Alastair Canaway’s journal round-up for 31st October 2016

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.

Ethical hurdles in the prioritization of oncology care. Applied Health Economics and Health Policy [PubMedPublished 21st October 2016

Recently between health economists, there has been significant scrutiny and disquiet directed towards the Cancer Drugs Fund with Professor Karl Claxton describing it as “an appalling, unfair use of NHS resources”. With the latest reorganization of the Cancer Drugs Fund in mind, this article examining the ethical issues surrounding prioritisation of cancer care was of particular interest. As all health economists will tell you, there is an opportunity cost with any allocation of scarce resources. Likewise, with prioritisation of specific disease groups, there may be equity issues with specific patients’ lives essentially being valued more greatly than those suffering other conditions. This article conducts a systematic review of the oncology literature to examine the ethical issues surrounding inequity in healthcare. The review found that public and political attention often focuses on ‘availability’ of pharmacological treatment in addition to factors that lead to good outcomes. The public and political focus on availability can have perverse consequences as highlighted by the Cancer Drugs Fund: resources are diverted towards availability and away from other more cost-effective areas, and in turn this may have had a detrimental effect on care for non-cancer patients. Additionally, by approving high cost, less cost-effective agents, strain will be placed upon health budgets and causing problems for existing cost-effectiveness thresholds. If prioritisation for cancer drugs is to be pursued then the authors suggest that the question of how to fund new therapies equitably will need to be addressed. Although the above issues will not be new to most, the paper is still worth reading as it: i) gives an overview of the different prioritisation frameworks used across Europe, ii) provides several suggestions for how, if prioritization is to be pursued, it can be done in a fairer manner rather than simply overriding typical HTA decision processes, iii) considers the potential legal consequences of prioritisation and iv) the impact of prioritisation on the sustainability of healthcare funding.

Doctor-patient differences in risk and time preferences: a field experiment. Journal of Health Economics Published 19th October 2016

The patient-doctor agency interaction, and associated issues due to asymmetrical information is something that was discussed often during my health economics MSc, but rarely during my day to day work. Despite being very familiar with supplier induced demand, differences in risk and time preferences in the patient-doctor dyad wasn’t something I’d considered in recent times. Upon reading, immediately, it is clear that if risk and time preferences do differ, then what is seen as the optimal treatment for the patient may be very different to that of the doctor. This may lead to poorer adherence to treatments and worse outcomes. This paper sought to investigate whether patients and their doctors had similar time and risk preferences using a framed field experiment with 300 patients and 67 doctors in Athens, Greece in a natural clinical setting. The authors claim to be the first to attempt this, and have three main findings: i) there were significant time preference differences between the patients and doctors – doctors discounted future health gains and financial outcomes less heavily than patients; ii) there were no significant differences in risk preferences for health with both doctors and patients being mildly risk averse; iii) there were however risk preference differences for financial impacts with doctors being more risk averse than patients. The implication of this paper is that there is potential for improvements in doctor-patient communication for treatments, and as agents for patients, doctors should attempts to gauge their patient’s preferences and attitudes before recommending treatment. For those who heavily discount the future it may be preferable to provide care that increases the short term benefits.

Hospital productivity growth in the English NHS 2008/09 to 2013/14 [PDF]. Centre for Health Economics Research Paper [RePEcPublished 21st October 2016

Although this is technically a ‘journal round-up’, this week I’ve chosen to include the latest CHE report as I think it is something which may be of wider interest to the AHEBlog community. Given limited resources, there is an unerring call for both productivity and efficiency gains within the NHS. The CHE report examines the extent to which NHS hospitals have improved productivity: have they made better use of their resources by increasing the number of patients they treat and the services they deliver for the same or fewer inputs. To assess productivity, the report uses established methods: Total Factor Productivity (TFP) which is the ratio of all outputs to all inputs. Growth in TFP is seen as being key to improving patient care with limited resources. The primary report finding was that TFP growth at the trust level exhibits ‘extraordinary volatility’. For example one year there maybe TFP growth followed by negative growth the next year, and then positive growth. The authors assert that much of the TFP growth measured is in fact implausible, and much of the changes are driven largely by nominal effects alongside some real changes. These nominal effects may be data entry errors or changes in accounting practices and data recording processes which results in changes to the timing of the recording of outputs and inputs. This is an important finding for research assessing productivity growth within the NHS. The TFP approach is an established methodology, yet as this research demonstrates, such methods do not provide credible measures of productivity at the hospital level. If hospital level productivity growth is to be measured credibly, then a new methodology will be required.


Chris Sampson’s journal round-up for 11th July 2016

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.

