Chris Sampson’s journal round-up for 17th June 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.

Mental health: a particular challenge confronting policy makers and economists. Applied Health Economics and Health Policy [PubMed] Published 7th June 2019

This paper has a bad title. You’d never guess that its focus is on the ‘inconsistency of preferences’ expressed by users of mental health services. The idea is that people experiencing certain mental health problems (e.g. depression, conduct disorders, ADHD) may express different preferences during acute episodes. Preference inconsistency, the author explains, can result in failures in prediction (because behaviour may contradict expectations) and failures in evaluation (because… well, this is a bit less clear). Because of preference inconsistency, a standard principal-agent model cannot apply to treatment decisions. Conventional microeconomic theory cannot apply. If this leaves you wondering “so what has this got to do with economists?” then you’re not alone. The author of this article believes that our role is to identify suitable agents who can interpret patients’ inconsistent preferences and make appropriate decisions on their behalf.

But, after introducing this challenge, the framing of the issue seems to change and the discussion becomes about finding an agent who can determine a patient’s “true preferences” from “conflicting statements”. That seems to me to be a bit different from the issue of ‘inconsistent preferences’, and the phrase “true preferences” should raise an eyebrow of any sceptical economist. From here, the author describes some utility models of perfect agency and imperfect agency – the latter taking account of the agent’s opportunity cost of effort. The models include error in judging whether the patient is exhibiting ‘true preferences’ and the strength of the patient’s expression of preference. Five dimensions of preference with respect to treatment are specified: when, what, who, how, and where. Eight candidate agents are specified: family member, lay helper, worker in social psychiatry, family physician, psychiatrist/psychologist, health insurer, government, and police/judge. The knowledge level of each agent in each domain is surmised and related to the precision of estimates for the utility models described. The author argues that certain agents are better at representing a patient’s ‘true preferences’ within certain domains, and that no candidate agent will serve an optimal role in every domain. For instance, family members are likely to be well-placed to make judgements with little error, but they will probably have a higher opportunity cost than care professionals.

The overall conclusion that different agents will be effective in different contexts seems logical, and I support the view of the author that economists should dedicate themselves to better understanding the incentives and behaviours of different agents. But I’m not convinced by the route to that conclusion.

Exploring the impact of adding a respiratory dimension to the EQ-5D-5L. Medical Decision Making [PubMed] Published 16th May 2019

I’m currently working on a project to develop and test EQ-5D bolt-ons for cognition and vision, so I was keen to see the methods reported in this study. The EQ-5D-5L has been shown to have only a weak correlation with clinically-relevant changes in the context of respiratory disease, so it might be worth developing a bolt-on (or multiple bolt-ons) that describe relevant functional changes not captured by the core dimensions of the EQ-5D. In this study, the authors looked at how the inclusion of respiratory dimensions influenced utility values.

Relevant disease-specific outcome measures were reviewed. The researchers also analysed EQ-5D-3L data and disease-specific outcome measure data from three clinical studies in asthma and COPD, to see how much variance in visual analogue scores was explained by disease-specific items. The selection of potential bolt-ons was also informed by principal-component analysis to try to identify which items form constructs distinct from the EQ-5D dimensions. The conclusion of this process was that two other dimensions represented separate constructs and could be good candidates for bolt-ons: ‘limitations in physical activities due to shortness of breath’ and ‘breathing problems’. Some think-aloud interviews were conducted to ensure that the bolt-ons made sense to patients and the general public.

A valuation study using time trade-off and discrete choice experiments was conducted in the Netherlands with a representative sample of 430 people from the general public. The sample was split in two, with each half completing the EQ-5D-5L with one or the other bolt-on. The Dutch EQ-5D-5L valuation study was used as a comparator data set. The inclusion of the bolt-ons seemed to extend the scale of utility values; the best-functioning states were associated with higher utility values when the bolt-ons were added and the worst-functioning states were associated with lower values. This was more pronounced for the ‘breathing problems’ bolt-on. The size of the coefficients on the two bolt-ons (i.e. the effect on utility values) was quite different. The ‘physical activities’ bolt-on had coefficients similar in size to self-care and usual activities. The coefficients on the ‘breathing problems’ bolt-on were a bit larger, comparable in size with those of the mobility dimension.

The authors raise an interesting question in light of their findings from the development process, in which the quantitative analysis supported a ‘symptoms’ dimension and patients indicated the importance of a dimension relating to ‘physical activities’. They ask whether it is more important for an item to be relevant or for it to be quantitatively important for valuation. Conceptually, it seems to me that the apparent added value of a ‘physical activity’ bolt-on is problematic for the EQ-5D. The ‘physical activity’ bolt-on specifies “climbing stairs, going for a walk, carrying things, gardening” as the types of activities it is referring to. Surely, these should be reflected in ‘mobility’ and ‘usual activities’. If they aren’t then I think the ‘usual activities’ descriptor, in particular, is not doing its job. What we might be seeing here, more than anything, is the flaws in the development process for the original EQ-5D descriptors. Namely, that they didn’t give adequate consideration to the people who would be filling them in. Nevertheless, it looks like a ‘breathing problems’ bolt-on could be a useful part of the EuroQol armoury.

