elucidate this by taking advantage of pension reforms within the Netherlands which meant certain cohorts of Dutch civil servants could qualify for early retirement at a younger age. This change led to a steep increase in retirement and provided an opportunity to examine causal impacts by instrumenting retirement with the early retirement window. Administrative data from the entire population was used to examine the probability of dying resulting from earlier retirement. Contrary to preconceptions, the probability of men dying within five years dropped by 2.6% in those who took early retirement: a large and significant impact. The biggest impact was found within the first year of retirement. An explanation for this is that the reduction of stress and lifestyle change upon retiring may postpone death for the civil servants which were in poor health. The paper is an excellent example of harnessing a natural experiment for research purposes. It provides a valuable contribution to the evidence base whilst also being reassuring for those of us who plan to retire in the next few years (lottery win pending).

Mapping to estimate health-state utility from non–preference-based outcome measures: an ISPOR Good Practices for Outcomes Research Task Force report. Value in Health [PubMed] Published 16th February 2017

Finally, I just wanted to signpost this new good practice guide. If you ever attend HESG, ISPOR, or IHEA, you’ll nearly always encounter a paper on mapping (cross-walking). Given the ethical issues surrounding research waste and the increasing pressure to publish, mapping provides an excellent opportunity to maximise the value of your data. Of course, mapping also serves a purpose for the health economics community: it facilitates the estimation of QALYs in studies where no preference based measure exists. There are many iffy mapping functions out there so it’s good to see ISPOR have taken action by producing a report on best practice for mapping. As with most ISPOR guidelines the paper covers all the main areas you’d expect and guides you through the key considerations to undertaking a mapping exercise, this includes: pre-modelling considerations, data requirements, selection of statistical models, selection of covariates, reporting of results, and validation. Additionally there is also a short section for those who are keen to use a mapping function to generate QALYs but are unsure which to pick. As with any set of guidelines, it’s not exactly a thriller, it is however extremely useful for anyone seeking to conduct mapping.

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Alastair Canaway’s journal round-up for 20th 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.

The estimation and inclusion of presenteeism costs in applied economic evaluation: a systematic review. Value in Health Published 30th January 2017

Presenteeism is one of those issues that you hear about from time to time, but rarely see addressed within economic evaluations. For those who haven’t come across it before, presenteeism refers to being at work, but not working at full capacity, for example, due to your health limiting your ability to work. The literature suggests that given presenteeism can have large associated costs which could significantly impact economic evaluations, it should be considered. These impacts are rarely captured in practice. This paper sought to identify studies where presenteeism costs were included, examined how valuation was approached and the degree of impact of including presenteeism on costs. The review included cost of illness studies as well as economic evaluations, just 28 papers had attempted to capture the costs of presenteeism, these were in a wide variety of disease areas. A range of methods was used, across all studies, presenteeism costs accounted for 52% (range from 19%-85%) of the total costs relating to the intervention and disease. This is a vast proportion and significantly outweighed absenteeism costs. Presenteeism is clearly a significant issue, yet widely ignored within economic evaluation. This in part may be due to the health and social care perspective advised within the NICE reference case and compounded by the lack of guidance in how to measure and value productivity costs. Should an economic evaluation pursue a societal perspective, the findings suggest that capturing and valuing presenteeism costs should be a priority.

Priority to end of life treatments? Views of the public in the Netherlands. Value in Health Published 5th January 2017

