Rita Faria’s journal round-up for 4th March 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.

Cheap and dirty: the effect of contracting out cleaning on efficiency and effectiveness. Public Administration Review Published 25th February 2019

Before I was a health economist, I used to be a pharmacist and worked for a well-known high street chain for some years. My impression was that the stores with in-house cleaners were cleaner, but I didn’t know if this was a true difference, my leftie bias or my small sample size of 2! This new study by Shimaa Elkomy, Graham Cookson and Simon Jones confirms my suspicions, albeit in the context of NHS hospitals, so I couldn’t resist to select it for my round-up.

They looked at how contracted-out services fare in terms of perceived cleanliness, costs and MRSA rate in NHS hospitals. MRSA is a type of hospital-associated infection that is affected by how clean a hospital is.

They found that contracted-out services are cheaper than in-house cleaning, but that perceived cleanliness is worse. Importantly, contracted-out services increase the MRSA rate. In other words, contracting-out cleaning services could harm patients’ health.

This is a fascinating paper that is well worth a read. One wonders if the cost of managing MRSA is more than offset by the savings of contracting-out services. Going a step further, are in-house services cost-effective given the impact on patients’ health and costs of managing infections?

What’s been the bang for the buck? Cost-effectiveness of health care spending across selected conditions in the US. Health Affairs [PubMed] Published 1st January 2019

Staying on the topic of value for money, this study by David Wamble and colleagues looks at the extent to which the increased spending in health care in the US has translated into better health outcomes over time.

It’s clearly reassuring that, for 6 out of the 7 conditions they looked at, health outcomes have improved in 2015 compared to 1996. After all, that’s the goal of investing in medical R&D, although it remains unclear how much of this difference can be attributed to health care versus other things that have happened at the same time that could have improved health outcomes.

I wasn’t sure about the inflation adjustment for the costs, so I’d be grateful for your thoughts via comments or Twitter. In my view, we would underestimate the costs if we used medical price inflation indices. This is because these indices reflect the specific increase in prices in health care, such as due to new drugs being priced high at launch. So I understand that the main results use the US Consumer Price Index, which means that this reflects the average increase in prices over time rather than the increase in health care.

However, patients may not have seen their income rise with inflation. This means that the cost of health care may represent a disproportionally greater share of people’s income. And that the inflation adjustment may downplay the impact of health care costs on people’s pockets.

This study caught my eye and it is quite thought-provoking. It’s a good addition to the literature on the cost-effectiveness of US health care. But I’d wager that the question remains: to what extent is today’s medical care better value for money that in the past?

The dos and don’ts of influencing policy: a systematic review of advice to academics. Palgrave Communications Published 19th February 2019

We all would like to see our research findings influence policy, but how to do this in practice? Well, look no further, as Kathryn Oliver and Paul Cairney reviewed the literature, summarised it in 8 key tips and thought through their implications.

To sum up, it’s not easy to influence policy; advice about how to influence policy is rarely based on empirical evidence, and there are a few risks to trying to become a mover-and-shaker in policy circles.

They discuss three dilemmas in policy engagement. Should academics try to influence policy? How should academics influence policy? What is the purpose of academics’ engagement in policy making?

I particularly enjoyed reading about the approaches to influence policy. Tools such as evidence synthesis and social media should make evidence more accessible, but their effectiveness is unclear. Another approach is to craft stories to create a compelling case for the policy change, which seems to me to be very close to marketing. The third approach is co-production, which they note can give rise to accusations of bias and can have some practical challenges in terms of intellectual property and keeping one’s independence.

I found this paper quite refreshing. It not only boiled down the advice circulating online about how to influence policy into its key messages but also thought through the practical challenges in its application. The impact agenda seems to be here to stay, at least in the UK. This paper is an excellent source of advice on the risks and benefits of trying to navigate the policy world.


Rita Faria’s journal round-up for 28th 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.

Appraising the value of evidence generation activities: an HIV modelling study. BMJ Global Health [PubMed] Published 7th December 2018

How much should we spend on implementing our health care strategy versus getting more information to devise a better strategy? Should we devolve budgets to regions or administer the budget centrally? These are difficult questions and this new paper by Beth Woods et al has a brilliant stab at answering them.

The paper looks at the HIV prevention and treatment policies in Zambia. It starts by finding the most cost-effective strategy and the corresponding budget in each region, given what is currently known about the prevalence of the infection, the effectiveness of interventions, etc. The idea is that the regions receive a cost-effective budget to implement a cost-effective strategy. The issue is that the cost-effective strategy and budget are devised according to what we currently know. In practice, regions might face a situation on the ground which is different from what was expected. Regions might not have enough budget to implement the strategy or might have some leftover.