Technology and college student mental health: challenges and opportunities. Frontiers in Psychiatry [PubMed] Published 15th April 2019

Universities in the UK and elsewhere are facing growing demand for counselling services from students. That’s probably part of the reason that our Student Mental Health Research Network was funded. Some researchers have attributed this rising demand to the use of personal computing technologies – smartphones, social media, and the like. No doubt, their use is correlated with mental health problems, certainly through time and probably between individuals. But causality is uncertain, and there are plenty of ways in which – as set out in this article – these technologies might be used in a positive way.

Most obviously, smartphones can be a platform for mental health programmes, delivered via apps. This is particularly important because there are perceived and actual barriers for students to accessing face-to-face support. This is an issue for all people with mental health problems. But the opportunity to address this issue using technology is far greater for students, who are hyper-connected. Part of the problem, the authors argue, is that there has not been a focus on implementation, and so the evidence that does exist is from studies with self-selecting samples. Yet the opportunity is great here, too, because students are often co-located with service providers and already engaged with course-related software.

Challenges remain with respect to ethics, privacy, accountability, and duty of care. In the UK, we have the benefit of being able to turn to GDPR for guidance, and universities are well-equipped to assess the suitability of off-the-shelf and bespoke services in terms of their ethical implications. The authors outline some possible ways in which universities can approach implementation and the challenges therein. Adopting these approaches will be crucial if universities are to address the current gap between the supply and demand for services.

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Chris Sampson’s journal round-up for 1st 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.

Toward a centralized, systematic approach to the identification, appraisal, and use of health state utility values for reimbursement decision making: introducing the Health Utility Book (HUB). Medical Decision Making [PubMed] Published 22nd March 2019

Every data point reported in research should be readily available to us all in a structured knowledge base. Most of us waste most of our time retreading old ground, meaning that we don’t have the time to do the best research possible. One instance of this is in the identification of health state utility values to plug into decision models. Everyone who builds a model in a particular context goes searching for utility values – there is no central source. The authors of this paper are hoping to put an end to that.

The paper starts with an introduction to the importance of health state utility values in cost-effectiveness analysis, which most of us don’t need to read. Of course, the choice of utility values in a model is very important and can dramatically alter estimates of cost-effectiveness. The authors also discuss issues around the identification of utility values and the assessment of their quality and applicability. Then we get into the objectives of the ‘Health Utility Book’, which is designed to tackle these issues.

The Health Utility Book will consist of a registry (I like registries), backed by a systematic approach to the identification and inclusion (registration?) of utility values. The authors plan to develop a quality assessment tool for studies that report utility values, using a Delphi panel method to identify appropriate indicators of quality to be included. The quality assessment tool will be complemented by a tool to assess applicability, which will be developed through interviews with stakeholders involved in the reimbursement process.

In the first place, the Health Utility Book will only compile utility values for cancer, and some of the funding for the project is cancer specific. To survive, the project will need more money from more sources. To be sustainable, the project will need to attract funding indefinitely. Or perhaps it could morph into a crowd-sourced platform. Either way, the Health Utility Book has my support.

A review of attitudes towards the reuse of health data among people in the European Union: the primacy of purpose and the common good. Health Policy Published 21st March 2019

We all agree that data protection is important. We all love the GDPR. Organisations such as the European Council and the OECD are committed to facilitating the availability of health data as a means of improving population health. And yet, there often seem to be barriers to accessing health data, and we occasionally hear stories of patients opposing data sharing (e.g. care.data). Maybe people don’t want researchers to be using their data, and we just need to respect that. Or, more likely, we need to figure out what it is that people are opposed to, and design systems that recognise this.

This study reviews research on attitudes towards the sharing of health data for purposes other than treatment, among people living in the EU, employing a ‘configurative literature synthesis’ (a new one for me). From 5,691 abstracts, 29 studies were included. Most related to the use of health data in research in general, while some focused on registries. A few studies looked at other uses, such as for planning and policy purposes. And most were from the UK.

