Paul Mitchell’s journal round-up for 2nd January 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.

Age effects in mortality risk valuation. European Journal of Health Economics [PubMed] [RePEcPublished 7th December 2016

Placing values on statistical life years has important public policy implications in measuring who benefits and how much they benefit from interventions. The authors of this study provide what they describe as the most comprehensive evidence to date against a constant value for a statistical life year, an assumption they argue is also applicable when calculating QALYs. Using a Spanish household survey collected over a large sample size (approximately 6,000 individuals), the authors study the relationship between willingness to pay (WTP) and age, by estimating individual WTP for reduction in risk of mortality due to acute myocardial infarction. Three different WTP elicitation procedures were performed. Parametric, semi-nonparametric and non-parametric models using marginal and total approaches were applied to understand the relationship using many alternative methods. Binary variables for income (proxied on a measure of self-perceived social status), education (>lower secondary level) and gender were also included as controls for the models. The results of the linear model show that WTP is lower as age increases. Those with higher income (i.e. social status) and education have higher WTP, while gender is not significant in any model. Sensitivity tests were as hypothesised. The non-parametric model produces similar results to the others, albeit with a higher senior discount. The senior discount is not independent of the income variable. From this, the authors estimate the value of a statistical life year for an 85 year old to be 3.5 times higher than that of a 20 year old. The authors are keen to highlight the strengths of their findings with a large sample size allowing for the robustness of results to be tested across a number of different model types. However, they do flag up the lack of comparability with previous studies that have focused on risk reductions with a lower probability of mortality. The assumption that the authors make that their findings for life years have direct applicability for QALYs is somewhat questionable, particularly for non-acute conditions and QALYs calculated for them. The rationale behind the three types of preference elicitation methods and how/why they were chosen is not apparent in the paper itself. The social status measure they use as a proxy for income is also questionable, and appeared to be applied to maximise sample size. If data for real income was used or imputation of income was included for missing data, it would be interesting to see what impact this may have had on their study findings.

Preferences for public involvement in health service decisions: a comparison between best-worst scaling and trio-wise stated preference elicitation techniques. European Journal of Health Economics [PubMedPublished 10th December 2016

Public involvement in health care is something that has become increasingly recognised as important to do and to be informed by public perspectives when making important decisions for their community. How and where that public involvement should feed into decision making is less well understood. In this study, the authors compare two methods, best worst scaling (BWS) case 2, and a new method the authors call ‘trio-wise’ where the choice task is presented in an equilateral triangle. Using ‘trio-wise’, respondents are able to click in any part of the triangle; this the authors argue gives additional insight on the strength of a respondent’s preferences and also accommodates indifferent preferences. Public preferences are sought using these two methods to understand what aspects of public involvement are most important. Eight general characteristics are included in the exercises. Respondents completed either BWS or the ‘trio-wise’ task (not both) using web based surveys. Approximately 1,700 individuals per arm were sampled. Only three of the eight general characteristics could be completed at any one time due to the trio-wise triangle approach. There was some evidence of position bias for both exercises. The authors say that weak preferences were observed using the trio-wise approach but this could be due to difficulty participants faced in choosing which generic characteristic was more important without further information. Impact and focus of public involvement are found to be the most important characteristics across both BWS and trio-wise. The authors find preference intensity has no bearing on choice probabilities, but this could be an artefact of the weak preferences observed in the sample. Although I can see the appeal of using the trio-wise approach when there are only three characteristics, BWS is advantageous in tasks with more characteristics. Indeed it feels that the findings from this experiment were impeded by the use of the trio-wise approach when much more useful information on guiding future public involvement practice could have been gathered using either BWS or a discrete choice experiment (DCE) across all eight characteristics and the options of public involvement within each characteristic.

How do individuals value health states? A qualitative investigation. Social Science & Medicine [PubMedPublished 22nd November 2016

The valuation tasks of health states used to generate QALYs have been previously found to be complex tasks for members of the general public to complete, who have little experience of such health states. This qualitative study seeks to gain a better understanding as to how the general public complete such tasks. Using a purposive sample, 21 individuals were asked to complete eight DCEs and three TTO tasks, based on the EQ-5D-5L valuation protocol. Participants were asked to complete the valuation tasks using think aloud, followed by semi-structured interviews. Three main themes emerged from the framework analysis undertaken on the interview transcripts. Firstly, individuals had to interpret a health state, using their imagination and experience to help visualise a realistic health state with those problems. Knowledge, understanding of descriptive system, additional information for a health state, re-writing of health states and problems with EQ-5D labels all impacted this process. The second theme was called conversion factors, which the authors took to mean in this context the personal and social factors that affected how participants valued health states. Personal interests, values and circumstances were said to have an effect on the interpretation of a health state. The final theme was based on the consequences of health states, that tended to focus on non-health effects caused by health problems, such as activities, enjoyment, independence, relationships, dignity and avoiding being a burden. The authors subsequently developed a three-stage explanatory account as to how people valued health states based on the interview findings. Although I would have some concerns about the generalisability of these findings to general public valuation studies, given the highly educated sample, it does highlight some issues about what health economists might implicitly think individuals are doing when completing such tasks compared to what they actually are doing. There are clearly problems for individuals completing such hypothetical health states, with the authors suggesting a more reflective and deliberative approach to overcome such problems. The authors also raise an interesting comment as to whether participants actually do weigh the consequences of health states and follow compensatory decision-making or instead are using simplifying heuristics based on one attribute, which I agree is an area that requires further investigation.

