Chris Sampson’s journal round-up for 11th June 2018

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.

End-of-life healthcare expenditure: testing economic explanations using a discrete choice experiment. Journal of Health Economics Published 7th June 2018

People incur a lot of health care costs at the end of life, despite the fact that – by definition – they aren’t going to get much value from it (so long as we’re using QALYs, anyway). In a 2007 paper, Gary Becker and colleagues put forward a theory for the high value of life and high expenditure on health care at the end of life. This article sets out to test a set of hypotheses derived from this theory, namely: i) higher willingness-to-pay (WTP) for health care with proximity to death, ii) higher WTP with greater chance of survival, iii) societal WTP exceeds individual WTP due to altruism, and iv) societal WTP may exceed individual WTP due to an aversion to restricting access to new end-of-life care. A further set of hypotheses relating to the ‘pain of risk-bearing’ is also tested. The authors conducted an online discrete choice experiment (DCE) with 1,529 Swiss residents, which asked respondents to suppose that they had terminal cancer and was designed to elicit WTP for a life-prolonging novel cancer drug. Attributes in the DCE included survival, quality of life, and ‘hope’ (chance of being cured). Individual WTP – using out-of-pocket costs – and societal WTP – based on social health insurance – were both estimated. The overall finding is that the hypotheses are on the whole true, at least in part. But the fact is that different people have different preferences – the authors note that “preferences with regard to end-of-life treatment are very heterogeneous”. The findings provide evidence to explain the prevailing high level of expenditure in end of life (cancer) care. But the questions remain of what we can or should do about it, if anything.

Valuation of preference-based measures: can existing preference data be used to generate better estimates? Health and Quality of Life Outcomes [PubMed] Published 5th June 2018

The EuroQol website lists EQ-5D-3L valuation studies for 27 countries. As the EQ-5D-5L comes into use, we’re going to see a lot of new valuation studies in the pipeline. But what if we could use data from one country’s valuation to inform another’s? The idea is that a valuation study in one country may be able to ‘borrow strength’ from another country’s valuation data. The author of this article has developed a Bayesian non-parametric model to achieve this and has previously applied it to UK and US EQ-5D valuations. But what about situations in which few data are available in the country of interest, and where the country’s cultural characteristics are substantially different. This study reports on an analysis to generate an SF-6D value set for Hong Kong, firstly using the Hong Kong values only, and secondly using the UK value set as a prior. As expected, the model which uses the UK data provided better predictions. And some of the differences in the valuation of health states are quite substantial (i.e. more than 0.1). Clearly, this could be a useful methodology, especially for small countries. But more research is needed into the implications of adopting the approach more widely.

Can a smoking ban save your heart? Health Economics [PubMed] Published 4th June 2018

Here we have another Swiss study, relating to the country’s public-place smoking bans. Exposure to tobacco smoke can have an acute and rapid impact on health to the extent that we would expect an immediate reduction in the risk of acute myocardial infarction (AMI) if a smoking ban reduces the number of people exposed. Studies have already looked at this effect, and found it to be large, but mostly with simple pre-/post- designs that don’t consider important confounding factors or prevailing trends. This study tests the hypothesis in a quasi-experimental setting, taking advantage of the fact that the 26 Swiss cantons implemented smoking bans at different times between 2007 and 2010. The authors analyse individual-level data from Swiss hospitals, estimating the impact of the smoking ban on AMI incidence, with area and time fixed effects, area-specific time trends, and unemployment. The findings show a large and robust effect of the smoking ban(s) for men, with a reduction in AMI incidence of about 11%. For women, the effect is weaker, with an average reduction of around 2%. The evidence also shows that men in low-education regions experienced the greatest benefit. What makes this an especially nice paper is that the authors bring in other data sources to help explain their findings. Panel survey data are used to demonstrate that non-smokers are likely to be the group benefitting most from smoking bans and that people working in public places and people with less education are most exposed to environmental tobacco smoke. These findings might not be generalisable to other settings. Other countries implemented more gradual policy changes and Switzerland had a particularly high baseline smoking rate. But the findings suggest that smoking bans are associated with population health benefits (and the associated cost savings) and could also help tackle health inequalities.

