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.

Credits

Rita Faria’s journal round-up for 15th 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.

Emulating a trial of joint dynamic strategies: an application to monitoring and treatment of HIV‐positive individuals. Statistics in Medicine [PubMed] Published 18th March 2019

Have you heard about the target trial approach? This is a causal inference method for using observational evidence to compare strategies. This outstanding paper by Ellen Caniglia and colleagues is a great way to get introduced to it!

The question is: what is the best test-and-treat strategy for HIV-positive individuals? Given that patients weren’t randomised to each of the 4 alternative strategies, chances are that their treatment was informed by their prognostic factors. And these also influence their outcome. It’s a typical situation of bias due to confounding. The target trial approach consists of designing the RCT which would estimate the causal effect of interest, and to think through how its design can be emulated by the observational data. Here, it would be a trial in which patients would be randomly assigned to one of the 4 joint monitoring and treatment strategies. The goal is to estimate the difference in outcomes if all patients had followed their assigned strategies.

The method is fascinating albeit a bit complicated. It involves censoring individuals, fitting survival models, estimating probability weights, and replicating data. It is worthy of a detailed read! I’m very excited about the target trial methodology for cost-effectiveness analysis with observational data. But I haven’t come across any application yet. Please do get in touch via comments or Twitter if you know of a cost-effectiveness application.

Achieving integrated care through commissioning of primary care services in the English NHS: a qualitative analysis. BMJ Open [PubMed] Published 1st April 2019

Are you confused about the set-up of primary health care services in England? Look no further than Imelda McDermott and colleagues’ paper.

The paper starts by telling the story of how primary care has been organised in England over time, from its creation in 1948 to current times. For example, I didn’t know that there are new plans to allow clinical commissioning groups (CCGs) to design local incentive schemes as an alternative to the Quality and Outcomes Framework pay-for-performance scheme. The research proper is a qualitative study using interviews, telephone surveys and analysis of policy documents to understand how the CCGs commission primary care services. CCG Commissioning is intended to make better and more efficient use of resources to address increasing demand for health care services, staff shortage and financial pressure. The issue is that it is not easy to implement in practice. Furthermore, there seems to be some “reinvention of the wheel”. For example, from one of the interviewees: “…it’s no great surprise to me that the three STPs that we’ve got are the same as the three PCT clusters that we broke up to create CCGs…” Hum, shall we just go back to pre-2012 then?

Even if CCG commissioning does achieve all it sets out to do, I wonder about its value for money given the costs of setting it up. This paper is an exceptional read about the practicalities of implementing this policy in practice.

The dark side of coproduction: do the costs outweight the benefits for health research? Health Research Policy and Systems [PubMed] Published 28th March 2019

Last month, I covered the excellent paper by Kathryn Oliver and Paul Cairney about how to get our research to influence policy. This week I’d like to suggest another remarkable paper by Kathryn, this time with Anita Kothari and Nicholas Mays, on the costs and benefits of coproduction.

If you are in the UK, you have certainly heard about public and patient involvement or PPI. In this paper, coproduction refers to any collaborative working between academics and non-academics, of which PPI is one type, but it includes working with professionals, policy makers and any other people affected by the research. The authors discuss a wide range of costs to coproduction. From the direct costs of doing collaborative research, such as organising meetings, travel arrangements, etc., to the personal costs on an individual researcher to manage conflicting views and disagreements between collaborators, of having research products seen to be of lower quality, of being seen as partisan, etc., and costs to the stakeholders themselves

As a detail, I loved the term “hit-and-run research” to describe the current climate: get funding, do research, achieve impact, leave. Indeed, the way that research is funded, with budgets only available for the period that the research is being developed, does not help academics to foster relationships.

This paper reinforced my view that there may well be benefits to coproduction, but that there are also quite a lot of costs. And there tends to be not much attention to the magnitude of those costs, in whom they fall, and what’s displaced. I found the authors’ advice about the questions to ask oneself when thinking about coproduction to be really useful. I’ll keep it to hand when writing my next funding application, and I recommend you do too!

Credits