Chris Sampson’s journal round-up for 29th April 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.

Here comes the SUN: self‐assessed unmet need, worsening health outcomes, and health care inequity. Health Economics [PubMed] Published 24th April 2019

How should we measure inequity in health care? Often, it is measured on the basis of health care use, and the extent to which people with different socioeconomic circumstances – conditional on their level of need – access services. One problem with this approach is that differences might not only reflect barriers to access but also heterogeneity in preferences. If people of lower socioeconomic status prefer to access services less (conditional on need), then this is arguably an artificial signal of inequities in the system. Instead, we could just ask people. But can self-assessed unmet need provide a valid and meaningful measure of inequity?

In this study, the researchers looked at whether self-reported unmet need can predict deterioration in health. The idea here is that we would expect there to be negative health consequences if people genuinely need health care but cannot access it. The Canadian National Population Health Survey asks whether, during the preceding 12 months, the individual needed health care but did not receive it, with around 10% reporting unmet need. General health outcomes are captured by self-assessed health and by the HUI3, and there are also variables for specific chronic conditions. A few model specifications, controlling for a variety of health-related and demographic variables, are implemented. For the continuous variables, the authors use a fixed effects model with lagged health, and for the categorical outcomes they used a random effects probit.

The findings are consistent across models and outcomes. People who report self-assessed unmet need are more likely to have poorer health outcomes in subsequent periods, in terms of both general health and the number of self-reported chronic conditions. This suggests that self-assessed unmet need is probably a meaningful indicator of barriers to access in health care. I’m not aware of any UK-based surveys that include self-assessed unmet need, but this study provides some reason to think that they should.

Cost effectiveness of treatments for diabetic retinopathy: a systematic literature review. PharmacoEconomics [PubMed] Published 22nd April 2019

I’ve spent a good chunk of the last 8 years doing research in the context of diabetic eye disease. Over that time, treatment has changed, and there have been some interesting controversies relating to the costs of new treatments. So this review is timely.

There are four groups of treatments that the authors consider – laser, anti-VEGF eye injections, corticosteroids, and surgery. The usual databases were searched, turning up 1915 abstracts, and 17 articles were included in the review. That’s not a lot of studies, which is why I’d like to call the authors out for excluding one HTA report, which I assume was Royle et al 2015 and which probably should have been included. The results are summarised according to whether the evaluations were of treatments for diabetic macular oedema (DMO) or proliferative diabetic retinopathy (PDR), which are the two main forms of sight-threatening diabetic eye disease. The majority of studies focussed on DMO. As ever, in reviews of this sort, the studies and their findings are difficult to compare. Different methods were employed, for different purposes. The reason that there are so few economic evaluations in the context of PDR is probably that treatments have been so decisively shown to be effective. Yet there is evidence to suggest that, for PDR, the additional benefits of injections do not justify the much higher cost compared with laser. However, this depends on the choice of drug that is being injected, because prices vary dramaticly. For DMO, injections are cost-effective whether combined with laser or not. The evidence on corticosteroids is mixed and limited, but there is promise in recently-developed fluocinolone implants.

Laser might still be king in PDR, and early surgical intervention is also still cost-effective where indicated. For DMO, the strongest evidence is in favour of using an injection (bevacizumab) that can only be used off-label. You can blame Novartis for that, or you can blame UK regulators. Either way, there’s good reason to be angry about it. The authors of this paper clearly have a good understanding of the available treatments, which is not always the case for reviews of economic evaluations. The main value of this study is as a reference point for people developing research in this area, to identify the remaining gaps in the evidence and appropriately align (or not) with prevailing methods.

Exploring the impacts of the 2012 Health and Social Care Act reforms to commissioning on clinical activity in the English NHS: a mixed methods study of cervical screening. BMJ Open [PubMed] Published 14th April 2019

Not everybody loves the Health and Social Care Act of 2012. But both praise and criticism of far-reaching policies like this are usually confined to political arguments. It’s nice to see – and not too long after the fact – some evidence of its impact. In this paper, we learn about the impact of the Act on cervical screening activity.