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Chris Sampson’s journal round-up for 4th June 2018

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.

A qualitative investigation of the health economic impacts of bariatric surgery for obesity and implications for improved practice in health economics. Health Economics [PubMed] Published 1st June 2018

Few would question the ‘economic’ nature of the challenge of obesity. Bariatric surgery is widely recommended for severe cases but, in many countries, the supply is not sufficient to satisfy the demand. In this context, this study explores the value of qualitative research in informing economic evaluation. The authors assert that previous economic evaluations have adopted a relatively narrow focus and thus might underestimate the expected value of bariatric surgery. But rather than going and finding data on what they think might be additional dimensions of value, the authors ask patients. Emotional capital, ‘societal’ (i.e. non-health) impacts, and externalities are identified as theories for the types of value that might be derived from bariatric surgery. These theories were used to guide the development of questions and prompts that were used in a series of 10 semi-structured focus groups. Thematic analysis identified the importance of emotional costs and benefits as part of the ‘socioemotional personal journey’ associated with bariatric surgery. Out-of-pocket costs were also identified as being important, with self-funding being a challenge for some respondents. The information seems useful in a variety of ways. It helps us understand the value of bariatric surgery and how individuals make decisions in this context. This information could be used to determine the structure of economic evaluations or the data that are collected and used. The authors suggest that an EQ-5D bolt-on should be developed for ’emotional capital’ but, given that this ‘theory’ was predefined by the authors and does not arise from the qualitative research as being an important dimension of value alongside the existing EQ-5D dimensions, that’s a stretch.

Developing accessible, pictorial versions of health-related quality-of-life instruments suitable for economic evaluation: a report of preliminary studies conducted in Canada and the United Kingdom. PharmacoEconomics – Open [PubMed] Published 25th May 2018

I’ve been telling people about this study for ages (apologies, authors, if that isn’t something you wanted to read!). In my experience, the need for more (cognitively / communicatively) accessible outcome measures is widely recognised by health researchers working in contexts where this is relevant, such as stroke. If people can’t read or understand the text-based descriptors that make up (for example) the EQ-5D, then we need some alternative format. You could develop an entirely new measure. Or, as the work described in this paper set out to do, you could modify existing measures. There are three descriptive systems described in this study: i) a pictorial EQ-5D-3L by the Canadian team, ii) a pictorial EQ-5D-3L by the UK team, and iii) a pictorial EQ-5D-5L by the UK team. Each uses images to represent the different levels of the different dimensions. For example, the mobility dimension might show somebody walking around unaided, walking with aids, or in bed. I’m not going to try and describe what they all look like, so I’ll just encourage you to take a look at the Supplementary Material (click here to download it). All are described as ‘pilot’ instruments and shouldn’t be picked up and used at this stage. Different approaches were used in the development of the measures, and there are differences between the measures in terms of the images selected and the ways in which they’re presented. But each process referred to conventions in aphasia research, used input from clinicians, and consulted people with aphasia and/or their carers. The authors set out several remaining questions and avenues for future research. The most interesting possibility to most readers will be the notion that we could have a ‘generic’ pictorial format for the EQ-5D, which isn’t aphasia-specific. This will require continued development of the pictorial descriptive systems, and ultimately their validation.