Everybody dies, and thus, end of life care is probably something that we should all have at least a passing interest in. The end of life context is an incredibly tricky research area with methodological pitfalls at every turn. End of life care is often seen as ‘different’ to other care, and this is reflected in NICE having supplementary guidance for the appraisal of end of life interventions. Similarly, in the Netherlands, treatments that do not meet typical cost per QALY thresholds may be provided should public support be sufficient. There, however, is a dearth of such evidence, and this paper sought to elucidate this issue using the novel Q methodology. Three primary viewpoints emerged: 1) Access to healthcare as a human right – all have equal rights regardless of setting, that is, nobody is more important. Viewpoint one appeared to reject the notion of scarce resources when it comes to health: ‘you can’t put a price on life’. 2) The second group focussed on providing the ‘right’ care for those with terminal illness and emphasised that quality of life should be respected and unnecessary care at end of life should be avoided. This second group did not place great importance on cost-effectiveness but did acknowledge that costly treatments at end of life might not be the best use of money. 3) Finally, the third group felt there should be a focus on care which is effective and efficient, that is, those treatments which generate the most health should be prioritised. There was a consensus across all three groups that the ultimate goal of the health system is to generate the greatest overall health benefit for the population. This rejects the notion that priority should be given to those at end of life and the study concludes that across the three groups there was minimal support for the possibility of the terminally ill being treated with priority.

Methodological issues surrounding the use of baseline health-related quality of life data to inform trial-based economic evaluations of interventions within emergency and critical care settings: a systematic literature review. PharmacoEconomics [PubMed] Published 6th January 2017

Catchy title. Conducting research within emergency and critical settings presents a number of unique challenges. For the health economist seeking to conduct a trial based economic evaluation, one such issue relates to the calculation of QALYs. To calculate QALYs within a trial, baseline and follow-up data are required. For obvious reasons – severe and acute injuries/illness, unplanned admission – collecting baseline data on those entering emergency and critical care is problematic. Even when patients are conscious, there are ethical issues surrounding collecting baseline data in this setting, the example used relates to somebody being conscious after cardiac arrest, is it appropriate to be getting them to complete HRQL questionnaires? Probably not. Various methods have been used to circumnavigate this issue; this paper sought to systematically review the methods that have been used and provide guidance for future studies. Just 19 studies made it through screening, thus highlighting the difficulty of research in this context. Just one study prospectively collected baseline HRQL data, and this was restricted to patients in a non-life threatening state. Four different strategies were adopted in the remaining papers. Eight studies adopted a fixed health utility for all participants at baseline, four used only the available data, that is, from the first time point where HRQL was measured. One asked patients to retrospectively recall their baseline state, whilst one other used Delphi methods to derive EQ-5D states from experts. The paper examines the implications and limitations of adopting each of these strategies. The key finding seems to relate to whether or not the trial arms are balanced with respect to HRQL at baseline. This obviously isn’t observed, the authors suggest trial covariates should instead be used to explore this, and adjustments made where applicable. If, and that’s a big if, trial arms are balanced, then all of the four methods suggested should give similar answers. It seems the key here is the randomisation, however, even the best randomisation techniques do not always lead to balanced arms and there is no guarantee of baseline balance. The authors conclude trials should aim to make an initial assessment of HRQL at the earliest opportunity and that further research is required to thoroughly examine how the different approaches will impact cost-effectiveness results.

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Alastair Canaway’s journal round-up for 28th November 2016

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.

The cost-effectiveness of antibiotic prophylaxis for patients at risk of infective endocarditis. Circulation [PubMed] Published 13th November 2016

Did NICE get it wrong? In 2008 NICE recommended stopping antibiotic prophylaxis (AP) for those at risk of infective endocarditis (IE). For those unfamiliar with this research area, AP refers to the use of antibiotics or similar to prevent infection complications. IE is an infection of the endocardial surface of the heart which can have severe, and potentially fatal consequences. NICE stopped the recommendation of AP for those at risk of IE whilst undergoing dental procedures citing lack of evidence of efficacy and cost-effectiveness. This paper sought to fill the void in evidence and conduct an economic evaluation of AP using the latest estimates of efficacy and resource use. The paper constructed a decision analytic model to estimate costs and benefits. Both resource use and adverse event rates were sourced through Hospital Episode Statistics. The results were pretty conclusive: AP was less costly and more effective (than no AP) for all patients at risk of IE. Scenario analyses suggested that AP would have to be substantially less effective than estimated for it to fail on grounds of cost-effectiveness. The paper estimated that the annual savings of reintroducing AP in England would be between £5.5m and £8.2m with a health gain of over 2600 QALYs. Given the low costs of AP, the consequent cost saving and health improvements, perhaps NICE will be persuaded to reconsider their decision.

