Chris Sampson’s journal round-up for 4th February 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.

Patient choice and provider competition – quality enhancing drivers in primary care? Social Science & Medicine Published 29th January 2019

There’s no shortage of studies in economics claiming to identify the impact (or lack of impact) of competition in the market for health care. The evidence has brought us close to a consensus that greater competition might improve quality, so long as providers don’t compete on price. However, many of these studies aren’t able to demonstrate the mechanism through which competition might improve quality, and the causality is therefore speculative. The research reported in this article was an attempt to see whether the supposed mechanisms for quality improvement actually exist. The authors distinguish between the demand-side mechanisms of competition-increasing quality-improving reforms (i.e. changes in patient behaviour) and the supply-side mechanisms (i.e. changes in provider behaviour), asserting that the supply-side has been neglected in the research.

The study is based on primary care in Sweden’s two largest cities, where patients can choose their primary care practice, which could be a private provider. Key is the fact that patients can switch between providers as often as they like, and with fewer barriers to doing so than in the UK. Prospective patients have access to some published quality indicators. With the goal of maximum variation, the researchers recruited 13 primary health care providers for semi-structured interviews with the practice manager and (in most cases) one or more of the practice GPs. The interview protocol included questions about the organisation of patient visits, information received about patients’ choices, market situation, reimbursement, and working conditions. Interview transcripts were coded and a framework established. Two overarching themes were ‘local market conditions’ and ‘feedback from patient choice’.

Most interviewees did not see competitors in the local market as a threat – conversely, providers are encouraged to cooperate on matters such as public health. Where providers did talk about competing, it was in terms of (speed of) access for patients, or in competition to recruit and keep staff. None of the interviewees were automatically informed of patients being removed from their list, and some managers reported difficulties in actually knowing which patients on their list were still genuinely on it. Even where these data were more readily available, nobody had access to information on reasons for patients leaving. Managers saw greater availability of this information as useful for quality improvement, while GPs tended to think it could be useful in ensuring continuity of care. Still, most expressed no desire to expand their market share. Managers reported using marketing efforts in response to greater competition generally, rather than as a response to observed changes within their practice. But most relied on reputation. Some reported becoming more service-minded as a result of choice reforms.

It seems that practices need more information to be able to act on competitive pressures. But, most practices don’t care about it because they don’t want to expand and they face no risk of there being a shortage of patients (in cities, at least). And, even if they did want to act on the information, chances are it would just create an opportunity for them to improve access as a way of cherry-picking younger and healthier people who demand convenience. Primary care providers (in this study, at least) are not income maximisers, but satisficers (they want to break-even), so there isn’t much scope for reforms to encourage providers to compete for new patients. Patient choice reforms may improve quality, but it isn’t clear that this has anything to do with competitive pressure.

Maximising the impact of patient reported outcome assessment for patients and society. BMJ [PubMed] Published 24th January 2019

Patient-reported outcome measures (PROMs) have been touted as a way of improving patient care. Yet, their use around the world is fragmented. In this paper, the authors make some recommendations about how we might use PROMs to improve patient care. The authors summarise some of the benefits of using PROMs and discuss some of the ways that they’ve been used in the UK.

Five key challenges in the use of PROMs are specified: i) appropriate and consistent selection of the best measures; ii) ethical collection and reporting of PROM data; iii) data collection, analysis, reporting, and interpretation; iv) data logistics; and v) a lack of coordination and efficiency. To address these challenges, the authors recommend an ‘integrated’ approach. To achieve this, stakeholder engagement is important and a governance framework needs to be developed. A handy table of current uses is provided.

I can’t argue with what the paper proposes, but it outlines an idealised scenario rather than any firm and actionable recommendations. What the authors don’t discuss is the fact that the use of PROMs in the UK is flailing. The NHS PROMs programme has been scaled back, measures have been dropped from the QOF, the EQ-5D has been dropped from the GP Patient Survey. Perhaps we need bolder recommendations and new ideas to turn the tide.

Check your checklist: the danger of over- and underestimating the quality of economic evaluations. PharmacoEconomics – Open [PubMed] Published 24th January 2019

This paper outlines the problems associated with misusing methodological and reporting checklists. The author argues that the current number of checklists available in the context of economic evaluation and HTA (13, apparently) is ‘overwhelming’. Three key issues are discussed. First, researchers choose the wrong checklist. A previous review found that the Drummond, CHEC, and Philips checklists were regularly used in the wrong context. Second, checklists can be overinterpreted, resulting in incorrect conclusions. A complete checklist does not mean that a study is perfect, and different features are of varying importance in different studies. Third, checklists are misused, with researchers deciding which items are or aren’t relevant to their study, without guidance.