GPs’ implicit prioritization through clinical choices – evidence from three national health services. Journal of Health Economics [RePEcPublished 7th July 2016

Through economic evaluation we inform high-level prioritisation decisions about (for example) which drugs should and should not be available. Meanwhile, GPs are able to prioritise at the individual level through their prescribing behaviour. But do they prioritise? And in what ways? This study reports on a discrete choice experiment carried out with 907 GPs in England, Scotland and Norway to try and elicit prescription behaviour in different decision making contexts. A key aspect that the study considers is the presence of a double agency problem, whereby the GP advocates both maximum patient benefit (‘patient agency’) and cost containment for society (‘social agency’). GPs were asked a generic question about prescribing either ‘Medicine A’ or ‘Medicine B’ and the DCE included 5 attributes: total costs, effect, patient costs, patient preference and physician’s experience. All else equal, GPs in all countries preferred lower total costs. There was variation both within and between countries in the extent to which GPs were willing to accept high societal costs for greater patient benefit. GPs in England seem to exhibit stronger social agency in that they were less willing to accept high costs than GPs in both Norway and Scotland. However, in regard to patient costs and patient preferences, UK GPs were willing to accept greater societal costs. The authors discuss a variety of possible reasons for these findings but suggest that strong governance reinforces social agency, while cultural aspects moderate the effect.

Unrelated future costs and unrelated future benefits: reflections on NICE Guide to the Methods of Technology Appraisal. Health Economics [PubMed] Published 3rd July 2016

NICE would prefer that we disregard UFC. That’s unrelated future costs (not Ultimate Fighting Championship) – for example, the costs of dementia care having prevented death from a heart attack. But the availability of these unrelated treatments will likely confer benefit that is not excluded from the analysis. So it’s easy to see how we could end up with suboptimal allocations of resources. In this editorial, the authors consider the arguments against the inclusion of unrelated future costs, which can be broadly considered as relating to ‘principles’, ‘practicalities’ and ‘implications’. The authors argue that current approaches in principle are no more acceptable than the inclusion of costs and exclusion of benefits, as both are inconsistent in their handling of future payoffs. Practically, the authors argue that it is simpler to incorporate projected future costs than to tease out future benefits. Some have argued that the implications are limited, but the authors highlight that issues such as the level of comorbidity could have a major impact. There’s a lot of research still to be done in this area, but for now we should at least strive for consistency in our handling of future costs and benefits.

The capability approach: a critical review of its application in health economics. Value in Health Published 29th June 2016

Friends know I’ve been guilty of a bit of ICECAP-bashing in the past. Though I like the capability approach in principle, I am not a fan of how it has been applied in health economics. Naturally, I was drawn to this “critical” review. In fact, it was published as a working paper just before I finished writing my chapter for Jeff’s book but I didn’t have time to read it let alone incorporate its findings. So here we are with the real (published) deal. The primary purpose of the review is to evaluate the extent to which current questionnaires (e.g. ICECAP) can actually capture capabilities. The article does an excellent job of concisely identifying fundamental problems in the use of current measures. One issue is that the use of terms like “able to” does not allow for trade-offs between domains. A person may have maximum capability in all domains, but not be able to achieve maximal functionings in all of them simultaneously. As such, unachievable capability sets could be defined. Another problem is that these measures do not capture all of the possible combinations of functionings, only the dominant one. Therefore, these measures fail to capture the key basis for the capability approach – the value in choice. We haven’t yet figured out how to properly value a set, rather than a single combination. The authors suggest a way forward, based on the estimation of ‘approximate capability’. This could identify dominant functionings and the degree of choice. A key benefit of this approach would be the conceptual clarity for which it allows. As I have argued, I think this is the main failure of the application of the capability approach (and indeed health state valuation more broadly) in health economics.

Clinical guidelines: a NICE way to introduce cost-effectiveness considerations? Value in Health Published 28th June 2016

Most UK health economists will be familiar with NICE clinical guidelines. They outline what should (and should not) be taking place as part of care pathways in the NHS. The production of guidelines isn’t (usually) triggered by any new intervention but rather they are designed to improve current standard of care. The recommendations take into account economic considerations. This article outlines some of the advantages of the NICE guidelines programme and describes the role of health economists. One advantage of the guideline development process is that it is a joint enterprise between NICE and the various royal colleges of medicine. But there is also tension in this relationship from an economics perspective as optimal individual patient care may be at odds with broader societal objectives (if you’ve skipped ahead, see the first article summarised above). This article identifies a key advantage of NICE guidelines as being able to make recommendations on disinvestment. A key potential that I see, which isn’t discussed here, is for whole disease modelling studies to be routinely funded as part of the guideline development process.

Photo credit: Antony Theobald (CC BY-NC-ND 2.0)