Maximizing health or sufficient capability in economic evaluation? A methodological experiment of treatment for drug addiction. Medical Decision Making [PubMed] Published 17th November 2016

The standard normative framework for economic evaluation within the UK is extra-welfarism, specifically, using health as the maximand (typically measured using QALYs). Thus, the evaluative space is health, with maximisation as the decision rule. Arguments have been made that health maximisation is not always the most appropriate framework. It has been suggested that the evaluative space be broadened to include capability wellbeing (based on the work of Sen), whilst a minimum threshold approach has been touted as an alternative approach to decision making. Such an approach is egalitarian and aims to ensure all members of society achieve a ‘sufficient’ level of capability wellbeing. This paper reports a pilot trial for the treatment of drug addiction to explore how i) changing the evaluative space to that of capability wellbeing, and ii) switching the decision-making principle to sufficient capability, impacts upon the decisions made. The drug addiction context is particularly pertinent due to non-health spill over impacts to the patient and others. The intervention considers three treatments: treatment as usual (TAU), TAU with social behaviour and network therapy (SBNT) and TAU with goal setting (GS). The two measures of interest within this study are the EQ-5D-5L and the ICECAP-A (capability measure for adults), QALYs and years of full capability (YFC) were calculated. Additionally, years of sufficient capability (YSC) were also calculated, sufficient capability was determined by a score of 33333: ‘a lot’ on each dimension of the ICECAP-A instrument. The study examined four situations: i) broadening the costing perspective from NHS/PSS to government, ii) broadening the evaluative space from QALYs to YFC, iii) broadening both costing perspective and evaluative space, and iv) changing the decision making rule to years of sufficient capability (YSC). The study found that changing from health maximisation to capability maximisation changed the treatment decision, as did changing the perspective: treatment recommendation is sensitive to choice of evaluative space and perspective. In the YSC analysis, the decision remained the same as the YFC analysis. The authors note a number of limitations with their study. The biggest for me, was the sample size of 83 – unsurprising given this was a pilot trial. As a result of the small numbers in each arm (30, 27, and 26) there is a surfeit of uncertainty, and just a handful of extreme cases in any one arm has the potential to change the results, and so it is difficult to draw any firm conclusions from this study. This paper however does provide a good starting point for the novel YFC approach, I’d be very interested in seeing this operationalised in a larger trial.

Does the EQ-5D capture the effects of physical and mental health status on life satisfaction among older people? A path analysis approach. Quality of Life Research [PubMed] Published 19th November 2016

This study sought to identify whether the EQ-5D captures impacts of mental and physical health on life satisfaction (LS) of older adults. This involved a retrospective cohort of 884 patients in Ireland. Path analysis was used to evaluate the direct and indirect effects. The EQ-5D-3L was used to measure health-related quality of life, whilst life satisfaction was measured with the life satisfaction index (LSI). Various specific measures of health status were also measured, e.g. co-morbidity level, activity limitation, and anxiety and depression. Within the analysis a number of assumptions were required, specifically around causation. The overall findings suggest that the EQ-5D-3L sufficiently captures the impact of physical health on life satisfaction, but not mental health. The author’s reflect that this may be due to a fundamental incommensurability of the general public’s preferences (who value the health states for the EQ-5D) and those who experience these health states. The authors conclude that the EQ-5D-3L should be used with caution within economic evaluations, and the use of the EQ-5D will underestimate benefits of treatment to mental health. The authors suggest alternative measures: HUI-3, AQoL and the ICECAP, and advocate their use alongside the EQ-5D within economic evaluation to better capture mental health impacts. A lot of this boils down to existing issues of debate: who should do the valuing (patient vs society), what are we trying to maximise (health vs well-being, or minimum threshold) and are existing measures doing the job they are supposed to be doing (is the EQ-5D fit for purpose). All these are interesting areas and it’s nice to see these issues being pushed to the fore once more.

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