The researchers used both qualitative and quantitative methods in their study in an attempt to identify whether the introduction of the Act influenced rates of screening coverage. With the arrival of the Act, responsibility for commissioning screening services shifted from primary care trusts to regional NHS England teams, while sexual health services were picked up by local authorities. The researchers conducted 143 (!) interviews with commissioners, clinicians, managers, and administrators from various organisations. Of these, 93 related to the commissioning of sexual health services, with questions regarding the commissioning system before and after the introduction of the Act. How did participants characterise the impact of the Act? Confusion, complexity, variability, uncertainty, and the idea that these characteristics could result in a drop in screening rates.

The quantitative research plan, and in particular the focus on cervical screening, arose from the qualitative findings. The quantitative analysis sought to validate the qualitative findings. But everyone had the Act dropped on them at the same time (those wily politicians know how to evade blame), so the challenge for the researchers was to identify some source of variation that could represent exposure to the effects of the Act. Informed by the interviewees, the authors differentiated between areas based on the number of local authorities that the clinical commissioning group (CCG) had to work with. Boundaries don’t align, so while some CCGs only have to engage with one local authority, some have to do so with as many as three, increasing the complexity created by the Act. As a kind of control, the researchers looked at the rate of unassisted births, which we wouldn’t expect to have been affected by the introduction of the Act. From this, they estimated the triple difference in cervical screening rates before and after the introduction of the Act, between CCGs with one or more than one local authority, minus the difference in the unassisted birth rate. Screening rates (and unassisted delivery rates) were both declining before the introduction of the Act. Without any adjustment, screening rates before and after the introduction of the act decreased by 0.39% more for GP practices in those CCGs that had to work with multiple local authorities. Conversely, unassisted delivery rates actually increased by a similar amount. The adjusted impact of the Act on screening rates was a drop of around 0.62%.

Clearly, there are big disclaimers attached to findings from a study of this sort, though the main finding seems to be robust to a variety of specifications. Any number of other things could explain the change in screening rates over the period, which the researchers couldn’t capture. But the quantitative findings are backed-up by the qualitative reports, making this a far more convincing piece of work. There’s little doubt that NHS redisorganisations of this kind create challenges in the short term, and we can now see the impact that this has on the provision of care.

Public involvement in health outcomes research: lessons learnt from the development of the recovering quality of life (ReQoL) measures. Health and Quality of Life Outcomes [PubMed] Published 11th April 2019

We’ve featured a few papers from the ReQoL project on this blog. The researchers developed several outcome measures to be used in the context of mental health. A couple of weeks ago, we also featured a paper turning a sceptical eye to the idea of co-production, whereby service users or members of the public are not simply research participants but research partners. This paper describes the experience of coproduction in the context of the ReQoL study. The authors are decidedly positive about co-production.

The logic behind the involvement of service users in the development of patient-reported outcome measures is obvious; measures need to be meaningful and understandable to patients, and enabling service users to inform research decisions could facilitate that. But there is little guidance on co-production in the context of developing patient-reported outcomes. Key decisions in the development of ReQoL were made by a ‘scientific group’, which included academics, clinicians, and seven expert service users. An overlapping ‘expert service user group’ also supported the study. In these roles, service users contributed to all stages of the research, confirming themes and items, supporting recruitment, collecting and analysing data, agreeing the final items for the measures, and engaging in dissemination activities. It seems that the involvement was in large part attendance at meetings, discussing data and findings to achieve an interpretation that includes the perspectives of services users. This resulted in decisions – about which items to take forward – that probably would not have been made if the academics and clinicians were left to their own devices. Service users were also involved in the development of research materials, such as the interview topic guide. In some examples, however, it seems like the line between research partner and research participant was blurred. If an expert service user group is voting on candidate items and editing them according to their experience, this is surely a data collection process and the services users become research subjects.

The authors describe the benefits as they saw them, in terms of the expert service users’ positive influence on the research. The costs and challenges are also outlined, including the need to manage disagreements and make additional preparations for meetings. We’re even provided with the resource implications in terms of the additional days of work. The comprehensive description of the researchers’ experiences in this context and the recommendations that they provide make this paper an important companion for anybody designing a research study to develop a new patient-reported outcome measure.

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Rita Faria’s journal round-up for 18th 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.