What if we spend some of the budget to get more information to make a better decision? This paper considers the value of perfect information given the costs of research. Depending on the size of the budget and the cost of research, it may be worthwhile to divert some funds to get more information. But what if we had more flexibility in the budgetary policy? This paper tests 2 more budgetary options: a national hard budget but with the flexibility to transfer funds from under- to overspending regions, and a regional hard budget with a contingency fund.

The results are remarkable. The best budgetary policy is to have a national budget with the flexibility to reallocate funds across regions. This is a fascinating paper, with implications not only for prioritisation and budget setting in LMICs but also for high-income countries. For example, the 2012 Health and Social Care Act broke down PCTs into smaller CCGs and gave them hard budgets. Some CCGs went into deficit, and there are reports that some interventions have been cut back as a result. There are probably many reasons for the deficit, but this paper shows that hard regional budgets clearly have negative consequences.

Health economics methods for public health resource allocation: a qualitative interview study of decision makers from an English local authority. Health Economics, Policy and Law [PubMed] Published 11th January 2019

Our first paper looked at how to use cost-effectiveness to allocate resources between regions and across health care services and research. Emma Frew and Katie Breheny look at how decisions are actually made in practice, but this time in a local authority in England. Another change of the 2012 Health and Social Care Act was to move public health responsibilities from the NHS to local authorities. Local authorities are now given a ring-fenced budget to implement cost-effective interventions that best match their needs. How do they make decisions? Thanks to this paper, we’re about to find out.

This paper is an enjoyable read and quite an eye-opener. It was startling that health economics evidence was not much used in practice. But the barriers that were cited are not insurmountable. And the suggestions by the interviewees were really useful. There were suggestions about how economic evaluations should consider the local context to get a fair picture of the impact of the intervention to services and to the population, and to move beyond the trial into the real world. Equity was mentioned too, as well as broadening the outcomes beyond health. Fortunately, the health economics community is working on many of these issues.

Lastly, there was a clear message to make economic evidence accessible to lay audiences. This is a topic really close to my heart, and something I’d like to help improve. We have to make our work easy to understand and use. Otherwise, it may stay locked away in papers rather than do what we intended it for. Which is, at least in my view, to help inform decisions and to improve people’s lives.

I found this paper reassuring in that there is clearly a need for economic evidence and a desire to use it. Yes, there are some teething issues, but we’re working in the right direction. In sum, the future for health economics is bright!

Survival extrapolation in cancer immunotherapy: a validation-based case study. Value in Health Published 13th December 2018

Often, the cost-effectiveness of cancer drugs hangs in the method to extrapolate overall survival. This is because many cancer drugs receive their marketing authorisation before most patients in the trial have died. Extrapolation is tested extensively in the sensitivity analysis, and this is the subject of many discussions in NICE appraisal committees. Ultimately, at the point of making the decision, the correct method to extrapolate is a known unknown. Only in hindsight can we know for sure what the best choice was.

Ash Bullement and colleagues take advantage of hindsight to know the best method for extrapolation of a clinical trial of an immunotherapy drug. Survival after treatment with immunotherapy drugs is more difficult to predict because some patients can survive for a very long time, while others have much poorer outcomes. They fitted survival models to the 3-year data cut, which was available at the time of the NICE technology appraisal. Then they compared their predictions to the observed survival in the 5-year data cut and to long-term survival trends from registry data. They found that the piecewise model and a mixture-cure model had the best predictions at 5 years.

This is a relevant paper for those of us who work in the technology appraisal world. I have to admit that I can be sceptical of piecewise and mixture-cure models, but they definitely have a role in our toolbox for survival extrapolation. Ideally, we’d have a study like this for all the technology appraisals hanging on the survival extrapolation so that we can take learnings across cancers and classes of drugs. With time, we would get to know more about what works best for which condition or drug. Ultimately, we may be able to get to a stage where we can look at the extrapolation with less inherent uncertainty.


Meeting round-up: Health Economists’ Study Group (HESG) Winter 2019

2019 started with aplomb with the HESG Winter meeting, superbly organised by the Centre for Health Economics, University of York.

Andrew Jones kicked off proceedings with his brilliant course on data visualisation in health econometrics. The eager audience learnt about Edward Tufte’s and others’ ideas about how to create charts that help to make it much easier to understand information. The course was tremendously well received by the HESG audience. And I know that I’ll find it incredibly useful too, as there were lots of ideas that apply to my work. So I’m definitely going to be looking further into Andrew’s chapter on data visualisation to know more.

The conference proper started in the afternoon. I had the pleasure to chair the fascinating paper by Manuela Deidda et al on an economic evaluation using observational data on the Healthy Start Voucher, which was discussed by Anne Ludbrook. We had an engaging discussion, that not only delved into the technical aspects of the paper, such as the intricacies of implementing propensity score matching and regression discontinuity, but also about the policy implications of the results.