An overarching theme was a low awareness among the population about the reuse of health data. However, in some studies, a desire to be better informed was observed. In general, views towards the use of health data were positive. But this was conditional on the data being used to serve the common good. This includes such purposes as achieving a better understanding of diseases, improving treatments, or achieving more efficient health care. Participants weren’t so happy with health data reuse if it was seen to conflict with the interests of patients providing the data. Commercialisation is a big concern, including the sale of data and private companies profiting from the data. Employers and insurance companies were also considered a threat to patients’ interests. There were conflicting views about whether it is positive for pharmaceutical companies to have access to health data. A minority of people were against sharing data altogether. Certain types of data are seen as being particularly sensitive, including those relating to mental health or sexual health. In general, people expressed concern about data security and the potential for leaks. The studies also looked at the basis for consent that people would prefer. A majority accepted that their data could be used without consent so long as the data were anonymised. But there were no clear tendencies of preference for the various consent models.

It’s important to remember that – on the whole – patients want their data to be used to further the common good. But support can go awry if the data are used to generate profits for private firms or used in a way that might be perceived to negatively affect patients.

Health-related quality of life in injury patients: the added value of extending the EQ-5D-3L with a cognitive dimension. Quality of Life Research [PubMed] Published 18th March 2019

I’m currently working on a project to develop a cognition ‘bolt-on’ for the EQ-5D. Previous research has demonstrated that a cognition bolt-on could provide additional information to distinguish meaningful differences between health states, and that cognition might be a more important candidate than other bolt-ons. Injury – especially traumatic brain injury – can be associated with cognitive impairments. This study explores the value of a cognition bolt-on in this context.

The authors sought to find out whether cognition is sufficiently independent of other dimensions, whether the impact of cognitive problems is reflected in the EuroQol visual analogue scale (EQ VAS), and how a cognition bolt-on affects the overall explanatory power of the EQ-5D-3L. The data used are from the Dutch Injury Surveillance System, which surveys people who have attended an emergency department with an injury, including EQ-5D-3L. The survey adds a cognitive bolt-on relating to memory and concentration.

Data were available for 16,624 people at baseline, with 5,346 complete responses at 2.5-month follow-up. The cognition item was the least affected, with around 20% reporting any problems (though it’s worth noting that the majority of the cohort had injuries to parts of the body other than the head). The frequency of different responses suggests that cognition is dominant over other dimensions in the sense that severe cognitive problems tend to be observed alongside problems in other dimensions, but not vice versa. The mean EQ VAS for people reporting severe cognitive impairment was 41, compared with a mean of 75 for those reporting no problems. Regression analysis showed that moderate and severe cognitive impairment explained 8.7% and 6.2% of the variance of the EQ VAS. Multivariate analysis suggested that the cognitive dimension added roughly the same explanatory power as any other dimension. This was across the whole sample. Interestingly (or, perhaps, worryingly) when the authors looked at the subset of people with traumatic brain injury, the explanatory power of the cognitive dimension was slightly lower than overall.

There’s enough in this paper to justify further research into the advantages and disadvantages of using a cognition bolt-on. But I would say that. Whether or not the bolt-on descriptors used in this study are meaningful to patients remains an open question.

Developing the role of electronic health records in economic evaluation. The European Journal of Health Economics [PubMed] Published 14th March 2019

One way that we can use patients’ routinely collected data is to support the conduct of economic evaluations. In this commentary, the authors set out some of the ways to make the most of these data and discuss some of the methodological challenges. Large datasets have the advantage of being large. When this is combined with the collection of sociodemographic data, estimates for sub-groups can be produced. The data can also facilitate the capture of outcomes not otherwise available. For example, the impact of bariatric surgery on depression outcomes could be identified beyond the timeframe of a trial. The datasets also have the advantage of being representative, where trials are not. This could mean more accurate estimates of costs and outcomes. But there are things to bear in mind when using the data, such as the fact that coding might not always be very accurate, and coding practices could vary between observations. Missing data are likely to be missing for a reason (i.e. not at random), which creates challenges for the analyst. I had hoped that this paper would discuss novel uses of routinely collected data systems, such as the embedding of economic evaluations within them, rather than simply their use to estimate parameters for a model. But if you’re just getting started with using routine data, I suppose you could do worse than start with this paper.

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Chris Sampson’s journal round-up for 27th August 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.

Ethically acceptable compensation for living donations of organs, tissues, and cells: an unexploited potential? Applied Health Economics and Health Policy [PubMed] Published 25th August 2018

Around the world, there are shortages of organs for transplantation. In economics, the debate around the need to increase organ donation can be frustratingly ignorant of ethical and distributional concerns. So it’s refreshing to see this article attempting to square concerns about efficiency and equity. The authors do so by using a ‘spheres of justice’ framework. This is the idea that different social goods should be distributed according to different principles. So, while we might be happy for brocolli and iPhones to be distributed on the basis of free exchange, we might want health to be distributed on the basis of need. The argument can be extended to state that – for a just situation to prevail – certain exchanges between these spheres of justice (e.g. health for iPhones) should never take place. This idea might explain why – as the authors demonstrate with a review of European countries – policy tends not to allow monetary compensation for organ donation.