Objectives, budgets, thresholds, and opportunity costs—a health economics approach: an ISPOR Special Task Force report. Value in Health [PubMedPublished 21st February 2018

The economic evaluation world has been discussing cost-effectiveness thresholds for a while. This paper has been out for a few months, but it slipped under my radar. It explains the relationship between the cost-effectiveness threshold, the budget, opportunity costs and willingness to pay for health. My take-home messages are that we should use cost-effectiveness analysis to inform decisions both for publicly funded and privately funded health care systems. Each system has a budget and a way of raising funds for that budget. The cost-effectiveness threshold should be specific for each health care system, in order to reflect its specific opportunity cost. The budget can change for many reasons. The cost-effectiveness threshold should be adjusted to reflect these changes and hence reflect the opportunity cost. For example, taxpayers can increase their willingness to pay for health through increased taxes for the health care system. We are starting to see this in the UK with the calls to raise taxes to increase the NHS budget. It is worth noting that the NICE threshold may not warrant adjustment upwards since research suggests that it does not reflect the opportunity cost. This is a welcome paper on the topic and a must read, particularly if you’re arguing for the use of cost-effectiveness analysis in settings that traditionally were reluctant to embrace it, such as the US.

Basic versus supplementary health insurance: access to care and the role of cost effectiveness. Journal of Health Economics [RePEc] Published 31st May 2018

Using cost-effectiveness analysis to inform coverage decisions not only for the public but also for the privately funded health care is also a feature of this study by Jan Boone. I’ll admit that the equations are well beyond my level of microeconomics, but the text is good at explaining the insights and the intuition. Boone grapples with the question about how the public and private health care systems should choose which technologies to cover. Boone concludes that, when choosing which technologies to cover, the most cost-effective technologies should be prioritised for funding. That the theory matches the practice is reassuring to an economic evaluator like myself! One of the findings is that cost-effective technologies which are very cheap should not be covered. The rationale being that everyone can afford them. The issue for me is that people may decide not to purchase a highly cost-effective technology which is very cheap. As we know from behaviour economics, people are not rational all the time! Boone also concludes that the inclusion of technologies in the universal basic package should consider the prevalence of the conditions in those people at high risk and with low income. The way that I interpreted this is that it is more cost-effective to include technologies for high-risk low-income people in the universal basic package who would not be able to afford these technologies otherwise, than technologies for high-income people who can afford supplementary insurance. I can’t cover here all the findings and the nuances of the theoretical model. Suffice to say that it is an interesting read, even if you avoid the equations like myself.

Surveying the cost effectiveness of the 20 procedures with the largest public health services waiting lists in Ireland: implications for Ireland’s cost-effectiveness threshold. Value in Health Published 11th June 2018

As we are on the topic of cost-effectiveness thresholds, this is a study on the threshold in Ireland. This study sets out to find out if the current cost-effectiveness threshold is too high given the ICERs of the 20 procedures with the largest waiting lists. The idea is that, if the current cost-effectiveness threshold is correct, the procedures with large and long waiting lists would have an ICER of above the cost-effectiveness threshold. If the procedures have a low ICER, the cost-effectiveness threshold may be set too high. I thought that Figure 1 is excellent in conveying the discordance between ICERs and waiting lists. For example, the ICER for extracapsular extraction of crystalline lens is €10,139/QALY and the waiting list has 10,056 people; the ICER for surgical tooth removal is €195,155/QALY and the waiting list is smaller at 833. This study suggests that, similar to many other countries, there are inefficiencies in the way that the Irish health care system prioritises technologies for funding. The limitation of the study is in the ICERs. Ideally, the relevant ICER compares the procedure with the standard care in Ireland whilst on the waiting list (“no procedure” option). But it is nigh impossible to find ICERs that meet this condition for all procedures. The alternative is to assume that the difference in costs and QALYs is generalisable from the source study to Ireland. It was great to see another study on empirical cost-effectiveness thresholds. Looking forward to knowing what the cost-effectiveness threshold should be to accurately reflect opportunity costs.

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Sam Watson’s journal round-up for 12th February 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.