I continued with the observational data theme by enjoying the discussion led by Panos Kasteridis on the Andrew McCarthy et al paper. Then I quickly followed this by popping over to catch Attakrit Leckcivilize’s excellent discussion of Padraig Dixon’s et al paper on the effect of obesity on hospital costs. This impressive paper uses Mendelian randomisation, which is a fascinating approach using a type of instrumental variable analysis with individuals’ genetic variants as the instrument.

The meeting continued in the stunning setting of the Yorkshire Museum for the plenary session, which also proved a fitting location to pay tribute to the inspirational Alan Maynard, who sadly passed away in 2018. Unfortunately, I was unable to hear the tributes to Alan Maynard in person, but fellow attendees were able to paint a moving portrait of the event on Twitter, that kept me in touch.

The plenary was chaired by Karen Bloor and included presentations by Kalipso Chalkidou, Brian Ferguson, Becky Henderson and Danny PalnochJane Hall, Steve Birch and Maria Goddard gave personal tributes.

The health economics community was united in gratitude to Professor Alan Maynard, who did so much to advance and disseminate the discipline. It made for a wonderful way to finish day 1!

Day 2 started bright and was full of stimulating sessions to choose from.

I chose to zone in on the cost-effectiveness topic in particular. I started with the David Glynn et al paper about using “back of the envelope” calculations to inform funding and research decisions, discussed by Ed Wilson. This paper is an excellent step towards making value of information easy to use.

I then attended Matthew Quaife’s discussion of Matthew Taylor’s paper on the consequences of assuming independence of parameters to decision uncertainty. This is a relevant paper for the cost-effectiveness world, in particular for those tasked with building and appraising cost-effectiveness models.

Next up it was my turn in the hot seat, as I presented the Jose Robles-Zurita et al paper on the economic evaluation of diagnostic tests. This thought-provoking paper presents a method to account for the effect of accuracy on the uptake of the test, in the context of maximising health.

As always, we were spoilt for choice in the afternoon. The paper “Drop dead: is anchoring at ‘dead’ a theoretical requirement in health state valuation” by Chris Sampson et al, competed very strongly with “Is it really ‘Grim up North’? The causes and consequences of inequalities on health and wider outcomes” by Anna Wilding et al, for the most provocative title. “Predicting the unpredictable? Using discrete choice experiments in economic evaluation to characterise uncertainty and account for heterogeneity”, from Matthew Quaife et al, also gave them a run for their money! I’ll leave a sample here of the exciting papers in discussion, so you can make your own mind up:

Dinner was in the splendid Merchant Adventurers’ Hall. Built in 1357, it is one of the finest Medieval buildings in the UK. Another stunning setting that provided a beautiful backdrop for a wonderful evening!

Andrew Jones presented the ‘Health Economics’ PhD Poster Prize, sponsored by Health Economics Wiley. Rose Atkins took the top honours by winning the Wiley prize for best poster. With Ashleigh Kernohan’s poster being highly commended, given its brilliant use of technology. Congratulations both!

Unfortunately, the vagaries of public transport meant I had to go home straight after dinner, but I heard from many trustworthy sources, on the following day, that the party continued well into the early hours. Clearly, health economics is a most energising topic!

For me, day 3 was all about cost-effectiveness decision rules. I started with the paper by Mark Sculpher et al, discussed by Chris Sampson. This remarkable paper sums up the evidence on the marginal productivity of the NHS, discussing how to use it to inform decisions, and proposes an agenda for research. There were many questions and comments from the floor, showing how important and challenging this topic is. As are so many papers in HESG, this is clearly one to look out for when it appears in print!

The next paper was on a very different way to solve the problem of resource allocation in health care. Philip Clarke and Paul Frijters propose an interesting system of auctions to set prices. The paper was well discussed by James Lomas, which kick-started an animated discussion with the audience about practicalities and implications for investment decisions by drug companies. Great food for thought!

Last, but definitely not least, I took in the paper by Bernarda Zamora et al on the relationship between health outcomes and expenditure across geographical areas in England. David Glynn did a great job discussing the paper, and especially in explaining data envelopment analysis. As ever, the audience was highly engaged and put forward many questions and comments. Clearly, the productivity of the NHS is a central question for health economics and will keep us busy for some time to come.

As always, this was a fantastic HESG meeting that was superbly organised, providing an environment where authors, discussants and participants alike were able to excel.

I really felt a feeling of collegiality, warmth and energy permeate the event. We are part of such an amazing scientific community. Next stop, HESG Summer meeting, hosted by the University of East Anglia. I’m already looking forward to it!