The author suggests that more guidance is needed and that a checklist for selecting the correct checklist could be the way to go. The issue of updating checklists over time – and who ought to be responsible for this – is also raised.

In general, the tendency seems to be to broaden the scope of general checklists and to develop new checklists for specific methodologies, requiring the application of multiple checklists. As methods develop, they become increasingly specialised and heterogeneous. I think there’s little hope for checklists in this context unless they’re pared down and used as a reminder of the more complex guidance that’s needed to specify suitable methods and achieve adequate reporting. ‘Check your checklist’ is a useful refrain, though I reckon ‘chuck your checklist’ can sometimes be a better strategy.

A systematic review of dimensions evaluating patient experience in chronic illness. Health and Quality of Life Outcomes [PubMed] Published 21st January 2019

Back to PROMs and PRE(xperience)Ms. This study sets out to understand what it is that patient-reported measures are being used to capture in the context of chronic illness. The authors conducted a systematic review, screening 2,375 articles and ultimately including 107 articles that investigated the measurement properties of chronic (physical) illness PROMs and PREMs.

29 questionnaires were about (health-related) quality of life, 19 about functional status or symptoms, 20 on feelings and attitudes about illness, 19 assessing attitudes towards health care, and 20 on patient experience. The authors provide some nice radar charts showing the percentage of questionnaires that included each of 12 dimensions: i) physical, ii) functional, iii) social, iv) psychological, v) illness perceptions, vi) behaviours and coping, vii) effects of treatment, viii) expectations and satisfaction, ix) experience of health care, x) beliefs and adherence to treatment, xi) involvement in health care, and xii) patient’s knowledge.

The study supports the idea that a patient’s lived experience of illness and treatment, and adaptation to that, has been judged to be important in addition to quality of life indicators. The authors recommend that no measure should try to capture everything because there are simply too many concepts that could be included. Rather, researchers should specify the domains of interest and clearly define them for instrument development.



Thesis Thursday: Firdaus Hafidz

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 Firdaus Hafidz who has a PhD from the University of Leeds. If you would like to suggest a candidate for an upcoming Thesis Thursday, get in touch.

Assessing the efficiency of health facilities in Indonesia
Tim Ensor, Sand Tubeuf
Repository link

What are some of the key features of health and health care in Indonesia?

Indonesia is a diverse country, with more than 17 thousand islands and 500 districts. Thus, there is a wide discrepancy of health outcomes across Indonesia, which also reflects the country’s double burden of both communicable and emerging non-communicable diseases. Communicable diseases such as tuberculosis, diarrhoea and lower respiratory tract infections remain as significant issues in Indonesia, especially in remote areas. At the same time, non-communicable diseases are becoming a major public health problem, especially in urban areas.

Total healthcare expenditure per capita grew rapidly, but in certain outcomes, such as maternal mortality rate, Indonesia performs less well than other low- and middle-income countries. Health facilities represent the largest share of healthcare expenditures, but utilisation is still considered low in both hospitals and primary healthcare facilities. Given the scarcity of public healthcare resources, out-of-pocket expenditure remains considerably higher than the global average.

To reduce financial barriers, the Government of Indonesia introduced health insurance in 1968. Between 2011 and 2014, there were three major insurance schemes: 1) Jamkesmas – poor scheme; 2) Jamsostek – formal sector workers scheme; and 3) Askes – civil servant scheme. In 2014, the three schemes were combined into a single-entity National Health Insurance scheme.

What methods can be used to measure the efficiency of health care in low and middle-income countries?

We reviewed measurements of efficiency in empirical analyses conducted in low- and middle-income countries. Methods, including techniques, variables, and efficiency indicators were summarised. There was no consensus on the most appropriate technique to measure efficiency, though most existing studies have relied on ratio analysis and data envelopment analysis because it is simple, easy to compute, low-cost and can be performed on small samples. The physical inputs included the type of capital (e.g. the number of beds and size of health facilities) and the type of labour (e.g. the number of medical and non-medical staff). Most of the published literature used health services as outputs (e.g. the number of outpatient visits, admission and inpatient days). However, because of poor data availability, fewer studies used case-mix and quality indicators to adjust outputs. So most of the studies in the literature review assumed that there was no difference in the severity and effectiveness of healthcare services. Despite the complexity of the techniques, researchers are responsible to provide interpretable results to the policymakers to guide their decisions for a better health policy on efficiency. Adopting appropriate methods that have been used globally would be beneficial to benchmark empirical studies.