QALYs in 2018—advantages and concerns. JAMA [PubMed] Published 24th May 2018

It’s difficult not to feel sorry for the authors of this article – and indeed all US-based purveyors of economic evaluation in health care. With respect to social judgments about the value of health technologies, the US’s proverbial head remains well and truly buried in the sand. This article serves as a primer and an enticement for the use of QALYs. The ‘concerns’ cited relate almost exclusively to decision rules applied to QALYs, rather than the underlying principles of QALYs, presumably because the authors didn’t feel they could ignore the points made by QALY opponents (even if those arguments are vacuous). What it boils down to is this: trade-offs are necessary, and QALYs can be used to promote value in those trade-offs, so unless you offer some meaningful alternative then QALYs are here to stay. Thankfully, the Institute for Clinical and Economic Review (ICER) has recently added some clout to the undeniable good sense of QALYs, so the future is looking a little brighter. Suck it up, America!

The impact of hospital costing methods on cost-effectiveness analysis: a case study. PharmacoEconomics [PubMed] Published 22nd May 2018

Plugging different cost estimates into your cost-effectiveness model could alter the headline results of your evaluation. That might seems obvious, but there are a variety of ways in which the selection of unit costs might be somewhat arbitrary or taken for granted. This study considers three alternative sources of information for hospital-based unit costs for hip fractures in England: (a) spell-level tariffs, (b) finished consultant episode (FCE) reference costs, and (c) spell-level reference costs. Source (b) provides, in theory, a more granular version of (a), describing individual episodes within a person’s hospital stay. Reference costs are estimated on the basis of hospital activity, while tariffs are prices estimated on the basis of historic reference costs. The authors use a previously reported cohort state transition model to evaluate different models of care for hip fracture and explore how the use of the different cost figures affects their results. FCE-level reference costs produced the highest total first-year hospital care costs (£14,440), and spell-level tariffs the lowest (£10,749). The more FCEs within a spell, the greater the discrepancy. This difference in costs affected ICERs, such that the net-benefit-optimising decision would change. The study makes an important point – that selection of unit costs matters. But it isn’t clear why the difference exists. It could just be due to a lack of precision in reference costs in this context (rather than a lack of accuracy, per se), or it could be that reference costs misestimate the true cost of care across the board. Without clear guidance on how to select the most appropriate source of unit costs, these different costing methodologies represent another source of uncertainty in modelling, which analysts should consider and explore.

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Thesis Thursday: James Oswald

On the third Thursday of every month, we speak to a recent graduate about their thesis and their studies. This month’s guest is Dr James Oswald who has a PhD from the University of Sheffield. If you would like to suggest a candidate for an upcoming Thesis Thursday, get in touch.

Title
Essays on well-being and mental health: determinants and consequences
Supervisors
Sarah Brown, Jenny Roberts, Bert Van Landeghem
Repository link
http://etheses.whiterose.ac.uk/18915/

What measures of health did you use in your research and how did these complement broader measures of well-being?

I didn’t use any measures of physical health. I used a few measures of subjective well-being (SWB) and mental health which vary across the chapters. In Chapter 2 I used life satisfaction and the Rutter Malaise Inventory. Life satisfaction is a global retrospective judgement of one’s life and is a measure of evaluative well-being (see Dolan and Metcalfe, 2012). The Rutter Malaise Inventory, a measure of affective well-being, is an index that is composed of 9 items that measure the respondent’s symptoms of psychological distress or depression. The measure of the mental health problems of adolescents that is used in Chapter 3 is the Strengths and Difficulties Questionnaire (SDQ). The SDQ is made up of four 5-item subscales: emotional problems, peer relationship problems, conduct problems, and hyperactivity/ inattention problems. Chapter 3 utilises the General Health Questionnaire (GHQ) as a measure of the mental health of parents. The GHQ is a screening instrument that was initially developed to diagnose psychiatric disorders. Chapter 4 utilises one measure of subjective well-being, which relates to the number of days of poor self-reported mental health (stress, depression, and problems with emotions) in the past 30 days.

Did your research result in any novel findings regarding the social determinants of mental well-being?