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Paul Mitchell’s journal round-up for 26th December 2016

Every Monday (even if it’s Boxing Day here in the UK) 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.

Out-migration and attrition of physicians and dentists before and after EU accession (2003 and 2011): the case of Hungary. European Journal of Health Economics [PubMedPublished 2nd December 2016

Medical staff migration is an important cross-national policy issue given the international shortage of supply of doctors to meet healthcare demand. This study uses a large administrative survey collected in Hungary from 2004-2011 and focuses on the trends of medical doctors (GPs, specialists, dentists) since Hungary joined the EU in 2004 and the introduction of full freedom of movement between Hungary with Austria and Germany in 2011. The author conducted a time-to-event analysis with monthly collection of data on a person’s occupation used as a guide for outward-migration. A competing-risks model was used to also consider medical doctors exiting the profession, becoming inactive or dying. From the 18,266 medical doctors found in this sample over the nine year period, 12% migrated, 17% exited the profession and 14% became inactive. A five-fold increase in migration was seen when the restrictions on freedom of movement between Hungary and Austria/Germany were lifted, a worrying sign of brain drain from Hungary. For those who stayed but exited the profession, relative income is argued to have been a contributory factor, with incomes increasing by on average 40% in their new line of work (although this does not account for the “thank you money” received by doctors in Hungary for healthcare access). Generous maternity leave was argued to play a key role in absence from employment. A recognised limitation in this study is the inability to conduct robust analysis on the migration patterns of new medical graduates who are likely to be more prone to migration than their established colleagues (estimated to be 40% of all medical graduates in Hungary between 2007-2010 who migrated, before restrictions on freedom of movement between Austria and Germany were lifted). Nonetheless, the study still manages to shine a light on the external (competing against countries with larger economies) but also the internal (“attrition and feminisation of workforce”) challenges to national doctor staffing policy.

Does the proportion of pay linked to performance affect the job satisfaction of general practitioners? Social Science & Medicine [PubMedPublished 24th November 2016

The impact of pay for performance (P4P) on healthcare practice has been subject to much debate surrounding the pros and cons of incentives for medical staff to achieve specific goals. This study focuses on the impact that the introduction of the Quality and Outcomes Framework (QOF) for GPs in the UK in 2004 had on their subsequent job satisfaction. Job satisfaction for GPs is argued to be an important topic area due to it having an important role in retaining GPs and the quality of care they provide to their patients. Using linked data from the the GP Worklife Survey and the QOF, that rewards GPs performance based on clinical, organisation, additional services and patient experience indicators, across three time points (2004, 2005 and 2008), the authors model the relationship between P4P exposure (i.e. the proportion of income related to performance) and job satisfaction. Using a continuous difference-in-difference model with a random effects regression, the authors find that P4P exposure has no significant effect on job satisfaction after 1 and 4 years following the introduction of the QOF P4P system. The introduction of the QOF did lead to a large increase in GP life satisfaction; this is likely to be due to the large increase in average income for GPs following the introduction of QOF. The authors argue that their findings suggest GP job satisfaction is unlikely to be affected by changes in P4P exposure, so long as the final income the GP receives remains constant. Given the generous increases on GP final income from the initial QOF, it remains to be seen how generalisable these results would be to P4P systems that did not lead to such large increases in staff income.

Country-level cost-effectiveness thresholds: initial estimates and the need for further research. Value in Health [PubMed] Published 14th December 2016

National thresholds used to determine if a health intervention is cost-effective have been under scrutiny in the UK in recent years. It has been argued on the grounds of healthcare opportunity costs that the NICE £20,000-30,000 per QALY gained threshold is too high, with an estimate of £13,000 per QALY gain proposed instead. Until now, less attention has been paid to international cost-effectiveness thresholds recommended by the WHO, who have argued for a threshold between one and three times the GDP of a country. This study provides preliminary estimates of cost-effectiveness thresholds across a number of countries with varying levels of national income. Using estimates from the recent £13,000 per QALY gain threshold study in England, a ratio between the supply-side threshold with the consumption value of health was estimated and used as a basis to calculate other national thresholds. The authors use a range of income elasticity estimates for the value placed on a statistical life to take account of uncertainty around these values. The results suggest that even the lower end of the WHO recommended threshold range of 1x national GDP is likely to be an overestimate in most countries. It would appear something closer to 50% of GDP may be a better estimate, albeit with a great amount of uncertainty and variation between high and low income countries. The importance of these estimates according to the authors is that the application of the current WHO thresholds could lead to policies that reduce instead of increase population health. However, the threshold estimates from this study rely on a number of assumptions based on UK data that may not provide an accurate estimate when setting cost-effectiveness thresholds at an international level.

