Paul Mitchell’s journal round-up for 17th April 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.

Is foreign direct investment good for health in low and middle income countries? An instrumental variable approach. Social Science & Medicine [PubMed] Published 28th March 2017

Foreign direct investment (FDI) is considered a key benefit of globalisation in the economic development of countries with developing economies. The effect FDI has on the population health of countries is less well understood. In this paper, the authors draw from a large panel of data, primarily World Bank and UN sources, for 85 low and middle income countries between 1974 and 2012 to assess the relationship between FDI and population health, proxied by life expectancy at birth, as well as child and adult mortality data. They explain clearly the problem of using basic regression analysis in trying to explain this relationship, given the problem of endogeneity between FDI and health outcomes. By introducing two instrumental variables, using grossed fixed capital formation and volatility of exchange rates in FDI origin countries, as well as controlling for GDP per capita, education, quality of institutions and urban population, the study shows that FDI is weakly statistically associated with life expectancy, estimated to amount to 4.15 year increase in life expectancy during the study period. FDI also appears to have an effect on reducing adult mortality, but a negligible effect on child mortality. They also produce some evidence that FDI linked to manufacturing could lead to reductions in life expectancy, although these findings are not as robust as the other findings using instrumental variables, so they recommend this relationship between FDI type and population health to be explored further. The paper also clearly shows the benefit of robust analysis using instrumental variables, as the results without the introduction of these variables to the regression would have led to misleading inferences, where no relationship between life expectancy and FDI would have been found if the analysis did not adjust for the underlying endogeneity bias.

Uncovering waste in US healthcare: evidence from ambulance referral patterns. Journal of Health Economics [PubMed] Published 22nd March 2017

This study looks to unpick some of the reasons behind the estimated waste in US healthcare spending, by focusing on mortality rates across the country following an emergency admission to hospital through ambulances. The authors argue that patients admitted to hospital for emergency care using ambulances act as a good instrument to assess hospital quality given the nature of emergency admissions limiting the selection bias of what type of patients end up in different hospitals. Using linear regressions, the study primarily measures the relationship between patients assigned to certain hospitals and the 90-day spending on these patients compared to mortality. They also consider one-year mortality and the downstream payments post-acute care (excluding pharmaceuticals outside the hospital setting) has on this outcome. Through a lengthy data cleaning process, the study looks at over 1.5 million admissions between 2002-2011, with a high average age of patients of 82 who are predominantly female and white. Approximately $27,500 per patient was spent in the first 90 days post-admission, with inpatient spending accounting for the majority of this amount (≈$16,000). The authors argue initially that the higher 90-day spending in some hospitals only produces modestly lower mortality rates. Spending over 1 year is estimated to cost more than $300,000 per life year, which the authors use to argue that current spending levels do not lead to improved outcomes. But when the authors dig deeper, it seems clear there is an association between hospitals who have higher spending on inpatient care and reduced mortality, approximately 10% lower. This leads to the authors turning their attention to post-acute care as their main target of reducing waste and they find an association between mortality and patients receiving specialised nursing care. However, this target seems somewhat strange to me, as post-acute care is not controlled for in the same way as their initial, insightful approach to randomising based on ambulatory care. I imagine those in such care are likely to be a different mix from those receiving other types of care post 90 days after the initial event. I feel there really is not enough to go on to make recommendations about specialist nursing care being the key waste driver from their analysis as it says nothing, beyond mortality, about the quality of care these elderly patients are receiving in the specialist nurse facilities. After reading this paper, one way I would suggest in reducing inefficiency related to their primary analysis could be to send patients to the most appropriate hospital for what the patient needs in the first place, which seems difficult given the complexity of the private and hospital provided mix of ambulatory care offered in the US currently.

Population health and the economy: mortality and the Great Recession in Europe. Health Economics [PubMed] Published 27th March 2017

Understanding how economic recessions affect population health is of great research interest given the recent global financial crisis that led to the worst downturn in economic performance in the West since the 1930s. This study uses data from 27 European countries between 2004 and 2010 collected by WHO and the World Bank to study the relationship between economic performance and population health by comparing national unemployment and mortality rates before and after 2007. Regression analyses appropriate for time-series data are applied with a number of different specifications applied. The authors find that the more severe the economic downturn, the greater the increase in life expectancy at birth. Additional specific health mortality rates follow a similar trend in their analysis, with largest improvements observed in countries where the severity of the recession was the highest. The only exception the authors note is data on suicide, where they argue the relationship is less clear, but points towards higher rates of suicide with greater unemployment. The message the authors were trying to get across in this study was not very clear throughout most of the paper and some lay readers of the abstract alone could easily be misled in thinking recessions themselves were responsible for better population health. Mortality rates fell across all six years, but at a faster rate in the recession years. Although the results appeared consistent across all models, question marks remain for me in terms of their initial variable selection. Although the discussion mentions evidence that suggests health care may not have a short-term effect on mortality, they did not consider any potential lagged effect record investment in healthcare as a proportion of GDP up until 2007 may have had on the initial recession years. The authors rule out earlier comparisons with countries in the post-Soviet era but do not consider the effect of recent EU accession for many of the countries and more regulated national policies as a consequence. Another issue is the potential of countries’ mortality rates to improve, where countries with existing lower life expectancy have more room for moving in the right direction. However, one interesting discussion point raised by the authors in trying to explain their findings is the potential impact of economic activity on pollution levels and knock-on health impacts from this (and to a lesser extent occupational health levels), that may have some plausibility in better mortality rates linked to physical health during recessions.

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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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