Tuskegee and the health of black men. The Quarterly Journal of Economics [RePEc] Published February 2018

In 1932, a study often considered the most infamous and potentially most unethical in U.S. medical history began. Researchers in Alabama enrolled impoverished black men in a research program designed to examine the effects of syphilis under the guise of receiving government-funded health care. The study was known as the Tuskegee syphilis experiment. For 40 years the research subjects were not informed they had syphilis nor were they treated, even after penicillin was shown to be effective. The study was terminated in 1972 after its details were leaked to the press; numerous men died, 40 wives contracted syphilis, and a number of children were born with congenital syphilis. It is no surprise then that there is distrust among African Americans in the medical system. The aim of this article is to examine whether the distrust engendered by the Tuskegee study could have contributed to the significant differences in health outcomes between black males and other groups. To derive a causal estimate the study makes use of a number of differences: black vs non-black, for obvious reasons; male vs female, since the study targeted males, and also since women were more likely to have had contact with and hence higher trust in the medical system; before vs after; and geographic differences, since proximity to the location of the study may be informative about trust in the local health care facilities. A wide variety of further checks reinforce the conclusions that the study led to a reduction in health care utilisation among black men of around 20%. The effect is particularly pronounced in those with low education and income. Beyond elucidating the indirect harms caused by this most heinous of studies, it illustrates the importance of trust in mediating the effectiveness of public institutions. Poor reputations caused by negligence and malpractice can spread far and wide – the mid-Staffordshire hospital scandal may be just such an example.

The economic consequences of hospital admissions. American Economic Review [RePEcPublished February 2018

That this paper’s title recalls that of Keynes’s book The Economic Consequences of the Peace is to my mind no mistake. Keynes argued that a generous and equitable post-war settlement was required to ensure peace and economic well-being in Europe. The slow ‘economic privation’ driven by the punitive measures and imposed austerity of the Treaty of Versailles would lead to crisis. Keynes was evidently highly critical of the conference that led to the Treaty and resigned in protest before its end. But what does this have to do with hospital admissions? Using an ‘event study’ approach – in essence regressing the outcome of interest on covariates including indicators of time relative to an event – the paper examines the impact hospital admissions have on a range of economic outcomes. The authors find that for insured non-elderly adults “hospital admissions increase out-of-pocket medical spending, unpaid medical bills, and bankruptcy, and reduce earnings, income, access to credit, and consumer borrowing.” Similarly, they estimate that hospital admissions among this same group are responsible for around 4% of bankruptcies annually. These losses are often not insured, but they note that in a number of European countries the social welfare system does provide assistance for lost wages in the event of hospital admission. Certainly, this could be construed as economic privation brought about by a lack of generosity of the state. Nevertheless, it also reinforces the fact that negative health shocks can have adverse consequences through a person’s life beyond those directly caused by the need for medical care.

Is health care infected by Baumol’s cost disease? Test of a new model. Health Economics [PubMed] [RePEcPublished 9th February 2018

A few years ago we discussed Baumol’s theory of the ‘cost disease’ and an empirical study trying to identify it. In brief, the theory supposes that spending on health care (and other labour-intensive or creative industries) as a proportion of GDP increases, at least in part, because these sectors experience the least productivity growth. Productivity increases the fastest in sectors like manufacturing and remuneration increases as a result. However, this would lead to wages in the most productive sectors outstripping those in the ‘stagnant’ sectors. For example, salaries for doctors would end up being less than those for low-skilled factory work. Wages, therefore, increase in the stagnant sectors despite a lack of productivity growth. The consequence of all this is that as GDP grows, the proportion spent on stagnant sectors increases, but importantly the absolute amount spent on the productive sectors does not decrease. The share of the pie gets bigger but the pie is growing at least as fast, as it were. To test this, this article starts with a theoretic two-sector model to develop some testable predictions. In particular, the authors posit that the cost disease implies: (i) productivity is related to the share of labour in the health sector, and (ii) productivity is related to the ratio of prices in the health and non-health sectors. Using data from 28 OECD countries between 1995 and 2016 as well as further data on US industry group, they find no evidence to support these predictions, nor others generated by their model. One reason for this could be that wages in the last ten years or more have not risen in line with productivity in manufacturing or other ‘productive’ sectors, or that productivity has indeed increased as fast as the rest of the economy in the health care sector. Indeed, we have discussed productivity growth in the health sector in England and Wales previously. The cost disease may well then not be a cause of rising health care costs – nevertheless, health care need is rising and we should still expect costs to rise concordantly.

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