Were you able to identify important sources of inefficiency in Indonesia?

We used several measurement techniques including frontier analysis and ratio analysis. We explored contextual variables to assess factors determining efficiency. The range of potential models produced help policymakers in the decision-making process according to their priority and allow some control over the contextual variables. The results revealed that the efficiency of primary care facilities can be explained by population health insurance coverage, especially through the insurance scheme for the poor. Geographical factors, such as the main islands (Java or Bali), better access to health facility, and location in an urban area also have a strong impact on efficiency. At the hospitals, the results highlighted higher efficiency levels in larger hospitals; they were more likely to present in deprived areas with low levels of education; and they were located on Java or Bali. Greater health insurance coverage also had a positive and significant influence on efficiency.

How could policymakers improve the efficiency of health care in Indonesia or other similar settings?

I think there are several ideas. First, we need to have a careful tariff adjustment as we found an association between low unit costs and high efficiency scores. Case base group tariffs need to account for efficiency scores to prevent unnecessary incentives for the providers, exacerbating inefficiency in the health system.

Secondly, we need flexibility in employment contracts, particularly for the less productive civil servant worker so the less productive worker could be reallocated. We also need a better remuneration policy to attract skilled labour and improve health facilities efficiency.

From the demand side, reducing physical barriers by improving infrastructure could increase efficiency in the rural health care facilities through higher utilisation of care. Facilities with very low utilisation rates still incur a fixed cost and thus create inefficiency. Through the same argument we also need to reduce financial barriers using incentives programmes and health insurance, thus patients who are economically disadvantaged can access healthcare services.

How would you like to see other researchers build on your work?

Data quality is crucial in secondary data analysis research, and it was quite a challenge in an Indonesian setting. Meticulous data management is needed to mitigate data errors such as inconsistency, outliers and missing values.

As this study used a 2011 cross-sectional dataset, replicating this study using a more recent and even longitudinal data would highlight changes in efficiency due to policy changes or interventions. Particularly interesting is the effect of the 2014 implementation of Indonesian national health insurance.

My study has some limitations and thus warrants further investigation. The stochastic frontier analysis failed to identify any inefficiency at hospitals when outpatient visits were included. The statistical errors of the frontier function cannot be distinguished from the inefficiency effect of the model. It might be related to the volume and heterogeneity of outpatient services which swamps the total volume of services and masks any inefficiency.

Chris Sampson’s journal round-up for 7th January 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.

Overview, update, and lessons learned from the international EQ-5D-5L valuation work: version 2 of the EQ-5D-5L valuation protocol. Value in Health Published 2nd January 2019

Insofar as there is any drama in health economics, the fallout from the EQ-5D-5L value set for England was pretty dramatic. If you ask me, the criticisms are entirely ill-conceived. Regardless of that, one of the main sticking points was that the version of the EQ-5D-5L valuation protocol that was used was flawed. England was one of the first countries to get a valuation, so it used version 1.0 of the EuroQol Valuation Technique (EQ-VT). We’re now up to version 2.1. This article outlines the issues that arose in using the first version, what EuroQol did to try and solve them, and describes the current challenges in valuation.

EQ-VT 1.0 includes the composite time trade-off (cTTO) task to elicit values for health states better and worse than dead. Early valuation studies showed some unusual patterns. Research into the causes of this showed that in many cases there was very little time spent on the task. Some interviewers had a tendency to skip parts of the explanation for completing the worse-than-dead bit of the cTTO, resulting in no values worse than dead. EQ-VT 1.1 added three practise valuations along with greater monitoring of interviewer performance and a quality control procedure. This dramatically reduced interviewer effects and the likelihood of inconsistent responses. Yet further improvements could be envisioned. And so EQ-VT 2.0 added a feedback module. The feedback module shows respondents the ranking of states implied by their valuations, with which respondents can then agree or disagree. 2.0 was tested against 1.1 and showed further reductions in inconsistencies thanks to the feedback module. Other modifications were not supported by the evaluation. EQ-VT 2.1 added a dynamic question to further improve the warm-up tasks.