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Meeting round-up: Priorities 2016

This was my first experience of the biennial conference organised by the International Society on Priorities in Health Care. The society was founded in 1996 at the University of Birmingham in the UK and returned to its spiritual home 20 years on. As well as bringing bioethicists, philosophers, economists, health care practitioners and patient advocates together, the conference also saw the combined wits of the Health Service Management Centre (HSMC) and the Health Economics Unit (HEU), co-chaired by Iestyn Williams and Joanna Coast (now at Bristol), who organised a very insightful programme that stimulated plenty of debate between attendants.

After a recent bad experience of plenary talks, Priorities 2016 managed to return my faith in the power of good plenary sessions. The opening session of the conference by Angela Coulter, Rachel Baker and Sally Brearley, focusing on the application and practicalities of incorporating patient views into healthcare decision-making, set the tone for high quality presentations over the three days. Although impossible to summarise all the relevant contributions made with simultaneous sessions throughout, I will focus on my highlights.

Multi-criteria decision analysis (MCDA) is something that has been gaining a lot of attention in health economics, so I jumped at the chance to learn more from some of the key names involved in its use and development. I was slightly surprised then to hear Rob Baltussen make a convincing argument why going beyond the quantification of more than two criteria is likely to muddle more than help decision-making. Instead, he made an argument for a deliberate form of MCDA when presenting decision makers with more than two criteria, sounding somewhat similar to a cost consequence analysis in health economics. This deliberative form of MCDA was also argued to align more closely with Norman Daniels’s accountability for reasonableness priority setting ethical framework.

There were numerous relevant health economics talks of interest. In terms of commissioning health services in England, there was an organised session led by Hugh McLeod on a new project starting in Gloucestershire Clinical Commissioning Group (CCG), who are planning to trial the use of the ICECAP capability measure to aid their decision-making. At the same time of this talk, there was also a Health Foundation sponsored session on how to set priorities across the NHS, with speakers including Cam Donaldson and Muir Gray. By many accounts, it was the highlight of the conference for those who attended.

Other notable health economics sessions looked at how benefits are measured, with Lidia Engel presenting twice from her PhD research, including a helpful conceptual map of the multiple options available when considering how going beyond the quality adjusted life year (QALY) could be operationalised in practice. Yvonne Michel looked at issues in asking patients with spinal cord injury about their mobility in terms of walking, a common feature in health measures used in the generation of QALYs. My talk on how capabilities could be an appropriate evaluative space in renal care also took place in this lively session.

Another session with an economic evaluation focus included a talk by Hareth Al-Janabi on his research looking at incorporating health spillover effects on the family from children with health conditions, with his example drawing from data on children with meningitis in the UK. Lars Schwettmann discussed inconsistencies in the willingness to pay for QALYs in the German sample of the EuroVaQ project. Joseph Millum discussed his attempts to place different values on the disutility of death at different ages of childhood, prompting the largest proportion of hands raised by those in attendance following a presentation that I have seen. There was also a talk from three US-based researchers who presented a systematic review for looking at how social justice could be incorporated into an economic evaluation. This session was chaired by Stirling Bryan, who had previously discussed his recently published paper in Medical Decision Making with Graham Scotland at the conference, on the search for efficiency in current health care provision versus the current focus of the majority of most health economic analysis on new interventions.

It was also a good conference in terms of getting international perspectives on how health economics is used to aid priority setting in different countries. Key debates included the use of health/QALY maximisation alone, versus how it is combined with equity concerns around absolute shortfall as implemented in Norway, presented by Trygve Ottersen and proportional shortfall as implemented in the Netherlands, presented by Werner Brouwer. Another interesting development is the use of income as an equity consideration to be incorporated alongside the health outcome in economic analysis, with Ole Norheim and Richard Cookson working on this new area of research.

The above is only a microcosm of the Priorities 2016 conference through the perspective of one attendant. I would highly recommend keeping your eyes peeled for when this conference comes around again in 2018. It may not have had health economics in the title, but I would highly recommend health economists to attend and share their experience with others in related areas of research and practice at this very worthwhile meeting.