The findings of Chapter 2 suggested that bullying victimisation at age 11 has a large, adverse effect on SWB as an adult. Childhood bullying remains prevalent – recent estimates suggest that approximately 20-30% of children are bullied by other children. The evidence provided in Chapter 3 indicated that greater externalising problems of adolescents are positively associated with the likelihood that they engage in antisocial behaviour. Chapter 4 indicated two important findings. Firstly, Hurricane Katrina had a negative effect on the SWB of individuals living in the states that were directly affected by the disaster. Secondly, the analysis suggested that the Indian Ocean tsunami and the Haiti earthquake increased the SWB of Americans living closest to the affected areas.

How can natural disasters affect mental health?

My thesis presents evidence to suggest that their impact depends upon whether you live in the disaster area. I explored the role of geography by exploring the effects of three disasters – hurricane Katrina in 2005 (USA), Indian Ocean tsunami in 2004 (East Asia), and the Haiti earthquake in 2010. Firstly, Hurricane Katrina had a negative effect on the SWB of individuals living in the states that were directly affected by the disaster. As a result, the findings suggest that government intervention in the aftermath of disasters is needed to help mitigate the adverse effects of natural disasters on the SWB of people who live in the directly affected areas. For example, appropriate mental health services and counselling could be offered to people suffering unhappiness or distress. Secondly, the analysis suggested that the Indian Ocean tsunami and the Haiti earthquake increased the SWB of Americans living closest to the affected areas. This surprising finding may be explained by the interdependence of utility functions. Following the disasters, Americans were exposed to widespread coverage of the disasters via social and traditional media sources. Because of the media coverage, they may have thought about the catastrophic repercussions of the disasters for the victims. Consequently, Americans who lived closest to the affected areas may have compared themselves to the disaster victims, leading them to feel thankful that the disaster did not affect them, thus increasing their SWB.

The empirical results support the case that the utility functions of strangers may be interdependent, rather than independent, an assumption generally made in economics. Furthermore, the findings indicated no evidence that the effects of the disasters were more pronounced for individuals of the same ethnicity as the disaster victims. The results therefore suggest that geographical proximity to the affected areas, rather than sharing similar characteristics with the disaster victims, may determine the effects of natural disasters on SWB outside of the areas that were directly affected by the disasters. This issue is discussed in greater detail in Chapter 4 of my thesis.

How did you go about identifying some of the consequences of mental health problems?

My thesis uses a range of econometric methods to explore the determinants and consequences of mental health and subjective well-being. In Chapter 2 – for childhood bullying and adult subjective well-being – I used a range of methods including random effects ordered probit models, Hausman tests, and Heckman models. Chapter 3 investigates how the mental health of adolescents affects their participation in antisocial behaviour. The analysis uses random effects probit, multivariate probit, and conditional logit models. Chapter 4 investigates the effects of three natural disasters on subjective well-being in the USA. The chapter uses difference-in-differences methodology with a count data model called a zero-inflated negative binomial model.

Are there any policy recommendations that you would make in light of your research?

Chapter 2 suggests that being bullied as a child adversely affects subjective well-being as an adult. My analysis supports the case that preventing children bullying in schools may have a positive effect on the SWB of a large percentage of the adult population. Chapter 3 indicated that greater externalising problems of adolescents are positively associated with the likelihood that they engage in antisocial behaviour. Previous research has suggested that adolescents who commit antisocial behaviour have an increased probability of committing crime as adults. Consequently, the findings suggest that mental health interventions to target the externalising problems of adolescents may reduce future crime. The findings also suggest that the money spent on the “Troubled Families” programme may be spent more cost-effectively in reducing antisocial behaviour by expanding access to mental health interventions for adolescents, such as via the Improving Access to Psychological Therapies programme.

The findings of Chapter 4 suggest that government intervention in the aftermath of disasters is needed to help mitigate the adverse effects of natural disasters on the SWB of people who live in the directly affected areas. For example, appropriate mental health services and counselling could be offered to people suffering unhappiness or distress because of natural disasters.