The paper cleverly sets out to taxonomise monetary and non-monetary reimbursement and compensation with reference to individuals’ incentives and the spheres of justice principles. From this, the authors reach two key conclusions. Firstly, that (monetary) reimbursement of donors’ expenses (e.g. travel costs or lost earnings) is ethically sound as this does not constitute an incentive to donate but rather removes existing disincentives. Secondly, that non-monetary compensation could be deemed ethical.

Three possible forms of non-monetary compensation are discussed: i) prioritisation, ii) free access, and iii) non-health care-related benefits. The first could involve being given priority for receiving organs, or it could extend to the jumping of other health care waiting lists. I think this is more problematic than the authors let on because it asserts that health care should – at least in part – be distributed according to desert rather than need. The second option – free access – could mean access to health care that people would otherwise have to pay for. The third option could involve access to other social goods such as education or housing.

This is an interesting article and an enjoyable read, but I don’t think it provides a complete solution. Maybe I’m just too much of a Marxist, but I think that this – as all other proposals – fails to distribute from each according to ability. That is, we’d still expect non-monetary compensation to incentivise poorer (and on average less healthy) people to donate organs, thus exacerbating health inequality. This is because i) poorer people are more likely to need the non-monetary benefits and ii) we live in a capitalist society in which there is almost nothing that money can’t by and which is strictly non-monetary. Show me a proposal that increases donation rates from those who can most afford to donate them (i.e. the rich and healthy).

Selecting bolt-on dimensions for the EQ-5D: examining their contribution to health-related quality of life. Value in Health Published 18th August 2018

Measures such as the EQ-5D are used to describe health-related quality of life as completely and generically as possible. But there is a trade-off between completeness and the length of the questionnaire. Necessarily, there are parts of the evaluative space that measures will not capture because they are a simplification. If the bit they’re missing is important to your patient group, that’s a problem. You might fancy a bolt-on. But how do we decide which areas of the evaluative space should be more completely included in the measure? Which bolt-ons should be used? This paper seeks to provide means of answering these questions.

The article builds on an earlier piece of work that was included in an earlier journal round-up. In the previous paper, the authors used factor analysis to identify candidate bolt-ons. The goal of this paper is to outline an approach for specifying which of these candidates ought to be used. Using data from the Multi-Instrument Comparison study, the authors fit linear regressions to see how well 37 candidate bolt-on items explain differences in health-related quality of life. The 37 items correspond to six different domains: energy/vitality, satisfaction, relationships, hearing, vision, and speech. In a second test, the authors explored whether the bolt-on candidates could explain differences in health-related quality of life associated with six chronic conditions. Health-related quality of life is defined according to a visual analogue scale, which notably does not correspond to that used in the EQ-5D but rather uses a broader measure of physical, mental, and social health.

The results suggest that items related to energy/vitality, relationships, and satisfaction explained a significant part of health-related quality of life on top of the existing EQ-5D dimensions. The implication is that these could be good candidates for bolt-ons. The analysis of the different conditions was less clear.

For me, there’s a fundamental problem with this study. It moves the goals posts. Bolt-ons are about improving the extent to which a measure can more accurately represent the evaluative space that it is designed to characterise. In this study, the authors use a broader definition of health-related quality of life that – as far as I can tell – the EQ-5D is not designed to capture. We’re not dealing with bolt-ons, we’re dealing with extensions to facilitate expansions to the evaluative space. Nevertheless, the method could prove useful if combined with a more thorough consideration of the evaluative space.

Sources of health financing and health outcomes: a panel data analysis. Health Economics [PubMed] [RePEc] Published 15th August 2018

There is a growing body of research looking at the impact that health (care) spending has on health outcomes. Usually, these studies don’t explicitly look at who is doing the spending. In this study, the author distinguishes between public and private spending and attempts to identify which type of spending (if either) results in greater health improvements.

The author uses data from the World Bank’s World Development Indicators for 1995-2014. Life expectancy at birth is adopted as the primary health outcome and the key expenditure variables are health expenditure as a share of GDP and private health expenditure as a share of total health expenditure. Controlling for a variety of other variables, including some determinants of health such as income and access to an improved water source, a triple difference analysis is described. The triple difference estimator corresponds to the difference in health outcomes arising from i) differences in the private expenditure level, given ii) differences in total expenditure, over iii) time.

The key finding from the study is that, on average, private expenditure is more effective in increasing life expectancy at birth than public expenditure. The author also looks at government effectiveness, which proves crucial. The finding in favour of private expenditure entirely disappears when only countries with effective government are considered. There is some evidence that public expenditure is more effective in these countries, and this is something that future research should investigate further. For countries with ineffective governments, the implication is that policy should be directed towards increasing overall health care expenditure by increasing private expenditure.

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