There are ongoing challenges with the cTTO, mostly to do with how to model the data. The authors provide a table setting out causes, consequences, and possible solutions for various issues that might arise in the modelling of cTTO data. And then there’s the discrete choice experiment (DCE), which is included in addition to the cTTO, but which different valuation studies used (or did not use) differently in modelling values. Research is ongoing that will probably lead to developments beyond EQ-VT 2.1. This might involve abandoning the cTTO altogether. Or, at least, there might be a reduction in cTTO tasks and a greater reliance on DCE. But more research is needed before duration can be adequately incorporated into DCEs.

Helpfully, the paper includes a table with a list of countries and specification of the EQ-VT versions used. This demonstrates the vast amount of knowledge that has been accrued about EQ-5D-5L valuation and the lack of wisdom in continuing to support the (relatively under-interrogated) EQ-5D-3L MVH valuation.

Do time trade-off values fully capture attitudes that are relevant to health-related choices? The European Journal of Health Economics [PubMed] Published 31st December 2018

Different people have different preferences, so values for health states elicited using TTO should vary from person to person. This study is concerned with how personal circumstances and beliefs influence TTO values and whether TTO entirely captures the impact of these on preferences for health states.

The authors analysed data from an online survey with a UK-representative sample of 1,339. Participants were asked about their attitudes towards quality and quantity of life, before completing some TTO tasks based on the EQ-5D-5L. Based on their response, they were shown two ‘lives’ that – given their TTO response – they should have considered to be of equivalent value. The researchers constructed generalised estimating equations to model the TTO values and logit models for the subsequent choices between states. Age, marital status, education, and attitudes towards trading quality and quantity of life all determined TTO values in addition to the state that was being valued. In the modelling of the decisions about the two lives, attitudes influenced decisions through the difference between the two lives in the number of life years available. That is, an interaction term between the attitudes variable and years variables showed that people who prefer quantity of life over quality of life were more likely to choose the state with a greater number of years.

The authors’ interpretation from this is that TTO reflects people’s attitudes towards quality and quantity of life, but only partially. My interpretation would be that the TTO exercise would have benefitted from the kind of refinement described above. The choice between the two lives is similar to the feedback module of the EQ-VT 2.0. People often do not understand the implications of their TTO valuations. The study could also be interpreted as supportive of ‘head-to-head’ choice methods (such as DCE) rather than making choices involving full health and death. But the design of the TTO task used in this study was quite dissimilar to others, which makes it difficult to say anything generally about TTO as a valuation method.

Exploring the item sets of the Recovering Quality of Life (ReQoL) measures using factor analysis. Quality of Life Research [PubMed] Published 21st December 2018

The ReQoL is a patient-reported outcome measure for use with people experiencing mental health difficulties. The ReQoL-10 and ReQoL-20 both ask questions relating to seven domains: six mental, one physical. There’s been a steady stream of ReQoL research published in recent years and the measures have been shown to have acceptable psychometric properties. This study concerns the factorial structure of the ReQoL item sets, testing internal construct validity and informing scoring procedures. There’s also a more general methodological contribution relating to the use of positive and negative factors in mental health outcome questionnaires.

At the outset of this study, the ReQoL was based on 61 items. These were reduced to 40 on the basis of qualitative and quantitative analysis reported in other papers. This paper reports on two studies – the first group (n=2,262) completed the 61 items and the second group (n=4,266) completed 40 items. Confirmatory factor analysis and exploratory factor analysis were conducted. Six-factor (according to ReQoL domains), two-factor (negative/positive) and bi-factor (global/negative/positive) models were tested. In the second study, participants were either presented with a version that jumbled up the positively and negatively worded questions or a version that showed a block of negatives followed by a block of positives. The idea here is that if a two-factor structure is simply a product of the presentation of questions, it should be more pronounced in the jumbled version.

The results were much the same from the two study samples. The bi-factor model demonstrated acceptable fit, with much higher factor loadings on the general quality of life factor that loaded on all items. The results indicated sufficient unidimensionality to go ahead with reducing the number of items and the two ordering formats didn’t differ, suggesting that the negative and positive loadings weren’t just an artefact of the presentation. The findings show that the six dimensions of the ReQoL don’t stand as separate factors. The justification for maintaining items from each of the six dimensions, therefore, seems to be a qualitative one.

Some outcome measurement developers have argued that items should all be phrased in the same direction – as either positive or negative – to obtain high-quality data. But there’s good reason to think that features of mental health can’t reliably be translated from negative to positive, and this study supports the inclusion (and intermingling) of both within a measure.